Postoperative nausea and vomiting following tonsillectomy is important to control for improved oral intake and satisfaction following surgery. Optimal management is still debated. This team from Beirut conducted a randomised double blind clinical trial comparing the effect of intravenous dexamethasone versus pre-incision infiltration of local anesthesia in paediatric tonsillectomy on postoperative nausea and vomiting (PONV), with the secondary objective being postoperative pain. Patients were randomised to group I, receiving intravenous dexamethasone with placebo pre-incision infiltration or group II, receiving pre-incision infiltration of local anesthesia mixture. PONV and pain were both assessed using questionnaires and children were followed up for five consecutive days. Twenty-four hours following surgery, the incidence of PONV was significantly higher in group I compared to group II (26.6% vs. 9.2% respectively) and PONV episodes and antiemetics given were significantly higher in group I. Baseline pain and pain during swallowing were significantly higher in group I at 6, 12 and 24h as well as days two through five. On the surface it appears that injection of local anesthetic pre tonsillectomy helps considerably with PONV and pain when compared to IV dexamethasone, however there are some considerations to be made. It is not clear whether the tonsillectomy technique used is consistent across both the groups. Comparing one treatment to another also throws up some confounding factors that are difficult to account for, and it may be useful in the future to look at local anesthetic infiltration versus placebo, with both groups getting steroid, rather than one treatment each. Finally, although no complications were reported in the study, the total sample size was 129 patients across the two groups and there have been significant complications previously reported from LA infiltration of the tonsil. Overall a good addition to the literature, but possibly more work to be done to convince that LA infiltration should be a standard addition to tonsillectomy.

The effect of IV dexamethasone versus local anesthetic infiltration technique in postoperative nausea and vomiting after tonsillectomy in children: a randomized double-blind clinical trial.
Naja Z, Kanawati S, Al Khatib R, et al.
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Louisa Ferguson

Evelina Childrens Hospital, London, UK.

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