Posttonsillectomy Hemorrhage in the Ibuprofen Era

The perioperative treatment of children undergoing tonsillectomy with or without adenoidectomy has changed considerably since the publication of the American Academy of Otolaryngology–Head and Neck Surgery Foundation "Clinical Practice Guideline: Tonsillectomy in Children" in 2011. Intraoperative dexamethasone has been advocated, perioperative antibiotics have been discouraged, and the previously commonly used combination of acetaminophen and narcotics (codeine or oxycodone hydrochloride) for postoperative pain management has been replaced by the alternative combination of acetaminophen and nonsteroidal anti-inflammatory drugs, principally ibuprofen. The latter recommendation is based principally on the following 3 factors: the comparative effectiveness of ibuprofen to narcotics for posttonsillectomy pain control; the absence of evidence in systematic review that the use of nonsteroidal anti-inflammatory drugs after tonsillectomy is associated with an increased risk for bleeding or clinical intervention owing to bleeding; and concerns regarding the ultrarapid metabolism of codeine and, to a lesser degree, oxycodone in specific individuals, resulting in significantly higher plasma concentrations of morphine compared with normal metabolizers. Indeed, documentation from 1969 to 2012 of multiple cases of death or overdose after tonsillectomy in pediatric patients who had taken codeine postoperatively prompted the US Food and Drug Administration to issue a black box warning in 2013 stating that codeine use was contraindicated in children for this indication.

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