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BMJ. 2007 May 19; 334(7602): 1019.
PMCID: PMC1871775
Recurrent Pharyngo-Tonsillitis

More advice to clinicians

Alun Tomkinson, consultant in otolaryngology and head and neck surgery,1 Rosemary Fox, specialist registrar in public health medicine,2 and Mark Temple, consultant in public health medicine2

Concerns over the safety of single use instruments led to a moratorium in Wales on tonsillectomy, which created a cohort of patients who fulfilled the criteria for tonsillectomy but were denied surgery for more than one year.1

We think that adults presenting with chronic or recurrent tonsillitis2 may expect as many as three or more episodes in the forthcoming six months and that these episodes are likely to result in time off work and further visits to the general practitioner. In contrast to the likely effect of intervention by tonsillectomy, we would not be able to give these patients any indication of if, or when, this was likely to change.

No randomised controlled trials have been conducted that support tonsillectomy in adults, but equally there are no studies that support denial of tonsillectomy as an alternative in patients with serious disease. As no test exists to determine if an individual patient will improve with time, “watchful waiting” is used by most clinicians as a diagnostic tool to determine whether surgery should be advised. Waiting is not a treatment in itself, and considerable morbidity may be associated with this option in some patients.

Ideally, a large scale randomised controlled trial with long term follow-up is required to examine the consequences of denying tonsillectomy to patients who previously would have been considered worthy of surgery. However, such a study may fail through lack of patient willingness to remain long enough in the control group. Furthermore, given the levels of morbidity measured in these patients and the large volumes of complaints we received from distressed patients and parents who were denied surgery, such a study may even be considered unethical.


Competing interests: None declared.


1. Fox R, Tomkinson A, Myers P. Morbidity in patients waiting for tonsillectomy in Cardiff: a cross sectional study. J Laryngol Otol 2006;120:214-8. [PubMed]
2. Alho OP, Koivunen P, Penna T, Teppo H, Koskela M, Luotonen J. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial. BMJ 2007;334:939-41. (5 May.) [PMC free article] [PubMed]

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