BACKGROUND:

Surgical removal of the tonsils, with or without adenoidectomy (adeno-/tonsillectomy), is a common ENT operation, but the indications for surgery are controversial. This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 1999 and previously updated in 2009.

OBJECTIVES:

To assess the effectiveness of tonsillectomy (with and without adenoidectomy) in children and adults with chronic/recurrent acute tonsillitis in reducing the number and severity of episodes of tonsillitis or sore throat.

SEARCH METHODS:

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 30 June 2014.

SELECTION CRITERIA:

Randomised controlled trials comparing tonsillectomy (with or without adenoidectomy) with non-surgical treatment in adults and children with chronic/recurrent acute tonsillitis.

DATA COLLECTION AND ANALYSIS:

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS:

This review includes seven trials with low to moderate risk of bias: five undertaken in children (987 participants) and two in adults (156 participants). An eighth trial in adults (40 participants) was at high risk of bias and did not provide any data for analysis. Good information about the effectiveness of adeno-/tonsillectomy is only available for the first year following surgery in children and for a shorter period (five to six months) in adults.
We combined data from five trials in children; these trials included children who were 'severely affected' (based on the specific 'Paradise' criteria) and less severely affected. Children who had an adeno-/tonsillectomy had an average of three episodes of sore throats (of any severity) in the first postoperative year, compared to 3.6 episodes in the control group; a difference of 0.6 episodes (95% confidence interval (CI) -1 to -0.1; moderate quality evidence). One of the three episodes in the surgical group was the 'predictable' one that occurred in the immediate postoperative period.
When we analysed only episodes of moderate/severe sore throat, children who had been more severely affected and had adeno-/tonsillectomy had on average 1.1 episodes of sore throat in the first postoperative year, compared with 1.2 episodes in the control group (low quality evidence). This is not a significant difference but one episode in the surgical group was that occurring immediately after surgery.
Less severely affected children had more episodes of moderate/severe sore throat after surgery (1.2 episodes) than in the control group (0.4 episodes: difference 0.8, 95% CI 0.7 to 0.9), but again one episode was the predictable postoperative episode (moderate quality evidence).
Data on the number of sore throat days is only available for moderately affected children and is consistent with the data on episodes. In the first year after surgery children undergoing surgery had an average of 18 days of sore throat (of which some - between five and seven on average - will be in the immediate postoperative period), compared with 23 days in the control group (difference 5.1 days, 95% CI 2.2 to 8.1; moderate quality evidence).
When we pooled the data from two studies in adults (156 participants), there were 3.6 fewer episodes (95% CI 7.9 fewer to 0.70 more; low quality evidence) in the group receiving surgery within six months post-surgery. However, statistical heterogeneity was significant. The pooled mean difference for number of days with sore throat in a follow-up period of about six months was 10.6 days fewer in favour of the group receiving surgery (95% CI 5.8 fewer to 15.8 fewer; low quality evidence). However, there was also significant statistical heterogeneity in this analysis and the number of days with postoperative pain (which appeared to be on average 13 to 17 days in the two trials) was not included. Given the short duration of follow-up and the differences between studies, we considered the evidence for adults to be of low quality.
Two studies in children reported that there was "no statistically significant difference" in quality of life outcomes, but the data could not be pooled. One study reported no difference in analgesics consumption. We found no evidence for prescription of antibiotics.
Limited data are available from the included studies to quantify the important risks of primary and secondary haemorrhage.

AUTHORS' CONCLUSIONS:

Adeno-/tonsillectomy leads to a reduction in the number of episodes of sore throat and days with sore throat in children in the first year after surgery compared to (initial) non-surgical treatment. Children who were more severely affected were more likely to benefit as they had a small reduction in moderate/severe sore throat episodes. The size of the effect is very modest, but there may be a benefit to knowing the precise timing of one episode of pain lasting several days - it occurs immediately after surgery as a direct consequence of the procedure. It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent 'tonsillitis', the impact of the procedure on 'sore throats' due to pharyngitis is much less predictable.
Insufficient information is available on the effectiveness of adeno-/tonsillectomy versus non-surgical treatment in adults to draw a firm conclusion.
The impact of surgery, as demonstrated in the included studies, is modest. Many participants in the non-surgical group improve spontaneously (although some people randomised to this group do in fact undergo surgery). The potential 'benefit' of surgery must be weighed against the risks of the procedure as adeno-/tonsillectomy is associated with a small but significant degree of morbidity in the form of primary and secondary haemorrhage and, even with good analgesia, is particularly uncomfortable for adults.

To determine the economic impact of adult chronic tonsillitis and the economic improvement from adult tonsillectomy, we studied patients who underwent adult tonsillectomy for chronic tonsillitis with the Glasgow Benefit Inventory and a questionnaire for disease severity parameters before and after tonsillectomy. The economic impact of chronic tonsillitis and adult tonsillectomy were computed with a break-even time analysis model. Eighty-three adult patients (average age, 27.3 years) completed the study with an average duration of follow-up of 37.7 months. The patients exhibited a mean improvement in quality of life of +27.54 +/- 4.63 after tonsillectomy according to the Glasgow Benefit Inventory. In the 12 months following the procedure, tonsillectomy resulted in yearly mean decreases in number of weeks on antibiotics by 5.9 weeks, number of workdays missed because of tonsillitis by 8.7 days, and physician visits for tonsillitis by 5.3 visits. In considering the medical costs of tonsillectomy only, the break-even point was found to be 12.7 years, whereas considering the overall economic impact of tonsillectomy resulted in a break-even point of 2.3 years after the procedure. We conclude that tonsillectomy results in significant improvement in quality of life, decreases health-care utilization, and diminishes the economic burden of chronic tonsillitis in the adult patient population.

