Tonsillectomy Versus Non-surgical Treatment for Chronic

Tonsillectomy versus non-surgical treatment for chronic/

recurrent acute tonsillitis (Review)

Burton MJ, Towler B, Glasziou P

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2006, Issue 1

http://www.thecochranelibrary.com

1Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis (Review)

Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .

2SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .

3METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .

6ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iTonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis (Review)


Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis (Review)

Burton MJ, Towler B, Glasziou P

Status: Commented

This record should be cited as:

Burton MJ, Towler B, Glasziou P. Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. The Cochrane

Database of Systematic Reviews 1999, Issue 3. Art. No.: CD001802. DOI: 10.1002/14651858.CD001802.

This version first published online: 26 July 1999 in Issue 3, 1999.

Date of most recent substantive amendment: 02 March 1999

A B S T R A C T

Background

Surgical removal of the tonsils (tonsillectomy) is a common but controversial ENT operation.

Objectives

To determine the effect of tonsillectomy in patients with chronic/recurrent acute tonsillitis.

Search strategy

Cochrane Controlled Trials Register, MEDLINE, EMBASE, bibliographies.

Selection criteria

Randomised controlled trials comparing tonsillectomy 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

No trials evaluating the effectiveness of tonsillectomy in adults were identified. Two trials from Pittsburgh assessed tonsillectomy in

children. Significant baseline differences between the surgical and non-surgical groups and the inclusion of children who also underwent

adenoidectomy prevent firm conclusions being drawn from the fully published trial. Limited and insufficient information is available

from the second study; further details are awaited.

Authors’ conclusions

The effectiveness of tonsillectomy has not been formally evaluated. Further trials addressing relevant outcome measures are required.

P L A I N L A N G U A G E S U M M A R Y

Synopsis pending.



B A C K G R O U N D

Surgical removal of the tonsils (tonsillectomy) is one of the com-

monest major operations carried out on children (Paradise 1996).

Increasingly, it is performed on adults who in the past would al-

most certainly have had their tonsils removed in childhood as a

matter of routine. However, the procedure is a controversial one,

and opinions vary greatly as to the relative risks and benefits. The

risks of surgery include those of the associated general anaesthetic

and those specific to the procedure, for example bleeding imme-

diately after surgery or as a result of secondary infection in the

10-14 day period after surgery.

The indications for surgery are equally controversial. It is gener-

ally accepted that tonsillectomy (with adenoidectomy if necessary)

is indicated in children with obstructive sleep apnoea. In many

countries large numbers of patients who have recurrent acute ton-

sillitis, chronic tonsillitis or recurrent ’sore throats’, have their ton-

sils removed. The frequency and severity of ’infections’ required

to justify surgery vary considerably.

A non-systematic review of tonsillectomy or adenotonsillectomy

for recurrent throat infection was published in 1998 (Marshall

1998). Marshall draws conclusions from trials which either did

not fulfil the inclusion criteria for the present systematic review

or which appeared to the present authors to contain significant

biases.

O B J E C T I V E S

To determine the effects of tonsillectomy compared with non-sur-

gical treatment in the management of (a) adults, and (b) children,

with chronic or recurrent acute tonsillitis.

The non-surgical treatments included, but were not limited to:

1. intermittent courses of antibiotics

2. long-term antibiotics

3. analgesia (pain relief ) only

4. no therapy

In particular, to determine if tonsillectomy is more effective in:

1. reducing the number and/or severity of episodes of tonsillitis or

sore throat

2. reducing the amount of time off work or away from school

3. reducing the consumption of analgesics (pain killers)

4. reducing the consumption of antibiotics

Finally, to compare the morbidity and mortality associated with

tonsillectomy with that associated with non-surgical or no treat-

ment.

C R I T E R I A F O R C O N S I D E R I N G

S T U D I E S F O R T H I S R E V I E W

Types of studies

All identified randomised controlled trials which fulfilled the cri-

teria outlined below were included. Controlled clinical trials were

also identified.

