1. A prospective double-blind randomized trial found that perioperative dexamethasone provided minor pain relief but significantly increased insulin requirements and risk of infections in patients undergoing reconstructive head and neck cancer surgery. 2. Dexamethasone did not accelerate recovery or shorten hospital stay and its use in head and neck cancer reconstruction provided no clear clinical benefits while increasing complications. 3. A randomized controlled trial of corticosteroids after transoral robotic surgery found extended perioperative dexamethasone was safe and may allow for earlier improvement in diet consistency and decreased hospital stay, though it minimally affected postoperative pain.

2. More harm than benefit of perioperative
dexamethasone on recovery following
reconstructive head and neck cancer
surgery: A prospective double-blind
randomized trial
S. Kainulainen, P. Lassus, A.L. Suominen, T. Wilkman, J. Tornwall, H.
Thoren and A.M. Koivusalo
Journal of Oral & Maxillofacial Surgery (November 2018)

3. Introduction
•Treatment of malignant tumors of the head and neck area causes a large number of
morbidities
•These patients often require microvascular reconstruction for repair of the surgical defect.
• Primary healing without postoperative complications is an important goal for surgeons
and patients.
•Glucocorticoids (GCs) are given to patients to relieve postoperative pain, swelling, and
postoperative nausea and vomiting (PONV), although the evidence of benefit in
postoperative use is contentious.
( According to Kormi E, Snäll J, Törnwall J, Thorén H. A survey of the use of perioperative glucocorticoids
in oral and maxillofacial surgery. Journal of Oral and Maxillofacial Surgery. 2016 Aug 1;74(8):1548-51 )
•The most common complication of GC treatment is an increase in serum glucose
concentrations which influence infections and wound healing.

4. Purpose of this study
•To clarify the effects of dexamethasone on quality and
speed of recovery, pain, PONV, lactate levels, and need for
insulin after surgery of patients with microvascular
reconstruction for head and neck cancer.
• The authors hypothesized that dexamethasone would
enhance recovery and diminish pain and nausea.

5. Subjects & Methods
•Study design- Prospective double-blind randomised trial.
•Place of study- Departments of Oral and Maxillofacial Surgery and
Plastic Surgery of the Helsinki University Hospital (Helsinki,
Finland).
•This study followed the Declaration of Helsinki on medical
protocol and ethics, and the regional ethical review board of the
Helsinki University Central Hospital approved the study.
•The study was registered with EudraCT (number 2008-000892-11).
•Duration of study: December 2008 to February 2013

6. Subjects & Methods
•Study population- A total of 110 consecutive
patients with oropharyngeal cancer who
underwent surgery with microvascular
reconstruction were included.
•Exclusion criteria: History of liver or kidney
dysfunction, glaucoma, peptic ulcer, psychosis
from the use of steroids, allergy to any constituent
of the dexamethasone preparation used, steroid
medication for other diseases, or non-provision of
written informed consent.
•Patients were randomized into 2 groups; one
received perioperative and postoperative
dexamethasone (DEX group) and the other did not
receive any steroids (controls; NON-DEX group).
Dexamethasone 10mg at
induction of anaesthesia
First post op day: 10mg TDS
2nd post op day: 10mg BID
3rd post op day: 10mg OD

7. Subjects & Methods
 Blinding: Randomization was performed using sealed envelopes by a
person not otherwise involved in the study. The information on which
patients would receive dexamethasone was provided in a sealed
envelope to the attending anaesthesiologist of the operation. The same
anaesthesiologist administered all doses to the patient during the
operation and in the ICU postoperatively. Surgeons were unaware of the
group to which patients were assigned. The information of the group
was not given to the surgeons at any stage during the patient’s
treatment.
Most tumours (92%) were squamous cell carcinomas.
 There were 83 fasciocutaneous and 10 osteofasciocutaneous
reconstructions. Groups were similar in localizations.
Patients were given antibiotics targeted for 7 days.
Patients were sedated with a continuous infusion of propofol and
alfentanil.

