Intended for healthcare professionals

Rapid response to:

Research

Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39140.632604.55 (Published 03 May 2007) Cite this as: BMJ 2007;334:939

Rapid Response:

Unnecessary tonsillectomy?

Crayford(1 )has questioned Alho et al's(2) assertion that adults
with
documented recurrent episodes of streptococcal pharyngitis are less likely
to
have further throat infections if they had their tonsils removed.
Tomkinson et
al(3) have reinforced our belief that “the jury is still out” on the role
of
tonsillectomy for recurrent sore throats in modern medical practice,
however,
they have referred to their earlier paper(4) on the considerable morbidity
in
patients awaiting tonsillectomy. Freeland and Curley(5) on the other hand

have shown that at least 20 percent of children “grow out” of their
problem
while waiting for tonsillectomy. We believe it is the time to seriously
consider
two interventions.

Firstly, and in the medium term, a definitive multi-centred
randomised
control study is required. We disagree with statements that a placebo or
no
intervention group would be unethical(3). We look to the experiences of
recently completed and soon to be published multi-centre RCT for the
treatment of Bells Palsy (Scottish Bells Palsy Study) which had a true
placebo
group. This national multi-centred trial had the support of ENT
departments
all over Scotland and has produced a study which is a credit to the
authors. In
the case of tonsillectomy for recurrent tonsillitis, the recent
controversy only
strengthens the ethical argument for an RCT. If this study is done at a
national multicentre level over 2 to 3 years, the large numbers enrolled
will
compensate for the inevitable dropout rate. Surely we owe it to our
patients
to ascertain the answer to this question?

Secondly, and in the short term, we need to urgently revisit current
guidelines. Bisset and Russell(6) have demonstrated that areas with less
deprivation (social class 1 and 2) tended to have lower tonsillectomy
rates
than those with more deprivation (classes 3 and 4). In addition the study
demonstrated surgical practice varied greatly among health regions. The
subsequent SIGN guidelines(7) set a standard to overcome some of these
issues and to which ENT Surgeons have practiced to. It is for this reason
that
the Dutch study(8) showing adenotonsillectomy to have no major clinical
benefits over watchful waiting in children with mild symptoms of throat
infections is probably not applicable to current UK practice. However
these
guidelines are now 8 years old, there is much that is new and relevant and
the
need to update is compelling.

Peter Ross

S S Musheer Hussain

Department of Otolaryngology,
Ninewells Hospital & Medical School,
Dundee DD1 9SY

Email musheer.hussain@nhs.net

References

1. Crayford TJB. Time to stop doing tonsillectomies. BMJ 2007; 334: 1019

2. 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;334:939-41

3. Tomkinson A et al. More advice to clinicians. BMJ 2007; 334: 1019

4. Fox R, Tomkinson A, Myers P. Morbidity in patients waiting for
tonsillectomy in Cardiff: a cross sectional study. J Laryngol Otol
2006;120:214-8

5. Freeland AP, Curley JW The consequences of delay in tonsil surgery.
Otolaryngol Clin North Am. 1987 May;20:405-8.

6. Bisset AF, Russell D. Grommets, tonsillectomies, and deprivation in
Scotland. BMJ 1994;308:1129-32.

7. SIGN Publication No. 34 Management of Sore Throat and Indications for
Tonsillectomy 1999 http://www.sign.ac.uk/guidelines/fulltext/34/
index.html Accessed 22.05.07

8. 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; 329:651

Competing interests:
The senior author (SSMH) is a
member of the Council of
British Association of
Otolaryngology Head & Neck
Surgery, The Scottish
Otolaryngological Society and
The Tonsil and Adenoid
subcommittee of the
American Academy of
Otolaryngology-Head & Neck
Surgery. The views expressed
are the authors own and do not
represent those of the above
organisations.

Competing interests: No competing interests

22 May 2007
S S Musheer Hussain
Consultant Otolaryngologist
Peter Ross
Ninewells Hospital & Medical School, Dundee DD1 9SY