Background

Adenotonsillectomy is a common surgical procedure performed on the pediatric population for either sleep apnea syndrome or chronic infections. The surgical removal of the palatine and/or pharyngeal tonsils has been associated with symptom relief; however, there is often a concomitant postoperative morbidity such as pain, hemorrhage or infection.1,2 Therefore, careful patient selection is vital prior to undergoing surgery.

Waldeyer's tonsillar ring is an annular arrangement of lymphoid tissue consisting of palatine, pharyngeal, lingual and tubal tonsils. These tonsils are mucosa-associated lymphoid tissues considered the first line of defense against exogenous pathogens through the production of immunoglobulins and B cells.3 The palatine tonsils are located in the tonsillar fossae between the palatoglossus and palatopharyngeus muscle, whereas the pharyngeal tonsils, or adenoids, are lymphoid tissues located on the posterior pharyngeal wall of the nasopharynx. Both these groups of tonsils can be surgically removed when associated with either recurrent infection or sleep-disordered breathing (SDB) secondary to tonsillar hypertrophy.

Recurrent infection of the palatine tonsils typically present as chronic tonsillitis or peritonsillar abscesses. These recurrent infections greatly affect the quality of life (QoL) of patients as they suffer from odynophagia, decreased oral intake and systemic symptoms.4 The indication for tonsillectomy in these patients is typically guided by a combination of clinician assessment and the Paradise criteria.5 Sleep-disordered breathing ranges from simple snoring to obstructive sleep apnea with distressing consequences such as growth impairment and neurocognitive deficits.6 As symptoms are commonly secondary to adenotonsillar hypertrophy with associated partial airway occlusion, surgical resection has been demonstrated to be associated with symptom improvement.7

Post-adenotonsillectomy morbidity is a common occurrence reported by both patients and carers. Postoperative pain is the most commonly reported symptom associated with decreased oral intake and re-admission for hydration and analgesia.8 Furthermore, post-tonsillectomy hemorrhage occurs in approximately 3% of patients, with potentially devastating outcomes such as death.9 Quality of life questionnaires are a useful assessment tool capable of encompassing a range of factors by reporting subjective patient-centered outcomes. These questionnaires are capable of measuring a patient's subjective assessment of the impact of an illness or treatment on their physical, psychological and general wellbeing.10 Quality of life questionnaires routinely employed in otolaryngology head and neck surgery are designed to measure a quantitative change in perception of the patient's QoL. There are generic and disease-specific questionnaires utilized in assessing the patient's QoL after tonsillectomy. Generic questionnaires are designed and validated to be utilized in a pediatric population across a range of diseases and interventions. They are capable of assessing a broad range of domains consisting of physical and emotional health, whereas disease-specific questionnaires are designed to be utilized in pediatric patients with SDB or chronic tonsillitis. The domains have a specific focus on disease processes and symptoms, such as sleep disturbance, breathing difficulties and feeding issues.11,12 Quality of life questionnaires appear to be typically heterogenous as they have been designed for specific conditions across specific pediatric age groups and also focus upon differing domains. Furthermore, not all QoL questionnaires are applicable to all indications of tonsillectomies.12,13 Due to these notable differences, the authors have chosen to conduct a scoping review to provide a descriptive overview of the currently utilized QoL questionnaires. As each QoL questionnaire has been designed and tested on specific patients and diseases, researchers must be familiar with indications and parameters of questionnaires utilized to ensure that they are used for the appropriate study. Prior to developing the present review protocol, the following sources were examined to identify the existence of any previously published or currently underway systematic reviews or scoping reviews on a similar or identical topic: MEDLINE (PubMed), CINAHL, Embase and Cochrane Database of Systematic Reviews. No relevant reviews were located. This proposed scoping review will follow the approach recommended by the Joanna Briggs Institute.14-17 The scoping review methodology was chosen for its suitability for addressing our proposed topic, namely, the comprehensive identification and assessment of QoL questionnaires utilized in pediatric patients undergoing tonsillectomy for chronic tonsillitis or SDB used in clinical practice that have been described in the published literature.

The current review aims to ascertain which QoL questionnaires are utilized in this population of patients, with the goal of guiding clinicians and researchers in choosing the most appropriate instrument.14-17 Furthermore, once the QoL questionnaires have been identified, the questionnaires will be summarized into the various components including frequency of use, indication for its use, target population, validity, responsiveness, ease of use, administrative burden and psychometric properties.10

Inclusion criteria

Types of participants

The participants of interest for this review will be pediatric patients 16 years of age or younger undergoing tonsillectomy with or without adenoidectomy for chronic tonsillitis or SDB. Chronic tonsillitis is defined as recurrent infections of the palatine tonsils.18 Sleep-disordered breathing ranges from upper airway resistance syndrome to obstructive sleep apnea syndrome diagnosed via history and clinical examination with or without a sleep study.12

