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Adult tonsillectomies work and they’re cost effective



A new randomized trial offers rare insight into outcomes in adult tonsillectomy, a surgical procedure that’s commonly performed in the United States yet falling out of favor. Tonsillectomies are both clinically effective and cost-effective in adult patients with recurrent acute tonsillitis, a British team reports.

The researchers declined to weigh in on whether the procedure is actually better than nonsurgical management. Still, “here at last, we have a substantial piece of scientific evidence which shows that, compared with nonsurgical management, removal of tonsils has a significant impact on the number of sore throat days and on the cost of managing sore throat disease in adults,” said study lead author Janet A. Wilson, MBChB, MD, an emerita professor of otolaryngology at Newcastle University (England), in an interview.

The study was published in The Lancet.

Tonsillectomies have become much less common over the past several decades as questions have arisen about their value. In the United States, the number of procedures performed each year plunged from a high of 1.4 million in 1959 to an estimated 286,000 tonsillectomies performed in children under 15 and 120,000 in people aged 15 in 2010.

It’s harder for adults to tolerate tonsillectomies than children, Dr. Wilson said. In children, surgeons can easily remove tonsils by scraping them off the throat’s side walls. But, she said, “an adult tonsillectomy is more akin to taking off the skin of an unripe orange, so it’s harder work for the surgeon and more traumatizing for the wall of the adult patient’s pharynx. We can only assume that this greater amount of fibrous tissue reflects the cumulative effect of infections over a period of years.”

While tonsillectomies are still performed hundreds of times a day in adults in the United States, a 2014 Cochrane Library review found there’s “insufficient information “to support them versus nonsurgical care as treatments to reduce sore throats.”

For the new multicenter, open-label, randomized study, researchers randomly assigned patients aged 16 and older with recurrent acute tonsillitis to immediate tonsillectomy or nonsurgical management, which Dr. Wilson said can include cold fluids, honey, analgesics/anti-inflammatories. and anesthetic throat lozenges. The study was conducted between 2015 and 2018.

Ultimately, there were 224 and 204 patients, respectively, in the two groups (average age = 23, [19-30], 78% female, 90% White).

Patients who underwent tonsillectomies versus nonsurgical treatment had fewer sore throats over 2 years (median 23 days [IQR 11-46 days] vs. 30 days [14-65 days]) with an incident rate ratio of 0.53 (95% confidence interval, 0.43-0.65, P < 0.0001) after adjustment for clinic site and baseline severity.

The study also shows that “adults who have severe recurrent throat infections with a frequency of seven episodes within 1 year, five or more for 2 consecutive years, or three or more in 3 consecutive years will suffer fewer days of sore throat in the 2 years following tonsillectomy than if they had kept their tonsils,” Dr. Wilson said.

The study doesn’t examine longer-term consequences. A 2018 study of children linked tonsillectomies to “significantly increased relative risk of later respiratory, allergic, and infectious diseases.”

In the new study, nearly 4 in 10 (39%) of the tonsillectomy patients had adverse events linked to the surgeries, and bleeding (19%) was the most common adverse effect. The researchers also estimated that “tonsillectomy has a high probability of being considered cost-effective.”

“Whichever way the results were analyzed and confounding variables allowed for, the result always seems to be the same: Tonsillectomy applied using current qualifying criteria was a worthwhile procedure,” Dr. Wilson said.

Dr. Wilson noted that tonsillectomy patients will suffer a persistent sore throat after surgery, “about the same as a bad episode of tonsillitis.” And she said patients will need to adjust their diet for a few days and take 1-2 weeks off work.

In an interview, internal medicine physician Noel Deep, MD, of Antigo, Wisc., said antibiotics are a common treatment for tonsillitis in primary care clinics. According to him, the United States doesn’t have guidelines for tonsillectomies in adults. He believes they can be considered if tonsillitis keeps recurring three to five times a year and disrupts quality of life.

Dr. Deep said the new study “reinforces the benefit of tonsillectomies. Several studies from Germany, Sweden, Finland, and the United Kingdom have demonstrated benefits of tonsillectomies, but they were only for short periods of less than a year and lacked long-term data.”

He noted that “there is no clear evidence as to when to recommend tonsillectomies.” Clinicians should talk to patients about the potential that tonsillectomies will reduce sore throat episodes and cost the patient less in the long run, he said. It’s also important, he said, to make sure tonsillitis is bacterial before prescribing antibiotics.

The United Kingdom’s National Institute for Health Research funded the study. Dr. Wilson disclosed support for meetings/travel from ENT Scotland, and the other authors report various disclosures, including grants and contracts. Dr. Deep serves on the editorial advisory board of Internal Medicine News and is chair of the American Medical Association Council on Science and Public Health.

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