Introduction
More than 40 000 patients in England and Wales have their tonsils removed each year, of which about 25 000 are children under the age of 16 years.1 The common indications for such surgery are recurrent acute tonsillitis or upper airway obstruction with or without obstructive sleep apnoea. Guidance on the threshold frequency of recurrent tonsillitis at which to recommend surgical tonsillectomy is available both from UK2 and USReference Paradise, Bluestone, Bachman, Colborn, Bernard and Taylor3 sources. A decision to remove the tonsils to treat upper airway obstruction is usually based on the clinical history, in the absence of symptoms of severe obstructive sleep apnoea (in which case specialised investigations (e.g. sleep study, echocardiography and electrocardiography) are indicated).Reference Leong and Davis4
In 2007, Dr T Crayford, President of the Association of Directors of Public Health, recommended that tonsillectomies should no longer be funded for National Health Service (NHS) patients.Reference Crayford5 In a presentation to The Association of Public Health Observatories, Dr Crayford advised that Primary Care Trusts should only commission tonsillectomies in cases of suspected malignancy.6 Dr Crayford was quoted in the popular press as saying,
Tonsillectomies do benefit some individuals but it is a very small number… . Lots of people believe that having their tonsils out did them good, but most research evidence suggests that it probably didn't.7
Method
At our hospital during the period June 2006 to June 2007, 77 children underwent elective tonsillectomy, with or without adenoidectomy or grommet surgery. These 77 children were included in the study. They were aged between three and 17 years; the mean age was 6.25 years. Forty were male and 37 female. Patient details were collected retrospectively from operating records, and the children's parents or guardians were identified from the hospital patient record database.
In order to minimise variation in surgical technique and outcome, only children operated upon by one author (PJR), using Coblation® (ArthroCare Corporation, Austin, TX, USA) dissection, were included in the study. All children were operated upon as day-case patients. A standard day-case anaesthetic technique (the Epsom protocol) was used to minimise the risk of post-operative pain, nausea or vomiting.Reference Ewah, Robb and Raw8 Two children (2.6 per cent) were taken back to the operating theatre on the same day because of reactionary haemorrhage. Two children (2.6 per cent) had a secondary haemorrhage requiring admission to hospital but not further surgical intervention.
Between five and 18 months after the operation, the children's parents (or legal guardians) were posted a structured questionnaire (Appendix 1). Forty-nine parents (63.6 per cent) had responded within 10 weeks of receiving the questionnaire, and these responses were available for analysis.
Results
Of the 77 children undergoing tonsillectomy, the main indication was almost equally split between frequent, recurrent attacks of tonsillitis (33/77) and obstructing tonsils (32/77). Twelve other children were diagnosed as having both recurrent tonsillitis and obstructive tonsils.
Recurrent tonsillitis
Of those children undergoing surgery for recurrent tonsillitis, the majority (95.9 per cent) were reported to have suffered more than three episodes per year (Figure 1).
Fig. 1 Frequency of tonsillitis attacks. Yr = year
Most of the children were reported to have experienced fever, sore throat, difficulty in eating and drinking, trouble with sleeping, and swollen neck glands with each episode. Headache, vomiting and abdominal pain were also frequently reported, and most parents reported observing white spots on the tonsils (as a proxy observation for clinical exudate) (Figure 2).
Fig. 2 Symptoms of tonsillitis episodes.
All but two children were reported as missing time off school with each attack of tonsillitis. Of the time missed, the median period was three to five days, with a range of one day to more than five days.
Twenty-nine parents reported that they always visited their general practitioner or general practice when their child was affected. Of those responding, 43/44 reported that antibiotics were prescribed; for 38/43, this was usually penicillin. The questionnaire did not attempt to identify those children allergic to penicillin or to differentiate between penicillin V and amoxicillin (the latter being relatively contraindicated in a pharyngitis that might be caused by infectious mononucleosis, but being widely prescribed in primary care for this clinical presentation).
Obstructive symptoms
For the children with obstructive tonsillar symptoms, nearly all parents reported snoring with restlessness and sweating at night. Most reported night time waking and tiredness during the day. Other common symptoms reported included choking on food and difficulty eating solids. A significant minority of respondents (12.2 per cent) reported bed-wetting (Figure 3).
Fig. 3 Symptoms of obstructive tonsils.
Following tonsillectomy, the median period of need for regular analgesia was reported as 6–7 days, with seven children requiring regular analgesia for only 2–3 days and one requiring analgesia regularly for up to 28 days.
Of the 47 parents who responded to the question about missed school days due to throat infections since the operation, 42/47 (89 per cent) reported that their child had not missed any school days since the operation. Forty-five of 48 (94 per cent) reported that the health of their child had been better or much better since the operation.
Forty-nine parents responded to the question ‘if you could turn back the clock, would you have chosen to have the operation again?’; 48 answered ‘yes’ and one answered ‘not applicable’.
