This review compared the clinical effectiveness and safety of surgery (removal of the tonsils - tonsillectomy, or adenotonsillectomy - removal of the tonsils and adenoid tissues) against non-surgical management in adults and children with frequent or chronic tonsillitis.
Surgical removal of the tonsils is a commonly performed operation in patients with chronic or recurrent infections of the tonsils (tonsillitis) or the other tissues at the back of the throat (pharyngitis). Sometimes, the adenoid tissues are also removed during the surgery. However, opinions vary greatly about whether or not the benefits of these operations outweigh the risks.
This review included evidence available up to 30 June 2014. Seven trials with low to moderate risk of bias were included: five in children (987 participants) and two in adults (156 participants). An eighth trial in 40 adults was at high risk of bias and did not provide any data for analysis.
Although some studies in children followed participants for two or three years, reliable information is only available for up to about one year after surgery due to the high number of participants missing follow-up after the first year. Some studies had recruited children who were more severely affected by tonsillitis than other studies (for example, they had tonsillitis more often and with more severe symptoms). Therefore, we grouped the children into 'severely affected' and 'less severely affected' subgroups.
Two studies in adults had a short duration of follow-up (five to six months following surgery).
We found that in general children affected by recurrent acute tonsillitis may have a small benefit from adeno-/tonsillectomy: this procedure will avoid 0.6 episodes of any type of sore throat in the first year after surgery compared to non-surgical treatment. The children who had surgery had three episodes of sore throat on average compared to 3.6 episodes experienced by the other children. One of the three episodes is the episode of pain caused by surgery.
When it comes to avoiding bad sore throats, children who have more severe or frequent tonsillitis may benefit more from surgery compared to less severely affected children. In less severely affected children the potential benefits of adeno-/tonsillectomy are more uncertain. There are no good quality data for the effects of surgery in the second or later years after surgery.
We did not find enough evidence to draw firm conclusions on the effectiveness of tonsillectomy in adults with chronic/recurrent acute tonsillitis. Evidence is only available for the short term and is of low quality. The data are also difficult to interpret as the studies do not take into account the days of pain that always follow the operation. Based on the two small trials, tonsillectomy seems to result in fewer days of sore throat in the first six months after surgery.
Two of the studies in children said that they could not find a difference in quality of life outcomes and one study could not find a difference in the amount of painkiller that children took to help with their sore throats.
Bleeding immediately after tonsillectomy or in the two weeks following surgery is an important complication. The studies did not provide good information to allow us to assess accurately the risk of these complications.
Quality of the evidence
We judged the quality of the evidence to be moderate for the data on children (this means that further research is likely to have an important impact on how confident we are in the results and may change those results). Quality is affected by a large number of children who are 'lost to follow-up' after the first year of the study. In addition, some children who are assigned to the 'no surgery' group end up having surgery.
The quality of evidence for tonsillectomy in adults in adults is low.
As always, any potential benefits of surgery should be carefully weighed against the possible harms as the procedure is associated with a small but significant degree of morbidity in the form of bleeding (either during or after the surgery). In addition, even with good pain relief medication, the surgery is particularly uncomfortable for adults.