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Abstract Objective: To evaluate the effect of the recently published pediatric tonsillectomy and polysomnography clinical guidelines on current practice patterns. Design: Survey of members of the American Academy of Otolaryngology – Head & Neck Surgery Setting: Tertiary medical center. Results: 93% of respondents read the Guidelines. Most respondents had completed a Pediatric Otolaryngology fellowship (84%). A small majority of physicians (54%) continue to prescribe antibiotics within 24 hours after surgery. One-third of respondents stopped prescribing antibiotics because of the new guidelines. Discord between severity of symptoms and tonsil size was the most common reason cited for ordering a polysomnogram prior to tonsillectomy (76%) in concordance with the Guideline’s recommendations. The most common reason cited for admission post-tonsillectomy was age less than three (40%). Less than half of physicians prescribe NSAID’s for pain control (45%) despite its safety profile and only 23% reported that the Guidelines influenced their use of NSAID’s postoperatively. Most respondents use intra-operative steroids (90%) as recommended. Conclusion: The Guidelines are intended to provide evidence based direction in tonsillectomy practices and improve referral patterns for polysomnography prior to tonsillectomy. A majority of the surveyed Otolaryngologists reviewed these guidelines. There is some evidence practice has changed secondary to the Guidelines.those using bronchodilators or anti-reflux medication. Introduction Clinical Practice Guidelines are commonly published with the intent to provide a consensus on management of patients as directed by evidence based medicine. The American Academy of Otolaryngology – Head & Neck Surgery has recently published two sets of guidelines regarding the second most common procedure performed by practicing Otolaryngologists, tonsillectomy 1 . The impact of these guidelines however may not be as great as intended. Results Survey Discussion Most Otolaryngologists read the Clinical Practice Guidelines. In situations where physicians were not in concordance with guidelines, 23-30% changed their practice Depending on the category, up to half of Otolaryngologists do not change their practice. A Dutch survey completed in 2012 found that non adherence to Otolaryngology guidelines was 45% 5 . Younger physicians were found to be more compliant according to previous reports 5 . As has been previously published, the practice of physicians is largely anecdotal and based upon prior experiences and training. The Clinical Practice Guidelines impact patient care, but to a less extent than most might assume. Conclusion This study was completed to evaluate whether practicing Otolaryngologists and specifically those dealing with the pediatric patient change their practice based upon the published Clinical Practice Guidelines. Compliance rates were similar to adherence rates published previously among Otolaryngologists 4-6 . Overall, physicians report that the Clinical Practice Guidelines affect their practice in some categories however not in others. References 1. Setabutr D, Adil EA, Adil TK, Carr MM. Emerging trends in tonsillectomy. Otolaryngol Head Neck Surg. 2011 Aug;145(2):223-9. 2. Baugh RF, Archer SM, Mitchell RB, et al. Clinical Practice Guideline: Tonsillectomy in Children. Otolaryngol Head Neck Surg. Dec 31, 2010 vol. 144 no. 1 suppl S1- S30. 3. Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, Kuhar S, Mitchell RB, Seidman MD, Sheldon SH, Jones S, Robertson P; American Academy of Otolaryngology—Head and Neck Surgery Foundation. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jul;145(1 Suppl):S1- 15. Epub 2011 Jun 15. 4. Farias M, Friedman KG, Powell AJ, de Ferranti SD, Marshall AC, Brown DW, Kulik TJ. Dynamic Evolution of Practice Guidelines: Analysis of Deviations From Assessment and Management Plans. Pediatrics. 2012 Jun 4. [Epub ahead of print] 5. Aarts MC, van der Heijden GJ, Siegers C, Grolman W, Rovers MM. Awareness of, opinions about, and adherence to evidence-based guidelines in otorhinolaryngology. Arch Otolaryngol Head Neck Surg. 2012 Feb;138(2):148-52. 6. Reuveni H, Asher E, Greenberg D, Press J, Bilenko N, Leibovitz E. Adherence to therapeutic guidelines for acute otitis media in children younger than 2 years. Int J Pediatr Otorhinolaryngol. 2006 Feb;70(2):267-73. Epub 2005 Aug 15. No Antibiotics 54% Administer Antibiotics 46% Antibiotic Use Is this a change since the guidelines? Yes 31% No 69% Yes 44% No 56% Do you recommend NSAIDs for post-operative pain control? Is this a change since the guidelines? Yes 23% No 77% 0 10 20 30 40 50 60 70 80 90 Yes, all the time No Sometimes Is this a change since the guidelines? Yes 2.5% No 97.5% 0 10 20 30 40 50 60 70 80 Age < 3 Age < 2 Age < 1 Obesity Trisomy 21 Mucopolysacharidosis Sickle cell anemia Craniofacial abnormalities Patients with small tonsils and SDB sx Unclear sx I do not order PSG Percent Which category of patients do you order polysomnograms for? Do you administer intraoperative steroids? 34 21 36 16 46 40 8 16 0 10 20 30 40 50 60 Routine admissions n = 278 n = 278 Reason for admitting patients post-tonsillectomy. Guidelines Reviewed Clinicians should not routinely administer or prescribe peri-operative antibiotics to children undergoing tonsillectomy. NSAIDs did not significantly increase the rate of bleeding following tonsillectomy. Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. Before performing tonsillectomy, the clinician should refer children with sleep-disordered breathing (SDB) for polysomnography (PSG) if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. The clinician should advocate for PSG prior to tonsillectomy for SDB in children without any of the comorbidities listed in prior statement for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of SDB. Clinicians should admit children with OSA documented in results of PSG for inpatient, overnight monitoring after tonsillectomy, if they are under age 3 years or have severe OSA (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). Methods A 15-question survey was distributed to members of the American Academy of Otolaryngology-Head and Neck Surgery.
