Clinical practice guidelines for pain management after tonsillectomy: Systematic quality appraisal using the AGREE II instrument

Louis Xavier Barrette, Jacob Harris, Emma De Ravin, Eesha Balar, Alvaro G. Moreira, Karthik Rajasekaran

Research output: Contribution to journalReview articlepeer-review

8 Scopus citations


Purpose: We identified and appraised clinical practice guidelines (CPGs) for the management of post-tonsillectomy pain using the Appraisal of Guidelines for Research and Evaluation (AGREE II) guideline research tool. Materials and methods: We conducted a literature search to identify CPGs addressing pain management after tonsillectomy. CPGs meeting inclusion criteria were then appraised by four independent reviewers in six areas of quality, as defined by AGREE II. Scaled domain scores were calculated for each quality domain. Intraclass correlation coefficients (ICC) were calculated in each domain to assess interrater reliability across guideline appraisals. Results: Nine guidelines meeting inclusion criteria were identified from a systematic search of the literature. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline detailing tonsillectomy and postoperative management in pediatric patients received the highest average score, with a mean of 90.1% in the six areas of quality. Three guidelines scored higher than >60% in five domains or more, defining ‘high’ quality per AGREE II: AAO-HNS, Scottish Intercollegiate Guides Network (SIGN), and Ontario Ministry of Health CPGs. The highest-scoring domain was domain 4: Clarity of presentation (87.4%) across guidelines, while the lowest scoring domain was domain 5: Applicability (49.4%). Variability in scaled domain scores between all CPGs was relatively consistent across domains, with a mean standard deviation of 22.4%. The average ICC calculated across all six domains was 0.78, indicating 'strong agreement' between reviewers regarding guideline quality. Conclusion: Of the nine available guidelines detailing pain management following tonsillectomy we identified, only three (33%) were deemed 'high'-quality after appraisal using the AGREE II instrument, suggesting a need for development of novel, methodologically rigorous CPGs.

Original languageEnglish (US)
Article number111091
JournalInternational Journal of Pediatric Otorhinolaryngology
StatePublished - May 2022


  • Clinical practice guidelines
  • Opioid
  • Pediatrics
  • Tonsillectomy

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Otorhinolaryngology


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