Paul R. Lambert, MD

Professor and Chair

Within the past year, the American Academy of Otolaryngology broadcasted a statement warning against the use of codeine in children undergoing adenotonsillectomy for adenotonsillar hypertrophy and associated sleep-disordered breathing. This statement was based on evidence that variations in the CYP2D6 genotypes result different rates of metabolism of codeine into active metabolites.

More than a quarter of patients in some ethnic groups are considered ultra rapid metabolizers and can be expected to experience respiratory depression from higher levels of active metabolites of codeine even when being dosed correctly according to weight. Compounding this issue is the fact that patients with obstructive sleep apnea have an increased respiratory sensitivity to narcotics and may already be at risk for narcotic-related respiratory events after pharyngeal surgery. Small children are especially at risk, since their therapeutic window is more narrow. These combined risk factors may set the stage for catastrophic postoperative complications. In fact nearly one fifth of all lawsuits after tonsillectomy are related to postoperative narcotic usage.

The Pediatric Otolaryngology Division, in 2007, decided to stop using codeine for postoperative pain control after adenotonsillectomy, however this decision was based on the high rate of side effects and the documented poor pain control provided in younger children. At that time, our division began using hydrocodone and acetaminophen for our routine postoperative management of children undergoing tonsillectomy. We have changed our management again recently since the AAO-HNS statement implicated ALL narcotics metabolized by enzymes in the CYP2D6 domain. These narcotics include not only codeine, but also hydrocodone and oxycodone. Recent pain control studies have also demonstrated the safety of ibuprofen use after tonsillectomy, further arguing against the usage of postoperative narcotics for pain management.

Until late 2012, our routine practice was to use hydrocodone/acetaminophen dosed according to weight in children as young as 3 years of age. Based on the above evidence and events, we changed our postoperative pain management to the protocol below, based partly on the pain management algorithm published by the AAO-HNS this fall.