Greater Manchester EUR Policy Statement. Title/Topic: Tonsillectomy Date: April 2014 Last reviewed: May 2015 Reference: GM028

Transcription

1 Greater Manchester EUR Policy Statement Title/Topic: Tonsillectomy Date: April 2014 Last reviewed: May 2015 Reference: GM028

2 VERSION CONTROL Version Date Details Page number /09/2013 Initial draft N/A /09/2013 Inclusion of criteria following discussion at the GM EUR Steering Group meeting on 18/09/ /10/2013 Date of policy changed to October. Policy Summary moved to Introduction in line with template. Absence of Evidence Summary added. Mechanism for Funding paragraph reworded in line with template. Inclusion of Appendix 1 Evidence Review Formatted /10/2013 Section 4, Mandatory criteria changed and where there is a history of: inserted between 2nd and 3rd bullet point to make clear that patients must meet first 2 bullet points and either one of the following /01/2014 Feedback from the consultation reviewed by the Steering Group. 25 people responded to the consultation. Following a review of the comments, the group agreed the following amendments: Obstructive Sleep Apnoea in children has been added to the criteria. The policy criteria has also been reformatted so that it is more explicit. Under Policy Exclusions For adults (> 16 years) has been added to the second paragraph. Addition of reference number 6: ENT UK / RCS Commissioning Guide: Tonsillectomy 2013, including additional reference in Search Strategy and section extract in Appendix N/A 3 & , 11 & /03/ /04/ /03/ /06/2015 Approved at Greater Manchester Heads of Commissioning and Greater Manchester Chief Finance Officers Approved at Greater Manchester Association Governing Group Bolton CCG adopted funding mechanism of IPA. Variance column removed and funding mechanism column added to table. Format of funding mechanism changed. N/A 4 9 2

3 2.0 25/06/2015 Changes made following annual review by GM EUR Steering Group on 20 May 2015: Branding change to North West CSU Evidence Review updated

4 POLICY STATEMENT Title/Topic: Tonsillectomy Issue Date: April 2014 Reviewed: May 2015 Commissioning Recommendation: Tonsillectomy is commissioned for children and adults who meet the following criteria: Sore throats are due to acute tonsillitis and recorded as such in medical notes. AND The episodes of sore throat are disabling and prevent normal functioning. AND Where there is a history of: o Seven or more well documented, clinically significant, adequately treated sore throats in the preceding year OR OR o OR o OR o Five or more such episodes in each of the preceding two years Three or more such episodes in each of the preceding three years A second episode of Quinsy, irrespective of the timescale. Tonsillectomy is the treatment of choice where there is secondary care confirmation of a primary care assessment of Obstructive Sleep Apnoea in a child (< or = 16 years), either on the basis of history and examination or, if necessary, findings from further investigations (e.g. Sleep study). See Section 4: Criteria for Commissioning Date of Review: One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. Prepared By: The North West Commissioning Support Unit Effective Use of Resources Policy Team. 4

5 Approved By Date Approved Funding Mechanism Greater Manchester Effective Use of Resources Steering Group 04/02/2014 GM EUR Steering Group recommended funding mechanism: Funding will be monitored approval via the relevant contracting arrangements and referrals may be accepted in line with the criteria. Where a patient does not meet the above criteria, but their clinical circumstances are deemed to be exceptional, funding will be made available on an individual funding request (exceptional case) basis and funding approval should be sought from the Greater Manchester Commissioning Support Unit IFR Team. Greater Manchester Association of Clinical Commissioning Groups 01/04/2014 N/A Bury Clinical Commissioning Group 04/06/2014 Recommended mechanism above Bolton Clinical Commissioning Group 02/05/2014 Individual Prior Approval for all requests Heywood, Middleton & Rochdale Clinical Commissioning Group Central Manchester Clinical Commissioning Group North Manchester Clinical Commissioning Group 18/07/2014 Recommended mechanism above 02/07/2014 Recommended mechanism above 14/05/2014 Recommended mechanism above Oldham Clinical Commissioning Group 05/06/2014 Recommended mechanism above Salford Clinical Commissioning Group 11/07/2014 Recommended mechanism above South Manchester Clinical Commissioning Group 25/06/2014 Recommended mechanism above Stockport Clinical Commissioning Group 14/05/2014 Recommended mechanism above Tameside & Glossop Clinical Commissioning Group 21/05/2014 Recommended mechanism above Trafford Clinical Commissioning Group 15/07/2014 Recommended mechanism above Wigan Borough Clinical Commissioning Group 21/05/2014 Recommended mechanism above 5

