Efficacy of peritonsillar infiltration of levobupivacaine-dexamethasone versus levobupivacaine-dexmedetomidine in children undergoing tonsillectomy surgery: a prospective, randomized double-blind study

Salwa M.S Hayes; Hisham Atef Ebada; Hanaa M El Bendary

doi:10.4103/roaic.roaic_36_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 9 | Issue : 4 | Page : 310-320

Efficacy of peritonsillar infiltration of levobupivacaine-dexamethasone versus levobupivacaine-dexmedetomidine in children undergoing tonsillectomy surgery: a prospective, randomized double-blind study

Salwa M.S Hayes¹, Hisham Atef Ebada², Hanaa M El Bendary¹
¹ Department of Anesthesia and Intensive Caer, Faculty of Medicine, Mansoura University, Mansoura, Egypt
² Department of Oto-Rhino-Laryngology, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission	05-Jul-2022
Date of Decision	24-Aug-2022
Date of Acceptance	27-Aug-2022
Date of Web Publication	29-Dec-2022

Correspondence Address:
MD Salwa M.S Hayes
Department of Anesthesia and Intensive Care, Faculty of Medicine, Mansoura University, Mansoura
Egypt

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/roaic.roaic_36_22

Abstract

Purpose We evaluated the quality of analgesia produced by peritonsillar infiltration of levobupivacaine with either dexamethasone or dexmedetomidine in children undergoing tonsillectomy surgery.
Patients and methods Patients scheduled for tonsillectomy were randomly allocated into three groups with 27 patients in each group. Group L received peritonsillar infiltration of 5 ml in volume of 0.4 mg/kg of 0.5% levobupivacaine, while group D received peritonsillar infiltration of 5 ml in volume of 0.4 mg/kg of 0.5% levobupivacaine mixed with dexamethasone 0.5 mg/kg and group X received peritonsillar infiltration of 5 ml in volume of 0.4 mg/kg of 0.5% levobupivacaine mixed with dexmedetomidine 1 μg/kg (with infiltration of 2.5 ml in each tonsil in all groups) with the first postoperative analgesic request as the primary outcome.
Results Postoperative time to first analgesic paracetamol request was prolonged in group D (19.51±2.34 h) compared with group L (4.15±0.53 h) and group X (15.74±2.29 h). Face, leg, activity, cry, consolability (FLACC) Behavioral Pain Assessment score at rest and during swallowing decreased in group D compared with group L and group X. Total postoperative analgesic consumption decreased in group D (581.48±165.7 mg) compared with group L (1303.51±90.10 mg) and group X (680.50±160.67 mg).
Conclusions We concluded that peritonsillar infiltration of levobupivacaine when mixed with either dexamethasone or dexmedetomidine for patients undergoing tonsillectomy produced prolonged analgesia; however, dexamethasone was superior to dexmedetomidine with more prolonged time to first paracetamol request and prolonged late postoperative pain relief.

Keywords: Peritonsillar infiltration, levobupivacaine, dexamethasone, dexmedetomidine

How to cite this article:
Hayes SM, Atef Ebada H, El Bendary HM. Efficacy of peritonsillar infiltration of levobupivacaine-dexamethasone versus levobupivacaine-dexmedetomidine in children undergoing tonsillectomy surgery: a prospective, randomized double-blind study. Res Opin Anesth Intensive Care 2022;9:310-20

How to cite this URL:
Hayes SM, Atef Ebada H, El Bendary HM. Efficacy of peritonsillar infiltration of levobupivacaine-dexamethasone versus levobupivacaine-dexmedetomidine in children undergoing tonsillectomy surgery: a prospective, randomized double-blind study. Res Opin Anesth Intensive Care [serial online] 2022 [cited 2023 Mar 26];9:310-20. Available from: http://www.roaic.eg.net/text.asp?2022/9/4/310/365794

