Background

Surgical removal of the tonsils, with or without adenoidectomy (adeno‐/tonsillectomy), is a common ENT operation but the indications for surgery are controversial.

Objectives

To determine the effects of tonsillectomy, with and without adenoidectomy, in patients with chronic/recurrent acute tonsillitis.

Search methods

Cochrane Controlled Trials Register (Cochrane Library Issue 2 2008), MEDLINE (1966 ‐ 2008), EMBASE (1974 ‐ 2008), bibliographies. The date of the last search was April 2008.

Selection criteria

Randomised controlled trials comparing tonsillectomy, with or without adenoidectomy, with non‐surgical treatment in adults and children with chronic/recurrent acute tonsillitis. Trials which included reduction in the number and severity of tonsillitis and sore throat as main outcome measures.

Data collection and analysis

Two authors applied the inclusion/exclusion criteria independently.

Main results

This review includes five studies: four undertaken in children (719 participants) and one in adults (70 participants). Good information about the effects of tonsillectomy is only available for children and for effects in the first year following surgery.

Children were divided into two subgroups: those who are severely affected (based on specific criteria which are often referred to as the 'Paradise criteria') and those less severely affected.

For more severely affected children adeno‐/tonsillectomy will avoid three unpredictable episodes of any type of sore throat, including one episode of moderate or severe sore throat in the next year. The cost of this is a predictable episode of pain in the immediate post‐operative period.

Less severely affected children may never have had another severe sore throat anyway and the chance of them so doing is modestly reduced by adeno‐/tonsillectomy. For them, surgery will mean having an average of two rather than three unpredictable episodes of any type of sore throat. The cost of this reduction is one inevitable and predictable episode of post‐operative pain. The 'average' patient will have 17 rather than 22 sore throat days but some of these 17 days (between 5 and 7) will be in the immediate post‐operative period. Whilst the concept of the 'average' patient is attractive, in practice, wide variability is likely.

One reason why the impact of surgery is so modest, is that many untreated patients get better spontaneously. There is a trade‐off for the physician and patient who must weigh up a number of different uncertainties: what proportion of my throat symptoms are attributable to my tonsils, and will I get better without any treatment? Similarly, the potential 'benefit' of surgery must be weighed against the risks of the procedure.

Authors' conclusions

Adeno‐/tonsillectomy is effective in reducing the number of episodes of sore throat and days with sore throats in children, the gain being more marked in those most severely affected. The size of the effect is modest, but there may be a benefit to knowing the precise timing of one episode of pain, lasting several days ‐ it occurs immediately after surgery as a direct consequence of it.

It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent "tonsillitis", the impact of the procedure on "sore throats" due to pharyngitis is much less predictable.