Considering Tonsillectomy? Factor in Evidence, Clinical Judgment, Patient Preference

SAN DIEGO-Weighing whether or not to perform tonsillectomy boils down to a balance between benefit and harm, declared Richard Rosenfeld, MD, MPH, at the lively and well-attended miniseminar on evidence-based tonsillectomy at the American Academy of Otolaryngology-Head and Neck Surgery annual meeting here.

The session was designed to help guide otolaryngologists in their decision-making. Even though the surgery is still commonly performed, Dr. Rosenfeld reminded his audience, it remains a nontrivial one.

Dr. Rosenfeld, Chairman and Professor of Otolaryngology at SUNY Downstate Medical Center in Brooklyn, NY, and his co-presenter, Martin J. Burton, MA, DM, of the Department of Otolaryngology- Head and Neck Surgery at Oxford Radcliffe Hospitals in the UK and founding editor of the Cochrane Collaboration ENT Section, summarized the dilemmas surrounding tonsillectomy, including appropriate indications, the most effective surgical methods, perioperative management, and clinical outcomes. Both presenters used humor to good effect during their well-organized presentation designed to introduce a more rational approach to tonsillectomy.

Tonsillectomy is not as common today as it was during the mid-20th century, when 1.5 million tonsillectomies were performed each year in the United States (that number had decreased to approximately 500,000 by 2000). Despite the abundance of research studies-770 randomized controlled trials, more than 440 of which have been published since 2000-there is still uncertainty regarding many aspects of tonsillectomy, including patient selection. Otolaryngologists are familiar with the Pittsburgh criteria advanced by Paradise et al. in the mid 1980s1 (7 throat infections in the past year, 5 per year for two years, or 3 per year for three years) and many use these criteria or a more relaxed version to guide their surgical decision-making.

However, other human and psychological factors can affect surgeons’ decisions. Mr. Burton cited results from a 2000 UK survey questionnaire, in which otolaryngologic surgeons were queried about factors that most influence their decisions to perform tonsillectomy. Surprisingly frank, the respondents reported that 50% of the time, assertive parents determined their decision to opt for a tonsillectomy.

Rarely Black or White

After a brief history of the indications for tonsillectomy-an operation that has existed since ancient times-Mr. Burton offered a panoply of the review efforts designed to ferret out the most appropriate use of tonsillectomy, as well as the best surgical techniques and perioperative management strategies. The Cochrane Collaboration, initiated by Sir Iain Chalmers, conducts systematic reviews of studies to help facilitate rational health care decision making. After comprehensive searches of the medical literature on a designated topic (using databases such as The Cochrane Library, MEDLINE, and EMBASE), editors cull through groups of relevant studies and rate the level of evidence (with randomized controlled trials [RCTs] ranked as level 1 evidence). Findings from studies that meet inclusion criteria (ie, that all address the same research question) are then combined and analyzed in the aggregate in order to arrive at general conclusions about the effects of interventions.