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Steroids have been prescribed to reduce acute pain and swelling in severe pharyngitis. They
provide symptomatic relief of pain, in particular in patients with severe or exudative sore
throat (Hayward et al, 2009 Level I). In particular, steroids in combination with analgesics and
antibiotics increased the likelihood of complete resolution of pain and the time to onset of
pain relief. Oral dexamethasone (Olympia et al, 2005 Level II; Niland et al, 2006 Level II) or IM
betamethasone (Marvez‐Valls et al, 1998 Level II) significantly reduced dysphagia and the
duration of symptoms in patients with severe streptococcal pharyngitis, although a study
in children failed to find any benefit with oral dexamethasone (Bulloch et al, 2003 Level II).
Following drainage and antibiotics for peritonsillar abscess, a single dose of IV steroid reduced
pain, trismus and fever (Ozbek et al, 2004 Level II).
Antibiotics for sore throat reduced pain, headache and fever by 50% on day 3 and shortened
the duration of symptoms by approximately one day. The NNT to prevent a sore throat at
day 3 was approximately 6 (95% CI 4.9 to 7.0) and at day 7, 21 (95% CI 13.2 to 47.9) (Del Mar
et al, 2006 Level I).
Acute pain associated with sinusitis and otitis media
There is no evidence to guide the choice of analgesia for acute pain associated with sinusitis
or otitis media. It may be appropriate to use nsNSAIDs, coxibs, paracetamol, weak opioids or
tramadol, based on evidence for treatment of dental pain. Nasal irrigation with physiological
saline may provide symptomatic relief (Clement et al, 1998; Low et al, 1997). Administration of
penicillin V decreased pain scores over 3 days in patients with severe sinus pain (Hansen et al,
2000 Level II). Local anaesthetic eardrops reduced pain in otitis media (Bolt et al, 2008 Level II);
however the overall effectiveness of eardrops in this condition was unclear (Foxlee et al, 2006
Level I).
Acute post-tonsillectomy pain
(Also see Sections 10.5.1, 10.5.2 & 10.5.5)
Peritonsillar infiltration or topical application of local anaesthetics produced a modest
reduction in post‐tonsillectomy pain (7 to 19 mm on a 100 mm VAS) for up to 24 hours, with
topical application and infiltration being equally effective (Grainger & Saravanappa, 2008 Level I).

Note: reversal of conclusion
This reverses the Level 1 conclusion in the previous edition of this
document; an earlier meta‐analysis had reported no improvement CHAPTER 9
in analgesia.

Injection of local anaesthesics in the tonsillar fossa improved pain scores, and reduced time to
first oral intake and the incidence of referred ear pain (Naja et al, 2005 Level II; Somdas et al, 2004
Level II). Ropivacaine 1.0% with adrenaline resulted in better pain relief for up to 3 days after
tonsillectomy than bupivacaine 0.25% with adrenaline or placebo (Arikan et al, 2008 Level II).
The addition of magnesium to levobupivacaine reduced analgesic requirements compared
with levobupivacaine alone or saline control (Karaaslan et al, 2008 Level II) and bupivacaine
0.25% with pethidine reduced analgesic requirements at rest, but did not affect other pain
outcomes compared with saline, following tonsillectomy in children (Nikandish et al, 2008
Level II).
Infiltration of the tonsillar bed with tramadol may reduce pain and analgesic requirements in
the first few hours after tonsillectomy (Atef & Fawaz, 2008a Level II), although infiltration may be
no more effective than an equivalent IM dose (Ugur et al, 2008 Level II). Peritonsillar infiltration
of ketamine reduced pain and analgesic requirements for up to 24 hours post‐tonsillectomy in

Acute pain management: scientific evidence 275