We thank Drs Bagade, Jefferson and Ball for their compliments and comments. We agree with the consensus guideline on the management of postoperatice nausea and vomiting (PONV). The principles of timing of each anti-emetic are valid given the long onset time of dexamethasone and the relative short duration of action of ondansetron. However, we reported a mean operating time of 20 min and consider it unlikely that giving the ondansetron 20 min later than we currently do would make a difference as it would in cases of longer duration. In addition, administering ondansetron at the end of surgery might increase the risk of its omission.

The second comment is with regard to emergence delerium following sevoflurane anaesthesia. Keaney et al. compared the recovery characteristics between sevoflurane and halothane, with no direct comparison with isoflurane [1]. The rapid emergence from sevoflurane anaesthesia can be used to an advantage and emergence delirium eliminated if adequate analgesia is provided at the time of awakening [2]. In addition, Viitanen and others [3] investigated induction with propofol followed by sevoflurane maintenance and sevoflurane induction and maintenance. They concluded that induction with propofol significantly diminished emergence delerium after sevoflurane anaesthesia, which is in keeping with our experience. Ketamine has received a mixed review regarding its analgesic efficacy following tonsillectomy [4, 5]. In our earlier pilot study a slight increase in sedation was observed without significantly increasing analgesia.

Drs Tremlett and Wright suggest that our main conclusion that our day-case technique results in minimal postoperative morbidity is not proven. They suggest that codeine is the only difference in our protocol and predicted that our worst pain scores will be similar to theirs. The pain score shown in Table 2 was presented in graphical form in our paper, and gives the worst pain during the 24-h period. This is corroborated by the fact that only one family visited their general practitioner and four families attended the ENT Outpatient Clinic for pain-related issues. That figure amounts to 5% of unscheduled visits to medical practitioners in comparison with the 31% reported in their audit. The mean time to first analgesia in our patients was 5 h. Codeine was dismissed as a possible cause for the difference in results. The quoted study by Williams et al. [6] reported that behavioural and self-report pain assessments did not differentiate between the codeine and morphine groups at any stage of the study. Furthermore, they stated that the concurrent use of diclofenac may also have masked any differences between the groups as such analgesic combinations are known to increase efficacy substantially in comparison with monotherapy. In addition, our protocol includes dexamethasone. Pappas and others [7] studied the effect of pre-operative dexamethasone on immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy. They concluded that dexamethasone significantly decreased the incidence of PONV, improved oral intake, decreased the frequency of parental phone calls and resulted in no hospital returns for the management of PONV and/or poor oral intake.

Table 2.   Post-operative pain score and vomiting rate following tonsillectomy in children.
  1. Pain score 0 = no pain; pain score 5 = it hurts a lot, tears.

Pain score 43%7%5%5%
Pain score 51%4%4%3%

Table 2 also shows the postoperative vomiting rate which was presented in our paper in graphical form. Food intake is excellent in the immediate post operative period. We stand by our original conclusion and suggest that the assumptions by Tremlett and Wright are not proven.


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