BMJ  2007;334:909 (5 May), doi:10.1136/bmj.39184.617049.80

Editorials

Recurrent pharyngo-tonsillitis

Tonsillectomy has some benefits over watchful waiting, but the net benefit is unclear and research into longer term outcomes is needed

In this week's BMJ, a randomised controlled trial by Alho and colleagues assesses the effectiveness and safety of tonsillectomy compared with watchful waiting in adults with recurrent streptococcal pharyngo-tonsillitis (three episodes of pharyngitis in six months or four in 12 months).¹ Although the minority of patients presenting to general practitioners with tonsillitis have recurrent tonsillitis, about 12% of the population has recurrent tonsillitis at some stage,² and a substantial familial element exists.² The trial found that tonsillectomy significantly reduced the recurrence of the principal outcome, streptococcal pharyngitis, at 90 days (1/36 (3%) v 8/34 (21%); adjusted relative risk 21%, 95% confidence interval 6% to 36%; number needed to treat 5, 3 to 16). A systematic review of tonsillectomy for chronic tonsillitis found limited data to support tonsillectomy in children and no data in adults,³ so the trial is the first to provide evidence to help doctors and patients decide on the best course of action.

Despite these promising results, the trial does have limitations that make it difficult to apply the results to a clinical setting. The main problem is that the follow-up period of six months is relatively short, and people in the watchful waiting group reported considerable improvement during the trial period—after six months the mean number of episodes of sore throats was 2.1, and patients had on average had 12 days of sore throat. This begs the question of whether the benefit of immediate tonsillectomy would be reduced if the follow-up was longer. Secondly, because of the small size of the trial, the effect sizes were imprecise and confidence intervals were wide. Thus the trial is consistent with as small a benefit as a 3% reduction in episodes of sore throat (number needed to treat 34). A third limitation is that we do not know how severe the episodes of pharyngitis were. The authors provide some data on the number of days with a sore throat, but because patients were encouraged to consult to have swabs taken, it is difficult to judge severity on the basis of consultation data. The episodes of sore throat lasted six days, which suggests that they were shorter than normal episodes presenting to general practitioners (where on average patients have had symptoms for three days before they present and symptoms last for a further five days⁴). Another issue relates to the chosen primary outcome measure of a reduction in streptococcal pharyngitis confirmed by culture, which is perhaps of limited clinical use as patients do not complain of streptococcal pharyngitis but of sore throats. More useful to clinicians and patients, is that the authors documented a reduction of 25% in episodes of sore throat (56% v 31%), and a sore throat for nine days less in the first 90 days of the follow-up period.

Any benefits of the operation must be balanced against potential disadvantages. The major disadvantage documented in the trial is the 13 days of sore throat after tonsillectomy, which can be severe in many patients.¹ Other disadvantages include the risks associated with an anaesthetic, otalgia, dehydration, dental injuries, burns, and soft tissue injuries, and a risk of life threatening complications, such as major haemorrhage or sepsis (mortality rates range from one in 16 000 to one in 35 000).⁵ The trial is underpowered to quantify the risk of these complications accurately, and although only minor bleeding was seen after tonsillectomy, more severe but rarer complications are probably of greater concern to patients.

What is the take home message for clinicians? Until the longer term outcomes in people who do not have surgery are available, and we have more precise estimates of the benefit in terms of the severity of the episodes prevented by surgery, it is difficult to provide firm advice to patients. Until such evidence is available, I would advise patients who have had four episodes of sore throat in one year or three in six months that they are likely to have on average two episodes (12 days) of sore throat in the next six months and two or three days of fever if they decide not to have the operation; if they decide to have the operation they are likely to have about 13 days of severe pain immediately after surgery, and then on average half an episode (3 days) of sore throat in the next six months and half a day of fever. I would also make them aware that they might have minor postoperative complications and very rarely life threatening complications.

University of Southampton, Aldermoor Health Centre, Southampton SO16 55T

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

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.39140.632604.55[Abstract/Free Full Text]
2. Kvestad E, Kvaerner K, Roysamb E, Tambs K, Harris J, Magnus P. Heritability of recurrent tonsillitis. Arch Otolaryngol Head Neck Surg 2005;131:383-7.[Abstract/Free Full Text]
3. Burton M, Towler B, Glasziou P. Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2007;(1):CD001802.
4. Little PS, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. An open randomised trial of prescribing strategies for sore throat. BMJ 1997;314:722-7.[Abstract/Free Full Text]
5. Randall D, Hoffer E. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998;118:61-8.[CrossRef][ISI][Medline]

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