Jump to comment:
- Page navigation anchor for Criteria for tonsillectomy and evidence of effectivenessCriteria for tonsillectomy and evidence of effectivenessWe did not undertake any updates of systematic reviews. However, we followed an uncontroversial evidence hierarchy: systematic reviews of RCTs (Cochrane reviews), RCTs, then weaker evidence where we exercised judgement in relation to quality. If we have missed any RCTs please let us know and provide us with references. The Cochrane review of obstructive sleep apnoea (OSA) finds moderate quality evidence for subjective outcomes (and polysomnography measures) and no benefit in objective measures. We interpreted this as insufficient evidence as unblinded trials produce biased estimates for subjective outcomes.1,2 Different judgements for all the less common indications - PFAPA, nephropathy, peritonsillar abscess, psoriasis, tonsillar tumour, OSA - make little difference to our conclusions. Adding them to the children meeting Paradise criteria makes only 15.8% of tonsillectomies evidence-based.Only one RCT3 investigated tonsillectomy in children with frequent, but undocumented sore throats. It found tonsillectomy ineffective. Undocumented sore throats could justify tonsillectomy in any of 1,630,807 children in the database. But this is a hard position to defend. Sore throat is common, a small minority consult GPs (the clinical iceberg), without documentation it is impossible to know if there were clinical features of severity. Proponents of an intervention must provide evidence of its effectiveness and safety. Eviden...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Criteria for tonsillectomyCriteria for tonsillectomyWe thank the authors for their response to our letter, but ask the authors to address the main point that we have to make. That is, the article1 rests entirely on the authors’ assessment of what is deemed ‘evidence-based’, yet it is unclear what methodology and criteria have been used in this judgement. This is essential to make meaningful conclusions. To help with this, we would be grateful for the authors to comment on the below issues:1. We requested2 a description of the method of systematic literature review that was used. Without this, the validity of their identification of literature is hard to ascertain. The response stating “the evidence on tonsillectomy for recurrent sore throat has been available for 34 years” is not a sufficiently clear description of their literature review.2. We requested2 an explanation of their criteria for considering that an intervention is evidence-based. Without this, the article can only be viewed in the context of the authors’ expert opinion.Without these clarifications, the following items (among a number of points) are somewhat difficult to understand.3. The author’s basis3 for exc...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Criteria for tonsillectomy - Response to Nash and ChandrasekharanCriteria for tonsillectomy - Response to Nash and Chandrasekharan
Thank you for your interest in our paper. Most of the issues you raise are answered in the paper.
The question of undocumented sore throats was addressed in 1978 and evidence of insufficient effectiveness to justify tonsillectomy in such patients was published in 2002.1,2 The great majority (93%) of sore throats are managed without consulting GPs but these are not indications for surgery.3 Primary care consultations greatly exceed A&E consultations and upper respiratory tract infections rarely present to A&E (see Discussion and eLetter).
In our primary analysis we almost certainly counted too many sore throat consultations as we included consultations for common cold, otitis media and sinusitis just in case sore throat might also have been a feature. Requiring a mention of the throat reduced the proportion evidence-based to 4.4% (see Discussion).Evidence of effectiveness from non-randomised studies is prone to bias. The review of tonsillectomy for obstructive sleep apnoea cited by the correspondents includes cohort studies. The Cochrane review includes only randomised trials and concludes: “high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting”.4 However, even including tonsillectomy for obstructive sleep apnoea only increases the proportion evidence-based to 15.6...Show MoreCompeting Interests: None declared. - Page navigation anchor for Criteria for tonsillectomy - response to ENT UKCriteria for tonsillectomy - response to ENT UKThank you for your interest in our paper.The evidence-based criteria for tonsillectomy derive from a 1984 clinical trial, are summarised in a 1998 systematic review and reiterated in the 2000 Cochrane review.1-3 Evidence of insufficient effectiveness in less severely affected children or those with undocumented sore throats was included (pre-publication) in the 1998 systematic review and published in 2002.4 Lack of awareness of the evidence is an unconvincing defence. We observed no change in pattern of sore throat indications over the 12 years despite changes in guidelines.Most sore throats, evidence suggests about 93%, are indeed managed without GP consultation.5 But undocumented sore throats do not predict future frequent sore throats.6We probably missed few sore throats because there are 300 million general practice attendances but only 23 million A&E attendances yearly and upper respiratory tract infections (URTI) rarely present to A&E 0% (95% CI: 0% to 3.4%) of those requesting treatment for URTI in one study.7,8 Rising hospital presentations for tonsillitis and peritonsillar abscess should be seen in the light of the marked decreases we observed in the much larger number of primary care attendances for recurrent sore throats and peritonsillar abscess....Show MoreCompeting Interests: None declared.
