Tonsillectomy for recurrent tonsillitis
Statutory Guidance
How up to date is this information?
Published January 2019 | Last reviewed September 2024
Using this guidance
The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.
Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.
Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.
Summary
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.
Recommendation
The NHS should only commission this surgery for treatment of recurrent severe episodes of sore throat when the following criteria are met, supported by ENT UK commissioning guidance and NICE:
- Sore throats are due to acute tonsillitis.
AND
- The risks of tonsillectomy vs active monitoring have been discussed with the adult or child and their family or carers, and a shared decision has been made on whether to have the procedure. This discussion should be documented.
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.
The impact of recurrent tonsillitis on a patient’s quality of life and ability to work or attend education should be taken into consideration. A fixed number of episodes, as described above, may not be appropriate for adults with severe or uncontrolled symptoms, or if complications (e.g. quinsy) have developed.
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 psoriasis.
- 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).
Rationale for recommendation
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, tonsillectomy is beneficial. The number of episodes required for referral is largely consensus based and is supported by NICE and ENT UK. The NATTINA pragmatic randomised control trial was conducted across 27 hospitals in the UK between 2015 and 2018. All participants fulfilled the UK referral criteria for tonsillectomy. The trial indicated that compared with continued conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent tonsillitis.
Tonsillectomy is a low-risk procedure but the pain after surgery can be particularly severe (especially in adults) for up to two weeks; this requires regular painkillers and can cause temporary difficulty swallowing. The Getting it Right First Time (GIRFT) ENT report (2018) found that the overall readmission (12.3%) and return to theatre rates following tonsillectomy are now much higher than previously reported in the literature. Rates are higher in adults (18.4%) compared to children (9.4%) and the readmissions are due to tonsillectomy complications and not unrelated causes. There is wide national variation in readmission rates and no particular independent variable or practice that accounts for the variation. There is some evidence that tonsillectomy performed using Coblation in paediatric patients is no longer associated with higher risk of complications than other techniques due to the advent of the intracapsular technique. This technique is associated with lower complication rates.
The most common post-operative complications requiring readmission to hospital include bleeding, infection, pain and vomiting. In the GIRFT report, the readmission rate for:
- Haemorrhage was found to be 8% (13% for adults and 5.7% for children) of with 1.3% returned to theatre (2.3% adult and 0.8% children).
- Infection 1.1% (1.4% for adults and 1.0% for children).
- Pain 0.5% (0.8% for adults and 0.4% for children).
- Nausea and vomiting 0.1% (0% for adults and 0.2% for children).
There is no alternative treatment for recurrent tonsillitis that is known to be beneficial, however symptoms often improve with a period of observation. The risks and benefits of surgery vs conservative management must be weighed up and a shared decision made with the adult or child and their family or carers.
Patient information
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.
Coding
WHEN Primary_Spell_Procedure IN ('F341','F342','F343','F344','F345','F346','F347','F348','F349','F361') AND ( Any_Spell_Diagnosis like '%J030%' OR Any_Spell_Diagnosis like '%J038%' OR Any_Spell_Diagnosis like '%J039%' OR Any_Spell_Diagnosis like '%J350%') AND not ( Any_Spell_Diagnosis like '%C[0-8][0-9]%' OR Any_Spell_Diagnosis like '%C9[0-7]%') AND not ( Any_Spell_Diagnosis like '%G473%' OR Any_Spell_Diagnosis like '%J36%' OR Any_Spell_Diagnosis like '%J390%') -- Only Elective Activity AND APCS.Admission_Method not like ('2%') THEN 'H_tonsil'
Exclusions
WHERE 1=1 -- Cancer Diagnosis Exclusion AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' AND Any_Spell_Diagnosis not like '%D0%' AND Any_Spell_Diagnosis not like '%D3[789]%' AND Any_Spell_Diagnosis not like '%D4[012345678]%' OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion AND apcs.Administrative_Category<>'02'
References
- NICE (2023) Sore throat – acute. Clinical Knowledge Summaries (CKS)
- ENT UK & RCS (2021) Commissioning guide: Tonsillectomy.
- ENT UK & NHS (2023) Making a decision about recurrent tonsillitis in children and adults.
- Marshall A. (2019) Ear, Nose and Throat Surgery. GIRFT Programme National Speciality Report. Get It Right First Time. https://gettingitrightfirsttime.co.uk/wp-content/uploads/2019/10/ENT-Report-Nov19-L-FINAL.pdf
- Wilson JA, O’Hara J, Fouweather T, Homer T, Stocken DD, Vale L, Haighton C, Rousseau N, Wilson R, McSweeney L, Wilkes S, Morrison J, MacKenzie K, Ah-See K, Carrie S, Hopkins C, Howe N, Hussain M, Mehanna H, Raine C, Sullivan F, von Wilamowitz-Moellendorff A, Teare MD. (2023) Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial. Lancet. 401: 2051-59. https://doi.org/10.1016/S0140-6736(23)00519-6.