Talk:Tonsillectomy

What about Coblation

The section on "Bipolar Radiofrequency Ablation" refers the reader to "Coblation Tonsillectomy", but this article does not exist.

Growing back?

-What's the source on the tonsils growing back after removal? That's really very interesting. --FMephit 05:11, 3 Dec 2004 (UTC)

I think that's a confusion of the tonsils with the adenoids. The adenoids can grow back after an adenotomy, IIRC, but for sources on that, STFW... Dabljuh 21:42, 17 January 2006 (UTC)

Tonsils can in fact grow back if some tonsil tissue was left behind during the surgery.

https://www.childrensmn.org/educationmaterials/parents/article/9145/can-tonsils-grow-back/#:~:text=During%20a%20tonsillectomy%2C%20most%20of,back%2C%20talk%20to%20your%20doctor. Prophylax (talk) 23:41, 9 September 2024 (UTC)

Citation concerns

The section on Methods of Tonsil Removal was lifted wholesale from this site (http://www.entnet.org/KidsENT/tonsil_procedures.cfm) listed in the External Links section without appropriate citation. Is this OK?

203.212.59.211 11:30, 10 December 2006 (UTC)

Looks like the site no longer exists. Why would this not be okay though? Prophylax (talk) 23:42, 9 September 2024 (UTC)

Pictures

I personally don't think that the current picture of the article is very useful unless we have a "before" picture to go with it. Maybe someone who has very swollen tonsils could take a picture of them before they have them taken out and add them to the article. I think that would greatly improve the visual aspect of the article. --Emery 23:26, 10 January 2007 (UTC)

That's not a bad suggestion, but one could also go to the "Palatine tonsil" page to see an image of tonsils. Prophylax (talk) 23:43, 9 September 2024 (UTC)

Post-Surgery and Revovery

It would be help to add some information regarding after surgery recommendations for the patient and what to expect 10-15 days later.

Ryan Martin —Preceding unsigned comment added by 65.186.208.223 (talk) 00:59, 27 September 2007 (UTC)

I've not seen much in the texts covering that. The focus is on the first 2 weeks.--RadioFan (talk) 14:38, 25 April 2009 (UTC)

Added a sentence about diet recommendations. Prophylax (talk) 23:46, 9 September 2024 (UTC)

Post-Op diet recommendations

I've removed the sentences which claim that North American physicians recommend a diet of soft foods while in the UK "crunchy" or "rough" foods are recommended to keep the tonsil beds "clean". It was completely unreferenced and counters what is suggested in the references I'm finding. The only mention I've found in texts to anything but soft foods being recommended was a study in 1992 which concluded that eating soft foods or rough foods after a tonsillectomy had no impact on recovery time, pain medication, etc. Without some reference to the differing advice between the UK and the US/Canada, the information doesn't belong here.--RadioFan (talk) 14:38, 25 April 2009 (UTC) National health service recommends a normal diet on it's own website http://www.nhs.uk/conditions/tonsillitis/pages/treatment.aspx should be updated to reflect? —Preceding unsigned comment added by 91.109.205.221 (talk) 16:40, 30 July 2010 (UTC)

I added a generic statement about some surgeons recommending a soft diet back to the post surgery care section. Prophylax (talk) 23:48, 9 September 2024 (UTC)

Side effects

How about a section on side effects and results? I'd be interested to know if removal of tonsils has been correlated either positively or negatively with weight gain. 69.143.26.71 03:58, 23 October 2007 (UTC)

Perhaps someone could do some research on this topic? Prophylax (talk) 23:48, 9 September 2024 (UTC)

I agree, I would like to request someone with more expertise to add material to this page, describing what the negative impacts of tonsilectomy are. The pages on tonsils and palatine tonsils say that the tonsils play a role in helping the immune system fight off upper respiratory-tract infections. I am sure this has been studied!!! This material is really critical on this page. Cazort (talk) 22:29, 5 March 2008 (UTC)

The complications section hopefully answers some of these questions, and there is a section dedicated to immune function of tonsils and impact of tonsillectomy. Prophylax (talk) 23:49, 9 September 2024 (UTC)

After nine years, you can now find information on the impact on the immune system of tonsillectomy. Zesd (talk) 19:13, 29 March 2017 (UTC)

There should be more info on what it's like post-op —Preceding unsigned comment added by 68.158.98.49 (talk) 02:03, 4 January 2009 (UTC)

Please see the post surgery care section now. Any advice for further addition to this section is welcome. Prophylax (talk) 23:50, 9 September 2024 (UTC)

Tonsillolith?

