Children's tonsils 'are being removed unnecessarily'


'Nine in 10 operations to remove children's tonsils 'unnecessary'' The Guardian reports


November 6th 2018



"Too many children have tonsils removed unnecessarily," BBC News reports.

The claim was prompted by a new study that suggests 7 out of 8 children who have their tonsils removed (tonsillectomy) will experience no benefit.

A tonsillectomy is recommended if a child has 7 or more sore throats from infected tonsils (tonsillitis) in the past year.

Evidence suggests the procedure doesn't really help much for less frequent tonsillitis.

This study reviewed medical records from more than 700 general practices between 2005 and 2016 to see how many tonsillectomies were performed for children, and the reason for doing so.

Overall, 2.5 children per 1,000 had a tonsillectomy each year. But only 1 in 8 of these cases met recommended criteria for the procedure.

The study provides a valuable insight, but medical records may not have provided the full picture – they may not have captured all the reasons why a tonsillectomy was performed.

The findings highlight a need for clearer and more up-to-date guidelines for GPs to follow about when to refer children for tonsillectomies.

Current guidelines around recurrent tonsillitis in children are from nearly 10 years ago and based on a fairly low level of evidence.

Where does the story come from?

The study was carried out by researchers from the University of Birmingham.

It was published in the peer-reviewed British Journal of General Practice.

One of the researchers received funding from the National Institute for Health Research.

The UK media's reporting of the study was accurate.

What kind of research was this?

This cohort study reviewed general practice medical records to see how often tonsillectomies were being performed and how many of these referrals were appropriate.

The NHS carried out 37,000 childhood tonsillectomies between April 2016 and March 2017, costing £42 million.

UK guidelines outlining who should be referred for a tonsillectomy from the Scottish Intercollegiate Guidelines Network (SIGN) date from 2010.

The 2010 guideline (p15) states that the procedure is only suitable for recurrent sore throats associated with tonsillitis that are severe enough to make a child unwell, and when there has been:

  • 7 or more reported episodes in the past year, or
  • 5 or more episodes in each of the past 2 years, or
  • 3 or more episodes in each of the past 3 years

Until now, no study had looked into how common tonsillectomy is among the general population and the reasons for this. This study aimed to find that out.

What did the research involve?

The study used The Health Improvement Network (THIN), a database containing anonymised medical records from more than 700 general practices in the UK.

The researchers reviewed medical records between 2005 and 2016 to see how many tonsillectomies were performed for children each year and the reasons why – for example, because of recurrent sore throats, an abscess in the throat, or breathing problems during sleep.

They were interested in how many of these tonsillectomies were evidence-based and therefore appropriate, ranking the strength of evidence for each procedure.

For example, if the child had a cancerous or abnormal change in their tonsils, this would be the strongest reason to refer, followed by an abscess, followed by the above SIGN criteria for recurrent sore throats.

What were the basic results?

The study looked at data relating to 1,630,807 children aged 7.8 years on average. In total, 18,281 tonsillectomies were performed.

The number of tonsillectomies performed was just 2.5 per 1,000 children each year.

Only 14% of children meeting the evidence-based criteria for a tonsillectomy actually had one.

And of the tonsillectomies that were carried out, only 12% were appropriate – that is, only 12% met the evidence-based criteria for referral.

The most common reason for the 88% of inappropriate tonsillectomies was the child having 2 to 4 sore throats in a year (rather than the required 7).

How did the researchers interpret the results?

The researchers concluded: "In the UK, few children with evidence-based indications undergo tonsillectomy and 7 in 8 of those who do (32,500 of 37,000 annually) are unlikely to benefit."

Conclusions

These findings suggest that most of the tonsillectomies that are carried out are not appropriate or necessary.

And many children who could potentially benefit from a tonsillectomy aren't getting one.

But bear in mind these points:

  • medical records can't always give the full picture as to why a referral is recommended – for example, some episodes of sore throat may not have been captured
  • we can't be certain that "7 out of 8 would not have not benefited" as these children weren't followed up further

A case could be made that updated guidelines on who should and shouldn't be treated with tonsillectomies would be useful.

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