What is the role of dexamethasone in the treatment of tonsillitis?

Dexamethasone in Tonsillitis

Dexamethasone should be administered as a single intravenous dose in children undergoing tonsillectomy, but its role in acute medical tonsillitis (non-surgical) is supported by lower-quality evidence suggesting benefit for symptom control when combined with antibiotics and NSAIDs.

Perioperative Use in Tonsillectomy (Strongest Evidence)

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends administering a single intraoperative dose of intravenous dexamethasone to all children undergoing tonsillectomy. 1

Benefits Demonstrated:

• Reduces postoperative nausea and vomiting by 50% - children receiving dexamethasone are half as likely to vomit in the first 24 hours (risk ratio 0.49) 2
• Decreases postoperative pain - reduces pain scores by approximately 1 point on a 0-10 visual analog scale (from 4.72 to 3.65) 2
• Accelerates return to normal diet - children are 45% more likely to advance to soft/solid foods on postoperative day one 2
• Reduces throat pain and time to resumption of oral intake, particularly beneficial when electrosurgery is used 1

Dosing for Tonsillectomy:

• Children: 0.15 mg/kg intravenously (maximum 8-25 mg), administered intraoperatively 1, 3
• Most published studies used 0.5 mg/kg, but lower doses (0.15 mg/kg) appear equally effective 1
• Pre-operative or intra-operative administration is superior to post-operative dosing for pain control and reduced nausea 4

Critical Safety Consideration - Hemorrhage Risk:

A major caveat exists regarding bleeding risk with higher doses. One randomized trial found dose-dependent increases in postoperative bleeding, with the 0.5 mg/kg dose associated with a 24% bleeding rate versus 4% with placebo (adjusted relative risk 6.80), requiring early trial termination 5. However, the American Academy of Otolaryngology guideline notes that only one study reported increased hemorrhage as a secondary outcome unadjusted for other risk factors, while all other randomized controlled trials reported no adverse events 1. This suggests that standard lower doses (0.15 mg/kg) are safe, but higher doses (0.5 mg/kg) should be avoided.

Contraindications:

• Exclude patients with endocrine disorders already receiving exogenous steroids 1
• Exclude diabetics or those in whom steroid administration may interfere with glucose-insulin regulation 1

Medical Management of Acute Tonsillitis (Non-Surgical)

For acute bacterial tonsillitis treated medically, dexamethasone can be used as adjunctive therapy alongside antibiotics and NSAIDs, though this recommendation is based on lower-quality evidence. 6

Treatment Approach for Acute Tonsillitis:

• Steroids (e.g., dexamethasone) - for symptom reduction 6
• NSAIDs (e.g., ibuprofen) - for pain and inflammation 6
• Beta-lactam antibiotics (e.g., penicillin or cefuroxime) - for bacterial infection 6

Mechanism of Action:

The mechanism of dexamethasone efficacy is likely related to its anti-inflammatory properties that reduce pain and swelling in the tonsillar region 1. This parallels its use in other inflammatory conditions of the upper airway.

Practical Considerations:

• Dexamethasone for medical tonsillitis lacks the robust guideline support seen in the perioperative setting - the evidence comes from clinical practice patterns rather than high-quality randomized trials 6
• The dose and duration for medical tonsillitis are not well-established in guidelines, unlike the clear perioperative recommendations
• Consider a short course (1-3 days) at anti-inflammatory doses when using for acute symptom control, though specific dosing protocols are not standardized

Key Clinical Pitfalls to Avoid:

1. Do not use high-dose dexamethasone (0.5 mg/kg) perioperatively - stick to 0.15 mg/kg to minimize bleeding risk 5
2. Do not confuse perioperative dosing (single dose) with medical tonsillitis treatment - these are different clinical scenarios with different evidence bases 1, 6
3. Do not administer dexamethasone to diabetic children or those with endocrine disorders without careful consideration 1
4. Ensure parents understand postoperative bleeding risks - all bleeding episodes, even minor, require proper evaluation as they can precede life-threatening hemorrhage 6