Research Gaps - Tonsillectomy in Children
While there is a body of literature from which guidelines were drawn, significant gaps remain in knowledge about pre-, intra-, and postoperative care in children who undergo tonsillectomy. As determined by the guideline panel’s review of the literature, assessment of current clinical practices, and determination of evidence gaps, research needs were determined as follows:
Investigate the treatment of recurrent throat infections by tonsillectomy versus antibiotics/watchful waiting (<12 and >12 months) using a multicenter randomized controlled trial design and including the following endpoints: QoL, health care utilization, missed school days, parental satisfaction, and recurrence of throat infections.
Conduct prospective cohort studies on indications for PSG in children with oSDB and other comorbidities.
Measure QoL and school performance (not just missed school days) following tonsillectomy in children with mild oSDB and those with recurrent infections whose history does not meet the Paradise criteria.
Determine if the 12-month watchful waiting period causes unnecessary morbidity based on QoL and school performance measures.
Determine the optimal follow-up schedule for oSDB following tonsillectomy.
Determine when postoperative polysomnogram is indicated after tonsillectomy for oSDB.
Determine when a preoperative polysomnogram is indicated.
Determine percentage of patients who have full resolution, partial resolution, or no resolution of OSA posttonsillectomy in the short and long term.
Assess how future weight gain or obesity play a role in failure to respond following tonsillectomy for OSA.
Assess the immunologic role of the tonsils and, specifically, at what point the benefits of tonsillectomy exceed the harm, using a biomarker approach.
Determine the cost-effectiveness (direct and indirect) of different tonsillectomy techniques.
Evaluate and compare oral postoperative pain medications.
To increase the value of future research, key stakeholders need to develop a unified set of core outcomes that are important to children and those who care for them after tonsillectomy.
Determine the optimal regimen for treating PONV in children who have received dexamethasone.
Investigate microbiologic and immunologic changes associated with tonsillectomy to provide a reasonable pathophysiologic explanation for perceived improvement with surgical intervention through a change in oropharyngeal and/or nasopharyngeal biofilms or flora.
Assess for areas of improvement on the postoperative coordination between the primary care provider and otolaryngologist.
Evaluate the impact and use of the guideline by determining how the guideline translates to performance measurement and performance improvement.
Evaluate shared decision making in tonsillectomy, specifically how to present risks and benefits in a quantitative or qualitative way to nonmedical individuals.
Defining the polysomnographic parameters that predispose children to having respiratory complications.
Self-monitoring of postoperative bleeding rates yearly.
Studies are required to determine if the risk of postoperative complications can be stratified to the patient’s disease severity as defined by PSG. This is important not only for otherwise healthy children but also for patients with Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, mucopolysaccharidoses, and obesity.
The degree to which overweight and/or obesity correlates with OSA severity as measured by PSG should be determined. PSG parameters that correlate with respiratory compromise perioperatively in obese children undergoing tonsillectomy should also be examined.
A large-scale prospective study should be conducted to determine the ability of PSG to predict surgical outcomes—specifically, to determine whether PSG parameters reliably predict the resolution of OSA after surgical intervention. This type of study would also be beneficial for predicting when tonsillectomy would be ineffective or potentially dangerous in the management of OSA.
Develop validated severity scales for PSG to benefit inpatient hospital admission and perioperative monitoring in children with severe OSA.
Study the impact of PSG findings (severity, including normal) on the need for additional pre- and postoperative evaluation and testing of children with or without OSA. Studies are needed to determine who would benefit from postoperative PSG.
Study the relationship between PSG findings (severity) and the perioperative management of children with OSA.
Outcomes study to determine the optimal anesthetic management to reduce the rate of postoperative complications in light of PSG findings (severity).
Study the role of portable monitoring in children with oSDB. This is of particular importance to patients who may lack access to a sleep laboratory and to those children who have difficulty sleeping in a foreign environment.
Additional studies of intraoperative anesthetic parameters such as end tidal CO2 may show promise in predicting postoperative respiratory complications in patients with SDB.
Studying the appropriate in-hospital monitoring setting among monitored bed, intensive care unit, and extended postanesthesia care unit stay.