6 CONTENTS Policy Statement... 7 Equality & Equity Statement... 7 Governance Arrangements Introduction Definition Aims and Objectives Criteria for Commissioning Description of Epidemiology and Need Evidence Summary Absence of Evidence Summary Rationale behind the Policy Statement Mechanism for Funding Audit Requirements Documents which have informed this Policy Links to other Policies Date of Review Glossary References Appendix 1 Evidence Review

7 Policy Statement The North West Commissioning Support Unit (NWCSU) has developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester who will commission Tonsillectomy in accordance with the criteria outlined in this document. In creating this policy the NWCSU has reviewed this treatment and the clinical conditions for which it is prescribed. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. Equality & Equity Statement The NWCSU/CCG has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act The NWCSU /CCG is committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, the NWCSU /CCG will have due regard to the different needs of protected equality groups, in line with the Equality Act This document is compliant with the NHS Constitution and the Human Rights Act This applies to all activities for which they are responsible, including policy development, review and implementation. In developing policy the NWCSU policy team will ensure that equity is considered as well as equality. Equity means providing greater resource for those groups of the population with greater needs without disadvantage to any vulnerable group. An Equality Analysis has been carried out on 1 st November For more information about the Equality Analysis, please contact policyfeedback.gmscu@nhs.net. Governance Arrangements Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association Governing Group (AGG). Further details of the governance arrangements can be found in the Greater Manchester EUR Operational Policy. 1. Introduction This commissioning policy has been produced in order to provide and ensure equity, consistency and clarity in the commissioning of Tonsillectomy procedures by Clinical Commissioning Groups in Greater Manchester. When this policy is reviewed all available additional data on outcomes will be included in the review and the policy updated accordingly. 2. Definition Tonsillectomy is a surgical procedure during which the tonsils are removed from either side of the throat. Tonsillectomy is carried out for the management of recurrent tonsillitis in adults and children who meet the current policy criteria. Tonsillitis is an acute infection of the palatine tonsils. 7

8 Episodes last for 5 to 14 days, during which the patient experiences some or all of the following: o Fever o Malaise o Nausea o severe throat pain o white spots on the tonsils o enlarged lymph glands in the neck (and sometimes abdomen) The attacks are common in children and their frequency may reduce with age. 3. Aims and Objectives Aim This policy document aims to specify the conditions under which Tonsillectomy will be routinely commissioned by Clinical Commissioning Groups in Greater Manchester. Objectives To reduce the variation in access to Tonsillectomy. To ensure that Tonsillectomy is commissioned for conditions where there is acceptable evidence of clinical benefit and cost-effectiveness, and are not commissioned where there is evidence to the contrary. To reduce unacceptable variation in the commissioning of Tonsillectomy across Greater Manchester. To promote the cost-effective use of healthcare resources. 4. Criteria for Commissioning Mandatory Criteria Tonsillectomy is commissioned for children and adults who meet the following criteria: Sore throats are due to acute tonsillitis and recorded as such in medical notes. AND The episodes of sore throat are disabling and prevent normal functioning. AND Where there is a history of: o Seven or more well documented, clinically significant, adequately treated sore throats in the preceding year OR o Five or more such episodes in each of the preceding two years OR o Three or more such episodes in each of the preceding three years OR o A second episode of Quinsy, irrespective of the timescale. OR 8