Thirty-eight of 45 parents reported no problems following the operation which had not been expected from the information booklet routinely sent with the admission letter.
Free text comments
Forty-seven parents added free text comments when completing the questionnaire; 45 of these were positive. One parent expressed anxiety about the experience of their child's secondary haemorrhage and admission to a hub hospital for intravenous antibiotics, and another noted that their child started to snore following the tonsillectomy. Verbatim comments typical of the free text feedback are included as Appendix 2.
Discussion
About 12 per cent of the population suffers recurrent tonsillitis at some stage, and there is a substantial familial element.Reference Little9 Little concluded that, in patients with four sore throats (sic) a year who do not undergo tonsillectomy, two and a half days of sore throat are likely in the next six months; in the long term, this represents five days per year indefinitely. Following tonsillectomy, four episodes of tonsillitis a year is replaced by no episodes ever again. This is analogous to undergoing an appendicectomy; it is impossible to have another episode of appendicitis thereafter. However, the benefits of tonsillectomy must be weighed against the risks of anaesthesia and surgery, including post-tonsillectomy bleeding, with an estimated mortality rate of 1:40 000 or more following tonsillectomy surgery.Reference Windfuhr, Chen and Remmert10
In the literature, much confusion surrounds the primary care diagnosis of acute bacterial tonsillitis. A throat swab has both low sensitivity and specificity in diagnosing haemolytic streptococcal throat infection when compared with the ‘gold standard’ of antistreptolysin O titre testing.Reference Graham and Fahey11, Reference Little and Williamson12 While 90 per cent of patients are well one week after the onset of a sore throat, with or without antibiotics, this fails to address the group with true bacterial tonsillitis.Reference Del Mar, Glasziou and Spinks13
• There is pressure from primary care trusts to decommission routine operations such as tonsillectomy
• The public health view is that tonsillectomy is a placebo operation
• A questionnaire study of parents whose children had undergone tonsillectomy contradicts the view that tonsillectomy is of no benefit
Rapid streptococcal antigen testing is both sensitive and specific, and is recommended by the American Academy of Family Physicians as the best confirmatory test to inform the decision to prescribe or withhold antibiotic treatment in a patient with symptoms of infective sore throat. This test is not routinely available in UK primary care, and this creates a fundamental problem both in managing children with throat infections and in documenting attacks of tonsillitis for those who may be heading toward surgical remedy.
In contrast, when streptococcal throat infections are documented, tonsillectomy is effective, for both adults and children, in abolishing future infections and reducing the need for future medical intervention for pharyngitis from other causes.Reference Alho, Koivunen, Penna, Teppo, Koskela and Luotonen14, Reference Orvidas, St Sauver and Weaver15 There is an improvement in general quality of life, based on the Glasgow benefit inventory assessment tool for health-related quality of life.Reference Schwentner, Höfer, Schmutzhard, Deibl and Sprinzl16
For upper airway obstruction and sleep-disordered breathing, adenotonsillectomy is effective in abolishing symptoms in otherwise healthy children, with a dramatic improvement in respiratory parameters as measured by polysomnography. Quality of life in general also improves following tonsillectomy.Reference Mitchell17 In our group, analysis of the median frequency of attacks of tonsillitis and of school days missed would appear to indicate a significant 35 days illness in a year, with significant school time missed. While both adenoidectomy and tonsillectomy contribute to airway improvement, tonsillectomy is the more symptomatic of the surgical interventions, and its morbidity is easier for parents to assess; for this reason, feedback about adenoidectomy was excluded from the questionnaire.
Conclusions
While a parental questionnaire carries less intrinsic scientific value than a well designed, prospective trial, our results contribute to the debate on the efficacy of tonsillectomy for both recurrent tonsillitis and upper airway obstruction.
Most parents are unwilling to submit their child to general anaesthesia and surgery, and the recognised risks of both, without good reason. Set against these risks is the expectation that the procedure will ultimately be of benefit to their child.
In our study, there appeared to be well documented observation of either recurrent throat infections, more severe than viral pharyngitis, or significant symptoms of upper airway obstruction.
The underlying public health debate should not centre on whether tonsillectomy is effective but rather on how to identify, in a primary care setting, those who will benefit from the operation, in order to inform referral to an ENT clinic accordingly. However, such discrimination will require the availability of more sensitive and specific diagnostic tools than those currently available to primary care practitioners.
Acknowledgements
We are grateful to Rebecca Annoh, clinical audit department, Epsom and St Helier University Hospitals NHS Trust, for assistance in formatting the data returns, and to Winifred Bradley and Janet Khorshid, ENT clinic receptionists at Epsom General Hospital, Bradbury Wing, for assistance with the patient database.
