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Rapid Responses: Rapid Responses published:
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Applicability of this study to UK practice
- Iain J Nixon (6 May 2007)
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Advice to clinicians in recurrent pharyngo-tonsillitis
- Alun Tomkinson, Rosemary Fox, Specialist Registrar in Public Health Medicine, National Public Health Service for Wales, Cardiff CF10 3NW and Mark Temple, Consultant in Public Health Medicine, National Public Health Service for Wales, Cardiff CF10 3NW (9 May 2007)
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Recurrent pharyngo-tonsillitis and guidelines for clinical practice.
- Moisés A. Santos-Peña MD, Frank C. Alvarez-Li MD, Eduardo M. Curbeira Hernández MDD, Eduardo E. Castillo-Betancourt MDD, Juana Hernández-Fernández MsC (9 May 2007)
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Tonsillectomy is effective for recurrent tonsillitis
- Peter J Robb, Richard Ramsden (15 May 2007)
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Recurrent infection and levamisole
- Md. Mujibur Rahman (17 May 2007)
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Frequency and Criteria for tonsillectomy in adult patients
- Alejandro Díaz-González MD, Jesús Fleites-Wong MD, Bárbara García-Hernández MD, Nelson Geroy-Amador MD, Juana Isabel Hernández-Fernández MsC. (18 May 2007)
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Fusobacterium necrophorum is a treatable cause of recurrent sore throat
- Gavin CKW Koh (18 May 2007)
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Iain J Nixon, SpR ENT West of Scotland Rotation
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I have some concerns regarding the applicability of this paper to current UK practice due to the patients included in the study. The Scottish Intercollegiate Guidelines Network (SIGN), Guideline 32: Management of Sore Throat and Indications for Tonsillectomy considers tonsillectomy reasonable when patients meet all of four criteria: five or more episodes of sore throat per year, symptoms for at least a year, episodes of sore throat are disabling and prevent normal functioning and when sore throats are due to tonsillitis. To be considered for inclusion in this study, patients could have had as few as 3 sore throats in the last 6 months, which fails to meet two of the SIGN criteria. As the editorial by Professor Little points out, it is impossible to judge the severity of symptoms experienced by the patients considered for inclusion. My main concern however is that the participants were not considered to have had tonsillitis, but pharyngitis. I feel that most ENT surgeons would recognise these two conditions as separate clinical entities, with tonsillitis resulting in greater pain, odynophagia, dehydration and systemic upset. Despite a lack of high quality evidence, both ENT surgeons and their patients feel that tonsillectomy offers an improved quality of life in patients suffering from recurrent acute tonsillitis. In my experience however clinicians in the UK do not routinely offer tonsillectomy as a treatment of recurrent sore throats or pharyngitis. Some clinicians specifically record on the preoperative consent form the fact that they have informed the patient that they may continue to suffer from sore throats following the procedure. Although not every patient undergoing tonsillectomy in the UK will meet all the criteria of the SIGN guideline, increasing pressure from the chief medical officer to avoid “unnecessary tonsillectomies” will probably result in more adherence to such published advice. I suspect that UK ENT surgeons will continue to offer tonsillectomy to their patients, although I also suspect that they will select patients who differ from the group included in this study. Competing interests: None declared |
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Alun Tomkinson, Consultant in Otolaryngology and Head & Neck Surgery University Hospital of Wales, Cardiff CF14 4XW, Rosemary Fox, Specialist Registrar in Public Health Medicine, National Public Health Service for Wales, Cardiff CF10 3NW and Mark Temple, Consultant in Public Health Medicine, National Public Health Service for Wales, Cardiff CF10 3NW