9 Tonsillectomy is the treatment of choice where there is secondary care confirmation of a primary care assessment of Obstructive Sleep Apnoea in a child (< or = 16 years) either on the basis of history and examination or, if necessary, findings from further investigations (e.g. Sleep study). Policy Exclusions This policy does not apply to possible malignant disease of the tonsils which should be managed via the two week pathway. For adults (> 16 years), tonsillectomy for obstructive sleep apnoea will require consideration via the Individual Funding Request (IFR) exceptionality route until such time as a sleep apnoea policy is in place. Clinicians can submit an Individual Funding Request (IFR) if they feel there is a good case for exceptionality. Exceptionality means a person to which the general rule is not applicable. Greater Manchester sets out the following guidance in terms of determining exceptionality; however the over-riding question which the IFR process must answer is whether each patient applying for exceptional funding has demonstrated that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by showing that s/he is: Significantly different to the general population of patients with the condition in question. and as a result of that difference They are likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. 5. Description of Epidemiology and Need Source: BMJ Best Practice In UK general practice, recurrent sore throat has an annual incidence of 100 per 1000 population. In the US, sore throat accounts for 2.1% of ambulatory visits. Acute tonsillitis is more common in children between the ages of 5 and 15 years. The prevalence of bacterial tonsillitis, specifically group A beta-haemolytic streptococci (GABHS), is 15% to 30% of children with sore throat and 5% to 15% of adults with sore throat. Acute tonsillitis is most commonly seen in winter and early spring in temperate climates, although it may occur at any time of the year. 6. Evidence Summary An initial search was carried out of NHS evidence, NICE Guidance and SIGN; as well as BMJ Best Practice and BMJ clinical evidence and the Royal College of Surgeons databases. Full details of the Evidence Review are contained with Appendix Absence of Evidence Summary See Search Strategy Table in Appendix 1. 9

10 8. Rationale behind the Policy Statement There needs to be a period of watchful waiting in the management of sore throat before tonsillectomy is performed. The criteria that define that period for this policy are derived from SIGN 117 with local adaptation in relation to managing quinsy. The rationale for the period of watchful waiting is to find a balance between intervening too early, as episodes of recurrent tonsillitis will diminish over time, and avoiding unnecessary episodes of debilitating illness. There is evidence (Cochrane review of tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent tonsillitis) that tonsillectomy does not always result in total prevention of recurrent sore throats although the numbers of attacks are reduced. The exceptionality route is available for those patients where the episodes are particularly frequent or debilitating and those where tonsillar enlargement is causing difficulties. Applications need to show that these patients will gain more benefit from earlier intervention than their peer group (all patients with recurrent tonsillitis). 9. Mechanism for Funding Clinical Commissioning Group Bury Heywood, Middleton & Rochdale Manchester Central Manchester North Manchester South Oldham Salford Stockport Tameside & Glossop Trafford Wigan Bolton Funding Mechanism Funding will be monitored approval via the relevant contracting arrangements and referrals may be accepted in line with the criteria. Where a patient does not meet the above criteria, but their clinical circumstances are deemed to be exceptional, funding will be made available on an individual funding request (exceptional case) basis and funding approval should be sought from the Greater Manchester Commissioning Support Unit IFR Team. Individual Prior Approval 10. Audit Requirements There is currently no national database. Service providers will be expected to collect and provide audit data on request. 11. Documents which have informed this Policy Greater Manchester Effective Use of Resources Operational policy 12. Links to other Policies This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). 13. Date of Review One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. 10

