Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. A randomized, controlled trial of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. The effect of antibiotic therapy on recovery after tonsillectomy in children. A controlled study. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial. Pediatric tonsillotomy with the radiofrequency technique: less morbidity and pain. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. Postoperative tonsillectomy pain in pediatric patients: electrocautery (hot) vs cold dissection and snare tonsillectomy--a randomized trial. The efficacy of a single dose antibiotic regimen in adults undergoing tonsillectomy. [Postoperative pain therapy after tonsillectomy in children. An observational study for 7 days].
In previous clinical trials involving children severely affected with recurrent throat infection (7 or more well-documented, clinically important, adequately treated episodes of throat infection in the preceding year, or 5 or more such episodes in each of the 2 preceding years, or 3 or more such episodes in each of the 3 preceding years), we found tonsillectomy efficacious in reducing the number and severity of subsequent episodes of throat infection for at least 2 years. The results seemed to warrant the election of tonsillectomy in children meeting the trials' stringent eligibility criteria but also provided support for nonsurgical management. We undertook the present trials to determine 1) whether tonsillectomy would afford equivalent benefit in children who were less severely affected than those in our earlier trials but who nonetheless had indications for tonsillectomy comparable to those in general use, and 2) whether, in such children, the addition of adenoidectomy would confer additional benefit.
                We conducted 2 parallel randomized, controlled trials in the Ambulatory Care Center of Children's Hospital of Pittsburgh. To be eligible, children were required to have had a history of recurrent episodes of throat infection that met standards slightly less stringent than the standards used in our earlier trials regarding either the frequency of previous episodes or their clinical features or their degree of documentation, but not regarding >1 of those parameters. These reduced standards were nonetheless more stringent than those in current official guidelines, which list "3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy" as an indication for tonsillectomy or adenotonsillectomy. Of 2174 children referred by physicians or parents, 373 met the current trials' eligibility criteria and 328 were enrolled. Of these, 177 children without obstructing adenoids or recurrent or persistent otitis media were randomized to either a tonsillectomy group, an adenotonsillectomy group, or a control group (the 3-way trial), and 151 children who had 1 or more such conditions were randomized to either an adenotonsillectomy group or a control group (the 2-way trial). Outcome measures were the occurrence of episodes of throat infection during the 3 years of follow-up; other, indirect measures of morbidity; and complications of surgery.
                By various measures, the incidence of throat infection was significantly lower in surgical groups than in corresponding control groups during each of the 3 follow-up years. However, even among control children, mean rates of moderate or severe episodes were low, ranging from 0.16 to 0.43 per year. Adenotonsillectomy was no more efficacious than tonsillectomy alone. Of 203 children treated with surgery, 16 (7.9%) had surgery-related complications of varying types and severity.
                The modest benefit conferred by tonsillectomy or adenotonsillectomy in children moderately affected with recurrent throat infection seems not to justify the inherent risks, morbidity, and cost of the operations. We conclude that, under ordinary circumstances, neither eligibility criteria such as those used for the present trials nor the criterion for surgery in current official guidelines are sufficiently stringent for use in clinical practice. We carried out a prospective, randomized, controlled trial to clarify the effect of tonsillectomy on the clinical course of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome.
                Twenty-six consecutive children (mean age 4.1 years) with at least 5 PFAPA attacks were recruited from 3 tertiary care pediatric hospitals during 1999-2003 and randomly allocated to tonsillectomy or follow-up alone. They were all followed up with symptom diaries for 12 months. Tonsillectomy was allowed after 6 months in the control group if the attacks recurred.
                Six months after randomization all 14 children in the tonsillectomy group and 6/12 children in the control group (50%) were free of symptoms (difference 50%, 95% confidence interval 23% to 75%, P < .001). Tonsillectomy was performed on 5/6 of the patients in the control group who still had symptoms after 6 months. The remaining unoperated child in the control group had recurrences of the fever episodes throughout the follow-up, but the symptoms became less severe, and the parents did not choose tonsillectomy.