Introduction

Tonsillectomy considered as one of the most common pediatric otolaryngology procedures which is recommended for recurrent throat infections for seven episodes in the past year, five episodes per year for 2 years, or three episodes per year for 3 years [1]. Posttonsillectomy pain may occur as a result of retractor compression, edema due to venous congestion, injury of the wound due to contact of fluid and food particles, and pharyngeal muscle damage with exposed nerve ending of tonsillar glossopharyngeal, lesser palatine, and maxillary trigeminal nerve branches [2]. This moderate to severe pain still an important concern and may cause postoperative nausea, vomiting, dysphagia, and fear of oral intake, which leads to weight loss, anxiety with sleep disturbance, constipation, dehydration, delayed discharge, and disturbances of child behavior [3]. Different strategies have been used for adequate analgesia, decrease morbidity, and better recovery such as topical application of local anesthetics, glossopharyngeal nerve block, perioperative hydration, and systemic analgesics as NSAIDs, opioids, and acetaminophen [4]. Grainger and Saravanappa in their systematic review observed that local anesthetic infiltration in the peritonsillar tissue provided effective analgesia for tonsillectomy and also demonstrated the role of local anesthetic infiltration in the peritonsillar tissue and local anesthetic could improve peripheral pain transduction as it inhibits the noxious impulse transmission from the incisional site [5].

Levobupivacaine is a local anesthetic drug belonging to the aminoamide group. It is the S-enantiomer of bupivacaine. It is the drug of choice in children with long duration of action, less cardiac and neurotoxicity [6],[7],[8].

Dexamethasone is a glucocorticosteroid with anti-inflammatory properties with the ability to act synergistically with local anesthetics for better quality and prolonged duration of analgesia, thus decreasing the use of alternative analgesics such as opioids [9],[10],[11].

Dexmedetomidine considered as a highly selective α2-adrenoceptor agonist, which produces sedation, anxiolysis, and analgesia without causing depression of respiration with a shorter elimination half-life [12]. The current study aimed to compare the quality of analgesia produced by peritonsillar levobupivacaine mixed with dexamethasone infiltration in comparison with levobupivacaine mixed with dexmedetomidine infiltration in children undergoing tonsillectomy with the first postoperative analgesic request as the primary outcome.

Patients and methods

After approval from the Institutional Research Board (IRB), this study was conducted on 81 patients aged from 6 to 10 years of either sex of the American Society of Anesthesiologist Physical Status grade I or II and scheduled for elective tonsillectomy. Written informed consent was taken from the parents.

Exclusion criteria

Children who complain of obstructive sleep apnea syndrome, previous peritonsillar abscess, cardiovascular, renal, liver disease, coagulation disorders, psychological, emotional disorders, any neurological conditions that limit a child’s ability to communicate with nurse personnel or understanding the verbal rating scale (VRS), and patients with known allergy to the study drugs were excluded.

Sample size calculation

Sample size calculation was done using a priori G-power analysis to estimate the study sample size. Assuming α (type 1 error)=0.05 and large effect size (0.40) with power=85%, 24 patients per group would be sufficient in each group. A dropout of 10% of cases was expected. Therefore, 27 patients were required in each group.

Patients preparation

All patients were assessed preoperatively by detailed history taking and physical examination. Basic demographic characteristics were recorded. Investigations were requested as appropriate.

Randomization and anesthesia

Patient randomization was done using the closed envelop method into one of the three study groups with 27 patients in each group according to peritonsillar infiltration drug solution used as following:

Group L: received peritonsillar infiltration of 5 ml in volume (2.5 ml per each tonsil) of 0.4 mg/kg of 0.5% levobupivacaine.

Group D: received peritonsillar infiltration of 5 ml in volume (2.5 ml per each tonsil) of 0.4 mg/kg of 0.5% levobupivacaine mixed with dexamethasone 0.5 mg/kg [13].

Group X: received peritonsillar infiltration of 5 ml in volume (2.5 ml per each tonsil) of 0.4 mg/kg of 0.5% levobupivacaine mixed with dexmedetomidine 1 μg/kg [14]. The study solutions were prepared by anesthetists not involved in the study protocol.