Types of participants

Adults and children diagnosed as having either ’recurrent acute

tonsillitis’ or ’chronic tonsillitis’ were included and considered

separately. These clinical diagnoses had been reached by primary

care physicians or specialists. No microbiological diagnosis was

required, a clinical diagnosis of tonsillitis was deemed satisfactory.

However, recurrence implied more than two distinct episodes in

a twelve-month period, and chronicity a period longer than three

months.

Types of intervention

Surgical treatment in the form of tonsillectomy by any method

(dissection, guillotine, laser) in any setting versus any other form

of treatment, including, but not limited to, (1) no treatment, (2)

repeated courses of antibiotics, (3) long-term antibiotics, (4) anal-

gesia only. It was intended to consider the different non-surgical

treatments separately and together.

Types of outcome measures

Important clinical outcomes are:

1. reduction in the number and severity of episodes of tonsillitis

or sore throat

2. morbidity and mortality of surgery

Secondary endpoints include:

1. reduction in time off work or school,

2. reduction in the consumption of analgesics

3. reduction in the consumption of antibiotics

Outcome was assessed at 3 months, 6 months and 12+ months.

S E A R C H M E T H O D S F O R

I D E N T I F I C A T I O N O F S T U D I E S

See: Ear, Nose and Throat Disorders Group methods used in re-

views.

Randomised control trials and controlled clinical trials of surgical

treatment (tonsillectomy) versus non-surgical treatment (of any

sort, including no treatment) were identified. The Cochrane Con-

trolled Trials Register was searched using the term TONSIL*. The

optimum search strategy for detecting controlled trials formulated

by the Cochrane Collaboration (as outlined in the Cochrane Re-

viewers’ Handbook) was combined with the term TONSIL* and

used to search MEDLINE from 1966 onwards. A similar search



was undertaken on EMBASE (using a search strategy for the iden-

tification of controlled clinical trials developed by the Cochrane

Schizophrenia Group). The initial search results were scanned by

one reviewer to identify trials which loosely met the inclusion cri-

teria. Reference lists from identified publications were scanned to

identify pre-1966 trials and authors were contacted as necessary.

A forward search was undertaken on the authors of the identified

trials. The full text articles of the retrieved trials were then re-

viewed by the first two reviewers and the inclusion criteria applied

independently. Any differences in opinion about which studies to

include in the review were resolved by the third reviewer. The re-

viewers were blind to the names of journals, authors and the study

results whilst applying the criteria for determining which studies

to include in the review.

M E T H O D S O F T H E R E V I E W

The following methods were initially proposed. In the absence of

suitable trials not all these stages were necessary. If further trials

are identified, these procedures will be applied.

QUALITY ASSESSMENT

The quality of all included trials was assessed blindly and inde-

pendently by two reviewers. A third reviewer was asked to resolve

differences in opinion. A modification of the method used by

Chalmers et al (Chalmers 1990) was used. The selected studies

were assessed for the following characteristics:

1. the adequacy of the randomisation process

2. the potential for selection bias after allocation to study group,

i.e. losses to follow-up and whether analysis was by intention to

treat

3. whether there was blinding of outcome assessors to the patients’

study group

4. quality of outcome assessment

Studies were graded A, B or C for their overall methodological

quality:

A: minimisation of bias in all four categories above, i.e. adequate

randomisation; few losses to follow-up and intention to treat anal-

ysis; blinding of outcome assessors; high quality outcome assess-

ment

B: each of the criteria in A partially met

C: one or more of the criteria in A not met

It was intended to use study quality for sensitivity analysis.

DATA EXTRACTION

Data from the studies were independently extracted by the first

two authors using standardised forms. Data were extracted so as

to allow an intention to treat analysis. Where data were missing,

the reviewers wrote to the authors of the study requesting further

information. Some further information was obtained from one

author (Paradise 1992).

DATA ANALYSIS

We planned to analyse data by intention to treat.