                Tonsillectomy appeared to be effective for treating PFAPA syndrome. The fever episodes ceased without any intervention in half of the control subjects. We conclude that although the mechanisms behind this syndrome are unknown, tonsillectomy can be offered as an effective intervention for children with PFAPA. Tonsillectomy continues to be a commonly performed operation in the pediatric age group. The postoperative period is often protracted and characterized by throat and ear pain, intermittent fever, foul odor from the oral cavity, and poor oral intake. Consequently, antibiotics are frequently prescribed in an effort to minimize these symptoms and/or avoid complications such as dehydration or secondary infection of the operative site. However, to our knowledge, no study to date has been performed to demonstrate the efficacy of antibiotic therapy in this setting. At the Children's Hospital of Philadelphia, a prospective, randomized, double-blind study was undertaken in which ampicillin (or placebo) was administered intravenously at the time of surgery and for 12 to 24 hours postoperatively. The children then continued to receive oral amoxicillin therapy (or placebo) for an additional seven days. The patients were then evaluated for the incidence and severity of postoperative symptoms and complications. Intraoperative cultures of the oropharynx and tonsillar tissue, as well as cultures of the tonsillar fossa, were obtained following completion of one week of therapy. Our results indicate that ampicillin sodium/amoxicillin trihydrate therapy is well tolerated and safe in the nonallergic child and is effective in minimizing fever and other troublesome postoperative symptoms, such as pain, lassitude, mouth odor, and poor oral intake after tonsillectomy. To determine the short term efficacy and safety of tonsillectomy for recurrent streptococcal pharyngitis in adults. Design Randomised controlled trial.
                Academic referral centre in Finland.
                70 adults with documented recurrent episodes of streptococcal group A pharyngitis.
                Instant tonsillectomy (n=36) or remaining on waiting list as control (n=34).
                Percentage change in the risk of an episode of streptococcal pharyngitis at 90 days. Rates of all episodes of pharyngitis and days with symptoms and adverse effects.
                The mean (SD) follow-up was 164 (63) days in the control group and 170 (12) days in the tonsillectomy group. At 90 days, streptococcal pharyngitis had recurred in 24% (8/34) in the control group and 3% (1/36) in the tonsillectomy group (difference 21%; 95% confidence interval 6% to 36%). The number needed to undergo tonsillectomy to prevent one recurrence was 5 (3 to 16). During the whole follow-up, the rates of other episodes of pharyngitis and days with throat pain and fever were significantly lower in the tonsillectomy group than in the control group. The most common morbidity related to tonsillectomy was postoperative throat pain (mean length 13 days, SD 4).
                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.
                Clinical Trials NCT00136877. To compare two techniques for pediatric tonsil surgery with respect to pain and postoperative morbidity. The two methods were the partial tonsil resection using radiofrequency (RF) technique (tonsillotomy [TT]) versus traditional tonsillectomy (TE).
                Prospective clinical randomized study in one tertiary care ENT clinic and two secondary care clinics.
                One hundred fifty children, between 5 and 15 years of age, were randomized to either TT with RF using the Surgitron Ellman, 1.7 MHz, or regular TE. Randomization was performed from the waiting list, including children with both a history of obstructive problems and recurrent tonsillitis. The TT was performed with a specially made sling electrode using a cut/coagulation mode.
                Forty-nine children were operated on with TT and 43 with TE. There was significantly less bleeding in the TT group, although two cases of primary postoperative bleeding occurred among the TT children and one in the TE group. The pain recordings showed significantly less pain for the TT children from the second hour postoperatively onward, and the TT children were pain free and in school 3 days earlier than the TE group. The TT group had less need of the prescribed drugs (diclofenac and paracetamol). After 9 days, 73% of the TT children were completely healed, but only 31% of the TE children. By that time, the TE children had lost a mean of 660 g, and the TT children had gained 127 g. The effect on snoring was the same for both groups.
                RF appears to be a safe and reliable method for tonsil surgery with much less postoperative morbidity than regular TE. We studied the efficacy of tonsillectomy, or tonsillectomy with adenoidectomy, in 187 children severely affected with recurrent throat infection. Ninety-one of the children were assigned randomly to either surgical or nonsurgical treatment groups, and 96 were assigned according to parental preference. In both the randomized and nonrandomized trials, the effects of tonsillectomy and of tonsillectomy with adenoidectomy were similar. By various measures, the incidence of throat infection during the first two years of follow-up was significantly lower (P less than or equal to 0.05) in the surgical groups than in the corresponding nonsurgical groups. Third-year differences, although in most cases not significant, also consistently favored the surgical groups. On the other hand, in each follow-up year many subjects in the nonsurgical groups had fewer than three episodes of infection, and most episodes among subjects in the nonsurgical groups were mild. Of the 95 subjects treated with surgery, 13 (14 per cent) had surgery-related complications, all of which were readily managed or self-limited. These results warrant the election of tonsillectomy for children meeting the trials' stringent eligibility criteria, but also provide support for nonsurgical management. Treatment for such children must therefore be individualized. To determine the effect of the method of tonsillectomy on postoperative pain in pediatric patients.
