Tonsillectomy in adults—to do or not to do

Abstract

Recurrent acute tonsillitis describes the repeated occurrence of acute bacterial infections of palatine tonsils with symptom-free intervals. Acute tonsillitis accounts for around a third of respiratory tract infections in primary care among people of all ages, 1 Petersen I Johnson AM Islam A Duckworth G Livermore DM Hayward AC Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007; 335: 982 Crossref PubMed Scopus (210) Google Scholar with an estimated 600 million symptomatic cases of group A streptococcus tonsillitis worldwide annually. 2 Carapetis JR Steer AC Mulholland EK Weber M The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005; 5: 685-694 Summary Full Text Full Text PDF PubMed Scopus (1995) Google Scholar Recurrent episodes occur in 12% of patients with tonsillitis—ie, around 12 000 per 100 000 people. 3 Kvestad E Kværner KJ Røysamb E Tambs K Harris JR Magnus P Heritability of recurrent tonsillitis. Arch Otolaryngol Head Neck Surg. 2005; 131: 383-387 Crossref PubMed Scopus (26) Google Scholar Beyond the relation to group A streptococcus infections, little is known about risk factors for the development of recurrent acute tonsillitis. 4 Roberts AL Connolly KL Kirse DJ et al. Detection of group A Streptococcus in tonsils from pediatric patients reveals high rate of asymptomatic streptococcal carriage. BMC Pediatr. 2012; 12: 3 Crossref PubMed Scopus (97) Google Scholar Recurrent acute tonsillitis could be a genetic immunosusceptibility disease because patients younger than 12 years show some subclinical antibody deficiency and aberrant T-cell function 5 Dan JM Havenar-Daughton C Kendric K et al. Recurrent group A Streptococcus tonsillitis is an immunosusceptibility disease involving antibody deficiency and aberrant TFH cells. Sci Transl Med. 2019; 11eaau3776 Crossref PubMed Scopus (1) Google Scholar and many undergo tonsillectomy. More than 30 000 tonsillectomies are performed annually in the UK. 6 Keltie K Donne A Daniel M et al. Paediatric tonsillectomy in England: a cohort study of clinical practice and outcomes using Hospital Episode Statistics data (2008–2019). Clin Otolaryngol. 2021; 46: 552-561 Crossref PubMed Scopus (16) Google Scholar Tonsillectomy can produce severe postoperative pain, complicated by postoperative bleeding which can result in death in rare cases. Clearly, we need evidence-based policies to guide health-care professionals for the indication of tonsillectomy. 7 Mandavia R Schilder AGM Dimitriadis PA Mossialos E Addressing the challenges in tonsillectomy research to inform health care policy: a review. JAMA Otolaryngol Head Neck Surg. 2017; 143: 943-947 Crossref PubMed Scopus (10) Google Scholar Unfortunately, not much has changed in the past 40 years. National guidelines are still based on the Paradise criteria from 1984, 8 Paradise JL Bluestone CD Bachman RZ 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: 674-683 Crossref PubMed Google Scholar stating that a tonsillectomy is indicated when around seven or more treated tonsillitis episodes occur in 1 year. The Paradise criteria were based on paediatrics clinical trials and later extrapolated for adult guidelines without any justifying research in the adult population. Thus, the 2014 Cochrane Review concluded that the effectiveness of tonsillectomy is low. 9 Burton MJ Glasziou PP Chong LY Venekamp RP Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014; 2014CD001802 PubMed Google Scholar Until now, there was no basis to make confident decisions using national guidelines. 7 Mandavia R Schilder AGM Dimitriadis PA Mossialos E Addressing the challenges in tonsillectomy research to inform health care policy: a review. JAMA Otolaryngol Head Neck Surg. 2017; 143: 943-947 Crossref PubMed Scopus (10) Google Scholar Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trialCompared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. Full-Text PDF Open Access