D E S C R I P T I O N O F S T U D I E S

No studies were identified in which tonsillectomy in adults was

assessed.

Six studies were identified which included children (Kaiser 1930;

Mawson 1967; McKee 1963; Roydhouse 1970; Paradise 1984;

Paradise 1992); they were reported in six papers and one abstract.

Five of the studies were randomised controlled trials (Mawson

1967; McKee 1963; Roydhouse 1970; Paradise 1984; Paradise

1992). In three of these (McKee 1963; Mawson 1967; Roydhouse

1970), all the participants randomised to surgical treatment un-

derwent adeno-tonsillectomy or an indeterminable proportion did

so (the others undergoing tonsillectomy alone). Removal of the

adenoids is often associated with a reduction in mouth breathing

and snoring. Both these factors may influence the tendency to ex-

perience recurrent sore throat or tonsillitis. As a consequence, it

was not appropriate to include these trials in this review. More-

over, in these three studies it was not clear whether the included

children had suffered from recurrent acute or chronic tonsillitis,

as trial admission criteria were poorly defined. For example, it was

possible to be included in the Mawson study by experiencing cer-

vical adenitis (inflamed glands in the neck) alone. The authors are

aware of one (possibly two) proposed trials which will be included

in future updates of this review.

The “Pittsburgh Tonsillectomy and Adenoidectomy Study”, re-

ported as two separate studies by Paradise (Paradise 1984; Paradise

1992), included groups of children in whom tonsillitis was diag-

nosed according to strict, pre-defined criteria.

The first study in 1984 considered children who were ’severely’

affected. They had to have episodes of ’throat infection’ (1) seven

or more times in the preceding year, or five or more times per year

for each of the preceding two years, or three or more times per year

for each of the preceding three years. The episodes had to be (2)

characterised by specific clinical features, and (3) had to have been

treated with antibiotics when streptococcal infection was proven

or suspected. Finally, (4) each episode had to be documented.

The second study in 1992 involved a group of children ’meeting

slightly less stringent criteria’. Details obtained from the authors

are published elsewhere (Marshall 1998).

In the first study, some children were randomised. Others were

assigned ’according to parental preference’. The two randomised

and non-randomised groups were studied and analysed separately.

The non-randomised group will not be considered further in this

review. Some children were deemed to merit adenoidectomy in ad-

dition to tonsillectomy. The randomised study therefore included

four groups of children: a ’tonsillectomy alone’ group and a control

group, and an adeno-tonsillectomy group with a second control

group.



Details of the second study (Paradise 1992) are at present only

available as an abstract. Further information was not available from

the authors. The study focused on children who were ’less severely

affected’ than those in the first study. Larger numbers of partici-

pants were enrolled in three groups - tonsillectomy, adeno-tonsil-

lectomy or control. The senior author confirms that the paper is

being completed (personal communication, April 1998).

M E T H O D O L O G I C A L Q U A L I T Y

The investigators of the first Paradise study (Paradise 1984) at-

tempted to conduct the study in a rigorous fashion to avoid bi-

ases in a situation where blinding was impossible. However, their

randomisation process resulted in important baseline differences

which make interpretation of the results problematic. The chil-

dren in the surgery groups (tonsillectomy alone or adeno-tonsil-

lectomy) differed from the control group in terms of the history

of episodes of throat infection before entry into the study and in

terms of parental socioeconomic status (Paradise 1984, Table 1).

Those in the surgical group were more often admitted to the trial

on the basis of frequent infection in the year prior to entry rather

than less frequent infections over a longer period. The surgical

group may therefore have included children with more severe dis-

ease. Alternatively, these may have been children with less severe,

but more short-lived disease in whom a period of frequent infec-

tions is more likely to be followed by spontaneous resolution than

in those with longer more chronic histories. The children in the

non-surgical group were more likely to have parents with higher

socio-economic status than those in the surgical group.