After fasting for 6 hours for solid food and 4 hours for water. On arrival to the operating room, anesthesia was standardized for all patients with preoxygenation for 3 min, then fentanyl 1 μg/kg, 2 mg/kg propofol, and atracurium (0.5 mg/kg was given for endotracheal tube insertion of suitable size). Peritonsillar infiltration was done by an anesthetist (who was not aware of the study protocol) before start of surgery according to group randomization using a 25-G spinal needle, the tonsillar bed and tonsillar tissues on each side infiltrated in fanwise injections of the studied solutions after aspiration through the superior pole and inferior pole of fossa and then surgery started 3 min after peritonsillar infiltration and the tonsils were removed using the sharp dissection method. Maintenance of anesthesia with the use of isoflurane minimum alveolar concentration (1MAC) with 50% oxygen and air while atracurium 0.2 mg/kg if needed was given according to the start of patient spontaneous respiration with adjustment of mechanical ventilation to keep end-tidal CO₂ between 30 and 40. Isoflurane was increased if the heart rate or the mean blood pressure increased by 20% of the basal value. Intraoperative fluids were given in the form of intravenous Ringer’s solution (10 ml/kg) and then with the end of surgical procedures anesthesia was stopped and reversal of residual neuromuscular blockade using intravenous neostigmine (0.04 mg/kg) and atropine (0.02 mg/kg). After this endotracheal tube was removed in the lateral position and after extubation, all patients were transferred to the postanesthesia care unit (PACU).

Recorded data

Standard intraoperative monitoring includes heart rate, noninvasive mean blood pressure, O₂ saturation, and end-tidal CO2, which were continuously monitored and recorded before induction of anesthesia (basal), after induction of anesthesia, before peritonsillar infiltration and then every 10 min after peritonsillar infiltration of the studied solutions till the end of surgery and at recovery. Anesthesia time (from the start of induction of anesthesia till extubation), duration of operation (from the start of surgery till the end of surgery), and extubation time (from stopping the anesthetics till extubation) were recorded.

In the PACU, monitoring data includes heart rate, mean blood pressure, and oxygen saturation all measured for the first and second hours postoperatively. Ramsay sedation score was measured on arrival to the PACU, at 15 min and at 30 min postoperatively [15]. Data collection was done by an anesthetist not included in the study protocol.

Postoperative time to first analgesic request, number of analgesia taken, and total analgesic consumption in the first 24 h postoperative were recorded. Early postoperative pain was assessed using the FLACC (face, leg, activity, cry, consolability) Behavioral Pain Assessment score at rest ([Table 1]) in the first 24 h at 30 min, 1, 2, 4, 6, 8, 10, 12, 18, and 24 h postoperatively [16].

Table 1 FLACC (faces, leg, activity, cry, consolability) Behavioral Pain Assessment Score

Click here to view

Also FLACC score was used to assess early postoperative pain during swallowing (drinking or eating) at 4, 6, 8, 10, 12, 18, 24 h postoperatively.

According to the hospital protocol, oral paracetamol (15 mg/kg every 4–6 h up to a maximum of 40 mg/kg/daily dose) was given at the first 24 h postoperatively if the FLACC score for pain assessment was more than 3.

Late postoperative pain assessment was recorded at every morning hours of the first postoperative week using the VRS, where 0=no pain, 1–3=mild pain, 4–6=moderate pain, and 7–10=severe pain by daily telephone contact with the parents of the patients who were familiar with the score [17].

Postoperative nausea and vomiting were assessed using the Apfel score [18] (grade 0 no nausea or vomiting and grade 1 nausea without vomiting and grade 2 retching and vomiting) were recorded and IV metoclopramide (0.1 mg/kg) was given as a rescue in case of score more than or equal to 1. Oral intake was started in patients if no nausea or vomiting was present after 4 h postoperatively.

Intraoperative bleeding was assessed by the surgeon using the following score (0=no bleeding, 1=bleeding as usual, 2=bleeding more than usual, 3=profuse, 4=excessive, and lastly 5=excessive and continuous).

Any complications related to peritonsillar infiltration or drug used including bleeding, arrhythmia, allergic reaction, and difficulty in swallowing and vomiting were recorded.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) program for Windows (standard version 26). The normality of data was first tested with one-sample Kolmogorov–Smirnov test. Qualitative data were described using number and percent. Association between categorical variables was tested using χ² test. Continuous variables were presented as mean±SD for normally distributed data and the two groups were compared with Student’s t test. For all the above-mentioned statistical tests done, the threshold of significance was fixed at the 5% level. The results were considered significant when P value less than or equal to 0.05. The smaller the P value obtained, the more significant the results.

Results

In the present study, 81 patients were randomized into three groups to receive either peritonsillar infiltration of either levobupivacaine alone, levobupivacaine mixed with dexamethasone, or levobupivacaine mixed with dexmedetomidine. Data analysis was performed on 27 patients in each group ([Figure 1]).

Figure 1 Consort flowchart of the study.

Click here to view

Regarding demographic data (age, sex, weight, height, and BMI), anesthesia time, and time of surgery there were no statistically significant differences between the studied groups, while extubation time was prolonged in group X (7.03±0.93 min) in comparison to group L (5.77±0.50 min) and (5.96±0.93 min) in group D ([Table 2]).

Table 2 Demographic data, duration of operation, anesthesia time, and extubation time

Click here to view

Hemodynamic parameters as regards mean blood pressure and heart rate showed a significant decrease in group X when compared with group L and group D from 10 min after peritonsillar infiltration up to recovery with P values less than or equal to 0.001 ([Figure 2] and [Figure 3]).

Figure 2 Perioperative mean arterial blood pressure (MBP) mmHg in the studied groups. Group L: levobupivacaine group. Group D: dexamethasone group. Group X: dexmedetomidine group. *Statistically significant differences between the studied groups.

Click here to view

Figure 3 Perioperative heart rate (HR) beat/min in the studied groups. Group L: levobupivacaine group. Group D: dexamethasone group. Group X: dexmedetomidine group. *Statistically significant differences between the studied groups.

Click here to view

O2 saturation and end-tidal CO2 readings were within normal ranges in the studied groups with no statistically significant differences.

Early postoperative pain in the first 24 h at rest was assessed using FLACC score; it showed a statistically significant decrease in group D and group X in comparison to group L throughout the postoperative 24 h with a P value less than or equal to 0.001; however, there was significant decrease in FLACC score in group D compared with group X at the following intervals: 10, 12, 18, and 24 h postoperatively ([Figure 4]) with a P value less than or equal to 0.001. Early postoperative pain in the first 24 h at swallowing was assessed using the FLACC score; it also showed statistically significant decreased values in group D in comparison to group L and group X (P=0.001 for all comparisons) and significant decreased values in group X in comparison to group L at 4, 6, 8, 10, 12, 18, and 24 h postoperatively with P value less than or equal to 0.001 ([Figure 5]).

Figure 4 FLACC (faces, leg, activity, cry, consolability) Behavioral Pain Assessment Score among the studied groups at rest in the first 24 h at 30 min, 1, 2, 4, 6, 8, 10, 12, 18, 24 h postoperatively. Group L: levobupivacaine group. Group D: dexamethasone group. Group X: dexmedetomidine group. *Statistically significant differences between studied groups.

Click here to view

Figure 5 FLACC (faces, leg, activity, cry, consolability) Behavioral Pain Assessment Score among the studied groups during swallowing in the first 24 h at 4, 6, 8, 10, 12, 18, 24 h postoperatively. Group L: levobupivacaine group. Group D: dexamethasone group. Group X: dexmedetomidine group. *Statistically significant differences between the studied groups.

Click here to view

As regards late pain assessment in the first week after surgery using VRS, it showed decreased pain score in group D in comparison to group L and group X with a P value of 0.001 from the second postoperative up to the fourth postoperative day and then from the fifth day up to seventh postoperative day no statistically or clinically significant differences were observed between the studied groups ([Figure 6]).

Figure 6 Verbal rating scale (VRS) in the studied groups in the 2nd, 3rd, 4th, 5th, 6th, and 7th postoperative days. Group L: levobupivacaine group. Group D: dexamethasone group. Group X: dexmedetomidine group. *Statistically significant differences between studied groups.

Click here to view

Time for the first postoperative analgesic paracetamol request was highly significantly prolonged in group D (19.51±2.34 h) when compared with group L (4.15±0.53 h) and group X (15.74±2.29 h). In addition, total analgesic consumption in 24 h postoperatively was significantly decreased in group D (581.48±165.7 mg) compared with group L (1303.51±90.10 mg) and group X (680.50±160.67 mg). Moreover, group D showed decreased total number of analgesia (1.59±0.50) in comparison to group L (3.33±0.48) and group X (2.18±0.62) ([Table 3]).

Table 3 Total postoperative analgesic (mg), number of analgesia, first analgesic request (h), Ramsay sedation score on arrival to the postanesthesia care unit at 15 min and at 30 min postoperatively and intraoperative blood loss

Click here to view

Postoperative Ramsey sedation scale showed significantly increased values with more sedation in group X in comparison to group L and group D on arrival to the PACU at 15 min and at 30 min postoperatively ([Table 3]).

