Abstract
Tonsillectomy with or without adenoidectomy is one of the most commonly performed surgical procedures in children in western countries. Its indications, however, remain uncertain as is reflected by the large variation in surgical rates across countries. Partly, this variation is explained by cultural differences, such as a preference for antibiotic
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or surgical management of upper respiratory infections, but inconsistent guidelines on indications for this common procedure also play an important role. The main reason for the absence of generally accepted clinical guidelines is the poor quality of the scientific evidence of the effects of (adeno)tonsillectomy in children. In general, doctors agree that (adeno)tonsillectomy is beneficial for children with very frequent throat infections (i.e. 7 or more per year) and for those with obstructive sleep apnoea. However, there is no consensus for the benefits of (adeno)tonsillectomy in a large proportion of children currently undergoing this procedure for less frequent throat infections and milder symptoms of adenotonsillar hypertrophy or for other indications such as recurrent upper respiratory infections, i.e. 65% of the children underging (adeno)tonsillectomy in the Netherlands.
To provide further evidence on this issue, we designed a randomised trial on the effectiveness of adenotonsillectomy in children selected for this operation according to current medical practice in the Netherlands and we initiated several additional cross-sectional and follow-up studies.
In Chapter 2 describes the age and sex-specific incidence and duration of fever episodes in children with relatively mild symptoms of throat infections or adenotonsillar hypertrophy, the main symptoms experienced by these children during fever episodes, and the consequences in terms of physician consultation rates and antibiotic prescription rates.
In Chapter 3 we tried to define a prediction rule that is easily applicable and can be used by general practitioners as a screening tool to identify children at risk for developing chronic recurrent upper respiratory infections.
Variation in the microbial flora in the tonsillar and adenoidal tissue may predispose children to upper respiratory infections and/or adenotonsillar hypertrophy. In Chapter 4 we investigated whether the tonsillar flora of children with adenotonsillar disease differs from that in children without adenotonsillar disease.
In Chapter 5 a systematic review based on all available evidence from randomised trials and non-randomised controlled studies on adenotonsillectomy in children is presented. This review will provide a quantitative estimate of the effects of (adeno)tonsillectomy on sore throat episodes, upper respiratory infections and sore throat associated school loss.
Since we decided to use the occurrence of fever as the primary objective outcome of our trial, we instructed parents to measure their child’s temperature daily with an infrared tympanic membrane thermometer. To ensure objectivity and avoid information bias we incorporated an electronic device in the thermometer that stored temperature measurements automatically on a daily basis. In Chapter 6 accuracy and feasibility of such daily temperature measurements at home are reported.
In Chapter 7 we present the results of our randomised trial on the effects of adenotonsillectomy in children with relatively mild symptoms of throat infections or adenotonsillar hypertrophy. Outcome measures are fever episodes, throat infections, upper respiratory infections and health-related quality of life.
The cost-effectiveness of adenotonsillectomy as compared to watchful waiting is presented in Chapter 8. Main outcome measures are incremental cost-effectiveness in terms of costs per fever episode avoided, per throat infection avoided and per upper respiratory infection avoided.
Prior belief of parents and doctors in the beneficial effect of adenotonsillectomy is usually strong. The results of trials, including ours, may not be in accordance with these beliefs and this may hamper successful implementation of the results. In the General discussion factors are explored that influence patients help-seeking behaviour and the tools that general practitioners have to implement the results of our randomised trial. Finally, the challenges for future research will be discussed.
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