GPs overwhelmingly incorrect in deciding on tonsillectomies

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TonsillectomyAn analysis of over 1.6m children from more than 700 UK general practices over 12 years found that only 13% of children suitable for tonsillectomy underwent the procedure. Of all children who did have tonsillectomies, only one in every eight actually had enough sore throats to justify surgery.

Researchers analysed the electronic medical records of over 1.6m children from more than 700 UK general practices dating between 2005 and 2016. They found that out of 18,271 children who had their tonsils removed during this time, only 2,144 (11.7%) had enough sore throats to justify surgery.

The researchers at the university’s Institute of Applied Health Research concluded that their evidence showed that annually 32,500 children undergo needless tonsillectomies at a cost to the UK’s National Health Service (NHS) of £36.9m. What’s more, they found that many children who might benefit from having their tonsils removed are not having the surgical procedure. They found that of 15,764 children who had records showing sufficient sore throats to undergo a tonsillectomy, just 2,144 (13.6%) actually went on to have one.

Current UK health policy, based on the best scientific evidence, is that to meet the criteria to benefit from a tonsillectomy, children must suffer from either more than seven documented sore throats in a year; more than five sore throats per year for two successive years; or three sore throats per year for three successive years.

The researchers found that, of those who had undergone a tonsillectomy, 12.4% had reported five to six sore throats in a year; 44.7% had suffered two to four sore throats in a year; and 9.9% had just one sort throat in a year.

Tom Marshall, professor or public health and primary care at the University of Birmingham, said: “Research shows that children with frequent sore throats usually suffer fewer sore throats over the next year or two. In those children with enough documented sore throats, the improvement is slightly quicker after tonsillectomy, which means surgery is justified.

“But research suggests children with fewer sore throats don’t benefit enough to justify surgery, because the sore throats tend to go away anyway.

“Our research showed that most children who had their tonsils removed weren’t severely enough affected to justify treatment, while on the other hand, most children who were severely enough affected with frequent sore throats did not have their tonsils removed. The pattern changed little over the 12-year period.

“Children may be more harmed than helped by a tonsillectomy. We found that even among severely affected children only a tiny minority of ever have their tonsils out. It makes you wonder if tonsillectomy ever really essential in any child.”

Abstract
Background: Neither the incidence of indications for childhood tonsillectomy nor the proportion of tonsillectomies that are evidence-based is known.
Aim: To determine the incidence of indications for tonsillectomy in UK children, and the proportion of tonsillectomies meeting evidence-based criteria.
Design and setting: A retrospective cohort study of electronic medical records of children aged 0–15 years registered with 739 UK general practices contributing to a research database.
Method: Children with recorded indications for tonsillectomy were identified from electronic medical records. Evidence-based indications included documented sore throats of sufficient frequency and severity (Paradise criteria); periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA); or tonsillar tumour. Other indications were considered non-evidence-based. The numbers of children subsequently undergoing tonsillectomy was then identified. The numbers with evidence-based and non-evidence-based indications for surgery among children who had undergone tonsillectomy were determined.
Results: The authors included 1 630 807 children followed up for 7 200 159 person–years between 2005 and 2016. Incidence of evidence-based indications for tonsillectomy was 4.2 per 1000 person years; 13.6% (2144/15 760) underwent tonsillectomy. Incidence of childhood tonsillectomy was 2.5 per 1000 person years; 11.7% (2144/18 281) had evidence-based indications, almost all with Paradise criteria. The proportion of evidence-based tonsillectomies was unchanged over 12 years. Most childhood tonsillectomies followed non-evidence-based indications: five to six sore throats (12.4%) in 1 year, two to four sore throats (44.6%) in 1 year, sleep disordered breathing (12.3%), or obstructive sleep apnoea (3.9%).
Conclusion: In the UK, few children with evidence-based indications undergo tonsillectomy and seven in eight of those who do (32 500 of 37 000 annually) are unlikely to benefit.

Authors
Dana Šumilo, Linda Nichols, Ronan Ryan, Tom Marshall

University of Birmingham material
British Journal of General Practice abstract


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