THE EFFECT OF DEXAMETHASONE ON POST TONSILLECTOMY MORBIDITIES IN CHILDREN

This study aimed to evaluate the effect of preoperative single dose of Dexamethasone on postoperative morbidities in children undergoing tonsillectomy. This is a prospective study considering 90 children with chronic tonsillitis who underwent tonsillectomy between June 2010 and December 2010 at the Department of Otolaryngology in Al-Diwaniah Teaching Hospital in Al-Diwaniah city, Iraq. Compared with placebo, Dexamethasone group have lower percentage of post tonsillectomy morbidities (pain, postoperative nausea & vomiting and uvular edema) but without statistical significant. In conclusion, there is no statistical beneficial effect of preoperative dexamethasone on the postoperative morbidities in children undergoing tonsillectomy. Introduction onsillectomy is one of the most common operations done in ENT specialty. Pain, nausea, vomiting, edema of uvula and poor oral intake regarded as the most common morbidities following this operation 1 . Postoperative nausea and vomiting (PONV) can result in dehydration, delayed discharging, tension in suture line, venous hypertension, bleeding and pulmonary aspiration. Several studies had been done to prevent or decrease these morbidities. The use of dexamethasone is one of the methods to eliminate these morbidities depending on the anti inflammatory effect and anti emetic effect for chemotherapy induced vomiting 2 . The aim of this study is to assess the effect of a single preoperative dose of Dexamethasone on postoperative morbidities (pain, vomiting, bleeding and edema of uvula) in children underwent tonsillectomy using a standardized anesthetic and surgical techniques 3 . Materials and methods This study is prospective in nature, it involves 90 children with chronic tonsillitis, they had been admitted to the ENT Department at Al-Diwania Teaching Hospital for tonsillectomy by dissection and/or adenoidectomy and/or myringotomy between June 2010 and December 2010. The age ranged from 3 years to 17 years. They were 45 males and 45 females. Children who received anti emetic steroid, antihistamine and antibiotic were excluded from this study. Study design is randomized double blind and placebo control. Patients are prospectively randomized to receive either 0.5mg/kg (max. dose 8mg of dexamethasone) or an equivalent volume of normal saline. In our study the Dexamethasone or saline is given immediately after IV access was established by the anaesthetist. Patient was transferred to the ENT ward after full recovery from GA. Pain assessment either by objective pain scale (ops 0-10) in patients below 8 years (appendix 1) 4 or by visual analogue scale(vas 0-100) in patients above 8 years( figure 1) 5 . For analysis, patients in each group (dexamethasone & control) are divided T Dexamethasone effect on post tonsillectomy morbidities in children Raid Y Yousef, & Saffaa K Faleh Bas J Surg, September, 17, 2011 83 into three pain groups for early period (06 hrs) and late period (6-24 hrs). Significant pain = ops > 6 or vas >40, mild pain = ops 4-5 or vas>20<40, pain free = ops 0-3 or vas<20. The nurse record the incidence of vomiting (vomiting repeated within 1-2 minutes recorded as a single episode) nausea is not recorded because it is difficult to assess in children. Uvula edema was assessed postoperatively by direct examination of oropharynx. Hemorrhage if occur was recorded. All morbidities (pain, vomiting, uvular edema and hemorrhage) are recorded in early period and late period after operation. The comparison of parameter data in this study was performed with chi-square test, a p value less than 0.05 was considered significant. Appendix (1): Objective pain scale Appendix 1 Objective pain scale observation Criteria points Blood pressure +10%of preoperative >20% of preoperative >30% of preoperative 0 1 2 Crying Not crying Crying but respond to tender loving care Crying & not respond to tender loving care 0 1 2 Movement Not Restless


Introduction
onsillectomy is one of the most common operations done in ENT specialty.Pain, nausea, vomiting, edema of uvula and poor oral intake regarded as the most common morbidities following this operation 1 .Postoperative nausea and vomiting (PONV) can result in dehydration, delayed discharging, tension in suture line, venous hypertension, bleeding and pulmonary aspiration.Several studies had been done to prevent or decrease these morbidities.The use of dexamethasone is one of the methods to eliminate these morbidities depending on the anti inflammatory effect and anti emetic effect for chemotherapy induced vomiting 2 .The aim of this study is to assess the effect of a single preoperative dose of Dexamethasone on postoperative morbidities (pain, vomiting, bleeding and edema of uvula) in children underwent tonsillectomy using a standardized anesthetic and surgical techniques 3 .

Materials and methods
This study is prospective in nature, it involves 90 children with chronic tonsillitis, they had been admitted to the ENT Department at Al-Diwania Teaching Hospital for tonsillectomy by dissection and/or adenoidectomy and/or myringotomy between June 2010 and December 2010.The age ranged from 3 years to 17 years.They were 45 males and 45 females.Children who received anti emetic steroid, antihistamine and antibiotic were excluded from this study.Study design is randomized double blind and placebo control.Patients are prospectively randomized to receive either 0.5mg/kg (max.dose 8mg of dexamethasone) or an equivalent volume of normal saline.In our study the Dexamethasone or saline is given immediately after IV access was established by the anaesthetist.Patient was transferred to the ENT ward after full recovery from GA. Pain assessment either by objective pain scale (ops 0-10) in patients below 8 years (appendix 1) 4 or by visual analogue scale(vas 0-100) in patients above 8 years( figure 1) 5 .For analysis, patients in each group (dexamethasone & control) are divided T into three pain groups for early period (0-6 hrs) and late period (6-24 hrs).Significant pain = ops > 6 or vas >40, mild pain = ops 4-5 or vas>20<40, pain free = ops 0-3 or vas<20.The nurse record the incidence of vomiting (vomiting repeated within 1-2 minutes recorded as a single episode) nausea is not recorded because it is difficult to assess in children.Uvula edema was assessed postoperatively by direct examination of oropharynx.Hemorrhage if occur was recorded.All morbidities (pain, vomiting, uvular edema and hemorrhage) are recorded in early period and late period after operation..These four studies showed that, Dexamethasone provide significant analgesia for patients who underwent tonsillectomy.Also in our results, we found that no significant difference was noted between ponv in Dexamethasone and control groups.This result agreed with Galin FI et al (1991) 7 , Volk MS, et al (1993) 8 , Ohlms LA, et al (1995) 9 , Anila D (2005) 13 .But this result disagreed with Splinter WM. et al (1991) 14 14 .

Appendix (1): Objective pain scale
These six studies showed that preoperative Dexamethasone significantly reduced ponv in children who underwent tonsillectomy, and for the relative safety and low cost most authors recommend routine use of cs during pediatric tonsillectomy 18 .Also in our study, we found that there's no significant effect of Dexamethasone on postoperative bleeding.These results agreed with most of the above studies 7- 11,13-15 .

Conclusion
We concluded that, a single preoperative iv dose (0.5mg/kg up to 8mg) of Dexamethasone have no effect in decreasing post tonsillectomy morbidities in children undergoing tonsillectomy.

Figure (1): Visual Analogue Scale
T=tonsillectomy A=Adenoidectomy M= myringotomy Ops=objective pain scale vas=visual analogue scale.Age, weight, duration of surgery &time of first oral intake presented as mean.