Secondly, the authors compared the outcomes of the tonsillectomy

alone and adeno-tonsillectomy groups. Finding no ’large or sta-

tistically significant’ differences between them, the data sets were

pooled and reported as a single ’surgical’ group. All the results

thereafter thus refer to a population which includes a proportion

of children who had had their adenoids removed. It is not clear

whether the sizes of the two original sub-groups were large enough

to detect any true difference between the effects of tonsillectomy

alone and adeno-tonsillectomy. Some part - potentially the great-

est part - of the effect of ’surgery’ could be due to removal of the

adenoids.

Too little information is available to allow evaluation of the quality

of the second study (Paradise 1984).

R E S U L T S

No conclusions can be drawn about the effectiveness, or lack

thereof, of tonsillectomy for chronic or recurrent acute tonsillitis

in adults.

The results of the Paradise 1984 study are based on surgical in-

tervention in 43 children compared to 48 control subjects. Of

those having surgery, only 27 underwent tonsillectomy alone. No

firm conclusions can be drawn about tonsillectomy for the reasons

mentioned above (see ’Methodological quality’). It is interesting

to note that despite the fact that the study included only children

who were severely affected by throat infections, following enrol-

ment in the trial, many of those in the control (non-operated)

group had few episodes of infection and these few were usually

mild.

The reliability of the results in the Paradise 1992 study cannot

be evaluated in the absence of further details of the trial design

and conduct. However the authors are concerned that the entry

criteria for the trial were not stringent enough for general use

as guidance for the appropriateness, or lack thereof, of surgery

(Paradise 1992). The senior author of this study indicates that

the results may influence practice and reimbursement policies in

the United States (personal communication April, 1998). Further

information is awaited and will be included in updates of this

review.

D I S C U S S I O N

The effectiveness of tonsillectomy for chronic or recurrent acute

tonsillitis in adults is unproven.

It became clear while undertaking this review that an issue of great

importance concerns the role of the palatine tonsils (the tissue re-

moved at tonsillectomy) in the pathogenesis of the clinical con-

dition of ’tonsillitis’, or indeed ’throat infection’. It is self-evident

that removal of the palatine tonsils will prevent ’tonsillitis’ in those

patients in whom infection of these structures is the sole cause

of their symptoms. However, many patients with ’tonsillitis’ will

have infection of other pharyngeal lymphoid tissue and other soft

tissues of this region. If infection of these tissues is critically depen-

dent on infection of the tonsils themselves, tonsillectomy might be

effective. If infection of non-tonsillar tissue is independent of ton-

sillar infection, removing the tonsils may be irrelevant. The pop-

ulation of patients with chronic or recurrent sore throats is likely

to be a heterogeneous one. Some, but by no means all, may have

symptoms primarily due to infection of the tonsils themselves.

Many patients who undergo tonsillectomy are pleased to have

done so (Blair 1996). Anecdotal evidence suggests that some chil-

dren are ’transformed’ by the procedure. Some of this effect may

be due to removing a source of infection. In others, the tonsils may

have produced mild obstructive symptoms, the relief of which is

responsible for their improvement. Tonsillectomy for frank ob-

structive sleep apnoea has not been considered in this review. It

is likely that some children undergoing tonsillectomy have symp-

toms that fall short of full sleep apnoea but that may affect the

quality of their sleep. Post-operative improvement may, at least in

part, be due to improvement in their sleep patterns.



A U T H O R S ’ C O N C L U S I O N S

Implications for practice

Tonsillectomy is widely performed for recurrent acute or chronic

tonsillitis. There is no evidence from randomised controlled trials

to guide the clinician in formulating the indications for surgery in

adults or children.

Implications for research

There is a need to obtain high quality evidence from randomised

controlled trials to establish the effectiveness of tonsillectomy in

both adults and children. Trials should assess the effectiveness of

the procedure in patients with throat infections of differing severity

and frequency. In particular, trials should

1. clearly define the inclusion criteria for adults and children

2. specify patient population sub-groups based on age (young chil-

dren, children, teenagers, young adults, older adults), severity and

frequency of illness

3. investigate the effects of tonsillectomy and adeno-tonsillectomy

separately

4. specify the randomisation process and attempt to conceal allo-

cation of patients to study groups

5. follow patients for at least 12 months to assess short- and long-

term effects of surgery

6. assess outcomes such as behaviour, general well-being, growth,

sleep and eating patterns in addition to severity and frequency of

infections and their consequences.