- Page navigation anchor for Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic recordsIncidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic recordsI read the recent article on tonsillectomy1 with interest. Given that the article is based on the authors’ assessment of which indications are evidence based, it is important that the authors describe their method of literature review used to systematically identify evidence, describe the findings of the quoted evidence clearly, and finally also define their criteria for considering an intervention to be evidence based or not. There are a number of points to make in this regard.The authors provide no evidence supporting tonsillectomy for tumour in children, but consider it is evidence based. Yet, they pass over a number of systematic reviews for tonsillectomy in the context of OSA which show benefit.2 The review which they select shows the benefit of adenotonsillectomy in OSA across a range of outcome measures, that persists for at least 7 months after surgery.3 This is relevant as OSA is an increasingly common indication for tonsillectomy4 – comprising 77% of patients’ indication in the USA.5 Furthermore, the current studies of tonsillectomy for sleep apnoea they identify cannot be used to support the authors’ assertions – one of these studies they quote specifically excludes patients with sleep apnoea,6 and another de facto excludes patients with sleep apnoea.7With...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic recordsIncidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic recordsOn behalf of ENT UK we would like to respond to the recent publication in your journal1:1. The current selection criteria have been applied to data from 2000-2016; in 2006, the threshold was 5 episodes/year not 7.2. No consideration was given to time lost from school by sufferers. Seven bouts of tonsillitis probably equates to a potential loss of 10 weeks of school.3. Some parents/patients will self-manage symptoms and then seek a referral.4. Categorising 3-4 and 5-6 episodes of sore throat in 1 year as “non-evidence based” is somewhat arbitrary given points 1 and 2 above.5. The apparent mismatch between “indicated” and “non-indicated” tonsillectomies as a proportion of the “indicated” pool probably reflects the fact that real life is a discussion between the doctor and patient about management.6. A&E attendances for ENT have risen by 0.5% over the last 4 years with an exponential increase in admissions in the last decade for complications related to acute tonsillitis including abscesses and deep neck space infections with the associated morbidity and cost to the health economy.2...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Criteria for tonsillectomyCriteria for tonsillectomyThank you for your interest. As tonsillectomy rates are much lower in Italy than the UK (54.1 versus 92.7 per 100,000 population) our findings may not be applicable to Italy.1We reported how many children met well-established, evidence-based criteria for tonsillectomy, derived from a paper published 34 years ago and referenced in UK, US and Italian guidelines.2,3 Our definition of “sore throat” was very broad, requiring neither evidence of Streptococcal infection, pyrexia, lymphadenopathy, nor tonsillar pus. These were required in the original study. As clinicians may have used broader clinical codes, we counted any upper respiratory tract infection even without any mention of the throat. In a sensitivity analysis when we required a sore throat to be coded the proportion of evidence-based tonsillectomies was 4.4%. Requiring documentation of would have reduced this proportion further. We also considered tonsillectomy evidence-based even if surgery was more than a year after the indication. A previous study found only 0.2% (2 of 863) children had sufficient sore throats in the 3 years prior to surgery.4The Cochrane review concludes the benefits of surgery for recurrent sore throat are modest.5 We included some rare indications for tonsillectomy, notably PFAPA and sore throats with glomerulonephritis or guttate/chronic plaque psoriasis. But...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Tonsillectomy is really outdated?Tonsillectomy is really outdated?We read with interest this extensive retrospective study, however, the analysis conducted shows some criticism due to the lack of some key elements and their clinical implications. Although the study was conducted accurately, above all in consideration of the mean numbers of sore throat episodes, it does not mention the serologic and clinical parameters. Blood samples for routine haematological and serological tests as well as throat swab culture, rapid antigen detection testing (RADT), or antistreptolysin titres (ASOT) are crucial to distinguish between a viral and a bacterial origin and may help identify those children who require specific surgical intervention. Moreover, this well-done analysis should also consider the Centor Score, that uses four signs and symptoms to estimate the probability of acute streptococcal tonsillitis.Furthermore, it is extremely important to evaluate streptococcal infection not only as an exclusively tonsillar problem, but in terms of a complex systemic involvement, as already mentioned by reference of psoriasis. However, references to other diseases related to streptococcal infection are lacking: there is no mention of a severe pathology, known by the acronym of PANDAS (Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection). IT is the acute onset of neuropsychiatric symptoms following Group A beta-haemolytic streptococcal infection. Surgical intervention by means of tonsille...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Long-term effects of tonsillectomyLong-term effects of tonsillectomyThank you for your interest in our analysis.Although personal experience of improvement following tonsillectomy is intuitively compelling, it is not evidence of effectiveness. We can easily cherry pick case studies of specific patients with unusual outcomes: either dramatic improvements or even deaths.1 These tell us as little about overall effectiveness as reports of lottery winners do about the value of investing in a lottery ticket. Recurrent sore throats improve with time and dramatic improvement is common even without surgery. The first clinical trial to show evidence of clinically important improvement with tonsillectomy (in severely affected children) found 14% (95% CI: 7% to 20%) of children in the control group had no sore throats in the next year.2Long-term effects of tonsillectomy were not the subject of our research, so we did not systematically review the research literature. We know of a few large, long-term, follow-up studies of childhood tonsillectomy. A study of 1.2 million Danish children identified an increased risk of developing respiratory, infectious, and allergic conditions including asthma among the 43,207 who underwent tonsillectomy.3 A Tasmanian study observed increased mortality in young adults who previously underwent tonsillectomy.4 An increased risk of autoimmune conditions such as thyroid disease, rheumatic diseas...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic recordsIncidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic recordsDoes the research consider the impact of not carrying out a tonsillectomy in determining this is unnecessary?As a child of the 1950's both my husband and I and our siblings had our tonsils removed before the age of 7 due to repeated tonsillitis as was the practice at the time.By the 1980's tonsillectomy was out of fashion and my son's tonsillitis was left untreated between the ages of 4 and 6 as the GP advice was not to visit the doctor until he had had a temperature for 5 days or more. During this period he began to have respiratory problems, usually at night and attended by an out of hours doctor rather than the GP, culminating in hospitalisation with near fatal asthma at the age of 7. In the preceding 12 month's he was treated with steroids, antibiotics and nebulisers for bronchitic asthma and/or bronchitis. During the hospital episode he presented with type 1 diabetes at the culmination of 4 days of intensive asthma medication which resolved itself but returned as full blown type 1 diabetes 3 years later.Has there been any research to consider whether there is a link between reduced tonsillectomy procedures and increased incidence of asthma over the last 40 years?This research highlights the saving that could be made by not conducting 'unnecessary' tonsillectomy. In my son's case he had 'massively' enlarge...Show MoreCompeting Interests: None declared.