We have good evidence from controlled clinical trials on when tonsillectomy can be useful. Children with very frequent, severe sore throats will have slightly fewer sore throats if they have their tonsils out. The effect is not dramatic, most children improve with or without surgery. The operation means one fewer sore throat over the next year. This is thought to be enough to justify surgery – although after two years there is no longer any difference.
How frequent? Either seven sore throats in the past year, or five yearly in the past two years, or three yearly in the past three years.
How severe? Sore throats with symptoms: either fever, or pus seen on the tonsils, or enlarged glands, or proven bacterial infection.
Research in less severely affected children has shown the benefit is too small for the risks of surgery.
We wanted to find out how many children who had tonsillectomies really needed the operation. We looked at the medical records of 1,630,807 children over 12 years. We found 18,281 children had tonsillectomies, but only one in eight had enough sore throats to have benefited. The pattern was the same from 2005 to 2016.
We also found 15,760 children who had enough sore throats to justify surgery but only one in seven had surgery.
This means six in seven children who arguably might benefit do not have the surgery – and they probably grow out of the problem – while seven in eight children who do have their tonsils removed do not benefit at all. At best tonsillectomy is unnecessary in these children, and at worst it is harmful.
Does this matter? The NHS carries out about 37,000 NHS tonsillectomies a year in children: mostly for recurrent sore throats. Many more are undertaken privately although numbers are hard to track down: private earnings typically double the salaries of ear, nose and throat surgeons.
Yet tonsillectomy is not without complications: 2% of patients are readmitted to hospital, often with bleeding. That is about 740 children a year. One in 40,000 patients die. About one a year.
In the long run having tonsils removed in childhood has also been linked to autoimmune conditions: future early onset diabetes, rheumatoid arthritis, thyroid disease and inflammatory bowel disease. Given the potential for harm, perhaps we should have a long hard think about whether so many tonsillectomies are really necessary?
Tom Marshall
Professor of Public Health & Primary Care
University of Birmingham
bjgp.org/content/early/2018/11/05/bjgp18X699833/tab-pdf