F E E D B A C K

Paradise 2000

Summary

In a recent Cochrane review (Burton 1999) critiquing our ran-

domized clinical trial of tonsillectomy in severely affected chil-

dren (Paradise 1984), Burton, Towler, and Glasziou concluded

that “significant baseline differences (in the history of antecedent

throat infections and in parents’ socioeconomic status) between

the surgical and non-surgical groups and the inclusion of children

who also underwent adenoidectomy prevent firm conclusions be-

ing drawn from the . . . trial.” However, the Burton review fails

to take into account a number of study features and findings that

argue strongly against the importance of these factors as potential

invalidators of our trial results.

First, consider the large differences in key outcomes favoring sur-

gical over control subjects: in the first follow-up year a 14-fold

reduction in throat infection episodes rated as moderate or severe

(3 episodes in 38 surgical subjects vs 41 episodes in 35 control

subjects), and in the second follow-up year, a 6-fold reduction (5

episodes in 31 surgical subjects vs 30 episodes in 29 control sub-

jects). Other outcome differences were less dramatic but consis-

tently in the same direction and also significant statistically.

Second, as we reported, tests for interaction albeit their limited

power showed no significant differences in treatment outcomes

that were related to any of the three factors cited by Burton et

al (i.e. history of antecedent episodes, socioeconomic status, and

presence or absence of indications for adenoidectomy), nor were

any of these factors related significantly to outcomes within the

control group. Imbalances in factors that are not prognostic cannot

fairly be considered sources of bias. Moreover, as we also reported,

within each identifiable clinical and sociodemographic subgroup

rates of throat infection were, without exception, lower for subjects

treated surgically than for controls.

Third, consider the differences in antecedent history, which in any

case may have been more apparent than real. Eligibility for our trial

required a history of seven or more episodes of throat infection in

the preceding year, five or more in each of the two preceding years,

or three or more in each of the three preceding years. Not stated

in our report were the facts that a number of children met more

than one of these criteria and that such children were categorized

as meeting the criterion involving the largest number of episodes.

As chance would have it, more children in the surgical group than

in the control group (20/43 vs 11/48) met the criterion of seven

or more episodes in the preceding year. From this, Burton et al

concluded that “the surgical group may therefore have included

children with more severe disease,” or “alternatively, these may

have been children with less severe, but more short-lived disease.”

Setting aside for a moment that the analyses cited above argue

against any prognostically important differences in disease sever-

ity, if the surgical group did indeed include children with more se-

vere disease, the resulting bias would have favored control subjects

rather than surgical subjects, in which case trial results would have

understated, not overstated, the efficacy of surgery. Burton et al

advance no rationale for their contrary, counterintuitive specula-

tion that such children might actually have had less severe disease,

but even if that had been the case the imbalance would hardly

seem sufficient to account for the large differences in outcome.

Fourth, the difference in socioeconomic status referred to by Bur-

ton et al favored the control group rather than the surgical group.

Again setting aside that the analyses cited above argued against

the possibility that the difference was important prognostically,

any resulting bias again might be expected to have favored control

subjects, not surgical subjects.

In summary, to explain the large outcome differences we found

favoring the surgical group on the basis of confounding would

have required extreme imbalances between the surgical and control

groups in variables that were strongly prognostic. In fact, however,

not only were the variables of concern not apparently prognostic

and their imbalances limited, but further, the expected effect of

the imbalances would have been to favor the control group.



