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Meta-Analysis
. 2020 Apr 29;4(4):CD011365.
doi: 10.1002/14651858.CD011365.pub2.

Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children

Helen Blackshaw #  1   2 , Laurie R Springford #  1   2 , Lai-Ying Zhang  3 , Betty Wang  3 , Roderick P Venekamp  4 , Anne Gm Schilder  1   2   5
Affiliations
Meta-Analysis

Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children

Helen Blackshaw et al. Cochrane Database Syst Rev. .

Abstract

Background: Obstructive sleep-disordered breathing (oSDB) is a condition encompassing breathing problems when asleep due to upper airway obstruction. In children, hypertrophy of the tonsils and/or adenoids is thought to be the commonest cause. As such, (adeno)tonsillectomy has long been the treatment of choice. A rise in partial removal of the tonsils over the last decade is due to the hypothesis that tonsillotomy is associated with lower postoperative morbidity and fewer complications.

Objectives: To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications.

Search methods: We searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 22 July 2019.

Selection criteria: Randomised controlled trials (RCTs) comparing the effectiveness of (adeno)tonsillectomy with (adeno)tonsillotomy in children aged 2 to 16 years with oSDB.

Data collection and analysis: We used standard Cochrane methods and assessed the certainty of the evidence for our pre-defined outcomes using GRADE. Our primary outcomes were disease-specific quality of life, peri-operative blood loss and the proportion of children requiring postoperative medical intervention (with or without hospitalisation). Secondary outcomes included postoperative pain, return to normal activity, recurrence of oSDB symptoms as a result of tonsil regrowth and reoperation rates.

Main results: We included 22 studies (1984 children), with predominantly unclear or high risk of bias. Three studies used polysomnography as part of their inclusion criteria. Follow-up duration ranged from six days to six years. Although 19 studies reported on some of our outcomes, we could only pool the results from a few due both to the variety of outcomes and the measurement instruments used, and an absence of combinable data. Disease-specific quality of life Four studies (540 children; 484 (90%) analysed) reported this outcome; data could not be pooled due to the different outcome measurement instruments used. It is very uncertain whether there is any difference in disease-specific quality of life between the two surgical procedures in the short (0 to 6 months; 3 studies, 410 children), medium (7 to 13 months; 2 studies, 117 children) and long term (13 to 24 months; 1 study, 67 children) (very low-certainty evidence). Peri-operative blood loss We are uncertain whether tonsillotomy reduces peri-operative blood loss by a clinically meaningful amount (mean difference (MD) 14.06 mL, 95% CI 1.91 to 26.21 mL; 8 studies, 610 children; very low-certainty evidence). In sensitivity analysis (restricted to three studies with low risk of bias) there was no evidence of a difference between the groups. Postoperative complications requiring medical intervention (with or without hospitalisation) The risk of postoperative complications in the first week after surgery was probably lower in children who underwent tonsillotomy (4.9% versus 2.6%, risk ratio (RR) 1.75, 95% CI 1.06 to 2.91; 16 studies, 1416 children; moderate-certainty evidence). Postoperative pain Eleven studies (1017 children) reported this outcome. Pain was measured using various scales and scored by either children, parents, clinicians or study personnel. When considering postoperative pain there was little or no difference between tonsillectomy and tonsillotomy at 24 hours (10-point scale) (MD 1.09, 95% CI 0.88 to 1.29; 4 studies, 368 children); at two to three days (MD 0.93, 95% CI -0.14 to 2.00; 3 studies, 301 children); or at four to seven days (MD 1.07, 95% CI -0.40 to 2.53; 4 studies, 370 children) (all very low-certainty evidence). In sensitivity analysis (restricted to studies with low risk of bias), we found no evidence of a difference in mean pain scores between groups. Return to normal activity Tonsillotomy probably results in a faster return to normal activity. Children who underwent tonsillotomy were able to return to normal activity four days earlier (MD 3.84 days, 95% CI 0.23 to 7.44; 3 studies, 248 children; moderate-certainty evidence). Recurrence of oSDB and reoperation rates We are uncertain whether there is a difference between the groups in the short (RR 0.26, 95% CI 0.03 to 2.22; 3 studies, 186 children), medium (RR 0.35, 95% CI 0.04 to 3.23; 4 studies, 206 children) or long term (RR 0.21 95% CI 0.01 to 4.13; 1 study, 65 children) (all very low-certainty evidence).

Authors' conclusions: For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. More robust data from high-quality cohort studies, which may be more appropriate for detecting differences in less common events in the long term, are required to inform guidance on which tonsil surgery technique is best for children with oSDB requiring surgery.

