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This commissioning statement refers to:
This commissioning statement does not refer to:
Recurrent acute sore throat due to tonsillitis and:
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:
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:
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.