                Prospective, randomized, single-blind, controlled clinical trial.
                A university pediatric hospital in Aberdeen, Scotland.
                A volunteer sample of 54 children, aged 3 to 12 years, with recurrent tonsillitis or symptomatic adenotonsillar hypertrophy. Two patients withdrew consent.
                Twenty-six children underwent a nonelectrical (ie, cold) dissection tonsillectomy with cold steel instruments, 5 of whom also had adenoidectomy by curettage. Monopolar diathermy forceps were used for tonsillar bed hemostasis. Twenty-four children had electrocautery (ie, hot) dissection tonsillectomy, 7 of whom underwent adenoidectomy by curettage without a suction coagulator.
                Postoperative analgesic consumption, time to regain normal diet and activity levels, and complications.
                Patients who underwent hot dissection tonsillectomy showed no difference in time to first drink or analgesic use within the first 24 postoperative hours compared with children undergoing cold nonelectrical dissection tonsillectomy. The hot dissection tonsillectomy group took 7.5 (95% confidence interval [CI], 1-14.1) more doses of analgesics than the cold dissection group over the next 12 days (P<.05). The hot dissection tonsillectomy group took 2.5 more days than the cold dissection tonsillectomy group to regain normal diet (P<.05). Thirteen children (54%; 95% CI, 34-74) in the hot dissection tonsillectomy group and 6 (23%; 95% CI, 7-39) in the cold dissection tonsillectomy group sought outpatient care for throat pain, otalgia, poor diet, pyrexia, and/or bleeding (P<.05). Throat pain delayed in onset or of prolonged duration affected 9 children (38%; 95% CI, 19-57) in the hot dissection tonsillectomy group as opposed to 3 children (12%; 95% CI, 0-24) in the cold dissection tonsillectomy group (P<.05).
                Hot dissection tonsillectomy increases morbidity in pediatric patients in the recovery period following hospital discharge. Several studies have indicated that antibiotics given for 5-7 days post-tonsillectomy are beneficial. A prospective double blind randomized study was undertaken to evaluate the efficacy of a long-acting antibiotic (Cefonicid) given prophylactically at the time of tonsillectomy. Dependent variables were percent weight loss, number of doses of pain medications required postoperatively, the number of days required to resume a normal diet, and return to work. The results of all independent tests indicated that there were no statistically significant differences between the Cefonicid group and the placebo group. The results of this study indicate that single dose prophylactic application of Cefonicid is not effective in adults undergoing tonsillectomy. We investigated the efficacy and side-effects of a concept for pain therapy after tonsillectomy in children.
                A total of 100 children aged between 6 and 14 years were treated according to the following protocol for pain therapy after tonsillectomy: after induction of anaesthesia the children received 35-40 mg/kg acetaminophen rectally and 0.1 mg/kg piritramide i.v.. Additionally, boluses of 0.05 mg/kg pitritramide i.v. were allowed in the recovery room and 2 doses of 20 mg/kg acetaminophen were given rectally every 6 h on the day of surgery. On the following day the children received 30 mg/kg acetaminophen 3 times per day and from the second postoperative day onwards 1 mg/kg diclofenac was given 3 times a day. The rescue therapy was 5 mg/kg metamizol orally. The severity of the postoperative pain was evaluated by a visual pain scale (VAS) (0-100), side-effects such as vomiting and postoperative haemorrhage were documented. The Friedman test was used for testing the time course of pain intensity.
                The median of the VAS was 42 on the day of surgery, 35 on the first postoperative day and fell continuously to 10 by the 6th postoperative day. The decrease of pain severity was statistically significant (p <0.05). A rescue therapy was necessary in 6 patients on the day of surgery and in 9 patients on the first postoperative day. 7 patients suffered a postoperative haemorrhage, 4 out of the 7 needed a surgical revision and 2 out of 100 patients vomited.
                We conclude that this protocol for pain therapy after tonsillectomy was effective. The incidence of postoperative haemorrhage and vomiting was low.
Adeno-/tonsillectomy is effective in reducing the number of episodes of sore throat and days with sore throats in children, the gain being more marked in those most severely affected. The size of the effect is modest, but there may be a benefit to knowing the precise timing of one episode of pain lasting several days - it occurs immediately after surgery as a direct consequence of it.
It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent 'tonsillitis', the impact of the procedure on 'sore throats' due to pharyngitis is much less predictable.