Tonsillectomy 2019

An explanation of PROSPECT methodology and Working Group processes can be found at the following link: http://esraeurope.org/prospect-methodology

For the tonsillectomy review, the Subgroup members were:

• Niamat Aldamluji¹
• A. Burgess²
• Esther Pogatzki-Zahn³
• Johan Raeder⁴
• Helene Beloeil⁵

1. Attending Physician, Department of Adult Anaesthesiology, Sidra Medicine, Qatar.
2. Physician, Department of Otolaryngology Head and Neck Surgery, Com Maillot-Hartmann Private Hospital, Neuilly sur Seine, France.
3. Professor, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany.
4. Professor, Department of Anaesthesiology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway.
5. Professor, Department of Anaesthesiology and Critical Care, Université Rennes, Rennes, France.

Tonsillectomy literature search

• Systematic review of the literature associated with analgesia after tonsillectomy up to 24 November 2019, with no time limitation.
• The following databases were searched: US National Library of Medicine Database (MEDLINE), the Excerpta Medica database (EMBASE), PubMed, OpenGrey, Web of Science and Cochrane Databases (Cochrane Central Register of Controlled Trials; Cochrane Database of Abstracts or Reviews of Effects; Cochrane Database of Systematic Reviews) (Search strategy).
• Included studies: RCTs or systematic reviews in English assessing postoperative pain after tonsillectomy using analgesic, anaesthetic or surgical interventions in adults or paediatric patients (<18 years of age).
• Excluded articles: studies that reported data pooled from patients undergoing mixed surgical procedures or procedures other than tonsillectomy or adenotonsillectomy were excluded. However, studies in which a combination of tonsillectomy and adenotonsillectomy procedures was performed were included.
• Of 4022 unique records identified, 719 full-text articles were assessed for eligibility.
• 226 studies were included in the qualitative analyses (Summary of literature selection; Included studies).
• 493 studies were excluded after full-text review.

• Among the 226 studies included, 158 included paediatric patients; 40 included adult patients; and 28 involved a mixed population.
• The definition of adult and paediatric age groups varied considerably among studies; some studies included within the paediatric group participants up to the age of 20, 18 or 16.
• Results are pooled for paediatric and adult patients as 28 of the studies included both. When results were different, or only studied in one population, we present specific analyses.

Assessments of the quality of study methodology and reporting

All included studies were assessed for quality according to PROSPECT methodology (Joshi 2019, http://esraeurope.org/prospect-methodology). The study quality assessments for tonsillectomy are summarised here: Quality assessments and level of evidence assigned to included trials.

• Data extraction and data analysis for tonsillectomy adhered to the PROSPECT methodology (Joshi 2019, http://esraeurope.org/prospect-methodology).
• Pain intensity scores were used as the primary outcome measure.
• In this study, we defined a change of more than 10 mm on the VAS or NRS as clinically relevant.
• The aim was to qualitatively assess the data and not to perform a meta-analysis.
• The review also examined whether patients received basic analgesics, defined as the prescription of the non-opioid analgesics paracetamol and NSAIDs or COX-2-selective inhibitors.

Recommendations were made according to PROSPECT methodology (Joshi 2019, http://esraeurope.org/prospect-methodology). This involved a grading of A–D according to the overall level of evidence, as determined by the quality of studies included, consistency of evidence and study design: Relationship between quality of the study and levels of evidence and grades of recommendation.

The proposed recommendations were sent to the PROSPECT Working Group for review and comments and a modified Delphi approach was used. Once a consensus was achieved the lead authors drafted the final document, which was ultimately approved by the working group.

Some limitations of this review are related to the limitations of the individual studies included:

• Considerable heterogeneity between studies, such as variable dosing regimens, methods of administration, control groups and time points of pain assessments.
• The small size of most studies has the potential for overestimation effects.
• Analgesic interventions were not always evaluated against a control group that included an optimised multimodal analgesic regimen. A significant proportion of the included studies assessed unimodal analgesic therapies rather than broader and more comprehensive analgesic techniques. Ideally, all patients should receive an optimised analgesic regimen, and the added procedure-specific benefit of individual interventions should then be tested against this baseline.
• Significant heterogeneity in study designs with respect to the analgesic regimen.

As it is not part of the methodology, recommendations were not weighted and dosage recommendations were not made.

Future adequately powered studies should assess the effects of analgesic interventions not only on pain, opioid consumption, opioid-related adverse events and complications associated with the intervention, but also outcome measures such as time to ambulation, length of hospital stay and everyday function after discharge. Another important aspect will be to bring patient-specific risk factors for postoperative pain into the studies.

The AGREE II instrument (Brouwers 2010) is used internationally to assess the methodological rigour and transparency of practice guidelines. As far as possible, the methodology of the PROSPECT Tonsillectomy review meets the requirements of ‘Domain 3: Rigour of development’ of the AGREE II instrument:

• Systematic methods were used to search for evidence
• The criteria for selecting the evidence are clearly described
• The strengths and limitations of the body of evidence are clearly described
• The methods for formulating the recommendations are clearly described
• The health benefits, side effects, and risks have been considered in formulating the recommendations
• There is an explicit link between the recommendations and the supporting evidence
• The guideline has been externally reviewed by experts prior to its publication. (The evidence and recommendations are made available on the website after peer review and publication)
• A procedure for updating the guideline is provided. (Methodology is provided so that the systematic review can be updated as required)