In the current study, none of the patients in any of the studied groups developed complications related to peritonsillar local anesthetic infiltration in the form of obstruction of the airway due to block of vagal or hypoglossal block, or in the form of inability for swallowing caused by the block of the glossopharyngeal nerve or facial nerve. There was no significant difference between the studied groups in terms of fever, bleeding, or dysphagia. Nausea and vomiting was not significant (four patients in group L, three patients in group D, and three patients in group X) suffered single attack of mild vomiting without the need for treatment.

Discussion

The current study was designed to compare the analgesic efficacy produced by peritonsillar infiltration of levobupivacaine mixed with either dexamethasone or dexmedetomidine in children scheduled for tonsillectomy surgery. In the current study, peritonsillar infiltration of levobupivacaine mixed with dexamethasone or with dexmedetomidine achieved prolonged time for the first postoperative analgesic request, decreased early and late postoperative pain and reduced total analgesic consumption in comparison to levobupivacaine group. However, levobupivacaine mixed with the dexamethasone group showed more prolonged time for the first postoperative analgesic request, decreased early and late postoperative pain and reduced total analgesic consumption in comparison to the dexmedetomidine group without causing hypotension, bradycardia, or any other adverse effects.

The oropharynx and the fossae of the tonsil are well innervated locally by the trigeminal nerve and glossopharyngeal nerve branches. Tonsillectomy surgery produced injury that leads to the release of the inflammatory mediators (bradykinin and serotonin), which stimulate the peripheral nociceptors together with the release of prostaglandins that sensitize the peripheral nociceptors to the released inflammatory mediators producing pain in the early postoperative period [2],[19]. Pain after tonsillectomy increased to become more severe on the postoperative first day and continues on the second day up to the fourth day postoperatively with the development of the scar tissue till the postoperative seventh day and then it gradually decreases [3],[4].

Oral intake restriction for pediatric patients may cause dehydration and increased morbidity so different medicines and peritonsillar infiltration of local anesthetic agents could reduce posttonsillectomy pain [3],[4].

In the current study, pain relief in the dexamethasone group and dexmedetomidine at an early period could be the explanation for early and sufficient oral intake. On the other hand, in the dexamethasone group this early pain relief together with the anti-inflammatory effect of dexamethasone both centrally and peripherally may be the explanation for late time pain relief up to the fourth postoperative day [20],[21].

Fikret and colleagues showed that pre-incisional peritonsillar infiltration of levobupivacaine or bupivacaine was effective than saline in reducing posttonsillectomy pain with less postoperative analgesic requirement [22], and also other studies have reported that levobupivacaine produced less systemic toxicity so it is likely to be more preferred than bupivacaine; however, another study demonstrated that no differences were found between levobupivacaine and bupivacaine as regards their analgesic efficacy [23],[24].

In a meta-analysis by Grainger and colleagues it has been proved that the most common cause of postoperative morbidity after tonsillectomy was pain and they observed that the quality of postoperative analgesia improved after peritonsillar local anesthetic infiltration with levobupivacaine at both concentrations (0.5 and 0.25%) and also decreased postoperative analgesic consumption without causing any adverse effects [5]. In previous studies demonstrating the effect of peritonsillar infiltration of local anesthetic in combination with different drugs such as ketamine or tramadol before or after surgical incision for tonsillectomy, they observed that peritonsillar infiltration provided effective analgesia and decreased postoperative analgesic requirements [25],[26],[27]. Moreover, dexamethasone could decrease postoperative analgesic requirement when added to local anesthetics for neuraxial blocks and peripheral nerve blocks [28],[29].

Dexamethasone was also recommended as a prophylaxis against postoperative nausea and vomiting after tonsillectomy surgery, which is considered as one of most common postoperative complications seen after tonsillectomy. On the other hand, dexamethasone with potent anti-inflammatory effects block the chemical mediators of inflammation and so it can effectively inhibit inflammation caused by surgery leading to reduction of postoperative pain [30],[31].

Basuni et al. [10] in agreement with the current study proved that dexamethasone when added to levobupivacaine achieved better quality of postoperative analgesia for peritonsillar levobupivacaine infiltration more than intravenous dexamethasone in children.