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Alho et al have provided some evidence for the potential benefit of tonsillectomy in appropriately selected adult patients1. Little points out some of the limitations of this study and makes a plea for more information on the long term outcomes of patients with chronic / recurrent tonsillitis who do not undergo surgery in the belief that none exists2. Concerns over the safety of single use instruments led to a moratorium in Wales on tonsillectomy. This unintentionally created a cohort of patients who fulfilled the criteria for tonsillectomy but were denied surgery for more than one year following this decision. The morbidity in these patients were examined3. In contrast to Little’s advice to clinicians2 we would suggest that adults presenting as described may expect as many as three or more significant episodes in the forthcoming six months and that these episodes are likely to result in them requiring time off work and further visits to the GP. In contrast to the likely effect of intervention by tonsillectomy, we would not be able to give these patients any indication of if, or when, this was likely to change. The situation appears to be worse in children3. As suggested, there have been no randomised controlled trials that support tonsillectomy in adults but equally there are no studies that support denial of tonsillectomy as an alternative in patients with significant disease. As no test exists to determine if an individual patient will improve with time “watchful waiting” is a used by most clinicians as a diagnostic tool to determine if a patient should be advised to consider surgery. Waiting is not a treatment in itself and there may be considerable morbidity associated with this option in some patients. Ideally, a large scale randomised controlled trial with long term follow up is required to examine the consequences of denying tonsillectomy to patients who previously would have been considered worthy of surgery. However, based on our experience such a study may fail through lack of patient willingness to remain long enough in the control group. Furthermore, given the levels of morbidity measured in these patients and the large volumes of complaints we received from distressed patients and parents who were denied surgery, such a study may even be considered unethical. 1. Alho OP, Koivunen P, Penna T, Teppo H, Koskela M, Luotonen J. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial. BMJ 2007;334(7600):939. 2. Little P. Recurrent pharyngo-tonsillitis. BMJ 2007;334(7600):909. 3. Fox R, Tomkinson A, Myers P. Morbidity in patients waiting for tonsillectomy in Cardiff: a cross sectional study. J Laryngol Otol 2006;120:214-218. Competing interests: None declared |
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Moisés A. Santos-Peña MD, Epidemiology Department Gustavo Aldereguía Lima University Hospital. Cienfuegos, Cuba, Frank C. Alvarez-Li MD, Eduardo M. Curbeira Hernández MDD, Eduardo E. Castillo-Betancourt MDD, Juana Hernández-Fernández MsC
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The discussion of some BMJ publications about recurrent pharyngo- tonsillitis has led the medical staff of our provincial hospital to assess the doctor’s behaviour in regards to this entity. 1,2 For more than a decade, the physicians of our teaching hospital have been working with the guidelines for clinical practice which are permanently up -to-date and their recurrent use is continuously assessed in our institution. These clinical practice guidelines, which are already published, contain an adequate management of adult patients with a diagnosis of streptococcal pharyngo-tonsillitis and establish the surgical criteria for performing tonsillectomy to all these patients who suffer from this disease as well. There is a close relationship between the fulfilment of these guidelines and the successful evolution of the patients. 3 Post tonsillectomy follow up has been satisfactory in 85,23% out of the 79 patients assessed in the outpatient consultation in a 3 year-period after the performance of the surgical procedure. Immediate and mediate post surgical complications were low. There was no need of surgical re- intervention in any tonsillectomized patient. The adequate use of the guidelines for clinical practice by the medical staff favours the satisfactory evolution of these patients and improves the quality of life. References: 1.Little P. Recurrente pharyngo-tonsillitis. BMJ 2007; 334: 909 doi: 10.1136/bmj.39184.617049.80. 2.Alho O-P, Koivunen P, penna T, Teppo H, Koskela M, Luotonen J. Tonsillectomy versus watchful waiting in recurrente streptococcal pharyngitis in audlts: randomised controlled trial. BMJ 2007 doi:10.1136/bmj.39140.632604.55. 3.http//:www.gal.sld.cu/gbpc/orl/faringoamigdalitisrecurente. Competing interests: None declared |
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Peter J Robb, President, British Association for Paediatric Otorhinolaryngology Epsom & St Helier University Hospitals NHS Trust, Richard Ramsden
