95 / 280
the senior authors’ practice following the strong recommen-
dation in the AAO-HNS guidelines against the routine use
of perioperative antibiotics.
9
The use of antibiotics has not
been definitively shown to affect postoperative morbidity,
specifically pain and hemorrhage.
15
Multivariable analysis
in the present study did not find antibiotic use to be a signif-
icant predictor of ED return.
The limitations of the present study include the retro-
spective nature of the study. It is possible that patients may
have visited an outside ED, and such events would not have
been included in our chart review. This potential is mini-
mized, however, because such information is routinely
obtained during the first postoperative visit. Due to the
severity of the warning from the FDA, it is unethical to
design a prospective study using codeine without screening
in some manner for rapid metabolizers. The value of the
present study is that it bridges both time periods—prior to
the FDA warning and after the FDA warning.
Unfortunately, the retrospective nature of the study pre-
cludes the use of direct or objective measures of pain con-
trol. The rate of return to the ED due to pain and/or
dehydration is a suitable surrogate metric and provides
useful clinical information on the efficacy of a given post-
operative analgesic regimen.
Conclusion
There is no difference in the primary and secondary out-
come measures in posttonsillectomy patients based on the
use of codeine and acetaminophen or ibuprofen and aceta-
minophen. Codeine and ibuprofen perform similarly for
postoperative analgesia in children after tonsillectomy with
or without adenoidectomy with respect to ED utilization.
Given the major concerns regarding codeine use in this pop-
ulation, ibuprofen represents an acceptable and safe alterna-
tive for pain control.
Author Contributions
Joshua R. Bedwell
, conceived of and designed the study, analyzed
the data, drafted the initial manuscript, and approved the final
manuscript as submitted;
Matthew Pierce
, collected the data, per-
formed initial data analysis, assisted in drafting the initial manu-
script, and approved the final manuscript as submitted;
Michelle
Levy
, collected the data, performed initial data analysis, and
approved the final manuscript as submitted;
Rahul K. Shah
,
designed the study, critically reviewed the manuscript, and
approved the final manuscript as submitted.
Disclosures
Competing interests:
None.
Sponsorships:
None.
Funding source:
None.
References
1. St Charles CS, Matt BH, Hamilton MM, Katz BP. A compari-
son of ibuprofen versus acetaminophen with codeine in the
young tonsillectomy patient.
Otolaryngol Head Neck Surg
.
1997;117:76-82.
2. Harley EH, Dattolo RA. Ibuprofen for tonsillectomy pain in
children: efficacy and complications.
Otolaryngol Head Neck
Surg
. 1998;119:492-496.
3. Pickering AE, Bridge HS, Nolan J, Stoddart PA. Double-blind,
placebo-controlled analgesic study of ibuprofen or rofecoxib in
combination with paracetamol for tonsillectomy in children.
Br J Anaesth
. 2002;88:72-77.
4. Krishna S, Hughes LF, Lin SY. Postoperative hemorrhage
with nonsteroidal anti-inflammatory drug use after tonsillect-
omy: a meta-analysis.
Arch Otolaryngol Head Neck Surg
.
2003;129:1086-1089.
5. Jeyakumar A, Brickman TM, Williamson ME, et al.
Nonsteroidal anti-inflammatory drugs and postoperative bleed-
ing following adenotonsillectomy in pediatric patients.
Arch
Otolaryngol Head Neck Surg
. 2008;134:24-27.
6. Yaman H, Belada A, Yilmaz S. The effect of ibuprofen on
postoperative hemorrhage following tonsillectomy in children.
Eur Arch Otorhinolaryngol
. 2011;268:615-617.
7. Kelly LE, Rieder M, van den Anker J, et al. More codeine
fatalities after tonsillectomy in North American children.
Pediatrics
. 2012;129:e1343-e1347.
8. Kirchheiner J, Schmidt H, Tzvetkov M, et al. Pharmacokinetics
of codeine and its metabolite morphine in ultra-rapid metaboli-
zers due to CYP2D6 duplication.
Pharmacogenomics J
. 2007;7:
257-265.
9. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice
guideline: tonsillectomy in children.
Otolaryngol Head Neck
Surg
. 2011;144(1)(suppl):S1-S30.
10. Blakley BW. Post-tonsillectomy bleeding: how much is too
much?
Otolaryngol Head Neck Surg
. 2009;140:288-290.
11. Sarny S, Ossimitz G, Habermann W, Stammberger H.
Hemorrhage following tonsil surgery: a multicenter prospec-
tive study.
Laryngoscope
. 2011;121:2553-2560.
12. Gallagher TQ, Hill C, Ojha S, et al. Perioperative dexametha-
sone administration and risk of bleeding following tonsillect-
omy in children: a randomized controlled trial.
JAMA
. 2012;
308:1221-1226.
13. Clark E, Plint AC, Correll R, Gaboury I, Passi B. A rando-
mized, controlled trial of acetaminophen, ibuprofen, and
codeine for acute pain relief in children with musculoskeletal
trauma.
Pediatrics
. 2007;119:460-467.
14. Friday JH, Kanegaye JT, McCaslin I, Zheng A, Harley JR.
Ibuprofen provides analgesia equivalent to acetaminophen-
codeine in the treatment of acute pain in children with extre-
mity injuries: a randomized clinical trial.
Acad Emerg Med
.
2009;16:711-716.
15. Dhiwakar M, Clement WA, Supriya M, McKerrow W.
Antibiotics to reduce post-tonsillectomy morbidity.
Cochrane
Database Syst Rev
. 2012;12:CD005607.
Otolaryngology–Head and Neck Surgery
73