Tonsillectomy – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • Tonsillectomy for recurrent tonsillitis in adults and children
  • Tonsillectomy is one of the most common surgical procedures in the UK.
  • There is good evidence for the effectiveness of tonsillectomy in selected children, but only limited evidence in adults.
  • This commissioning policy is needed in order to clarify the ELIGIBILITY CRITERIA for referral to secondary care for surgery for recurrent tonsillitis

This commissioning statement does not refer to:

  • When urgent referral is required for
    • Peritonsillar abscess (quinsy)
    • Adult obstructive sleep apnoea with tonsillar enlargement (if trials of continuous positive airway pressure (CPAP) and the use of mandibular advancement devices are unavailable or unsuccessful).
  • Severe neck infection
  • Excluding possible malignancy eg lymphoma
  • Sleep disordered breathing (apnoea) in children
  • Patients with sore throat who have stridor, progressive dysphagia, bleeding, increasing pain or severe systemic symptoms (may require hospital admission)
  • Tonsil bleeding

Status

Eligibility Criteria

Recurrent acute sore throat due to tonsillitis and:

  • The frequency of episodes of acute tonsillitis is confirmed by the patient's GP or appropriately trained member of clinical team as follows:
    • 7 or more well documented, clinically significant, adequately treated episodes of tonsillitis in the last year
    • 5 or more such episodes per year in the preceding two years
    • 3 or more such episodes per year in the preceding three years
  • There has been significant impact on quality of life indicated by documented evidence of symptoms that act as a barrier to employment or education or carrying out carer activities; OR Failure to thrive
  • Marked tonsillar asymmetry, which there is clinical suspicion sinister pathology
  • Halitosis thought to be caused by tonsils but ONLY where there is clear evidence of tonsillar debris

When in doubt as to whether tonsillectomy would be beneficial, a six-month period of watchful waiting to establish pattern of symptoms and allow time for patient, parents and carers to consider implications of surgery.

Tonsillectomy/adenotonsillectomy will be funded in children under 16 where obstruction of the airway results in obstructive sleep apnoea syndrome, and the following apply:

  • A significant impact on development, behaviour and/or quality of life demonstrated by supporting evidence such as growth charts, letters from GPs; OR
  • A strong clinical history (± sleep studies) suggestive of sleep apnoea

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

The literature on surgery for recurrent tonsillitis is limited. Most published studies refer to a paediatric population. The quality of the evidence for tonsillectomy in children is poor, but it suggests that surgery may be beneficial in selected cases. The small amount of information about adult sore throat and the effect of tonsillectomy is not scientifically robust but suggests that surgery can be beneficial for recurrent sore throats.

The benefits of surgery compared to non-surgical treatment was the subject of a Cochrane Collaboration review (since updated) which provided additional evidence for the SIGN guidance4, 5. The consensus is that these criteria help to identify patients most likely to gain benefit from surgical intervention but the evidence level is low at 3/4 and clinical judgement is needed to identify patients where exceptionality applies.

The Cochrane review found no randomised trials in adults and found that the evidence in children was limited by the lack of studies. Two randomised trials were found, but it was not possible to draw conclusions because many of the children also underwent adenoidectomy [Burton and Glasziou, 2009].

The authors of the Scottish Intercollegiate Guidelines Network (SIGN) guidance commented on5:

  • Four randomised clinical trials. One trial (which was included in the Cochrane review) found that there was no significant difference between the group that had a tonsillectomy and the group who did not. The other three studies had all taken place before 1972 and no conclusions could be drawn because of methodological flaws.
  • Three additional non-controlled studies. These suggested benefits of tonsillectomy for both reducing the number of sore throats, and improving general health.

The evidence on referral criteria for sore throats is based on evidence from a paediatric population. At the time that the referral criteria were written there were no randomised controlled trials concerning the management of recurrent sore throats in adults3.

A randomised trial in adults (people over 15 years of age) compared tonsillectomy (n = 36) with watchful waiting (n = 34) [Alho et al, 2007]: Criteria for entry to the trial were three or more episodes of pharyngitis in 6 months, or four or more episodes in 12 months.

The primary end point was the proportion of people with an acute episode of group A streptococcal pharyngitis during the 90 days' follow up, as determined by signs and symptoms of acute pharyngitis and a positive result of throat culture.

At 90 days streptococcal pharyngitis had recurred in 24% (8/34) of the control group and in 3% (1/36) of the tonsillectomy group (difference 21%, 95% CI 6 to 36).

The number of people needing to undergo tonsillectomy to prevent one recurrence of streptococcal pharyngitis during the few months after tonsillectomy was five (NNT = 5).

The authors concluded that tonsillectomy is an effective alternative for adults with a documented history of recurrent episodes of pharyngitis.

References

  1. Baugh, R.F., Archer, S.M., Mitchell, R.B. et al. (2011) Clinical practice guideline: tonsillectomy in children. Otolaryngology - Head and Neck Surgery 144(1 Suppl), S1-S30. [Abstract]
  2. NICE (2005) Referral for suspected cancer (NICE guideline) Clinical guideline 27. National Institute for Health and Clinical Excellence.www.nice.org.uk
  3. Royal College of Surgeons Commissioning guide Tonsillectomy Sept 2013 https://www.rcseng.ac.uk/-/.../ent-uk-tonsillectomy-revised-commissioning-guide-201
  4. Cochrane Review of Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis (Cochrane Review) Nov 2014 http://www.ncbi.nlm.nih.gov/pubmed/25407135
  5. Scottish Intercollegiate Guideline Network (SIGN) guideline: Management of sore throat and indications for tonsillectomy, a national clinical guideline [SIGN, 2010 report number 117] and the Centor clinical prediction score [Centor et al, 1981; Aalbers et al, 2011; ESCMID Sore Throat Guideline Group et al, 2012]. http://www.sign.ac.uk/guidelines/fulltext/117/index.html
  6. NICE CKS Management of acute sore throat and evidence base for tonsillectomy July 2015 scenario and supporting evidence NHS England Tonsillectomy Policy 2013
  7. Royal College of Surgeons. National prospective tonsillectomy audit: final report of an audit carried out in England and Northern Ireland between July 2003 and September 2004. London: Royal College of Surgeons of England; 2005.
  8. Burton MJ, Glasziou PP, Burton MJ, Glasziou PP. Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. [Review] [20 refs][
  9. Update of Cochrane Database Syst Rev. 2000;(2):CD001802; PMID: 10796824]. Cochrane Database of Systematic Reviews 2009;(1):CD001802.
  10. SIGN GUIDANCE http://www.sign.ac.uk/pdf/qrg117.pdf
  11. DEVON -https://southwest.devonformularyguidance.nhs.uk/referral-guidance/policies/tonsillectomy

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Last Updated: 12.2017
  • Review Date: 04.2018
  • Ref No: PA12 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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