Also in agreement with the current study, Albrecht et al. [21] in a meta-analysis reported that dexamethasone may be a better alternative perineural adjunct when compared with dexmedetomidine as it produced prolonged duration of analgesia without the accompanying risk of hypotension or sedation.

Another study by Shembi et al. [32] in a meta-analysis based on the available evidence concluded that regardless of the route of administration, addition of dexamethasone as an adjunct to local anesthetic associated with prolonged durations of sensory blockade and better analgesia more than dexmedetomidine.

Hypotension and bradycardia are the most common sympatholytic adverse effects of dexmedetomidine [33]. In the current study, there was significant decrease in the heart rate and mean arterial blood pressure together with increased Ramsey sedation score with prolonged extubation time in the dexmedetomidine group in comparison to levobupivacaine group and dexamethasone group; these results were in agreement with the results of a study by Hatami et al. [27] in which they observed prolonged extubation time and eye-opening time in the dexmedetomidine group compared with the tramadol group and control group and also significant decrease in the mean arterial blood pressure in the dexmedetomidine group compared with the control group.

Also in agreement with the current study Kaygusuz et al. [34] observed that addition of 1 µg/kg dexmedetomidine for an axillary brachial plexus prolonged the postoperative time to first analgesics and decreased total rescue analgesic consumption without causing adverse effects. Similarly She et al. [35] added dexmedetomidine to levobupivacaine and they observed that the duration of analgesia was prolonged during caudal block in children. Another study by Esmaoglu et al. [36] concluded that the duration of the axillary brachial plexus block occurred with more prolonged duration of postoperative analgesia on addition of dexmedetomidine to levobupivacaine. In addition, Elfawal et al. [37] demonstrated that dexmedetomidine could be a good adjuvant to levobupivacaine than fentanyl for caudal postoperative analgesia and arousable sedation in children without causing any respiratory depression. Also another study by Koceroglu et al. [38] in patients who underwent adenotonsillectomy observed that dexmedetomidine produced effective postoperative analgesia than tramadol although dexmedetomidine produced long time to extubation and decreased heart rate.

Nausea and vomiting are commonly occurred after adenotonsillectomy operations because of the swallowed blood resulting in irritation of the oropharynx [31].

Postoperative complications after tonsillectomy include hemorrhage, airway obstruction, allergy, and complications related to the block such as intra-arterial injection, cardiac arrest and convulsion, bilateral vocal cord paralysis, facial nerve paralysis, and deep cervical abscess [39]. On the other hand, in the current study there were no significant differences between the studied groups and none of the patients in the studied groups had any posttonsillectomy complications that may require intervention, which may be explained by the fact that we applied the study solutions superficially. On the other side, another study by Shlizerman and Ashkenazi [40] reported that when local anesthetic infiltration was added to the tonsillar bed for reduction of posttonsillectomy pain, occurrence of complications including facial nerve paralysis, obstruction of the upper airway, and vocal cord paralysis have been noticed.

Conclusion

In the current study, we concluded that peritonsillar infiltration of levobupivacaine when mixed with either dexamethasone or dexmedetomidine for patients undergoing tonsillectomy surgery could provide better quality of analgesia with decreased posttonsillectomy pain scores at rest and during swallowing, prolonged time to first analgesic request, and decreased total analgesic paracetamol consumption and decreased post tonsillectomy pain scores at rest and during swallowing in comparison to levobupivacaine group however, dexamethasone was superior to dexmedetomidine with more prolonged time to first paracetamol request and prolonged late postoperative pain relief so dexamethasone considered as cheap, effective and safe alternative adjuvant to local anesthetic.

Authors’ contributions

Study design: Salwa M.S. Hayes, Hanaa M. El Bendary. Patient recruitment: Salwa M.S. Hayes, Hanaa M. El Bendary. Surgical procedure: Hisham Atef Ebada. Data collection and analysis: Salwa M.S. Hayes, Hanaa M. El Bendary.

