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Tonsillectomy for Obstructive Sleep-Disordered Breathing or Recurrent Throat Infection in Children
Comparative Effectiveness Reviews, No. 183
Investigators: David O Francis, MD, MS, Sivakumar Chinnadurai, MD, MPH, Nila A Sathe, MA, MLIS, Anna Morad, MD, Atia K Jordan, MD, Shanthi Krishnaswami, MBBS, MPH, Christopher Fonnesbeck, PhD, and Melissa L McPheeters, PhD, MPH.
Author Information and AffiliationsStructured Abstract
Objectives:
To systematically review evidence addressing tonsillectomy in children with obstructive sleep-disordered breathing (OSDB) or recurrent throat infections.
Data sources:
Multiple databases from January 1980 through June 2016.
Review methods:
We included comparative studies of tonsillectomy, perioperative medications to improve outcomes, and postoperative medications for pain. We also included case series and database studies with ≥1,000 children to address harms. Two investigators independently screened studies and rated risk of bias. We extracted and summarized data qualitatively and quantitatively via Bayesian meta-analyses. We also assessed strength of the evidence (SOE).
Results:
We identified 218 unique studies (141 randomized controlled trials [RCTs], 12 nonrandomized trials, 7 prospective and 5 retrospective cohort studies, and 53 database or registry studies or case series [67 low, 110 moderate, and 41 high risk of bias]). Populations; surgical approaches; anesthetic, analgesic, and antiemetic regimens varied across studies. For children with OSDB, most studies reported better sleep-related outcomes in those who had a tonsillectomy versus no surgery. For children with recurrent throat infections, tonsillectomy improved the number of infections, associated utilization (clinician visits), and work/school absences in the first postsurgical year. These benefits did not persist over time, however, and longer term outcomes are limited. Partial tonsillectomy was associated with faster return to normal diet or activity versus total tonsillectomy but also with a risk of tonsillar regrowth requiring reoperation. Commonly used “hot” techniques were generally associated with faster return to normal diet and activity than was cold dissection. In meta-analyses, frequency of post-tonsillectomy hemorrhage (PTH) was less than 4 percent, and frequency of bleeding-associated revisits or reoperations was less than 8 percent. Meta-analysis of nine RCTs reporting bleeding associated with perioperative dexamethasone compared with placebo did not indicate a significantly increased risk of bleeding with steroids, although confidence bounds were wide. Studies of perioperative medications were heterogeneous, but dexamethasone was consistently associated with less need for rescue analgesia than placebo. Preemptive perioperative 5-hydroxytryptamine (5-HT) antiemetics were associated with less need for postoperative antiemetics than placebo. Few studies of postoperative medications addressed the same agents or outcomes.
Conclusions:
Tonsillectomy can produce short-term improvement in sleep outcomes compared with no surgery in children with OSDB (moderate SOE). In children with recurrent throat infections undergoing tonsillectomy, number of throat infections (moderate SOE) and associated health care utilization and work/school absences (low SOE) improved in the first postsurgical year. These benefits did not persist, and data on longer term results are lacking. Short-term improvements must be weighed against the risk of PTH (high SOE for low frequency of PTH). Surgical technique had little bearing on return to normal diet or activity (low SOE). Perioperative dexamethasone and pre-emptive 5-HT receptor antagonist antiemetics reduced the need for additional analgesics or antiemetics (low SOE). Dexamethasone did not increase risk of PTH compared with placebo, but estimates had wide confidence bounds (low SOE). Little evidence addressed the use of postoperative medications for pain-related outcomes (insufficient SOE).
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Results of Literature Searches for Key Questions
- Key Question 1. Effectiveness of Tonsillectomy Versus No Surgery for OSDB
- Key Question 1a. Effectiveness of Tonsillectomy for Children With OSDB and Neuromuscular or Craniofacial Abnormalities
- Key Question 1b. Effectiveness of Tonsillectomy for Children With OSDB Under 3 Years of Age
- Key Question 1c. Effectiveness of Tonsillectomy for Children With OSDB and Down Syndrome
- Key Question 1d. Effectiveness of Tonsillectomy for Children With OSDB and Obesity
- Key Question 2. Effectiveness of Tonsillectomy Versus No Surgery for Recurrent Throat Infection
- Key Question 3. Effectiveness of Partial Versus Total Tonsillectomy
- Key Question 4. Effectiveness of Surgical Techniques
- Harms of Tonsillectomy
- Key Question 5. Effectiveness of Perioperative Medications To Improve Outcomes
- Key Question 6. Effectiveness of Postoperative Medications To Reduce Pain-Related Outcomes After Tonsillectomy
- Discussion
- State of the Literature
- Summary of Key Findings and Strength of the Evidence
- Findings in Relation to What Is Already Known
- Applicability
- Implications for Clinical and Policy Decisionmaking
- Limitations of the Comparative Effectiveness Review Process
- Limitations of the Evidence Base
- Research Gaps and Areas for Future Research
- Conclusions
- References
- Acronyms and Abbreviations
- Appendix A. Analytic Frameworks
- Appendix B. Search Strategies
- Appendix C. Information for Screening, Risk of Bias Assessment, and Strength of the Evidence
- Appendix D. Excluded Studies
- Appendix E. Methods for Meta-Analyses
- Appendix F. Risk of Bias Ratings
- Appendix G. Applicability of Findings
- Appendix H. Detailed Tables of Findings
- Appendix I. Summary of Existing Systematic Reviews
Suggested citation:
Francis DO, Chinnadurai S, Sathe NA, Morad A, Jordan AK, Krishnaswami S, Fonnesbeck C, McPheeters ML. Tonsillectomy for Obstructive Sleep-Disordered Breathing or Recurrent Throat Infection in Children. Comparative Effectiveness Review No. 183. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2015-00003-I.) AHRQ Publication No. 16(17)-EHC042-EF. Rockville, MD: Agency for Healthcare Research and Quality. January 2017. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Vanderbilt Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00003-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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