Summary of intervention

This guidance relates to surgical procedures to remove the tonsils as a treatment for recurrent sore throats in adults and children.

 

Recurring sore throats are a very common condition that presents a large burden on healthcare; they can also impact on a person’s ability to work or attend school. It must be recognised however, that not all sore throats are due to tonsillitis and they can be caused by other infections of the throat. In these cases, removing the tonsils will not improve symptoms.

 

Number of CCG intervention 2017/18

32,238

 

Recommendation

The NHS should only commission this surgery for treatment of recurrent severe episodes of sore throat when the following criteria are met, as set out by the SIGN guidance and supported by ENT UK commissioning guidance:

  • Sore throats are due to acute tonsillitis AND
  • The episodes are disabling and prevent normal functioning AND
  • Seven or more, documented, clinically significant, adequately treated sore throats in the preceding year OR
  • Five or more such episodes in each of the preceding two years OR
  • Three or more such episodes in each of the preceding three years.

 

There are a number of medical conditions where episodes of tonsillitis can be damaging to health or tonsillectomy is required as part of the on-going management. In these instances tonsillectomy may be considered beneficial at a lower threshold than this guidance after specialist assessment:

  • Acute and chronic renal disease resulting from acute bacterial tonsillitis
  • As part of the treatment of severe guttate
  • Metabolic disorders where periods of reduced oral intake could be dangerous to health
  • PFAPA (Periodic fever, Apthous stomatitis, Pharyngitis, Cervical adenitis)
  • Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous

 

Further information on the Scottish Intercollegiate Guidelines Network guidance can be found here: http://www.sign.ac.uk/assets/sign117.pdf

 

Please note this guidance only relates to patients with recurrent tonsillitis. This guidance should not be applied to other conditions where tonsillectomy should continue to be funded, these include:

  • Obstructive Sleep Apnoea / Sleep disordered breathing in Children
  • Suspected Cancer (e.g. asymmetry of tonsils)
  • Recurrent Quinsy (abscess next to tonsil)
  • Emergency Presentations (e.g. treatment of parapharyngeal abscess)

 

It is important to note that national randomised control trial comparing surgery versus conservative management for recurrent tonsillitis in adults is underway. This may warrant review of this guidance in the near future.

 

 

Rationale for recommendation

Recurrent sore throats are a very common condition that presents a considerable health burden. In most cases they can be treated with conservative measures. In some cases, where there are recurrent, documented episodes of acute tonsillitis that are disabling to normal function, then tonsillectomy is beneficial, but it should only be offered when the frequency of episodes set out by the Scottish Intercollegiate Guidelines Network criteria are met.

 

The surgery carries a small risk of bleeding requiring readmission to hospital (3.5%). A previous national audit quoted a 0.9% risk of requiring emergency surgery to treat bleeding after surgery but in a more recent study of 267, 159 tonsillectomies, 1.88% of patients required a return to theatre. Pain after surgery can be severe (especially in adults) for up to two weeks after surgery; this requires regular painkillers and can cause temporary difficulty swallowing. In addition to bleeding; pain or infection after surgery can require readmission to hospital for treatment. The Getting it Right First Time ENT report is due late 2018 and will present updated figures on readmission rates in relation to tonsillectomy.

 

There is no alternative treatment for recurrent sore throats that is known to be beneficial, however sometimes symptoms improve with a period of observation.

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