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14th May 2007 Dear Editor The Alho et al research paper [1] and Professor Little’s editorial [2] in the same edition of the BMJ are a helpful contribution to the continuing debate surrounding the efficacy of tonsillectomy for recurrent tonsillitis. Dr Godlee’s Editors Choice alludes to the emergence of explicit healthcare rationing; [3] tonsillectomy, an operation that improves health but is rarely life saving, will be one of the many procedures that commissioners may choose to exclude from the portfolio of operations they purchase from providers. One of the main difficulties assessing data related to tonsil surgery is the index diagnosis. In the UK, most practitioners delivering primary care do not have access to rapid antigen streptococcal testing kits; the diagnosis of streptococcal tonsillitis is made clinically. For individuals who are referred and receive surgery for recurrent viral pharyngitis, the benefit is small. ENT surgeons in the UK recognise that tonsillectomy will not benefit those with viral sore throats and that surgery is beneficial only in abolishing recurrent acute tonsillitis. In the Alho paper, only one positive rapid antigen test or swab was required to satisfy the inclusion criteria. The absence of trial data in adults and the limited data available [4] for children to support tonsillectomy is a problem of familiarity of the risks and benefits of an operation that has been available for 3000 years. [5] It would be difficult to enthuse a research group to conduct a prospective randomised controlled trial of the efficacy of paracetamol for the treatment of tension headache. The low threshold for tonsillectomy surgery in the Alho et al paper [1] reflects an important difference in the threshold for surgery between the UK and other developed countries in Scandinavia, Europe and the USA. (This may reflect the easier access to primary care and a prescription for antibiotics in the UK). The rate of tonsillectomy in the UK has fallen by 34% in the ten years between 1994-5 and 2004-5. [6] Surgeons in the UK, accepting current guidelines, would not generally consider tonsillectomy after only three episodes in six months or four episodes in twelve months. [7] Discussing the disadvantages of tonsillectomy, Professor Little quotes the many uncommon potential complications. These are not quantified in the original paper. [2] The mortality rate of one in 16 000 to one in 35 000 is data from the United States in the 1990’s. [8] The 2005 UK National Prospective Tonsillectomy Audit reported a mortality in the UK of one in 40 000. [9] The same study reported an average operating time of 22 minutes, shorter than the one hour reported by Alho et al. [1] The 13 day period of post operative pain discussed in both papers is difficult to assess. Four surgeons used two distinctly different surgical techniques, associated with significantly different patterns of post-operative pain. [10] Returning to question of healthcare rationing, will primary care trusts refuse to fund tonsillectomy for recurrent tonsillitis in adults and children? Dr Tim Crayford, President of the Association of Directors of Public Health of the United Kingdom believes that the tonsillectomy is a "placebo operation”, (Crayford T 2007, personal communication), and that the NHS should no longer fund this procedure. It is difficult to credit Dr Crayford’s assertion for an operation that is successful in abolishing tonsillitis in the same way that cholecystectomy abolishes recurrent cholecystitis. We do not recognise his interpretation of a placebo operation. Dr Crayford’s bmj.com Rapid Response asserts that the NHS could save £40m per year by refusing to fund tonsillectomies. [11] Based on his own calculations, this is incorrect and the figure would be nearer £28m. [12] If witholding the operation for adults and children could be justified, this is in the context of an annual NHS budget of approximately £90bn. Accepting the de facto evidence that tonsillectomy abolishes attacks of tonsillitis, consider an adult in the Alho study having three attacks of tonsillitis per year, aged of 30, who elects to have a tonsillectomy. The operation costs about £720. If the patient had not had the operation and continued having attacks three times a year, with three days off work on each occasion until retirement at age 60, this would have resulted in three months total time off work. Excluding the discomfort, ill-health and loss of productivity, the theoretical loss of income would have been £5 000. The primary care consultation and prescription costs for antibiotics and painkillers are close to the index cost of the operation. The risk of mortality is similar to the life-time risk of a