Financial support and sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

References

1.	Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA et al. Clinical Practice Guideline: tonsillectomy in children (update)-executive summary. Otolaryngol Head Neck Surg 2019; 160:187–205.
2.	Davidoss NH, Eikelboom R, Friedland PL, Santa Maria PL. Wound healing after tonsillectomy − a review of the literature. J Laryngol Otol 2018; 132:764–770.
3.	Sutters KA, Isaacson G. Posttonsillectomy pain in children. Am J Nurse 2014; 114:36–42.
4.	Bean-lijewski JD, Kruitbosch SH, Hutchinson L, Browen B. Post-tonsillectomy pain management in children: can we do better ?. Otolaryngol Head Neck Surg 2007; 137:545–551.
5.	Grainger J, Saravanappa N. Local anesthetic for post-tonsillectomy pain: a systematic review and meta-analysis. Clin Otolaryngol 2008; 33:411–419.
6.	Mazoit JX, Dalens BJ. Pharmacokinetics of local anesthetics in infants and children. Clin Pharmacokinet 2004; 43:17–32.
7.	Breschan C, Jost R, Krumpholz R, Schaumbergr F, Stettner H, Marhofer P et al. A prospective study comparing the analgesic efficacy of levobupivacaine,ropivacaine and bupivacaine in pediatric patients undergoing caudal blockade. Pediatr Anesth 2005; 15:301–306.
8.	Burlacu CL, Buggy DJ. Update on local anesthetics: focus on levobupivacaine. Ther Clin Risk Manag 2008; 4:381–392.
9.	Kaygusuz I, Susaman N. The effects of dexamethasone, bupivacaine and topical lidocaine spray on pain after tonsillectomy. Int J Pediatr Otorhinolaryngol 2003; 67:737–742.
10.	Basuni AS, Ahmed Ezz HA, ALbirmawy OA. Preoperative peritonsillar infiltration with dexamethasone and levobupivacaine reduces pediatric post-tonsillectomy pain: a double-blind prospective randomized clinical trial. J Anesth 2013; 27:844–849.
11.	Baeriswyl M, Kirkham KR, Jacot-Guillarmod A, Albrecht E. Efficacy of perineural vs systemic dexamethasone to prolong analgesia after peripheral nerve block: a systematic review and meta-analysis. Br J Anaesth 2017; 119:183–191.
12.	Vorobeichik L, Brull R, Abdallah FW. Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth 2017; 118:167–181.
13.	Kirkham KR, Jacot-Guillarmod A, Albrecht E. Optimal dose of perineural dexamethasone to prolong analgesia after brachial plexus blockade: a systematic review and meta-analysis. Anesth Analg 2018; 126:270–279.
14.	Abdel-ghaffar HS, Abdel-Haleem AK. Efficacy and safety of intraoperative dexmedetomidine in pediatric posttonsillectomy pain: peritonsillar versus intravenous administration. Egypt J Anaesth 2011; 27:219–225.
15.	Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxolone-alphadalone. BMJ 1974; 2:656–659.
16.	Merkel SI, Voepel-lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997; 23:293–297.
17.	Kilinc L, Türk B, Türk HS, Cinar S, Turgut S, İslamoğlu S. Peritonsillar dexamethasone-bupivacaine vs. bupivacaine infiltration for post-tonsillectomy pain relief in children: a randomized, double-blind, controlled study. Eur Arch Otorhinolaryngol 2019; 276:2081–2089.
18.	Pierre S, Benais H, Pouymayou J. Apfel’s simplified score may favorably predict the risk of postoperative nausea and vomiting. Can J Anaesth 2002; 49:237–242.
19.	Fumimasa A, Yuta I, Megumi M, Mika S. Tissue injury and related mediators of pain exacerbation. Curr Neuropharmacol 2013; 11:592–597.
20.	Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. Br J Anaesth 2014; 112:427–439.
21.	Albrecht E, Vorobeichik L, Jacot-Guillarmod A, Fournier N, Abdallah FW. Dexamethasone is superior to dexmedetomidine as a perineural adjunct for supraclavicular brachial plexus block: systematic review and indirect meta-analysis. Anesth Analg 2019; 128:543–554.
22.	Fikret LK, Nur FK, Gokhan T, Omar AO, Atila K, Selcuk O. Comparison of peritonsillar levobupivacaine and bupivacaine infilteration for post-tonsillectomy pain relief in children. Int J Pediatr Otorhinolaryngol 2011; 75:322–326.
