Watchful waiting is useful for children with recurrent throat infections
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《英国医生杂志》
1 Primary Medical Care, Community Clinical Sciences Division, Southampton University, Aldermoor Health Centre, Southampton SO16 5ST psl3@soton.ac.uk
Van Staaij et al's study is a welcome addition to a controversial subject.1 It shows that for children with moderately frequent throat infections (on average three in the previous year) a "wait and see" approach results in acceptable control of symptoms and avoids postoperative pain and complications (1% requiring operative surgery for haemorrhage, and 2.6% having severe nausea or dehydration). The major limitation of the study is the large number of children from the watchful waiting group who had tonsillectomy (34%). Since a per protocol analysis was not done—that is, comparing those who had tonsillectomy with those who did not, controlling for severity indices—it cannot be concluded that tonsillectomy in itself is ineffective but simply that immediate tonsillectomy is not effective. The data from this trial, however, match data from a similar trial, which reported little symptomatic benefit and a significant rate of complications (7%) among children who had tonsillectomy for more severe symptoms.2
Should children with more severe symptoms be offered surgery? With the normal caveats about subgroup analysis, there was some evidence from Van Staaij et al's trial that those more severely affected (three or more infections a year) had some benefit from immediate tonsillectomy—one less episode of sore throat. The earlier Paradise trial assessed tonsillectomy among selected children with severe symptoms3—the "Paradise" criteria of seven or more throat infections in the preceding year, or five or more a year for each of the preceding two years, or three or more a year for each of the preceding three years. This trial showed a reduction of around one episode, rated as moderate or severe (3 of 38 surgical patients v 41 of 35 controls); however, the trial was small and was criticised by the Cochrane review for imbalances of important baseline characteristics (the author argued that this was unlikely to affect inferences).4
Given the paucity of evidence and controversy about existing evidence, more data are clearly needed on tonsillectomy among children with recurrent throat infections, and particularly data on non-surgical approaches. Until this evidence is available it would be reasonable for doctors to share with parents the probable benefits of surgery—among children with the Paradise criteria, one less episode of moderately severe or severe sore throat a year; among children with at least three infections in the past year, one less episode of sore throat a year—but also the important harms of operation—a complication rate of 4-7%. For the remaining children, doctors should probably not offer tonsillectomy.
Competing interests. PL has been paid for two consultancy sessions from Abbott Pharmaceuticals for antibiotics for complications of respiratory tract infections.
References
Van Staaij BK, van den Akker, EH, Rovers MM, Hordijk GJ, Hoes AW, Schilder AGM. Effectiveness of adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy: open, randomised controlled trial. BMJ 2004;
Paradise J, Bluestone C, Colborn D, Bernard B, Rockette H, Kurs-Lasky M. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002;110: 7-15.
Paradise J, Bluestone C, Bachman R, Colborn D, Bernard B, Taylor F, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310: 674-83.
Burton M, Towler B, Glasziou P. Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2000;(2): CD001802.(Paul Little, professor of)
Van Staaij et al's study is a welcome addition to a controversial subject.1 It shows that for children with moderately frequent throat infections (on average three in the previous year) a "wait and see" approach results in acceptable control of symptoms and avoids postoperative pain and complications (1% requiring operative surgery for haemorrhage, and 2.6% having severe nausea or dehydration). The major limitation of the study is the large number of children from the watchful waiting group who had tonsillectomy (34%). Since a per protocol analysis was not done—that is, comparing those who had tonsillectomy with those who did not, controlling for severity indices—it cannot be concluded that tonsillectomy in itself is ineffective but simply that immediate tonsillectomy is not effective. The data from this trial, however, match data from a similar trial, which reported little symptomatic benefit and a significant rate of complications (7%) among children who had tonsillectomy for more severe symptoms.2
Should children with more severe symptoms be offered surgery? With the normal caveats about subgroup analysis, there was some evidence from Van Staaij et al's trial that those more severely affected (three or more infections a year) had some benefit from immediate tonsillectomy—one less episode of sore throat. The earlier Paradise trial assessed tonsillectomy among selected children with severe symptoms3—the "Paradise" criteria of seven or more throat infections in the preceding year, or five or more a year for each of the preceding two years, or three or more a year for each of the preceding three years. This trial showed a reduction of around one episode, rated as moderate or severe (3 of 38 surgical patients v 41 of 35 controls); however, the trial was small and was criticised by the Cochrane review for imbalances of important baseline characteristics (the author argued that this was unlikely to affect inferences).4
Given the paucity of evidence and controversy about existing evidence, more data are clearly needed on tonsillectomy among children with recurrent throat infections, and particularly data on non-surgical approaches. Until this evidence is available it would be reasonable for doctors to share with parents the probable benefits of surgery—among children with the Paradise criteria, one less episode of moderately severe or severe sore throat a year; among children with at least three infections in the past year, one less episode of sore throat a year—but also the important harms of operation—a complication rate of 4-7%. For the remaining children, doctors should probably not offer tonsillectomy.
Competing interests. PL has been paid for two consultancy sessions from Abbott Pharmaceuticals for antibiotics for complications of respiratory tract infections.
References
Van Staaij BK, van den Akker, EH, Rovers MM, Hordijk GJ, Hoes AW, Schilder AGM. Effectiveness of adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy: open, randomised controlled trial. BMJ 2004;
Paradise J, Bluestone C, Colborn D, Bernard B, Rockette H, Kurs-Lasky M. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002;110: 7-15.
Paradise J, Bluestone C, Bachman R, Colborn D, Bernard B, Taylor F, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310: 674-83.
Burton M, Towler B, Glasziou P. Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2000;(2): CD001802.(Paul Little, professor of)