fatal car crash. Tonsillectomy appears to be an operation within a public health agenda to save money and meet 18-week pathway targets soon to be introduced. This agenda misunderstands the benefits of the procedure and the overriding driver of patient choice. Tonsillectomy is an operation that patients choose to have. They do so in the certain knowledge that after the post operative pain has subsided, they may have a viral sore throat in the future, but will never have another attack of systemic illness due to tonsillitis. This benefit is life-long and not limited to a year or two after the operation. The longitudinal study Dr Crayford proposes [11] to assess QALY cost and benefit over time would be impracticable to run over a potential period of 80 years or more. Alho et al make a helpful contribution to the debate over the efficacy of tonsillectomy, but why don’t we ask the patients if it worked for them? Surely 40 000 competent parents and individuals each year do not ask to have an operation that doesn’t work? In the UK, the emerging question is whether or not PCT’s will withhold the choice of those who ask for tonsillectomy to stop their attacks of tonsillitis for ever after the operation. Yours faithfully Richard Ramsden FRCS President British Association of Otorhinolaryngology - Head & Neck Surgery Peter J Robb FRCS President British Association for Paediatric Otorhinolaryngology References 1 Alho O-P, Koivunen P, Penna T, Teppo H, Koskela M, Luotonen J. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial. BMJ 2007 doi: 10.1136/bmj. 39140.632604.5. 2 Little P. Recurrent pharyngo-tonsillitis. BMJ 2007 doi: 10.1136/bmj. 39184.617049.80. 3 Godlee F. Editor’s choice: For patient or population? BMJ 2007 doi: 10.1136/bmj.39203.526481.47. 4 Burton M, Towler B, Glasziou P. Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2007; (1):CD001802. 5 Drake A. Tonsillectomy. www.emedicine.com/ent/topic315.htm accessed May 6th 2007. 6 Department of Health Episode Statistics. http://www.hesonline.nhs.uk/ Ease/servlet/ContentServer?siteID=1937&categoryID=410 accessed May 6th 2007. 7 SIGN guideline No. 34. Management of sore throat and indications for tonsillectomy. www.sign.ac.uk accessed January 7th 2007. 8 Randall D, Hoffer E. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998; 118:61-8. 9 National Prospective Tonsillectomy Audit. 2005. Royal College of Surgeons of England. London. 10 Atallah N, Kumar M, Hilali A, Hickey S. Post-operative pain in tonsillectomy: bipolar electrodissection technique versus dissection ligation technique. A double-blind randomized prospective trial. J Laryngol Otol 2000; 114: 667-670. 11 Crayford TJB 2007. http://www.bmj.com/cgi/eletters/ 334/7600/939#163261 Accessed May 6th 2007. 12 Crayford TJB 2007. Informing Healthier Choices. http:// www.swpho.nhs.uk/resource/item.aspx?RID=29828 Accessed May 6th 2007 Competing interests: None declared |
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Md. Mujibur Rahman, Assistant Professor, Microbiology Rangpur Medical College, Bangladesh
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Recurrent infection is a common manifestation of impaired immunity. Recurrent pharyngo- tonsillitis is also mostly is due to impaired immune condition. Repeated antibiotics doses are usual treatment in these cases when no complications present. There are some ideas to correct these impaired immunity by applying drugs and thereby to avoid repeated antibiotics and to avoid complications or surgical intervention. Among all these I preferred levamisole to correct these impaired immunity and I, for the last 19 years treated successfully more than 40 cases of different ages particularly among the children, of different types of recurrent infections including recurrent tonsillitis, sinusitis, recurrent ARI in children, recurrent herpes labialis, soft tissue infection (Job’s syndrome - diagnosed clinically), recurrent dacrocystis in children and some other type of infections. So, recurrent pharyngo-tonsillitis can be easily treated by levamisole to avoid complications or surgery. HIV infection is very rare in our country but I suggest to treat this infection by levamisole because it has been proved that, levamisole obviously can correct cell mediated immunity and so opportunistic infections will be easily opposed in levamisole treated HIV infected patients. Dr. Md. Mujibur Rahman
Competing interests: None declared |
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Alejandro Díaz-González MD, ENT Department Gustavo Aldereguía Lima University Hospital. Cienfuegos, Cuba, Jesús Fleites-Wong MD, Bárbara García-Hernández MD, Nelson Geroy-Amador MD, Juana Isabel Hernández-Fernández MsC.
