Thursday, January 26, 2017
Tonsillectomies offer only modest benefits, studies find
Removing tonsils modestly reduced throat infections in the short term in children with moderate obstructive sleep-disordered breathing or recurrent throat infections, according to a systematic review conducted by the Vanderbilt Evidence-based Practice Center for the Agency for Healthcare Research and Quality.
Four papers derived from the larger review include two that were published online on Jan. 17 and appear in the February issues of Pediatrics. These papers report results regarding the effectiveness of tonsillectomy for treating children with obstructive sleep-disordered breathing or recurrent throat infections. The papers concluded that more research is necessary to determine the long-term impacts of tonsillectomies in those groups.
In the full systematic review, Vanderbilt researchers considered almost 10,000 studies of tonsillectomy efficacy, primarily randomized control trials.
"It's probably the most comprehensive study in tonsillectomy literature ever done," said investigator David Francis, M.D., M.S., assistant professor of Otolaryngology. "We determined the lay of the land of what's known and what's not known about this extremely common procedure."
For the paper, "Tonsillectomy vs. Watchful Waiting for Recurrent Throat Infection: A Systematic Review," researchers examined illness rates and quality of life for children who have undergone tonsillectomies versus watchful waiting for throat infections. Though there is more robust evidence to support tonsillectomy in children with high infection rates, most of the literature identified for the review concentrated on children with a moderate number of infections.
The researchers found that throat infections and school absences declined in the first year after children received tonsil surgery, as well as health care visits for sore throats. However, the benefits of reduced infection did not persist over time.
A companion paper, "Tonsillectomy for Obstructive Sleep-Disordered Breathing: A Meta-Analysis," examined whether children with obstructive sleep-disordered breathing showed improvement after tonsillectomy. The same authors found that children who had surgery had better sleep outcomes than those who engaged in watchful waiting.
Another companion study, published in Otolaryngology -- Head & Neck Surgery, also considered the risks of tonsil surgery, which is primarily bleeding. Regardless of tonsillectomy technique used, fewer than 4 percent of patients experienced bleeding and fewer than 1 percent needed readmission or reoperation as a result, Francis said.
The investigators involved in the report also acknowledged its limitations and opportunities for further study. Siva Chinnadurai, M.D., MPH, associate professor of Otolaryngology, another author of the report, said the type of study, known as a meta-analysis, is only as strong as the studies available in the literature.
"Our greatest impediment to draw really wide, sweeping conclusions is the lack of consistency in the way we as a specialty define the problems that we're treating," he said.
The benefits of surgery waned over time and long-term outcome information is limited because most studies don't follow children over the long term, Francis said. Also, the definition of infection was not consistent in the studies, and, in the case of obstructive sleep-disordered breathing, other factors that could cause the condition weren't consistently taken into account in the studies. These areas are opportunities for further research.
Francis said that the precision of the findings and the identified limitations in the current literature will help inform policymakers as they refine current tonsillectomy guidelines.
The authors conclude that doctors and patient families need to make shared decisions on about whether an individual child should undergo tonsillectomies, weighing the benefits and the risks illuminated in this report.
"I think that for any individual child who is considered a candidate for surgery, the family really has to have a personalized discussion with their health care provider about all of the factors that may be in play and how tonsils fit in as one factor in the overall picture of that child's health," Chinnadurai said.
The full AHRQ report is available at https://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2423
"This enormous effort can happen only in an ecosystem like Vanderbilt where surgeons can work and attract funding with colleagues from other disciplines to create a unified picture of the tonsil galactic world from thousands of smaller studies," said Ron Eavey, M.D., Guy M. Maness Professor and chair of Otolaryngology and director of the Vanderbilt Bill Wilkerson Center. "Many patients and parents and physicians will benefit from this achievement."