Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis

For the current issue of the Journal, we asked Dr Hamdy El-Hakim to comment on and put into context the recent Cochrane Review on tonsillectomy (Ts) or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Surgical removal of the tonsils, with or without adenoidectomy (adeno-/tonsillectomy), is a common Otolaryngology Head & Neck Surgery (ORL-HNS) operation, but the indications for surgery are controversial. This is an update of a Cochrane Review first published in The Cochrane Library in Issue 3, 1999 and previously updated in 2009. Randomized controlled trials comparing Ts (with or without adenoidectomy) with non-surgical treatment in adults and children with chronic/recurrent acute tonsillitis. This review includes seven trials with low-to-moderate risk of bias: five undertaken in children (987 participants) and two in adults (156 participants). An eighth trial in adults (40 participants) was at high risk of bias and did not provide any data for analysis. Good information about the effectiveness of adeno-/tonsillectomy is only available for the first year following surgery in children and for a shorter period (5 to 6 months) in adults. We combined data from five trials in children; these trials included children who were ‘severely affected’ (based on the specific ‘Paradise criteria’) and less severely affected. Children who had an adeno-/tonsillectomy had an average of 3 episodes of sore throats (of any severity) in the first postoperative year, compared with 3.6 episodes in the control group with a difference of 0.6 episodes (95% confidence interval [CI] –1 to –0.1; moderate quality evidence). One of the three episodes in the surgical group was the ‘predictable’ one that occurred in the immediate postoperative period. When we analyzed only episodes of moderate/severe sore throat, children who had been more severely affected and had adeno-/tonsillectomy had on average 1.1 episodes of sore throat in the first postoperative year, compared with 1.2 episodes in the control group (low quality evidence). This is not a significant difference, but one episode in the surgical group occured immediately after surgery. Less severely affected children had more episodes of moderate/severe sore throat after surgery (1.2 episodes) than in the control group (0.4 episodes: difference 0.8, 95% CI 0.7 to 0.9), but again one episode was the predictable postoperative episode (moderate quality evidence). Data on the number of sore throat days are only available for moderately affected children and are consistent with the data on episodes. In the first year after surgery, children undergoing surgery had an average of 18 days of sore throat (of which some—between five and seven on average—will be in the immediate postoperative period), compared with 23 days in the control group (difference 5.1 days, 95% CI 2.2 to 8.1; moderate quality evidence). When we pooled the data from two studies in adults (156 participants), there were 3.6 fewer episodes (95% CI 7.9 fewer to 0.70 more; low quality evidence) in the group receiving surgery within 6 months postsurgery. However, statistical heterogeneity was significant. The pooled mean difference for number of days with sore throat in a follow-up period of about 6 months was 10.6 days fewer in favour of the group receiving surgery (95% CI 5.8 fewer to 15.8 fewer; low quality evidence). However, there was also significant statistical heterogeneity in this analysis and the number of days with postoperative pain (which appeared to be on average 13 to 17 days in the two trials) was not included. Given the short duration of follow-up and the differences between studies, we considered the evidence for adults to be of low quality. Two studies in children reported that there was ‘no statistically significant difference’ in quality-of-life outcomes, but the data could not be pooled. One study reported no difference in analgesics consumption. We found no evidence for prescription of antibiotics. Limited data are available from the included studies to quantify the important risks of primary and secondary haemorrhage. Adeno-/tonsillectomy leads to a reduction in the number of episodes of sore throat and days with sore throat in children in the first year after surgery compared with (initial) non-surgical treatment. Children who were more severely affected were more likely to benefit as they had a small reduction in moderate/severe sore throat episodes. The size of the effect is very 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 the procedure. It is clear that some children get better without any surgery, and that while removing the tonsils will always prevent ‘tonsillitis’, the impact of the procedure on ‘sore throats’ due to pharyngitis is much less predictable. Insufficient information is available on the effectiveness of adeno-/tonsillectomy versus non-surgical treatment in adults to draw a firm conclusion. The impact of surgery, as demonstrated in the included studies, is modest. Many participants in the non-surgical group improve spontaneously (although some people randomized to this group do in fact undergo surgery). The potential ‘benefit’ of surgery must be weighed against the risks of the procedure as adeno-/tonsillectomy is associated with a small but significant degree of morbidity in the form of primary and secondary