What are the indications for tonsillectomy in children? - Clinical inquiries: from the Family Practice Inquiries Network

Journal of Family Practice, April, 2002 by Richard A. Neill, Caryn Scoville

EVIDENCE-BASED ANSWER

Tonsillectomy with or without adenoidectomy is minimally effective when combined with tympanostomy robe placement in preventing recurrent otitis media in the 3 years following surgery. The risks of surgery must be weighed against potential benefit. (Grade of recommendation: B, based on low-quality randomized controlled trials [RCTs]). The evidence supporting tonsillectomy for recurrence of sore throat is controversial. (1) There is insufficient evidence to recommend other potential indications (Table). (Grade of recommendation: C, based on case series.)

EVIDENCE SUMMARY

Cochrane: "There is no evidence from randomized controlled trials to guide the clinician in formulating the indications for surgery in adults or children." (1) The few existing trials are complicated by differences in treatment and control groups at baseline and by differential complication rates in groups receiving tonsillectomy or adenotonsillectomy. For example, 2 RCTs showed minimal effect at 1 year and no effect at 3 years of follow-up in preventing recurrent sore throat. (2,3) However, 1 of these could not be critically appraised because it was published in abstract format only.

Two other trials of tonsillectomy and adenotonsillectomy in children, both with and without tympanostomy robe placement, have shown a small, brief reduction in episodes of recurrent otitis. (4-6) In the largest study, (6) controls had a mean of 2.1 episodes of recurrent otitis media in the first postoperative year while those undergoing adenotonsillectomy had had 1.8 episodes (P = .25) and those undergoing adenoidectomy had 1.4 episodes (P < .001). However, these benefits did not persist beyond the first year. Several case series report no evidence of effectiveness of tonsillectomy for immunoglobulin A (IgA) nephropathy, psoriasis, or nocturnal enuresis.

RECOMMENDATIONS FROM OTHERS

The Infectious Diseases Society of America states: "Surgical removal of the tonsils may be considered for the ram patient whose symptomatic episodes [of strep pharyngitis] do not diminish in frequency over time and for whom no alternative explanation for the recurrent pharyngitis is evident. Tonsillectomy may decrease recurrences of symptomatic pharyngitis in selected patients, but only for a limited period of time." (4)

The American Academy of Pediatrics position is as follows: "Tonsillectomy, either alone or with adenoidectomy, has not been found effective for treatment of otitis media with effusion." (5) The Scottish Intercollegiate Guidelines Network (SIGN): "The following are recommended as reasonable indications for consideration of tonsillectomy in both children and adults, based on the current level of knowledge, clinical observation in the field and the results of clinical audit." According to SIGN, patients should meet all these criteria: sore throats are caused by tonsillitis; 5 or more episodes of sore throat per year; symptoms have lasted for at least 1 year; and the episodes of sore throat "are disabling and prevent normal functioning." (7)

TABLE
INDICATIONS FOR TONSILLECTOMY

                                        Evidence of
Potential Indication                   Effectiveness?

Preventing recurrent otitis media in     Yes, small
the 3 years following surgery           effect size

Preventing recurrent sore throat             No
caused by tonsillitis

Preventing recurrent peritonsillar           No
abscess

Treating sleep apnea in children             No

Treating IgA nephropathy                     No

Treating guttate psoriasis                   No

Treating nocturnal enuresis                  No

                                       Grade of
Potential Indication                   Recommendation

Preventing recurrent otitis media in   B (RCTs, case series)
the 3 years following surgery

Preventing recurrent sore throat       B (systematic review
caused by tonsillitis                  of flawed RCTs)

Preventing recurrent peritonsillar     C (case series, consensus
abscess                                statements)

Treating sleep apnea in children       C (case series (2))

Treating IgA nephropathy               C (case series)

Treating guttate psoriasis             C (case series (3))

Treating nocturnal enuresis            C (case series)

IgA denotes immunoglobulin A; RCTs, randomized controlled trials.

REFERENCES

(1.) Burton MJ, Towler B, Glasziou P. Cochrane Database of Systematic Reviews, Issue 2, 2001, Oxford. England: Update Software.

(2.) Paradise JL, Bluestone CD, Bachman RZ, et al N Engl J Med 1984;310:674-83.

(3.) Paradise JL, Bluestone CD, Rogers KD. et al. Pediatr Res 1992; 31:126A.

(4.) Bisno AL, Gerber MA, Gwaltney JM Jr, et al [abstract]. Clin Infect Dis 1997; 25:574-83.

(5.) American Academy of Pediatrics. Pediatrics 1994; 94:766-73.

(6.) Paradise JL, Bluestone CD, Colborn DK, et al. JAMA 1999; 282:949-53.

(7.) Scottish Intercollegiate Guidelines Network, Scottish Cancer Therapy Network. SIGN publication no 34; January 1999.

Richard A. Neill, MD, Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia