8/1/2016
Tonsillectomy Techniques and
Outcomes
David J. Beste, MD
Pediatric Otolaryngology
Department of Otolaryngology and
Communication Sciences
August 6-9, 2016 | The American Club | Kohler, WI
Outcomes legal definition
• Noun - achievement, aftereffect,
aftermath, answer, attainment, close,
completion, consequence, creation,
culmination, decision, denouement,
development, effect, end, end product,
ending, eventuation, finding, finish, fruit,
fruition, fulfillment, issue, judgment,
offspring, outgrowth, etc., etc, etc.
August 6-9, 2016 | The American Club | Kohler, WI
Outcomes definition business
• Determination and evaluation of the
results of an activity, plan, process, or
program and their comparison with the
intended or projected results. See also
output measure.
August 6-9, 2016 | The American Club | Kohler, WI
1
8/1/2016
Outcomes Research definition
• Outcomes research was defined in 1998
as “the study of the end results of health
services that takes patients' experiences,
preferences, and values into account …
intended to provide scientific evidence
relating to decisions made by all who
participate in health care.”1
August 6-9, 2016 | The American Club | Kohler, WI
Draft : Effectiveness comparative
review, 2016
Tonsillectomy for Obstructive
Sleep-Disordered Breathing or
Recurrent Throat Infection in
Children
Agency for Healthcare Research
and Quality
US Department of Health and
Human services
August 6-9, 2016 | The American Club | Kohler, WI
Review Database from 1980-Aug
2015
Comparative studies for:
• Tonsillectomy
• Perioperative medications
• Postoperative medications for painrelated outcomes
• Case series and database or registry
studies with > 1000 children to address
harms
August 6-9, 2016 | The American Club | Kohler, WI
2
8/1/2016
State of the Tonsillectomy literature
• 197 unique studies addressing benefits
and harms
– Tonsillectomy, adenotonsillectomy, partial
tonsillectomy, tonsillotomy
– 136 randomized controlled studies (RCT), 10
nonrandomized CT, 6 prospective, 4
retrospective cohort, 18 database or registry
studies, 23 case series,
August 6-9, 2016 | The American Club | Kohler, WI
Tonsillectomy or adenotonsillectomy versus non‐surgical treatment for
chronic/recurrent acute tonsillitis
Cochrane Database of Systematic Reviews
19 NOV 2014 DOI: 10.1002/14651858.CD001802.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001802.pub3/full#CD001802‐fig‐0003
5 Key questions were asked
1. Effectiveness of Tonsillectomy vs no
surgery for OSDB
– Neuromuscular or craniofacial abnormalities
– Under 3 years of age
– Down Syndrome
– Obesity
August 6-9, 2016 | The American Club | Kohler, WI
3
8/1/2016
5 Key questions were asked
2. Effectiveness of tonsillectomy vs No
surgery for recurrent throat infections
3. Effectiveness of partial vs Total
tonsillectomy
4. Effectiveness of surgical techniques
5. Effectiveness of perioperative medications
to improve outcomes.
August 6-9, 2016 | The American Club | Kohler, WI
Obstructive Sleep disordered
Breathing - OSBD
Tonsillectomy versus no intervention
Most studies reported Better sleep related
outcomes with tonsillectomy
Improvements moderate and mixed
Tonsillectomy versus CPAP
Few studies but no superiority over CPAP
Few studies about special populations
(e.g. Down’s syndrome, obesity)
August 6-9, 2016 | The American Club | Kohler, WI
Recurrent Throat infection
Definition
• 5 or more episodes of true tonsillitis a year
• Symptoms for at least a year
• Episodes that are disabling and prevent
normal functioning.
– Lack of consensus on “disabling symptoms”
August 6-9, 2016 | The American Club | Kohler, WI
4
8/1/2016
Recurrent Throat infections
• Tonsillectomy versus no surgery (still
getting medical care)
– First year postoperatively, improvement in
number of infections, associated utilization,
(clinician visits), days of school/work missed,
quality of life
– “Benefits diminished over time, however, and
data on longer term outcomes are limited.
August 6-9, 2016 | The American Club | Kohler, WI
Techniques of tonsillectomy
• “Hot” vs Cold
tonsillectomy
dissection
– “Hot”, i.e. coblation
and electrocautery
– “Hot” - Faster recovery
• Partial vs Total
Tonsillectomy
– Partial associated with
faster recovery, i.e.
return to normal diet
and activity
– Partial has risk of
regrowth requiring
reoperation
August 6-9, 2016 | The American Club | Kohler, WI
Bleeding related harms with
tonsillectomy
• Low rate (<4% in meta-analysis)
August 6-9, 2016 | The American Club | Kohler, WI
5
8/1/2016
Perioperative care in tonsillectomy
Dexamethasone
Preemptive anti-emetics
• Less need for rescue
analgesia
• Reduced bleeding
• Less need for
postoperative antiemetics
Postoperative medications
• Few studies addressed the same agents
or outcomes
August 6-9, 2016 | The American Club | Kohler, WI
References
1.
http://www.businessdictionary.com/definition/outcomemeasure.html#ixzz4E6TTZ1FM
Clancy CM, Eisenberg JM. Outcomes research: measuring
the end results of health care. Science. 1998;282:245–246.
3. Draft : Effectiveness comparative review, 2016
Tonsillectomy for Obstructive Sleep-Disordered Breathing or
Recurrent Throat Infection in Children, Agency for Healthcare
Research and Quality, US Department of Health and Human
services, http://effectivehealthcare.ahrq.gov/search-for-guidesreviews-andreports/?pageaction=displayproduct&productid=2141
2.
August 6-9, 2016 | The American Club | Kohler, WI
6