By Philip R. Fischer, MD, DTM&H

Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN

Dr. Fischer reports no financial relationships relevant to this field of study.

SYNOPSIS: For children with recurrent throat infections, tonsillectomy leads to fewer throat infections and less school absence during the first post-operative year (as compared to similar children who did not undergo tonsillectomy). However, beneficial effects of surgery do not persist over time.

SOURCE: Morad A, Sathe NA, Francis DO, et al. Tonsillectomy versus watchful waiting for recurrent throat infection: A systematic review. Pediatrics 2017;139:e20163490.

Tonsillectomy often is performed for recurrent throat infections. Research studies of beneficial outcomes of tonsillectomy, however, have used varied definitions of “recurrent infections,” measures of outcomes, and durations of follow-up. Morad and colleagues, therefore, undertook a rigorous systematic review of the literature to determine the actual benefits of tonsillectomy for recurrent infection.

A comprehensive review of the English-language literature centered on tonsillectomy and throat infections. Comparative studies were included, whether the investigations were randomized, controlled trials or either prospective or retrospective cohort studies. The initial broad search identified 9,608 article citations. Seven studies met inclusion criteria and were assessed to have only low or moderate risk of bias. Of these seven studies that were included in the analysis, four were randomized, controlled trials, one was a non-randomized trial, and two were retrospective cohort studies. These seven studies were published during the years 2002 to 2015.

The reviewed studies revealed important findings. Children undergoing tonsillectomy had fewer recorded days of sore throat during the year after the procedure than did children managed medically (1.0 episode per month prior to the intervention or starting time, 0.50 vs. 0.64 sore throat episodes during the first follow-up year). After tonsillectomy, children had 1.74 medical visits for sore throat during the first post-operative year as compared to 2.93 in similar patients not treated surgically. Children who did not have their tonsils removed were 3.1 times more likely to test positive for group A streptococci than those treated with tonsillectomy. There was less missed school during the first year of follow-up if patients were treated with tonsillectomy; there was no statistically significant difference in school absence between groups during the second and third years of follow-up. There were not enough large studies with good follow-up over multiple years to identify any lasting benefit of tonsillectomy in reducing infections after the first post-operative year.

Three studies reported quality-of-life data. There were no differences in measured quality of life between the surgical and non-surgical treatment groups.

The researchers concluded that “tonsillectomy can produce short-term reduction in throat infections compared with no surgery in children” with recurrent throat infections during the preceding one to three years and that there were also fewer missed school days and fewer medical visits needed in the children treated surgically. However, these beneficial effects did not persist after the first post-treatment year.

COMMENTARY

Why do some of us climb mountains? Because they are there. And, why do some surgeons remove tonsils? As the semi-tongue-in-cheek joke responds, because they are there.

Tonsillectomy, with or without adenoidectomy, is one of the most common surgical procedures in the United States. The current tonsillectomy “rate” is approximately two per 1,000 children.1

In fact, recurrent throat infection is accepted as an appropriate indication for tonsillectomy in children. Morad and colleagues have contributed to our understanding and clinical care by rigorously reviewing decades of outcomes literature and, in the process, quantifying the actual benefits of tonsillectomy.

Indeed, for children with at least three throat infections per year prior to surgery, tonsillectomy was associated with reduced infection and reduced school absence during the first post-tonsillectomy year. All children, as they aged, had some reduction in infection and absence, but the reductions were more marked in the children treated surgically.

This new systematic review did not look at complications of tonsillectomy. Of course, any benefit even extending through the first post-operative year must be balanced against potential complications. Tonsillectomy does carry cost, a slight risk of serious complications, and relatively frequent (about 20%) risks for significant discomfort, poor oral intake, and bleeding.1 Sub-total intracapsular tonsillectomy has lower complication rates, but it is not yet known whether application of this previously used new-again approach is equally effective in reducing throat infections.1

Recurrent infection is not, however, the only indication for tonsillectomy. In fact, more tonsillectomies now are performed for obstructive rather than infectious indications.2 Some of Morad’s colleagues concurrently reported a systematic review of benefits of tonsillectomy for sleep-disordered breathing and found good short-term improvement in sleep outcomes compared with no surgery in children with obstructive sleep-disordered breathing.3 Again, evidence of longer-term favorable outcomes was lacking.3

Tonsillectomy often is combined with adenoidectomy, especially in young children. The combined surgical procedures can help improve drainage of ear fluid and decrease risks for hearing loss in patients with persistent otitis media with effusion.4

What do parents think? Some parents have doubts about the value of subjecting a child to tonsillectomy. A recent report found that parents with doubts entering the operation are more likely to regret having the operation afterward.5 This is a reminder that physicians and parents considering tonsillectomy for a child should be fully informed and confident pre-operatively to avoid whatever regrets might follow later.

REFERENCES

  1. Rubinstein BJ, Derkay CS. Rethinking surgical technique and priorities for pediatric tonsillectomy. Am J Otolaryngol 2017; in press. doi: 10.1016/j.amjoto.2017.01.011.
  2. Bochner RE, Gangar M, Belamarich PF. A clinical approach to tonsillitis, tonsillar hypertrophy, and peritonsillar and retropharyngeal abscesses. Pediatr Rev 2017;38:81-92.
  3. Chinnadurai S, Jordan AK, Sathe NA, et al. Tonsillectomy for obstructive sleep-disordered breathing: A meta-analysis. Pediatrics 2017;139:e20163491.
  4. Wallace IF, Berkman ND, Lohr KN, et al. Surgical treatments for otitis media with effusion: A systematic review. Pediatrics 2014;133:296-311.
  5. Carr MM, Derr JB, Karikari K. Decisional conflict and regret in parents whose children undergo tonsillectomy. Otolaryngol Head Neck Surg 2016;155:863-868.