Finally, with regard to the adenoidectomy issue, Burton et al sug-

gest that “Some part--potentially the greatest part--of the effect

of ’surgery’ could be due to removal of the adenoids.” On the

contrary--and again apart from the analyses described above--the

addition of adenoidectomy in a minority of the surgically treated

subjects could certainly not have accounted for the fact that mod-

erate and severe throat-infection episodes were also virtually elim-

inated in the majority of such subjects who underwent tonsillec-

tomy only.

We stand by our conclusion that in these severely affected chil-

dren, tonsillectomy was unequivocally efficacious in reducing the

occurrence of throat infection.

REFERENCES

Burton MJ, Towler B, Glasziou P. Tonsillectomy versus non-sur-

gical treatment for chronic / recurrent acute tonsillitis (Cochrane

Review). In: The Cochrane Library, Issue 3, 1999. Oxford: Up-

date Software.

Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard

BS, Taylor FH, Rogers KD, Schwarzbach RH, Stool SE, Friday

GA, Smith IH, Saez CA. Efficacy of tonsillectomy for recurrent

throat infection in severely affected children: Results of parallel

randomized and nonrandomized clinical trials. N Engl J Med

1984;310:674-683.

Author’s reply

Contributors

Jack L Paradise

Children’s Hospital of Pittsburgh

3705 Fifth Ave.

Pittsburgh

PA 15213

USA

Email: [email protected]

P O T E N T I A L C O N F L I C T O F

I N T E R E S T

None known.

A C K N O W L E D G E M E N T S

The authors acknowledge the support of the members of the UK

Cochrane Centre.

S O U R C E S O F S U P P O R T

External sources of support

• No sources of support supplied

Internal sources of support

• No sources of support supplied

R E F E R E N C E S

References to studies included in this review

Paradise 1984 {published data only}

Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard BS,

Taylor FH, et al. Efficacy of tonsillectomy for recurrent throat infec-

tion in severely affected children. New England Journal of Medicine

1984;310(11):674–83.

Paradise 1992 {published data only}

Paradise JL, Bluestone CD, Rogers KD, Taylor FH, Colborn K,

Bernard BS, et al. Comparative efficacy of tonsillectomy for recurrent

throat infection in more vs less severely affected children. Pediatric

Research 1992;31:126A.

References to studies excluded from this review

Kaiser 1930

Kaiser AD. Results of Tonsillectomy. A comparative study of twenty-

two hundred tonsillectomized children with an equal number of con-

trols three and ten years after operation. Journal of the American Med-

ical Association 1930;95:837–42.

Mawson 1967

Mawson SR, Adlington P, Evans M. A controlled study evaluation of

adeno-tonsillectomy in children. Journal of Laryngology and Otology

1967;81:777–90.

Mawson SR, Adlington P, Evans M. A controlled study evaluation of

adeno-tonsillectomy in children. Journal of Laryngology and Otology

1967;82:963–79.

McKee 1963

McKee WJE. A controlled study of the effects of tonsillectomy and

adenoidectomy in children. British Journal of Preventive and Social

Medicine 1963;17:49–69.

Roydhouse 1970

Roydhouse N. A controlled study of adenotonsillectomy. Archives of

Otolaryngology 1970;92:611–6.

References to ongoing studies

Schilder

Ongoing study Starting date of trial not provided. Contact author

for more information.



Additional referencesBlair 1996

Blair RL, McKerrow WS, Carter NW, Fenton A. The Scottish ton-

sillectomy audit. Journal of Laryngology and Otology 1996;110(Suppl

20):1–25.

Carden 1978

Carden TS. Tonsillectomy - trials and tribulations. Journal of the

American Medical Association 1978;240(18):1961–2.

Chalmers 1990

Chalmers I, Adams M, Dickersin K, Hetherington J, Tarnow-Mordi

W, Meinert C, et al. A cohort study of summary reports of controlled

trials. Journal of the American Medical Association 1990;263:1401–5.

Marshall 1998

Marshall 1998. A review of tonsillectomy for recurrent throat infec-

tion. British Journal of General Practice 1988;48:1331–5.