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After having analysed the BMJ article entitled “Recurrent pharyngo-tonsillitis”1, we would like to share our experience in regards to the topic. For a period of 20 years or more, in my medical practice as an ENT specialist, I have observed the changes in criteria that have ocurred about tonsillectomy either in children and adults since the 80s. From 6 tosillectomies carried out weekly in adult patients as an average in our ENT department the figure has declined markedly in such a way that in the latest years tonsillectomies have been performed once or twice a month in adolescents or early adults ( tonsillectomies due to malignant tumors were not included) and we wonder what has been happening. The answer could be so simple as the controversial points that appear in medical literature with more specific and rigurous indications, consolidation of antibiotic therapy and better knowledge of the immunological role of the tonsils, aspects that have influenced our work, which uses as surgical considerations the recommendations of the guidelines of good clinical practice, guidelines that have been applied in our teaching hospital since the year 2000 and that state as criteria for tosnsillectomy the following: 1-Recurrent infections of acute tonsillitis (5-7 episodes)characterized by fever, poliarthralgias, antibiotics use and medical assistance for a one-year-peroid. These aspects depend on the medical staff experience and medical literature, but without a concluded scientific evidence that assess the efficacy of tonsillectomy. 2,3 It is routine to explain to patients the symptoms they can suffer after tonsillectomy is performed, which include irritation , pharyngeal discomfort for a certain period of time, laryngo-pharigeal-gastric reflux, environmental irritations and the presence of a hypertrophic mucus as a defense response to different noxas including the psychosomatic aspect of the patient. Therefore, we believe that the staff related to this medical topic must continue searching for the best decision to take all factors into account in the management of the adult patient with recurrent tonsillitis who looks for medical assistance in our outpatient department. References: 1-Little,P. Recurrente phryngo-tonsillitis. BMJ 2007;334:909 doi:10.1136/bmj.39184.61049.80 2-http//:www.gal.sld.cu/gbpc/orl/faringoamigdalitisrecurente. 3-Cenjor. C, Ramos A, García-Rodríguez A. Documento de consenso sobre tratamiento antimicrobiano de la faringoamigdalitis. Acta Otorrinolaringol Esp 2003;(54):369-383. Competing interests: None declared |
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Gavin CKW Koh, Visiting Researcher Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
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Alho and colleagues are to be congratulated for their trial which adds useful information to the management of recurrent streptococcal pharyngitis.1 It is probably worth emphasising (as Professor Little pointed out in his editorial) that this study is applicable only to all cases of recurrent streptococcal sore throat, and not to all cases of recurrent sore throat. It seems likely that as many as 21% of recurrent sore throats may be associated with Fusobacterium necrophorum,2 which is well known as the cause of Lemmiere’s Disease and also previously listed in textbooks as a throat commensal,3 but is now known not to be found in healthy people.4 F. necrophorum infection may be treated with a course of metronidazole which terminates the cycle of recurrent sore throats and eliminates the need for tonsillectomy. Current recommended methods of processing of throat swabs in the UK5 will not routinely identify F. necrophorum, as the organism requires longer than 24 hours incubation to grow; the astute clinician may be advised to ask the microbiology laboratory specifically to look for F. necrophorum (by culture or by PCR) in cases of recurrent sore throat where no causative organism has otherwise been found.
1. Alho O-P, Koivunen P, Penna T, Teppo H, Koskela M, Luotonen J. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial. Br Med J 2007;334:939-941. Competing interests: None declared |
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