haemorrhage and, even with good analgesia, is particularly uncomfortable for adults. The full text of the Cochrane Review is available in The Cochrane Library: Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Ts or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database of Systematic Reviews 2014, Issue 11, Art. No.: CD001802. DOI: 10.1002/14651858.CD001802.pub3. Perhaps no procedure other than Ts has ever been cited by a head of state (Barack Obama) to exemplify the effect of financial incentives on decision-making in medicine (1). Considering the resources and effort involved and the renewal of evidence on the debatable benefit of Ts, it merits constant surveillance on a wide scale. In general, Canadian data concerning Ts are scarce, and that stratified by age and indication are even harder to find. There is some (relatively outdated) epidemiological data that demonstrated very wide provincial variations in performing Ts in Canada, where Ontario topped the list with over sevenfold the figure from Quebec (2). However, this information was neither stratified by age nor by indication of surgery and did not include outpatient procedures which currently account for the majority of cases. A more recent effort in the UK was dedicated to children’s services, more detailed, and included data from the public and part of the private sectors (3). It demonstrated curiously a similar sevenfold difference across different regions, but with no consistent disparity between rural and urban centres. Further, the authors did not demonstrate a correlation between the two sets of data to potentially suggest that the private sector compensates for the shortage of resources in the public one. While it is expected that practitioners in North America will follow the American Academy of Otolaryngology – Head & Neck Surgery guidelines on the threshold for surgery (4), the debate about the definition for a sore throat, along with the weak evidence on which the guidelines are founded, partly fuels this variability. It seems that in one study, the geographical variability in rates per head of population of several surgeries in the USA actually correlated with the ambiguity of their indications in guidelines (5). It is commonly thought that the factors of scarce resources, the gap between knowledge and practice, a poor knowledge base and insufficient prioritization are responsible for the variability in practices. I personally support the notion that dissemination of local information about the variability is a strong impetus to gain insight and review individual practices leading to change (6), which indicates that periodic audits of high-volume services such as Ts is one key step. Getting back to Canadian facts, information from Quebec (7) and Manitoba (8) demonstrated intra-provincial variability, some of which indicating rural figures fivefold those of the urban counterparts, and a 28% higher paediatric Ts in particular. But the methodology in these studies and others (9) demonstrate the effect of different ways of classifying rural versus urban sites and varying access to tertiary facilities. In the USA, different urban areas exhibited larger differences when compared with one another than when comparing an urban area with the surrounding ‘fringe’ or rural areas. The inclusion of such confounders as age groups, and insurance, may minimize (or explain) the traditional disparity between rural and urban figures. The follow-up meta-analysis by Burton et al. (10) confirms the limited evidence on the effectiveness of Ts/tonsillectomy and adenoidectomy (T&A) in treating recurrent acute or chronic tonsillitis in children. They comment on the ostensible problems of design and execution, some of which may be related to the issues I mentioned earlier. Currently, members of the public have great faith in the age-old operation, and draw implicit support from their family physicians and paediatricians when referred to have the operation. It is time they learn the facts. And it is time we partner with them to improve that situation. Whereas the ‘Paradise criteria’ are known to be watered down by physicians in day-to-day practice, parents are actually able to discern the difference between ‘acute tonsillitis’ and a simpler ‘sore throat’ (11). Tightening the indication to an illness more likely related to the palatine tonsils is a step in the right direction. Additionally, we should work with families to produce an instrument specific for tonsillitis to measure the impact upon their quality of life. Perhaps this might displace the ‘Paradise criteria’. The step that is crucial in my opinion is factual counselling on complications and safety of Ts/T&A. Effectiveness is a term that conveys by default efficacy, safety and cost. Whereas the British societies possess information on bleeding rates after the operation (12,13), North American professional societies have no similar bench-marks. It is also definitely incumbent on individual surgeons to advise the parents on their individual numbers and bear in mind the geographical challenges each case may harbour. Unfortunately, there are no large studies that can enlighten the counselling process regarding the pain associated with Ts/T&A and the best practices of control that would keep it at bay. It is now our duty to change the image of Ts.

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