Paradise 1996

Paradise JL. Tonsillectomy and adenoidectomy. In: Bluestone CD,

Stool SE, Kenna MA, editor(s). PediatricOtolaryngology. 3rd Edition.

Philadelphia: WB Saunders, 1996:1054–65.

∗Indicates the major publication for the study

T A B L E S

Characteristics of included studies

Study Paradise 1984

Methods Random allocation: method uncertain

Participants Children aged 3 to 15 years meeting strict criteria for tonsillectomy

Interventions Tonsillectomy or adeno-tonsillectomy or control (courses of antibiotics as necessary in both groups)

Outcomes PRIMARY

Episodes of throat infection

SECONDARY

Isolated cervical lymphadenopathy; parent-reported sore throat days; sore-throat associated school absence

Notes Blinding: the outcome assesors were not blind to the treatment group

Follow-up: Cumulative proportion of patients lost to follow-up at the end of each of three years were

respectively:

Tonsillectomy group: 12%, 30%, 49%

Control group: 13%, 15%, 25%

Cumulative proportion of control group electing for surgical treatment at end of each year: 15%, 25%, 33%

Allocation concealment B

Study Paradise 1992

Methods Random allocation: method unclear

Participants Children “less severely affected”

Interventions Tonsillectomy or adeno-tonsillectomy or control (not defined)



Characteristics of included studies (Continued )

Outcomes Episodes of pharyngitis

Notes Limited information available: abstract only

Allocation concealment B

Characteristics of excluded studies

Kaiser 1930 Allocation: Non-randomised retrospective cohort study

Mawson 1967 Allocation: Randomised

Participants: Children (4-12 years) with recurrent tonsillitis and/or sore throats and/or cervical adenitis

Interventions: Tonsillectomy alone or adeno-tonsillectomy

Notes: (a) Recurrent adenitis alone considered an indication for inclusion, (b) Some participants had no attacks

in year prior to trial or number was unknown [Mawson 1967, Table VI], (c) Impossible to separate tonsillectomy

patients from adeno-tonsillectomy patients

McKee 1963 Allocation: Randomised using hospital number

Participants: Children (<15 years) with throat infections or “acute upper respiratory infections with cervical adenitis”

Interventions: Adeno-tonsillectomy

Roydhouse 1970 Allocation: “Selection of cases [as] described by McKee” [randomised using hospital number]

Participants: Children (2-13 years) with “recurrent ... tonsillitis and other respiratory tract infections”.

Interventions: Adeno-tonsillectomy

G R A P H S A N D O T H E R T A B L E S

This review has no analyses.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Acute Disease; Chronic Disease; Recurrence; ∗Tonsillectomy; Tonsillitis [∗surgery]

MeSH check words

Humans

C O V E R S H E E T

Title Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis

Authors Burton MJ, Towler B, Glasziou P

Contribution of author(s) MARTIN BURTON: protocol development, searching for trials, quality assessment of

trials, data extraction, review development.

BERNIE TOWLER: protocol development, quality assessment of trials, data extraction,

review development.

PAUL GLASZIOU: protocol and review development.

Issue protocol first published 1999/1

Review first published 1999/3

Date of most recent amendment 16 August 2005



Date of most recent

SUBSTANTIVE amendment

02 March 1999

What’s New Information not supplied by author

Date new studies sought but

none found

Information not supplied by author

Date new studies found but not

yet included/excluded


Date new studies found and

included/excluded


Date authors’ conclusions

section amended


Contact address Mr Martin Burton

Consultant Otolaryngologist

Department of Otolaryngology - Head and Neck Surgery

The Radcliffe Infirmary

Woodstock Road

Oxford

OX2 6HE

UK

E-mail: [email protected]

Tel: +44 1865 224143

Fax: +44 1865 224460

DOI 10.1002/14651858.CD001802

Cochrane Library number CD001802

Editorial group Cochrane Ear, Nose and Throat Disorders Group

Editorial group code HM-ENT



Tonsillectomy Versus Non-surgical Treatment for Chronic

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