Tonsillectomy for recurrent tonsillitis

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.

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

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.

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.

Information for Patients

Surgery to remove your tonsils (tonsillectomy) for recurrent tonsillitis is a procedure which should only be carried out when specific criteria are met. Although the operation was common many years ago, this is no longer the case because the medical evidence tells us the intervention can sometimes do more harm than good and there are alternative treatments for treating sore throats.

About the condition

Recurring sore throats are a very common condition. It must be recognised 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.

It’s important you and your doctor make a shared decision about what’s best for you or your child if the sore throat is becoming a problem. When deciding what’s best you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Surgery to remove your tonsils will only benefit those with recurrent episodes of acute tonsillitis.

What are the RISKS?

Tonsillectomies require an operation and the risks include: infection, bleeding, pain, difficulty swallowing and the risks of anaesthetic. Pain after surgery can be severe for up to a fortnight after the procedure.

What are the ALTERNATIVES?

There are many alternative treatments to ease a sore throat. During acute episodes, you should rest, as the symptoms usually improve after a few days. Drink plenty of water and gargle regularly with salt water. Pain killers, throat lozenges or sprays to reduce the inflammation can all be bought over the counter at your chemist.

What if you do NOTHING?

Sore throats can be painful and you may not be able to eat or drink comfortably. Doing nothing will not be harmful, some of the suggested alternatives above may help ease the symptoms, and prevent the need for surgery. If the symptoms persist and you cannot tolerate the pain you should see your doctor.

1. Rubie I, Haighton C, O’Hara J, Rousseau N, Steen N, Stocken DD, Sullivan F, Vale L, Wilkes S, Wilson The National randomised controlled Trial of Tonsillectomy IN Adults (NATTINA): a clinical and cost-effectiveness study: study protocol for a randomised control trial. Trials. 2015 Jun ;16:263. doi: 10.1186/s13063-015-0768-0.
2. SIGN (2010) Management of sore throat and indications for tonsillectomy A national clinical guideline
3. Osbourne MS, Clark MPA. The surgical arrest of post-tonsillectomy haemorrhage: Hospital Episode Statistics 12 years on. Annals RCS. 2018. May (100) 5: 406-408

Last revised December 2023