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Few evidence-based tonsillectomies performed in UK
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Few children in the U.K. underwent evidence-based tonsillectomy and most likely did not benefit from the procedure, according to findings recently published in the British Journal of General Practice.
“Evidence indicates tonsillectomy results in modest, short-term reductions in recurrent sore throats in severely affected children (aged 3 to 15 years) but is not worthwhile in less severely affected children. U.K. and U.S. evidence-based guidelines therefore suggest offering tonsillectomy for children with seven or more documented sore throats in 1 year; five or more yearly in 2 successive years; or three or more yearly in 3 successive years: the Paradise criteria,” Dana Sumilo, DPhil, FFPH, and research fellow at Institute of Applied Health Research at the University of Birmingham, England, and colleagues wrote.
“Sore throats should be characterized by at least one of the following: lymphadenopathy, tonsillar pus, fever, or evidence of streptococcal infection,” they added.
Researchers studied electronic medical records of 1,630,807 children aged 0 to 15 years followed up for 7,200,159 person-years between 2005 and 2016.
Sumilo and colleagues found incidence of evidence-based indications for tonsillectomy was 4.2 per 1,000 person-years, but 13.6% (2,144/15,760) underwent tonsillectomy. In addition, incidence of childhood tonsillectomy was 2.5 per 1,000 person-years, even though 11.7% (2,144/18,281) had indications largely consistent with Paradise criteria. The proportion of evidence-based tonsillectomies did not change during the period studied.
Clinicians should consider the recommended criteria and the likelihood of benefit for the patient when discussing options with patients and parents, according to researchers.
“Because they are undertaken on children who do not benefit, most tonsillectomies may cause more harm than good. This is ethically dubious and not a good use of resources. Most children meeting evidence-based criteria do not undergo tonsillectomy, therefore, it cannot be considered a necessity,” Sumilo and colleagues wrote.
“Doctors should already be informing parents of the likely effectiveness of tonsillectomy, and should now also inform them that most children with either recurrent sore throats or sleep apnea do not undergo tonsillectomy and have no need to,” they added. – by Janel Miller
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Donald Solomon, MD
It is important to note that in the U.K., most tonsillectomies are performed for recurrent sore throats, whereas only about 20% to 30% of tonsillectomies here in the U.S. in children younger than 15 years of age are for done for that purpose. Most tonsillectomies in children that live in the U.S. are performed to help them with their obstructive sleep apnea.
Even with that caveat, primary care physicians and pediatricians often face a lot of pressure from parents to perform tonsillectomies if their child(ren) get one or two sore throats or strep throats a year. However, it is important to note that these medical conditions are not always a sign that a tonsillectomy is warranted.
Groups like the American Academy of Otolaryngology–Head and Neck Surgery have guidelines that specifically state that only after a patient has a sore throat in concert with fever, positive strep throat, swollen lymph nodes on the neck and/or ulcerations/exudate on the tonsils seven times in 1 year, five times 2 years in a row and three times, 3 years in a row, is it time to start thinking a tonsillectomy may be appropriate to alleviate the sore throats and strep throats. PCPs and pediatricians can refer patients to these guidelines. Or the PCP and pediatrician can bring in an otolaryngologist or surgeon to bolster the reasoning for their argument. Parents should also be made aware of the risks for tonsillectomy surgery including bleeding and in rare instances, death. Sometimes that is enough to convince parents to hold off on this surgery when it does not meet the strict criteria for the procedure.
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