8. Primary outcomes
Post operative pain: Measured on visual analog scale (VAS) and by
postoperative opioid (oxycodone) consumption.
Patient rehabilitation/ recovery time
Glucose balance: Measured by postoperative insulin consumption.
Postoperative nausea and vomiting (PONV)
C-reactive protein (CRP), leukocyte, and lactate levels.

9. Statistical analysis
 The relevance of associations between groups and categorical variables
was evaluated by Chi-squaretests
 Differences in mean values between groups and continuous variables
were evaluated by Wilcoxon 2-sample tests.
 Differences in pain measured by the VAS and levels of insulin, lactate,
and CRP area under the curve (VAS AUC) between groups were assessed
by logistic regression.

10. Results
Out of 110 consecutive
patients
97 patients met the
inclusion criteria
Out of this 4 patients
were excluded. 93
patients were included
in the study
51
42
93 patients were randomly
divided into 2 groups
DEX group NON-DEX group

11. Results

12. Results
1. Recovery: There were no differences
between groups in parameters of
postoperative mobilization or ability to drink
fluids after surgery. There also were no
relevant differences in the length of ICU and
hospital stay between groups.
2. Pain: The total oxycodone dose for 5 days
postoperatively was significantly lower in
the DEX group than in the NON-DEX group
(P = 0.040)
3. PONV: The most relevant difference was on
the second postoperative day when 6
patients in NON-DEX group received
significantly more antiemetics compared
with only 1 patient in DEX group (P = .0264).

13. Results
4. Glucose balance: Patients in the DEX group
required considerably more insulin for 6
postoperative days compared with patients in
the NON-DEX group (total insulin needed, 93.5
vs 10.3 U, respectively; P < .001). This may be
due to the effect of dexamethasone on
glucose metabolism.
5. Metabolic and inflammatory response:
Lactate levels were significantly higher in the
DEX group than in the control group (P < .001)
for the first 5 postoperative days.
CRP levels were significantly lower (P < .001)
and leukocyte counts were significantly higher
(P < .001) in the DEX group.

14. Discussion
• The present study showed that dexamethasone had only a minor effect on
postoperative healing.
•Although the use of dexamethasone decreased the total amount of
analgesics and pain, dexamethasone did not accelerate the healing and
recovery process and did not shorten the hospital stay.
•Dexamethasone did not help in making any clinical difference regarding the
PONV.
•Wattwil et al found that ondansetron and dexamethasone were equally
effective in the prevention of PONV after surgery.
•The present study showed that accurate glucose monitoring is needed for at
least 5 days after surgery, because the need for insulin increases
considerably owing to the effect of dexamethasone on glucose metabolism
•Low CRP values (caused by dexamethasone) might cause doctors to
overlook early-onset infections

15. Dexamethasone in head and neck cancer patients with
microvascular reconstruction: No benefit, more complications
S. Kainulainen, P. Lassus, A.L.Suominen, T. Wilkman, J. Tornwall, H. Thoren and A.M. Koivusalo
Oral oncology (2017)
Subject & methods
Prospective double-blind randomized
controlled trial comprised of 93
patients.
The main primary outcome variables
were: Neck swelling, length of
intensive care unit and hospital stay,
duration of intubation or
tracheostomy, and delay to start of
possible radiotherapy.
Complications were also recorded.
Results
No statistical differences emerged
between the two groups in any of the
main primary outcome variables.
However, there were more major
complications, especially infections,
needing secondary surgery within
three weeks of the operation in
patients receiving dexamethasone
than in control patients (27% vs. 7%,
P = 0.012
Conclusion
The use of dexamethasone in oral
cancer patients with microvascular
reconstruction did not provide a
benefit. More major complications,
especially infections, occurred in
patients receiving dexamethasone