23.	Ozmen S, Ozmen O, Kasapoglu F. Effects of levobupivacaine versus bupivacaine infiltration on postoperative analgesia in pediatric tonsillectomy patients: A randomized, double-blind, placebocontrolled study. Ann Otol Rhinol Laryngol 2011; 120:489–493.
24.	Kasapoglu F, Demir UL, Kaya FN, Cetin YS, Yavascaoglu B. The effects of levobupivacaine infiltration on post-tonsillectomy pain relief in adults: a single-blinded, randomized, and controlled clinical study. Eur Arch Otorhinolaryngol 2013; 270:761–766.
25.	Ayatollahi V, Behdad S, Hatami M, Moshtaghiun H, Baghianimoghadam B. Comparison of peritonsillar infiltration effects of ketamine and tramadol on post tonsillectomy pain: a doubleblinded randomized lacebocontrolled clinical trial. Croat Med J 2012; 53: 155–161.
26.	Heiba M, Atef A, Mosleh M, Mohamed R, El-Hamamsy M. Comparison of peritonsillar infiltration of tramadol and lidocaine for the relief of post-tonsillectomy pain. J Laryngol Otol 2012; 126:1138–1141.
27.	Hatami M, Jalali M, Ayatollahi V, Baradaranfar M, Vaziribozorg S. Comparison of the effect of peritonsillar infiltration of tramadol vs dexmedetomidine on post-tonsillectomy pain. Eur Arch Otorhinolaryngol 2021; 279:2665–2669.
28.	Thimmasettaiah NB, Chandrappa RG. A prospective study to compare the effects of pre, intra and post operative steroid (dexamethasone sodium phosphate) on post tonsillectomy morbidity. Pharmacol Pharmacother 2012; 3:254–258.
29.	Huynh TM, Marret E, Bonnet F. Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: a meta-analysis of randomised controlled trials. Eur J Anaesthesiol 2015; 32:751–758.
30.	Movafegh A, Soroush AR, Navi A, Sadeghi M, Esfehani F, Akbarian-Tefaghi N. The effect of intravenous administration of dexamethasone on postoperative pain, nausea, and vomiting after intrathecal injection of meperidine. Anesth Analg 2007; 104:987–989.
31.	Elhakim M, Ali NM, Rashed I, Riad MK, Refat M. Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy. Can J Anesth 2003; 50:392–397.
32.	Shembi H, Brull R, Ceballos KR, Shah UJ, Martin J, Tobias A et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus. Anesthesia 2021; 76:974–990.
33.	Ghali AM, Shabana AM, El Btarny AM. The effect of low-dose dexmedetomidine as an adjuvant to levobupivacaine. Anesth Analg 2015; 121:1378–1382.
34.	Kaygusuz K, Kol OI, Duger C, Gursoy S, Ozturk H, Kayacan U et al. Effects of adding dexmedetomidine to levobupivacaine in axillary brachial plexus block. Curr Ther Res Clin Exp 2012; 73:103–111.
35.	She YJ, Xie GT, Tan YH, kuang XH, Yu GF, Lian GH et al. A prospective study comparing the onset and analgesic efficacy of different concentrations of levobupivacaine with/without dexmedetomidine in young children undergoing caudal blockade. J Clin Anesth 2015; 27:17–22.
36.	Esmaoglu A, Yegenoglu F, Akin A, Turk CY. Dexmedetomidine added to levobupivacaine prolongs axillary brachial plexus block. Anesth Analg 2010; 111:1548–1551.
37.	Elfawal SM, Abdelaal WA, Hosny MR. A comparative study of dexmedetomidine and fentanyl as adjuvants to levobupivacaine for caudal analgesia in children undergoing lower limb orthopedic surgery. Saudi J Anesth 2016; 10:423–427.
38.	Koceroglu I, Devrim S, Bingol Tanriverdi T, Gura CM. The effects of dexmedetomidine and tramadol on post-operative pain and agitation, and extubation quality in paediatric patients undergoing adenotonsillectomy surgery: a randomized trial. J Clin Pharm Ther 2020; 45:340–346.
39.	Weksler N, Nash M, Rozentsveig V, Schwartzartz JA, Schily M, Gurman GM. Vocal cord paralysis as a consequence of peritonsillar infiltration with bupivacaine. Acta Anaesthesiol Scand 2001; 45:1042–1044.
40.	Shlizerman L, Ashkenazi D. Peripheral facial nerve paralysis after peritonsillar infiltration of bupivacaine: a case report. Am J Otolaryngol 2005; 26: 406–407.