March 16, 2007 — Tonsillectomy reduces further incidence of infection and lessens throat pain in adults with recurrent streptococcal pharyngitis, according to the results of a randomized trial reported in the March 8 Online First issue of the BMJ.

"Traditionally, tonsillectomy has been used to prevent recurrent streptococcal throat infections," write Olli-Pekka Alho, MD, from the University of Oulu in Finland, and colleagues. "Yet according to a recent Cochrane review, there is no empirical evidence to show that it is effective in adults. The exact role played by infection of the palatine tonsils (the tissue removed in tonsillectomy) in streptococcal pharyngitis is unknown, as other pharyngeal lymphoid and soft tissues are often also infected.

At an academic referral center in Finland, 70 adults with documented recurrent episodes of streptococcal group A pharyngitis were randomized to instant tonsillectomy (n = 36) or to remaining on the waiting list (control; n = 34). The primary endpoints were percentage change in the risk for an episode of streptococcal pharyngitis at 90 days, rates of all episodes of pharyngitis, and days with symptoms and adverse effects.

Mean follow-up was 164 ± 63 days in the control group and 170 ± 12 days in the tonsillectomy group. At 90 days, recurrence rate for streptococcal pharyngitis was 24% (8/34) in the control group and 3% (1/36) in the tonsillectomy group (difference, 21%; 95% confidence interval [CI], 6% - 36%). The number needed to treat with tonsillectomy to prevent one recurrence was 5 (95% CI, 3 - 16).

During follow-up, the tonsillectomy group had significantly lower rates of other episodes of pharyngitis and days with throat pain and fever than did the control group. Postoperative throat pain was the most common morbidity related to tonsillectomy (mean length, 13 ± 4 days).

"Adults with a history of documented recurrent episodes of streptococcal pharyngitis were less likely to have further streptococcal or other throat infections or days with throat pain if they had their tonsils removed," the authors write. "According to our results, tonsillectomy is an effective alternative for adults with a documented history of recurrent episodes of pharyngitis."

Study limitations include relatively short follow-up period and possible information bias as throat culture specimens were taken when patients sought medical advice.

"The most common postoperative complications were sore throat and mild bleeding," the authors conclude. "Several other factors, such as risks of anaesthesia, otalgia, fever, dehydration, dental injuries, burns, and soft tissue injuries, have been described. These complaints are usually mild, but a small risk of even life threatening complications exists (recent reported mortality ranging from 1 in 16,000 to 1 in 35,000). Physicians and patients must decide whether these clinical benefits outweigh the risk of further morbidity and the risks involved in the operation."

The study had no external funding, and the authors have disclosed no relevant financial relationships.

BMJ. Published online March 8, 2007.

Clinical Context

Study Highlights

• Patients eligible for study participation were older than 15 years and had experienced 3 or more episodes of pharyngitis in 6 months or 4 episodes in 12 months. Only 1 of these episodes was required to have a positive culture for group A streptococcus. Patients with a history of peritonsillar abscess or with recurrent disease possibly caused by treatment noncompliance were excluded from study participation.
• Participants were randomized to receive tonsillectomy or to be placed on a surgical waiting list. Tonsillectomy was performed an average of 13 days following randomization into the surgery cohort.
• The main study outcome was the rate of culture-confirmed group A streptococcal pharyngeal infection within 90 days of follow-up. To gather this data, patients were encouraged to visit their primary care clinicians for symptoms of pharyngitis. Researchers also followed total episodes of pharyngitis, defined as 2 consecutive days of sore throat symptoms.
• 70 subjects enrolled in the trial. Baseline data were similar between the surgery and control groups. The mean age was 26 years old, and the mean number of episodes of acute pharyngitis was 3.4 in the previous 6 months. 13% of participants had evidence of chronically infected tonsils, and three quarters of the cohort had evidence of tonsillar scarring.
• Rates of sampling for streptococcal pharyngitis within the first 90 days were 20 in the control group and 5 in the surgery group. The respective numbers of positive cultures were 8 and 1 (difference in rates of culture-confirmed streptococcal pharyngitis, 21%). Generally, subjects in the control group also experienced a faster time to the first episode of pharyngitis.
• Rates of pharyngitis associated with medical consultation were 41% and 11% in the control and tonsillectomy groups, respectively, whereas the respective rates for any pharyngitis were 56% and 31%.
• Tonsillectomy incurred an average of 1 hour of time in the operating department, 1 day of hospital admission, and 13 days of throat pain following surgery. There were no major adverse events associated with tonsillectomy, and 2 subjects experienced minor bleeding after surgery.

Pearls for Practice

• Previous research has not confirmed the precise role of the palatine tonsils in recurrent streptococcal pharyngitis, and there have been few studies focused on the role of tonsillectomy for this indication in adults. Tonsillectomy appears to be only mildly beneficial for recurrent pharyngitis in children.
• The current study demonstrates that tonsillectomy improves rates of streptococcal pharyngitis and any pharyngitis in the first 3 months following surgery on adults with recurrent pharyngitis. Tonsillectomy was associated with 13 days of postoperative throat pain and no major adverse events.

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