11 14. Glossary Term BMJ Exceptionality NICE Obstructive Sleep Apnoea Quinsy SIGN Tonsillectomy Tonsillitis Meaning British Medical Journal A person to which the general rule is not applicable (see policy exclusions sections above for a detailed definition). National Institute for Health and Care Excellence A condition that causes interrupted breathing during sleep. An abscess that forms between the tonsils and the wall of the throat also known as a peritonsilar abscess. Scottish Intercollegiate Guidelines Network A surgical procedure during which the tonsils are removed from either side of the throat. An acute infection of the palatine tonsils. References 1. SIGN (Scottish Intercollegiate Guidelines Network): Management of sore throat and indications for tonsillectomy, A national clinical guideline (117) 2. BMJ Clinical Evidence: Tonsillectomy versus no surgery in adults Christos C Georgalas, Neil S Tolley, and Antony Narula Search date: March BMJ Clinical Evidence: Tonsillectomy versus no surgery in children Christos C Georgalas, Neil S Tolley, and Antony Narula Search date: March Cochrane Review of Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis (Cochrane Review) 5. North of England and Scotland Study of Tonsillectomy and Adeno-tonsillectomy in Children (NESSTAC): a pragmatic randomised controlled trial with a parallel non-randomised preference study Health Technol Assess Mar;14(13):1-164, iii-iv. doi: /hta Lock C, Wilson J, Steen N, Eccles M, Mason H, Carrie S, Clarke R, Kubba H, Raine C, Zarod A, Brittain K, Vanoli A, Bond J. Source: Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. 6. ENT UK / RCS Commissioning Guide: Tonsillectomy

12 Appendix 1 Evidence Review (Updated: April 2015) Title/Topic: Tonsillectomy Ref: GM028 Search Strategy Database NICE NHS Evidence Result None related to clinical guidelines but treatment related reviews include IPGs 9,150,178,186,196 and 328 and MTG 11 not cited here No relevant documents found SIGN SIGN 117 Cochrane York Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis (Review) North of England and Scotland Study of Tonsillectomy and Adenotonsillectomy in Children (NESSTAC): a pragmatic randomised controlled trial with a parallel nonrandomised preference study BMJ Clinical Evidence Tonsillitis: Tonsillectomy versus no surgery in adults and Tonsillectomy versus no surgery in children Search date: March 2009 Christos C Georgalas, Neil S Tolley, and Antony Narula Added at review: April 2015: One RCT added to above. Categorisation unchanged (trade off between benefits and harms) Review conclusion still as cited in original evidence summary BMJ Clinical Evidence review: Tonsillectomy: Cold-steel tonsillectomy versus diathermy tonsillectomy (Added at review: April 2015) Christos C. Georgalas, Neil S. Tolley and Professor Anthony Narula Web publication date: 22 July 2014 (based on April 2014 search) (Note: this review is applicable to clinical management rather than commissioning so not cited here) BMJ Best Practice General Search (Google) Medline Patient information from the BMJ Group Tonsillitis (information leaflet not cited below) NHS Choices Quinsy leaflet UHSM guidelines for tonsillectomy (Available on request not cited below) Due to the volume of high quality evidence reviews available the search was restricted to key papers related to the above reviews (not cited below as they support those cited) ENT UK / RCS Commissioning Guide: Tonsillectomy 2013 reference used following feedback from consultation and agreement to include Obstructive Sleep Apnoea in children (<16) as part of the policy. 12

13 Summary of the evidence The key papers relevant to the commissioning of tonsillectomy were the SIGN guidance and the York review. SIGN 117 advocates a period of watchful waiting and suggests that the patient should have had either: 7 episodes of confirmed tonsillitis in the last year 5 episodes a year in the previous 2 years 3 episodes a year in the preceding 3 year period These criteria are based the inclusion criteria for a single trial using best practice criteria from an experienced surgeon. Ref: Paradise JL, Bluestone CD, Bachman RZ. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310(11): Laing MR, McKerrow WS. Adult tonsillectomy. Clin Otolaryngol. SIGN classes the evidence for these criteria as level D (Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+). The benefits of surgery compared to non-surgical treatment was the subject of a Cochrane Collaboration review which provided additional evidence for the SIGN guidance. The consensus is that these criteria help to identify patients most likely to gain benefit from surgical intervention however the evidence level is low at 3/4 and clinical judgement is needed to identify patients where exceptionality applies. The UHSM guidelines and the NHS choices information suggest that tonsillectomy should take place after the second confirmed episode of Quinsy this reduces the risk of complications associated with surgery. Treatment for sleep apnoea was outside the scope of the current review however the Cochrane review of this topic does suggest that in some cases tonsillectomy can correct sleep apnoea in children where the tonsils are very enlarged. The evidence Levels of evidence Level 1 Level 2 Level 3 Level 4 Level 5 Meta-analyses, systematic reviews of randomised controlled trials Randomised controlled trials Case-control or cohort studies Non-analytic studies e.g. case reports, case series Expert opinion 1. Level N/A SIGN (Scottish Intercollegiate Guidelines Network): Management of sore throat and indications for tonsillectomy, A national clinical guideline (117) Extract from: Section 2.3: Surgical Management 13

14 Watchful waiting is more appropriate than tonsillectomy for children with mild sore throats. Tonsillectomy is recommended for recurrent severe sore throat in adults. The following are recommended as indications for consideration of tonsillectomy for recurrent acute sore throat in both children and adults: sore throats are due to acute tonsillitis the episodes of sore throat are disabling and prevent normal functioning seven or more well documented, clinically significant, adequately treated sore throats in the preceding year or five or more such episodes in each of the preceding two years or three or more such episodes in each of the preceding three years. 2. Level 1: Review Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic / recurrent acute tonsillitis (Cochrane Review) This review includes five studies: four undertaken in children (719 participants) and one in adults (70 participants). Good information about the effects of tonsillectomy is only available for children and for effects in the first year following surgery. Children were divided into two subgroups: those who are severely affected (based on specific criteria which are often referred to as the Paradise criteria ) and those less severely affected. For more severely affected children adeno-/tonsillectomy will avoid three unpredictable episodes of any type of sore throat, including one episode of moderate or severe sore throat in the next year. The cost of this is a predictable episode of pain in the immediate postoperative period. Less severely affected children may never have had another severe sore throat anyway and the chance of them so doing is modestly reduced by adeno-/tonsillectomy. For them, surgery will mean having an average of two rather than three unpredictable episodes of any type of sore throat. The cost of this reduction is one inevitable and predictable episode of postoperative pain. The average patient will have 17 rather than 22 sore throat days but some of these 17 days (between five and seven) will be in the immediate postoperative period. Whilst the concept of the average patient is attractive, in practice, wide variability is likely. One reason why the impact of surgery is so modest, is that many untreated patients get better spontaneously. There is a trade-off for the physician and patient who must weigh up a number of different uncertainties: what proportion of my throat symptoms are attributable to my tonsils, and will I get better without any treatment? Similarly, the potential benefit of surgery must be weighed against the risks of the procedure. Authors conclusions Adeno-/tonsillectomy is effective in reducing the number of episodes of sore throat and days with sore throats in children, the gain being more marked in those most severely affected. The size of the effect is modest, but there may be a benefit to knowing the precise timing of one episode of pain lasting several days - it occurs immediately after surgery as a direct consequence of it. It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent tonsillitis, the impact of the procedure on sore throats due to pharyngitis is much less predictable. 3. Level 1: BMJ Clinical Evidence Reviews Tonsillectomy versus no surgery in adults 14

