Supraglottic airway devices versus endotracheal tube in children undergoing adenotonsillectomy – A systematic review and meta-analysis

Background and Aims: The use of supraglottic airway devices (SGADs) is still controversial in paediatric otorhinolaryngological surgeries. We conducted this review and analysis to compare SGADs to endotracheal tubes (ETTs) regarding the feasibility of their use in children. Methods: Randomised controlled trials (RCTs) that compared SGADs versus ETTs in patients ≤18 years undergoing adenotonsillectomy surgery under general anaesthesia were searched from PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Embase till November 2024 and re-examined on 31 August 2025. The primary outcome measure was conversion from SGAD to ETT, and other outcomes included comparison of perioperative respiratory adverse events, laryngospasm, and surgical time. Results: Six trials ( n = 750) were included in the analysis. The failure rate of SGAD was 6.5% [95% confidence interval (CI): 2.2, 0.9%, P = 0.001]. The odds ratio of developing [perioperative respiratory adverse event (PRAE) with SGAD was significantly less than the ETT odds ratio (OR) 0.55 (95% CI: 0.36, 0.82, P = 0.004)]. There was a statistically similar incidence of laryngospasm with OR 0.84 (95% CI: 0.39, 1.81). No difference was found in the operating times with a mean difference of 0.82 mins (95% CI: -2.08, 3.72). The level of evidence was graded as moderate to low. Conclusion: SGADs are a feasible alternative to ETT in paediatric adenotonsillectomy with an anticipated failure rate of 6.5%. Larger and more rigorous RCTs are needed to establish the safety of these airway devices in terms of PRAE and efficacy in terms of duration of surgery in comparison to ETTs.