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Indications for Tonsillectomy: Setting the Bar High Enough

Indications for Tonsillectomy: Setting the Bar High Enough In their clinical trial of adenotonsillectomy in children with “mild to moderate symptoms of throat infection,” Buskens et al1 found that children in the adenotonsillectomy group, compared with children in the watchful-waiting group, experienced 0.21 fewer episodes of throat infection per person-year during a median follow-up period of 22 months. The authors concluded, with good reason, that this degree of benefit was inconsequential. Notably, however, the criteria for entry in their trial consisted of either a history obtained from parents (but without mention, by the authors, of documentation) of 3 or more episodes of throat infection in the preceding year or “other indications such as symptoms of obstruction or recurrent upper respiratory tract infections.” Approximately one-half of the children in the trial were enrolled on the basis of these “other indications,” and in these children, a history of throat infection, if any, was not described. It seems axiomatic that children with indications other than a history of throat infection could not anticipate substantial benefit from adenotonsillectomy regarding subsequent episodes of throat infection. Previously, in clinical trials, my colleagues and I tested the efficacy of tonsillectomy and adenotonsillectomy in a group of children whose histories of throat infection episodes met stringent criteria in each of 4 categories: frequency of occurrence, clinical features, treatment, and documentation.2 These standards were considerably more stringent than those used by Buskens et al,1 but the benefit conferred by surgery in our trials was similarly modest—a reduction of about 1 mild episode per person-year in each of 3 follow-up years. We concluded that children should meet an even more stringent set of standards, such as those we had tested earlier,3 in order to justify subjecting them to the risks, morbidity, and cost of surgery. Buskens and coauthors' report reminds us of the inappropriateness of offering tonsillectomy to children whose indications are weak. However, for many other children whose indications are stronger than those described in their report, the value of tonsillectomy is similarly dubious. In selecting children for tonsillectomy, the bar needs to be set considerably higher than Buskens and colleagues' article suggests. Correspondence: Dr Paradise, Department of Pediatrics, Children's Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213 (jpar@pitt.edu). References 1. Buskens Evan Staaij Bvan den Akker JHoes AWSchilder AGM Adenotonsillectomy or watchful waiting in patients with mild to moderate symptoms of throat infections or adenotonsillar hypertrophy: a randomized comparison of costs and effects. Arch Otolaryngol Head Neck Surg 2007;133 (11) 1083- 1088PubMedGoogle ScholarCrossref 2. Paradise JLBluestone CDColborn DKBernard BSRockette HEKurs-Lasky M Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002;110 (1, pt 1) 7- 15PubMedGoogle ScholarCrossref 3. Paradise JLBluestone CDBachman RZ et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310 (11) 674- 683PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Indications for Tonsillectomy: Setting the Bar High Enough

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Indications for Tonsillectomy: Setting the Bar High Enough

Abstract

In their clinical trial of adenotonsillectomy in children with “mild to moderate symptoms of throat infection,” Buskens et al1 found that children in the adenotonsillectomy group, compared with children in the watchful-waiting group, experienced 0.21 fewer episodes of throat infection per person-year during a median follow-up period of 22 months. The authors concluded, with good reason, that this degree of benefit was inconsequential. Notably, however, the criteria for entry in...
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References (3)

Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archotol.134.6.673-a
Publisher site
See Article on Publisher Site

Abstract

In their clinical trial of adenotonsillectomy in children with “mild to moderate symptoms of throat infection,” Buskens et al1 found that children in the adenotonsillectomy group, compared with children in the watchful-waiting group, experienced 0.21 fewer episodes of throat infection per person-year during a median follow-up period of 22 months. The authors concluded, with good reason, that this degree of benefit was inconsequential. Notably, however, the criteria for entry in their trial consisted of either a history obtained from parents (but without mention, by the authors, of documentation) of 3 or more episodes of throat infection in the preceding year or “other indications such as symptoms of obstruction or recurrent upper respiratory tract infections.” Approximately one-half of the children in the trial were enrolled on the basis of these “other indications,” and in these children, a history of throat infection, if any, was not described. It seems axiomatic that children with indications other than a history of throat infection could not anticipate substantial benefit from adenotonsillectomy regarding subsequent episodes of throat infection. Previously, in clinical trials, my colleagues and I tested the efficacy of tonsillectomy and adenotonsillectomy in a group of children whose histories of throat infection episodes met stringent criteria in each of 4 categories: frequency of occurrence, clinical features, treatment, and documentation.2 These standards were considerably more stringent than those used by Buskens et al,1 but the benefit conferred by surgery in our trials was similarly modest—a reduction of about 1 mild episode per person-year in each of 3 follow-up years. We concluded that children should meet an even more stringent set of standards, such as those we had tested earlier,3 in order to justify subjecting them to the risks, morbidity, and cost of surgery. Buskens and coauthors' report reminds us of the inappropriateness of offering tonsillectomy to children whose indications are weak. However, for many other children whose indications are stronger than those described in their report, the value of tonsillectomy is similarly dubious. In selecting children for tonsillectomy, the bar needs to be set considerably higher than Buskens and colleagues' article suggests. Correspondence: Dr Paradise, Department of Pediatrics, Children's Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213 (jpar@pitt.edu). References 1. Buskens Evan Staaij Bvan den Akker JHoes AWSchilder AGM Adenotonsillectomy or watchful waiting in patients with mild to moderate symptoms of throat infections or adenotonsillar hypertrophy: a randomized comparison of costs and effects. Arch Otolaryngol Head Neck Surg 2007;133 (11) 1083- 1088PubMedGoogle ScholarCrossref 2. Paradise JLBluestone CDColborn DKBernard BSRockette HEKurs-Lasky M Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002;110 (1, pt 1) 7- 15PubMedGoogle ScholarCrossref 3. Paradise JLBluestone CDBachman RZ et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310 (11) 674- 683PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck Surgery – American Medical Association

Published: Jun 1, 2008

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