Concept

Quality of life questionnaires utilized for patients following tonsillectomies for chronic tonsillitis or SDB will be identified and reviewed. The QoL questionnaires utilized in the studies must be in English. Components of the questionnaires assessed will include frequency of use, age parameters, respondent and domains assessed. Respondent refers to the one who completes the questionnaire, typically for the younger child this is completed via the parent as a surrogate responder or via a structured interview with a trained interviewer. Questionnaire format will be stratified into the number of items, scale, scoring system and reported time to completion. The number of items refers to the number of questions present in the questionnaire. In addition, QoL questionnaire psychometric assessment will be addressed according to validity, reliability and responsiveness to change. Assessment of psychometric testing was based on the article by Solans et al.19 Validity will be divided into three components: construct validity, content validity and criterion validity. Construct validity ensures that the instrument measures the domain of interest and not associated variables. Content validity describes the appropriateness of the items employed to measure the construct of interest. Criterion validity is defined as the extent to which the instrument is compared to an external marker of "gold standard."19 Reliability is defined as the consistency and reproducibility of an instrument's results. This is measured by the instruments test-retest reliability and internal consistency of Cronbach's [alpha] >= 0.7.20 The questionnaires will be grouped into generic and disease-specific questionnaires. The goal of this review is to identify questionnaires available for use in this target population and summarize the important components. This scoping review will help guide clinicians in choosing the most appropriate instrument for their tonsillectomy study.

Context

The context of this review will be settings with pediatric patients undergoing tonsillectomies for chronic tonsillitis or SDB and where quantitative QoL questionnaires are used pre- and/or postoperatively by parents or caregivers of patients treated with tonsillectomies or adenotonsillectomies.

Sources

The current review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. Quality of life questionnaires utilized in reviews and conference abstracts will not be included to avoid duplication of data. Unpublished and gray literature will not be included in this review, as this review will focus on quantitative questionnaires that have undergone psychometric testing and validated for pediatric patients undergoing tonsillectomy for chronic tonsillitis or SDB.

Search strategy

The search strategy will aim to find published studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE (PubMed) and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all included reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. The search will be conducted from the inception of each included databases to the present. The databases to be searched include MEDLINE (PubMed), CINAHL, Embase and Cochrane CENTRAL. The initial search strategy that will be used when searching the MEDLINE (PubMed) database is presented in Appendix I. The authors have chosen not to search gray literature as it is deemed not likely to result in additional evidence due to the goal of identifying validated QoL questionnaires. The authors of primary studies will be contacted if there are missing data.

Methods

Extraction of results

Data extraction will focus on all the quantitative QoL questionnaires utilized on pediatric patients who have undergone tonsillectomies with or without adenoidectomies for chronic tonsillitis or SDB. Key information to be extracted will include the target population and indication of questionnaire. Furthermore, various components of each QoL questionnaire will be extracted and summarized. Components reviewed include frequency of use in studies, age parameters, respondent, number of items assessed, scale, scoring system, domains assessed, validity, reliability and responsiveness to change. The extraction form is presented in Appendix II.

Presentation of results

All the questionnaires will be presented in a table with frequency of usage and components assessed. In addition, a narrative summary of each questionnaire will be included to provide further detail. This review will provide a detailed summary of QoL questionnaires utilized in pediatric tonsillectomies to quantify the change in QoL for pediatric patients undergoing tonsillectomy for tonsillitis or SDB. The findings from this review will be useful for surgeons to select an appropriate generic and/or disease-specific QoL questionnaire for their pediatric tonsillectomy study.

Appendix I: Initial search (PubMed)

Tonsillectomy[mh] OR Tonsillectom^*[tw] OR Adenoidectomy[mh] OR Adenoidectom^*[tw] OR

Adenotonsillectom^*[tw] OR Tonsil^*[tw] OR Palatine tonsil^*[tw] OR Palatal tonsil^*[tw] OR Pharyngeal tonsil^*[tw] OR Pharynx tonsil^*[tw] OR Adenoid^*[tw]

AND

Paediatrics[mh] OR Paediatric^*[tw] OR Pediatric^*[tw] OR Child[mh] OR Child^*[tw] OR Infant[mh] OR Infant^*[tw] OR Toddler^*[tw] OR Adolescent[mh] OR Adolescen^*[tw] OR Youth^*[tw] OR Juvenile^*[tw]

AND

Quality of life[mh] OR Quality of life[tw] OR Quality-of-life[tw] OR Quality of lives[tw] OR Quality-of-lives[tw] OR Qualities of life[tw] OR Qualities-of-life[tw] OR Qualities of lives[tw] OR Qualities-of-lives[tw] OR Life qualit^*[tw] OR Quality of life assessment[tw] OR Quality of life index[tw] OR QOL[tw] OR HRQL[tw] OR Surveys and Questionnaire[mh] OR Questionnaire^*[tw] OR Survey^*[tw] OR Patient report^*[tw] OR Patient-report^*[tw]

Appendix II: Data extraction form

References