Trial registration: ClinicalTrials.gov NCT01676181 NCT01319058.

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Conflict of interest statement

Helen Blackshaw: none known.

Laurie R Springford: none known.

Lai‐Ying Zhang: none known.

Betty Wang: none known.

Roderick P Venekamp: Roderick P Venekamp is editor of Cochrane ARI and ENT, but had no role in the editorial process for this review.

Anne GM Schilder: Anne Schilder is joint Co‐ordinating Editor of Cochrane ENT, but had no role in the editorial process for this review. Her evidENT team at UCL is supported in part by the National Institute of Health Research University College London Hospitals Biomedical Research Centre. Their research is funded by the NIHR and EU Horizon2020. She is the national chair of the NIHR Clinical Research Network ENT Specialty. She is the Surgical Specialty Lead for ENT for the Royal College of Surgeons of England's Clinical Trials Initiative. She is co‐investigator on the NIHR PGfAR grant 'Defining best Management for Adults with Chronic RhinOsinusitis: the MACRO Programme'. In her role as director of the NIHR UCLH BRC Deafness and Hearing Problems Theme, she acts as an advisor on clinical trial design and delivery to a range of biotech companies.

Figures

1
1
Process for sifting search results and selecting studies for inclusion.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Tonsillectomy versus tonsillotomy, outcome: 1.1 Peri‐operative blood loss [mL].
5
5
Forest plot of comparison: 1 Tonsillectomy versus tonsillotomy, outcome: 1.3 Need for medical intervention within 7 days.
6
6
Forest plot of comparison: 1 Tonsillectomy versus tonsillotomy, outcome: 1.28 Return to normal diet [days].
1.1
1.1. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 1: Peri‐operative blood loss
1.2
1.2. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 2: Peri‐operative blood loss (sensitivity analysis)
1.3
1.3. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 3: Need for medical intervention within 7 days
1.4
1.4. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 4: Need for medical intervention within 7 days (sensitivity analysis)
1.5
1.5. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 5: Behaviour (CBCL 6 months)
1.6
1.6. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 6: Behaviour (CBCL 24 months)
1.7
1.7. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 7: Measures of respiratory events during sleep (AHI 6 months)
1.8
1.8. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 8: Recurrence of SDB symptoms (6 months)
1.9
1.9. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 9: Recurrence of SDB symptoms (6 months sensitivity analysis)
1.10
1.10. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 10: Recurrence of SDB symptoms (12 months)
1.11
1.11. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 11: Recurrence of SDB symptoms (12 months sensitivity analysis)
1.12
1.12. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 12: Recurrence of SDB symptoms (24 months)
1.13
1.13. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 13: Reoperation rates (12 months)
1.14
1.14. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 14: Reoperation rates (18 months)
1.15
1.15. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 15: Incidence of throat infection (6 months)
1.16
1.16. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 16: Incidence of throat infection (12 months)
1.17
1.17. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 17: Incidence of throat infection (24 months)
1.18
1.18. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 18: Duration of surgery
1.19
1.19. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 19: Duration of surgery (sensitivity analysis)
1.20
1.20. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 20: Severity of postoperative pain (24 hours)
1.21
1.21. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 21: Severity of postoperative pain (24 hours sensitivity analysis)
1.22
1.22. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 22: Severity of postoperative pain (2 to 3 days)
1.23
1.23. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 23: Severity of postoperative pain (2 to 3 days sensitivity analysis)
1.24
1.24. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 24: Severity of postoperative pain (4 to 7 days)
1.25
1.25. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 25: Severity of postoperative pain (4 to 7 days sensitivity analysis)
1.26
1.26. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 26: Days until analgesics no longer required
1.27
1.27. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 27: Days until analgesics no longer required (sensitivity analysis)
1.28
1.28. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 28: Return to normal diet
1.29
1.29. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 29: Return to normal diet (sensitivity analysis)
1.30
1.30. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 30: Return to normal activity
1.31
1.31. Analysis
Comparison 1: Tonsillectomy versus tonsillotomy, Outcome 31: Return to normal activity (sensitivity analysis)
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD011365

References

References to studies included in this review

Beriat 2013 {published data only}
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Chaidas 2013 {published data only}
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Korkmaz 2008 {published data only}
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References to studies excluded from this review

Babademez 2011 {published data only}
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References to ongoing studies

NCT01676181 {published data only}
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References to other published versions of this review

Blackshaw 2014
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