15 Data from one good-quality RCT (albeit with limited follow-up) confirm consensus that tonsillectomy is an effective treatment for adults with severe recurrent sore throat, and that it should be offered to patients unless there are contraindications, despite the absence of strong evidence from RCTs. Tonsillectomy versus no surgery in children The effectiveness of tonsillectomy has to be judged against the potential harms. Tonsillectomy is more beneficial in children with severe symptoms, while in populations with a low incidence of tonsillitis, the modest benefit may be outweighed by the morbidity associated with the surgery. Tonsillectomy is associated with intraoperative and postoperative morbidity, including haemorrhage, while antibiotics are associated with adverse effects, such as rash. The above is taken from three systematic reviews (search dates 1998, 2003, and 2008, respectively), which identified seven RCTs in total. 4. Level 2: Randomised Control Trial North of England and Scotland Study of Tonsillectomy and Adeno-tonsillectomy in Children (NESSTAC): a pragmatic randomised controlled trial with a parallel non-randomised preference study Health Technol Assess Mar;14(13):1-164, iii-iv. doi: /hta Lock C, Wilson J, Steen N, Eccles M, Mason H, Carrie S, Clarke R, Kubba H, Raine C, Zarod A, Brittain K, Vanoli A, Bond J. Source: Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. Abstract: Objectives: To examine the clinical effectiveness and cost-effectiveness of tonsillectomy/adenotonsillectomy in children aged 4-15 years with recurrent sore throats in comparison with standard nonsurgical management. Design: A pragmatic randomised controlled trial with economic analysis comparing surgical intervention with conventional medical treatment in children with recurrent sore throats (trial) and a parallel nonrandomised cohort study (cohort study). Setting: Five secondary care otolaryngology departments located in the north of England or west of Scotland. Participants: 268 (trial: 131 allocated to surgical management; 137 allocated to medical management) and 461 (cohort study: 387 elected to have surgical management; 74 elected to have medical management) children aged between 4 and 15 years on their last birthday with recurrent sore throats. Participants were stratified by age (4-7 years, 8-11 years, years). Interventions: Treatment was tonsillectomy and adeno-tonsillectomy with adenoid curettage and tonsillectomy by dissection or bipolar diathermy according to surgical preference within 12 weeks of randomisation. The control was non-surgical conventional medical treatment only. Main Outcome Measures: The primary clinical outcome was the reported number of episodes of sore throat in the 2 years after entry into the study. Secondary clinical outcomes included: the reported number of episodes of sore throat; number of sore throat-related GP consultations; reported number of symptom-free days; reported severity of sore throats; and surgical and anaesthetic morbidity. In addition 15

16 to the measurement of these clinical outcomes, the impact of the treatment on costs and quality of life was assessed. Results: Of the 1546 children assessed for eligibility, 817 were excluded (531 not meeting inclusion criteria, 286 refused) and 729 enrolled to the trial (268) or cohort study (461). The mean (standard deviation) episode of sore throats per month was in year 1 - cohort medical 0.59 (0.44), cohort surgical 0.71 (0.50), trial medical 0.64 (0.49), trial surgical 0.50 (0.43); and in year 2 - cohort medical 0.38 (0.34), cohort surgical 0.19 (0.36), trial medical 0.33 (0.43), trial surgical 0.13 (0.21). During both years of follow-up, children randomised to surgical management were less likely to record episodes of sore throat than those randomised to medical management; the incidence rate ratios in years 1 and 2 were 0.70 [95% confidence interval (CI) 0.61 to 0.80] and 0.54 (95% CI 0.42 to 0.70) respectively. The incremental cost-effectiveness ratio was estimated as 261 pounds per sore throat avoided (95% confidence interval 161 pounds to 586 pounds). Parents were willing to pay for the successful treatment of their child's recurrent sore throat (mean 8059 pounds). The estimated incremental cost per quality-adjusted life-year (QALY) ranged from 3129 pounds to 6904 pounds per QALY gained. Authors Conclusions: Children and parents exhibited strong preferences for the surgical management of recurrent sore throats. The health of all children with recurrent sore throat improves over time, but trial participants randomised to surgical management tended to experience better outcomes than those randomised to medical management. The limitations of the study due to poor response at follow-up support the continuing careful use of 'watchful waiting' and medical management in both primary and secondary care in line with current clinical guidelines until clear-cut evidence of clinical effectiveness and cost-effectiveness is available. 5. Level N/A ENT UK / RCS Commissioning Guide: Tonsillectomy 2013 Relevant section extract: 1.2 High Value Care Pathway: Children (<16) with sleep disordered breathing Primary care assessment Carefully assess (history and examination) a child with symptoms of significant snoring and disruptive breathing patterns whilst asleep. Make note of large tonsils with or without nasal obstruction. Carefully assess and document impact on development, behaviour and quality of life. Referral If sleep disordered breathing is suspected, refer to secondary care. Secondary care Confirmation of primary care assessment, either on basis of history and examination or, if necessary, findings from further investigations (e.g. Sleep study) Consider impact on quality of life, behaviour and development. Consultation with parent/carers about management options using shared decision making strategies and tools where appropriate. Management options: tonsillectomy or adenotonsillectomy, or, if appropriate, referral to paediatrician or discharge back to primary care. Surgical setting Within a paediatric surgical facility. Children with severe symptoms will need access to paediatric intensive care facilities 16