Response to “Further Concerns Regarding Opioids after Tonsillectomy in Children”

Our survey of senior otolaryngology residents revealed that the significant complications related to codeine use for posttonsillectomy pain management in children have not yet been incorporated into otolaryngology residency training curricula. Dr Isaacson has noted that over half of the respondents indicated that they were planning on using other opioids, and we did not comment on this finding, as these drugs may also be complicated by variable rates of metabolism depending on allelic variants of the CYP2D6 gene. However, the optimal strategy or clinical standard for pain management posttonsillectomy has yet to be determined.

Anecdotal and published evidence is retrospective in nature but has mostly demonstrated no significant harm and potential benefit for the use of ibuprofen to avoid opioid-related complications, as Dr Isaacson has pointed out. The primary concern with widespread adoption of ibuprofen for posttonsillectomy pain control stems from the fear of increased postoperative hemorrhage, which has yet to be adequately studied. Recent reports by Yaman et al ¹ (dose not reported) and Ozkiris et al ² (30 mg/kg/d) found that no difference in posttonsillectomy hemorrhage rates was found in patients who were administered ibuprofen vs other nonnarcotic pain medications. Jeyakumar et al ³ also previously reported that use of ibuprofen (5 mg/kg in the postoperative recovery unit and without restriction in the postoperative period) did not result in increased bleeding rates. A meta-analysis of 1368 pooled patients by Krishna et al ⁴ found that nonaspirin, nonsteroidal anti-inflammatory drugs after tonsillectomy did not pose an increased risk for postoperative bleeding with an odds ratio of 0.93 (95% confidence interval, 0.44-1.95; P ≥ .05).

We believe that the available, current state of evidence is insufficient to make a definitive recommendation to declare a standard of care for posttonsillectomy pain control. Furthermore, a prospective randomized study is certainly warranted to address this question and to potentially stratify patients, based on age, to optimize the risk-benefit ratio.