OBJECTIVES:

We used a retrospective case series to perform a preliminary study to determine the clinical effectiveness and cost-effectiveness of tonsillectomy for recurrent acute tonsillitis.

METHODS:

We studied 25 children and 16 adults who had tonsillectomy for recurrent acute tonsillitis. The adult patients and the children's caregivers were asked to respond to a questionnaire regarding the efficacy of their tonsillectomy. The cost of medical care and the work disability cost for tonsillitis and for tonsillectomy were calculated. We then applied the technique of break-even time analysis to assess when the total health care cost savings from surgery overtook the total cost of tonsillectomy.

RESULTS:

In children, the overall economic costs (medical costs and work-related costs) were recovered at 1.6 years after tonsillectomy (break-even point). In adults, the overall economic costs (medical costs and work-related costs) were recovered at 2.5 years after tonsillectomy (break-even point).

CONCLUSIONS:

Tonsillectomy for recurrent acute tonsillitis is both clinically effective and cost-effective for children and adults in Japan.

BACKGROUND:

The aim of this study was to assess the effect of tonsillectomy in adults with recurrent tonsillitis on their quality of life and on their use of medical resources.

METHOD:

114 patients who had had at least three episodes of acute tonsillitis in the 12 months preceding tonsillectomy were evaluated pre- and postoperatively with a questionnaire developed by the authors, and with the Glasgow Benefit Inventory.

RESULTS:

97 patients (85%) filled out the questionnaires completely. The Glasgow Benefit Inventory revealed an improvement in the overall score (+19) and in the partial scores for general well-being (+18) and physical health (+39). The degree of support from friends and family was unchanged (±0). Significant decreases were observed in visits to a physician, analgesic and antibiotic consumption, days off from work, and episodes of sore throat. The number of visits to a physician because of sore throat decreased from an average of five preoperatively to one postoperatively; the number of episodes of sore throat, from seven to two; and the number of days taken off from work, from twelve to one per year. 65% of the patients surveyed took analgesics for sore throat preoperatively, 7% postoperatively. 95% took antibiotics for sore throat preoperatively, 22% postoperatively.

CONCLUSION:

Although this study had a number of limitations (small size, retrospective design, short follow-up), it was able to show that tonsillectomy for adults with recurrent tonsillitis improves health and quality of life and reduces the need to consume medical resources.

To investigate whether the personal attention paid to a patient can affect his or her subjective recovery from acute tonsillitis, a controlled study was performed on 100 patients consulting a doctor for this disease. At the consultation a randomly assigned experimental group (n = 50) was given more detailed information about the diagnosis, treatment and prognosis and also a more extensive physical examination than a control group (n = 50). At a follow-up interview two days later significantly more of the experimental group felt that their symptoms had improved (P less than 0.005) than the control group, significantly more felt that the treatment had helped them (P less than 0.005) and significantly more felt they had received sufficient information about their illness and treatment (P less than 0.001). A deliberate attempt to maximize the expectation effect was thus shown to influence the clinical course of acute tonsillitis, recorded as the degree of subjective improvement.

The objective of this study was to determine the benefits of tonsillectomy in adult patients with chronic tonsillitis with special emphasis on the influence of age and gender. Cross-sectional survey analysis of patients at least 1 year after undergoing adult tonsillectomy at a university department. We used the Glasgow Benefit Inventory and a specifically constructed illness inventory (Specific Benefits from Tonsillectomy Inventory). One hundred and nine patients completed the survey. Significant improvements were demonstrated in three out of four GBI scores ['total score' (+16.9), 'general health' (+12.9), 'physical functioning' (+46.6), all P<0.0001] and in all SBTI scores ['symptom change' (+58.3), 'reduced use of resources' (+70.9), 'general benefit' (+52.1), all P<0.0001]. Gender did not play a significant role in benefit evaluation whereby younger patients evaluated the surgery as more beneficial than older patients. Adult patients with chronic tonsillitis definitely benefit significantly from tonsillectomy. Younger adult patients perceived greater surgical benefits than older adult patients. Patient gender did not significantly influence tonsillectomy benefit evaluation.

OBJECTIVE:

To compare intracapsular tonsillectomy (IT) and traditional tonsillectomy (TT) in treating recurrent adenotonsillitis or streptococcal pharyngitis.

DESIGN:

Retrospective chart review.

SETTING:

Tertiary care pediatric referral center.

RESULTS:

Of 166 patients who met all inclusion criteria, 117 received TT and 49 received IT. Seventeen TT patients and 8 IT patients were treated at least once postoperatively for streptococcal pharyngitis or tonsillitis. The mean number of infections after surgery in each group did not reach statistical significance (P = 0.295).

CONCLUSION:

There was no difference between the IT and TT groups in postoperative infection rates.

The aim of this study was to determine if children with recurrent tonsillitis are smaller than expected before tonsillectomy and if they have an altered height or weight gain 1 year post-operatively. All (204) children attending the hospital for tonsillectomy with or without adenoidectomy had their height and weight measured pre-operatively and 1 year after operation. The results of 2204 children in local schools were used as a control population. Analysis was by comparison of each population with the Tanner charts. This study suggests that our population of children listed for tonsillectomy were not lighter or smaller than expected before operation but that one year after tonsillectomy, there was an increase in their weight gain. The height gain was no different than expected after operation. Overweight seems to be a medium term complication of tonsillectomy. It may be necessary to redefine the indications for tonsillectomy in children who are already obese.

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