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

Mr. Burton was lead author, along with another colleague, of the most recently published systematic review of tonsillectomy or adenotonsillectomy versus nonsurgical treatment for chronic-recurrent acute tonsillitis.2 A compendium of five RCTs with a total of 719 children and 70 adult participants, the review did reveal a modest advantage for tonsillectomy over nonsurgical treatment-and this was for the children with the most serious disease according to the Pittsburgh criteria. As is often observed in clinical practice, however, many children with more moderate infections simply got better over time without surgery. This review, published in January, was an updated version of an earlier review examining the same question, and was slightly more definitive. Even though the 2009 review revealed a modest effect for removing the tonsils in the subgroup of severely affected children, its conclusions do not tell the full story, said Mr. Burton. The predictability of postoperative sore throat episodes may actually be a gain for parents and families, he said, and might be preferred over the disruptive effects of the unpredictable illness episodes over the span of a year.

Even systematic reviews do not offer answers that are clearly black or white, said Mr. Burton. Earlier, he pointed out another drawback of relying on RCTs and systematic reviews for definitive answers regarding tonsillectomy. Sample sizes are often too small to detect rare outcomes, he said. (This was the case for a Cochrane review comparing surgical techniques.3) To tease out rare outcomes, one can turn to other study designs, which, although not randomized, are a perfectly legitimate vehicle for deciphering this information. One such example was the National Prospective Tonsillectomy Audit, conducted in the UK between July 2003 and July 2004, which included more than 30,000 patients. The data, said Mr. Burton, are the best we will ever get to answer the question, ‘What are the risks of rare events after tonsillectomy?’ The results from the audit revealed that, compared to cold steel dissection, a variety of different surgical techniques (including monothermy, diathermy, and coblation) all carried much higher risks of postoperative hemorrhage. The risk of hemorrhage after coblation, for example, was three times higher than after cold steel dissection.

When presenting these data, Mr. Burton invited his audience to consider the tradeoffs implicit in their surgical decisions. If you could show that your new technique or new wonderful instrument was better in terms of less pain, how much better does it have to be to warrant an increase in hemorrhage? I don’t know the answer to that, he admitted, but you need to ask that question for yourselves.