Study adds little to tonsil surgery debate
Based on a study that found that adults with recurrent severe sore throats had fewer sore throats if they had their tonsils removed
, a number of news papers have reported that the NHS "should remove more tonsils,"
describing how we should "return closer to the 1950s culture of whipping tonsils out in spite of the cost".
The story came from a small Finnish study that was published in the peer-reviewed Canadian Medical Association Journal. There is limited evidence about the benefits of tonsillectomy
in adult patients and this research wanted to look at the short-term effectiveness of tonsillectomy for patients with recurring sore throat.
It is important to note, however, that this study looked at whether removing the tonsils was effective for reducing the number of episodes of inflammation of the throat in general (pharyngitis). The study concluded that removing tonsils may be effective
at preventing severe sore throats. However, there was no difference in the number of people who had a severe sore throat after 5 months
. Most people are familiar with the notion that taking out tonsils will remedy tonsillitis.
The media reporting the story overstated the importance of this research. It failed to highlight many of the important limitations of this study. The research has many limitations to consider that make it less reliable, or applicable to the UK:
- This was a very small study based in Finland that looked at outcomes for just 86 patients. This means it may not be representative of people who would generally be considered for tonsillectomy in the UK
- The waiting time for surgery in Finland is restricted to 6 months by law, so the research could only follow-up people in the control group for around 5 months before they had surgery. This limits the study's ability to assess whether a significant number of the control group would spontaneously improve during a longer follow-up period, and leaves open the possibility that the beneficial effect of tonsillectomy may be temporary if pharyngitis recurred after 6 months.
- There is likely to have been bias in the selection of the control group, as they were told that they would undergo surgery eventually. Those that wanted surgery earlier are likely to have declined to participate in the study.
- There were relatively few eligible cases of recurrent pharyngitis in this study, shown by the fact only 86 were recruited over a 3-year period. For this reason, it does not seem to be a particularly common problem for people. However, it does suggest that tonsillectomy may be beneficial to this group of patients.
- The study authors highlight a recent Cochrane systematic review on tonsillectomy for recurrent tonsillitis that found only a single trial involving adults. It included adults severely affected by a specific infective cause (recurrent group A streptococcal pharyngitis, known as 'strep throat'). This means there is relatively little evidence available on this topic to reliably inform decision-making.
- Tonsillectomy is usually carried out under a general anaesthetic and, as with all surgeries, carries a risk of complications. A common complication is bleeding at the site where the tonsils are removed. This is estimated to affect around one in 30 adults and one in 100 children. Minor bleeding is not usually cause for concern and heals itself, but heavier bleeding can cause vomiting and coughing up blood, requiring immediate medical advice.
This story will reignite the debate about whether tonsillectomies should be performed more often as some would argue that the “myth” that removing the tonsils does not work has led to a substantial increase in the number of emergency admissions
However, regardless of the debate, it is true that the surgical procedure carries a number of inherent risks including haemorrhaging, anaesthesia, aspiration pneumonia, injury to the uvula (the visible soft tissue that hangs from the roof of the throat) and infection. But it is also the case that some damage can also occur during the procedure as a result of a medical mistake such as burns during surgical cautery. There may be a failure to remove all of the tonsils
during a tonsillitis procedure causing prolonged throat pain and recurring tonsillitis and resulting in a further operation.