16. Postoperative nausea and vomiting in facial fracture
patients: A Randomized controlled trial on the effect of dexamethasone
A. Haapanen, H. Thoren, J. Tornwall, A.L. Suominen, J. Snall (IJOMS 2017)
The specific aim was to
investigate the effect of
perioperative dexamethasone
on PONV. A total of 119 adult
patients with facial fractures
were analysed in this
prospective study
• Objective
The dexamethasone group
received 10 mg of
dexamethasone intravenously
during anaesthesia induction and
an additional 10 mg
intramuscularly every 8 hours
over 16 hours, up to a total dose
of 30 mg of dexamethasone
• Methodology
Dexamethasone can be given in high-risk
trauma patients but routine use of
dexamethasone as an antiemetic drug during
facial trauma surgery cannot be
recommended. Alternative medications such as
metoclopramide, ondansetron, etc. should be
considered as they have lesser side effects.
• Conclusion

17. A Randomized Controlled Trial of Corticosteroids for
Pain After Transoral Robotic Surgery
Clayburgh D, Stott W, Bolognone R, Palmer D, Graville D, Andersen P, Gross ND.
The Laryngoscope. 2017 Nov;127(11):2558-64.
Conclusion
Extended perioperative
corticosteroids after TORS is
safe and may allow earlier
improvement in diet
consistency and decreased
length of hospital stay,
although postoperative pain
appears minimally affected.
Methodology
Patients undergoing TORS for initial
treatment of oropharyngeal
squamous cell carcinoma received a
single intraoperative dose of 10-mg
dexamethasone and then were
randomized to receive 8-mg
dexamethasone every 8 hours, or
placebo, for up to 4 days after
surgery. Pain, measured by visual
analog scale (VAS), was the primary
outcome measure. Secondary
outcome measures included length
of stay, dysphagia assessments, and
complications.
Objectives
To determine if an extended
perioperative course of
corticosteroids will improve
pain control following
transoral robotic surgery
(TORS).

18. A Randomized Double-Blinded Placebo Controlled Study of
Four Interventions for the Prevention of Postoperative
Nausea and Vomiting in Maxillofacial Trauma Surgery
Jahromi HE, Gholami M, Rezaei F. Journal of Craniofacial Surgery. 2013 November
• This study aimed to determine if
preoperative oral administration of
metoclopramide, chlorpromazine,
gabapentin, or dexamethasone
would effectively control PONV in
the first 24 hours after surgery in
patients undergoing maxillofacial
trauma surgery
Purpose
• 150 patients with maxillofacial
trauma were randomly assigned
to receive one of the study drugs
orally, 1 hour preop. All patients
were observed in the first 24 hours
for PONV.
Methods •Unlike other 3 drugs
dexamethasone did not
significantly reduced
PONV in maxillofacial
trauma patients
Conclusion

19. Limitations of this study
Despite being the largest prospective randomized double-blinded trial
of patients with reconstructive surgery for head and neck cancer and
perioperative use of dexamethasone, the total number of patients could
have been larger.
Lots of variables as the study population includes carcinoma of the
whole head and neck region, different types of free flaps were used,
etc.
No multivariate analysis were done to see whether there was any
association with recovery time and alcohol consumption/ smoking or
systemic conditions like diabetes.
The title could have been much simpler.

20. Conclusion
This study is the first prospective randomized trial to evaluate the
perioperative use of dexamethasone in patients with head and neck cancer
and microvascular reconstruction.
The only benefit of perioperative dexamethasone use was the lower total
dose of oxycodone and reduction in post op pain.
The disadvantages of dexamethasone use were greater which include the
need for increased insulin, disturbed glucose metabolism, higher lactate
levels, and misleading CRP values.
Increased risk of postoperative infections.
(Capes SE, Hunt D, Gerstein HC. Stress hyperglycaemia and increased risk of death after
myocardial infarction in patients with and without diabetes: a systematic overview. The
Lancet. 2000 Mar.)
This study does not recommend routine use of dexamethasone in
reconstructive head & neck cancer surgery.