Risk of Routine Use of Steroids after Adenotonsillectomy

Does the administration of IV steroids immediately after adenotonsillectomy impact the frequency of post-operative bleeding requiring reoperation?

Background: Nausea and emesis commonly complicate the immediate post-operative period after adenotonsillectomy. IV steroids are commonly used in this context to mitigate these symptoms and expedite recovery; however, there have been suggestions in the literature that IV steroids after adenotonsillectomy can increase the frequency of post-operative hemorrhage and the need for operative intervention.

Study design: This study was retrospective in nature and used a national inpatient database in Japan (Japanese Diagnosis Procedure Combination Database) to obtain information regarding patients who underwent adenotonsillectomy between July and December for the years 2007 to 2009, the entire years from 2010 to 2012, and from January to March of 2013.

Setting: Retrospective review of data from a national Japanese database.

Synopsis: Patients who received steroids on the day of tonsillectomy (steroid group) or those who did not receive steroids (control group) during the entire hospitalization were included in the study. Patients who received steroids on any day other than the day of surgery were excluded. Patients with malignant pharyngeal tumors, those older than 50 years, those with asthma on routine steroids, those with IgA nephropathy, those with palmoplantar pustulosis, and patients with hereditary bleeding disorders were excluded. Patient demographics, comorbidities, and post-operative bleeding requiring reoperation were noted.

The authors identified 61,430 eligible patients from 817 hospitals. Of this cohort, 4,767 patients received steroids on the day of surgery and 56,663 did not receive any steroids. The reoperation rate was significantly higher in all patients in the steroid group compared with the control group (1.6% vs 0.9%; P<.001). Looking at just the pediatric subgroup, defined as patients 15 years old and younger, the rate of bleeding in the steroid group was higher than in the control group (1.2% vs 0.5%, P<.001). There was not a significant difference in the adult cohort, defined as older than 15 years of age, between patients who received steroids and those who did not. Interestingly, post-tonsillectomy bleed rates were higher for children undergoing adenotonsillectomy in academic settings compared with nonacademic settings. The highest frequency of reoperation for post-tonsillectomy bleeding occurred seven days after the operation. This study was limited by the fact that it is retrospective and uses a national database.

Bottom line: Based on the size of the cohort and the study design utilized, this study suggests that IV steroids administered on the day of surgery can increase the rate of post-tonsillectomy bleeds; however, this increase seems to be small. Therefore, the next question to be addressed is whether the benefits of steroids after adenotonsillectomy offset this small increase in post-tonsillectomy bleed rates.

Citation: Suzuki S, Yasunaga H, Matsui H, et al. Impact of systemic steroids on posttonsillectomy bleeding: analysis of 61 430 patients using a national inpatient database in Japan [published online ahead of print September 18, 2014]. JAMA Otolaryngol Head Neck Surg. doi: 10.1001/jamaoto.2014.2009.

—Ravindhra G. Elluru, MD, PhD