Appendix 1. Survey letter and questionnaire
Letter
Dear
TONSILLECTOMY PATIENT SATISFACTION SURVEY
We are seeking the views of the parents of children who have had their tonsils removed.
You may have seen recent press reports stating that some public health doctors believe that tonsillectomy is an unnecessary operation. They believe that the NHS should not pay for tonsillectomy surgery, as it does no good.
We believe that tonsillectomy is an operation that is helpful to stop attacks of tonsillitis (but not viral sore throats), and also for those who have significant difficulty breathing because their tonsils are so big.
We would be very grateful if you would take a few minutes to complete the enclosed questionnaire and return it to us in the self-addressed envelope.
Thank you for taking the time to help with this survey.
P J Robb FRCS, Consultant ENT Surgeon,
K Gowrinath FRCS, ENT Associate Specialist,
K Agyeman FRCS, ENT Associate Specialist,
J Joseph FRCSI, Staff Grade Surgeon
Questionnaire
What was the main reason for your child having their tonsils removed? (Please tick):
Frequent attacks of tonsillitis
Very large tonsils causing problems with breathing
Other problems (please say what these were) _____
If your child had attacks of tonsillitis, how many times in a year?
Which of the following did your child have with each episode of tonsillitis? (Please tick):
Fever/high temperature (more than 38°C or 101°F)
Throat pain requiring regular painkillers
Headache
Vomiting
Tummy pain
Difficulty drinking
Difficulty eating
Glands in the neck
White spots on tonsils
Poor sleeping
How many days did your child miss from school with each attack? (Please circle):
1 day
2–3 days
3–5 days
More than 5 days
Did you always visit your GP or practice nurse? (Please circle):
Yes
No
Was your child prescribed antibiotics? (Please circle):
Never
Sometimes
Usually
Always
If your child was prescribed antibiotics, was this usually penicillin? (Please circle):
Yes
No
How long did it usually take for the antibiotics to help the symptoms of tonsillitis? (Please circle):
1 day
2–3 days
3–5 days
More than 5 days
If your child had their tonsils (and/or adenoids) removed because they were very large, which of the following problems did they have before the operation? (Please tick):
Snoring
Stopping breathing at night (sleep apnoea)
Very restless at night
Very sweaty at night
Bed-wetting
Waking up at night
Tired in the daytime
Having a daytime nap
Difficulty eating solids
Choking on food
Difficult to understand speech
Underweight and skinny
After the operation, how many days did it take for your child to get back to normal eating and drinking?
After the operation, how many days did your child need regular painkillers?
Has your child missed any school days for throat infections since the operation? (Please circle):
Yes
No
If yes, how many? _____
Since the operation, has your child's health been (please circle):
Worse
The same
Better
Much better
If you could turn back the clock, would you choose to have the operation again? (Please circle):
Yes
No
If ‘no’, why not? _____
Did your child have any problems after the operation that you had not expected from what you had been told or read in the information booklet? (Please circle):
Yes
No
If ‘yes’, what were these? _____
Please add any other comments or remarks that you wish: _____
Appendix 2. Free text examples from questionnaire responses
‘She no longer snores, sleeps throughout the night, has not had an infection in last 10 months and only one prior to that.’
‘He is in perfect health now.’
‘The idea that tonsillectomy should not be available on the NHS is ridiculous. It is just another way to cut costs. Lose unnecessary managerial staff instead!’
‘Whoever says it's not needed is an idiot! Both of my children suffered for years and missed so much school, now they are fine. An unnecessary operation??? Yes, let's save some more NHS money and watch all the children suffer shall we? Idiots!!!’
‘No parent would put a child through a general anaesthetic unless it was absolutely necessary. This operation has changed my daughter's life for the better.’
‘Harry was having five or six throat infections per year involving visits to the doctors, antibiotics and time off school. Since having his tonsils out he has had no trouble whatsoever.’
‘Public Health doctors have clearly never had tonsillitis.’
‘I would suggest that these public health doctors have never had a child with tonsillitis and are just ‘money grabbing’.'
‘The difference in our daughter in the last six months since the operation has been remarkable – the best thing is she is enjoying all aspects of life to the full.’
‘Can't stress enough the improvement to my daughter's health and well being, so glad she has finally had operation.’
‘My daughter has only gone from strength to strength since her tonsillectomy. She has slept through the night for the first time since she was born.’
‘The quality of our son's life has drastically improved since having his tonsils out.’
‘It is ludicrous for the NHS to suggest that this is not a necessary operation! The improvement in my child was life-changing!’
‘This operation has had a dramatically positive effect on X and the family.’
‘A success. Thank you very much.’
‘I would happily argue with any health professional or politician who claims that this is not a worthwhile and necessary operation. I was very fortunate that the NHS paid for my child's tonsillectomy and it would be shameful if other children could not have their lives improved by this surgery.’
