Watchful waiting is useful for children with recurrent throat infections

doi:10.1136/bmj.329.7467.654

BMJ 2004;329:654 (18 September), doi:10.1136/bmj.329.7467.654

Commentary

Watchful waiting is useful for children with recurrent throat infections

Paul Little, professor of primary care research¹

¹ Primary Medical Care, Community Clinical Sciences Division, Southampton University, Aldermoor Health Centre, Southampton SO16 5ST psl3{at}soton.ac.uk

Van Staaij et al's study is a welcome addition to a controversialsubject.¹ It shows that for children with moderately frequentthroat infections (on average three in the previous year) a"wait and see" approach results in acceptable control of symptomsand avoids postoperative pain and complications (1% requiringoperative surgery for haemorrhage, and 2.6% having severe nauseaor dehydration). The major limitation of the study is the largenumber of children from the watchful waiting group who had tonsillectomy(34%). Since a per protocol analysis was not done—thatis, comparing those who had tonsillectomy with those who didnot, controlling for severity indices—it cannot be concludedthat tonsillectomy in itself is ineffective but simply thatimmediate tonsillectomy is not effective. The data from thistrial, however, match data from a similar trial, which reportedlittle symptomatic benefit and a significant rate of complications(7%) among children who had tonsillectomy for more severe symptoms.²

Should children with more severe symptoms be offered surgery?With the normal caveats about subgroup analysis, there was someevidence from Van Staaij et al's trial that those more severelyaffected (three or more infections a year) had some benefitfrom immediate tonsillectomy—one less episode of sorethroat. The earlier Paradise trial assessed tonsillectomy amongselected children with severe symptoms³—the "Paradise"criteria of seven or more throat infections in the precedingyear, or five or more a year for each of the preceding two years,or three or more a year for each of the preceding three years.This trial showed a reduction of around one episode, rated asmoderate or severe (3 of 38 surgical patients v 41 of 35 controls);however, the trial was small and was criticised by the Cochranereview for imbalances of important baseline characteristics(the author argued that this was unlikely to affect inferences).⁴

Given the paucity of evidence and controversy about existingevidence, more data are clearly needed on tonsillectomy amongchildren with recurrent throat infections, and particularlydata on non-surgical approaches. Until this evidence is availableit would be reasonable for doctors to share with parents theprobable benefits of surgery—among children with the Paradisecriteria, one less episode of moderately severe or severe sorethroat a year; among children with at least three infectionsin the past year, one less episode of sore throat a year—butalso the important harms of operation—a complication rateof 4-7%. For the remaining children, doctors should probablynot offer tonsillectomy.

Competing interests. PL has been paid for two consultancy sessionsfrom Abbott Pharmaceuticals for antibiotics for complicationsof respiratory tract infections.

References

Van Staaij BK, van den Akker, EH, Rovers MM, Hordijk GJ, Hoes AW, Schilder AGM. Effectiveness of adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy: open, randomised controlled trial. BMJ 2004;
Paradise J, Bluestone C, Colborn D, Bernard B, Rockette H, Kurs-Lasky M. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002;110: 7-15.[Abstract/Free Full Text]
Paradise J, Bluestone C, Bachman R, Colborn D, Bernard B, Taylor F, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310: 674-83.[Abstract]
Burton M, Towler B, Glasziou P. Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2000;(2): CD001802.