Should information about the tonsillolith be in the section about reasons for removal? I know some people do it just to stop it from happening, and I may have it done too. Any ideas? Montymintypie (talk) 08:38, 15 May 2008 (UTC)

Tonsilloliths are listed as one of the indicators for the proceedure, what else did you want to see there?--RadioFan (talk) 14:42, 25 April 2009 (UTC)

Actually looks like this has been removed from the article completely. Prophylax (talk) 23:51, 9 September 2024 (UTC)

Side Effect - Loss of Taste

I think it is important to note serious side effects such as a loss of taste, or metallic taste in the back of the mouth due to nerve damage caused during tonsillectomy. This issue seems to affect many adults who have had tonsillectomies. See here. —Preceding unsigned comment added by 124.171.225.70 (talk) 05:48, 28 April 2009 (UTC)

This is in the article. Prophylax (talk) 23:51, 9 September 2024 (UTC)

In Russia

It was a very popular surgery for children in 80-es in USSR. Dissection and snare method was usually used without any kind of anesthesia. In modern Russia less surgeries are performed and local or general anesthesia is often (but not always) used.

--Varnav (talk) 12:31, 18 December 2009 (UTC)

Perhaps you could add it to the article? Prophylax (talk) 23:51, 9 September 2024 (UTC)

How Old?

Lead sentence says it's been practiced for 2000 yrs, but further down it says it's been practiced for 3000 yrs. Maybe it was in clniical trials for the first 1000 yrs... Please check and update where needed. Oaktree b (talk) 15:55, 19 May 2010 (UTC)

The source suggests that it the complete tonsillectomy is at least 2000 yrs old. Not 3000. The source does use a quote from 1000BC that describes a partial, not complete, tonsillectomy. So in principle, surgery on the tonsils is at least 3000 years old and a complete removal is at least 2000 years old. 62.194.132.49 (talk) 19:36, 25 August 2013 (UTC)

Just had my Tonsils REMOVED!!!

Hi

I have just had my Tonsils removed 6 weeks ago, before the operation I was searching the net for information, but did not find what I was looking for, so here is the REAL truth about my operation on the N.H.S !!!

I am a 40 year old male, fit and healthy, do not smoke and not overwieght, I attend a gym 3 times a week. I had my Tonsils removed to hopefully stop me from Snoring!!

I was told I would need two weeks off work after the operation, which was an overnight stay in hospital, surely it can not be that bad I thought to myself??. I awoke after the operation with hardly any pain, but slowly during my overnight saty it became worse, I was taking pain killers and anti biotics every 6 hours, I left hospital the folowing morning and felt really drowsy..I could not return to work. I was still taking loads of pain killers and anti biotics given to me by the Hospital, which I had to take every 6 hours for the next 21 days!!..after 5 days at home I returned to work..M<ASSIVE mistake, by day 7 I was in total agony, in all fairness the Doctor told me it gets worse about 7 days after the ooperation, and man was he right!!!..all I could swallow was water and soup which was total agony, this went on for about 2 weeks, I felt terrible. Finally after approx 5/6 weeks I am now able to eat normal food and also taste the food.

All I can say is take 2 weeks off work to recover, and expect plenty of pain!!!..I lost 2 stone in 6 weeks with not eating correctly and had no energy whats so ever.

But YES I have stopped SNORING so my Wife says it was well worth it. —Preceding unsigned comment added by 81.144.178.190 (talk) 07:25, 1 June 2010 (UTC)

Tonsillectomy and voice-change

This article does not cover the most talked-about after-effect of a tonsillectomy - possible voice change. There's a lot of talk about the extent to which a person can undergo a change of voice, post tonsillectomy. Some people, on the other hand, do not undergo any sort of voice-change. Can anybody shed more light about this? 59.184.164.16 (talk) 03:53, 2 June 2010 (UTC)

It's not a common complication of tonsillectomy, but some people occasionally may report it. Perhaps someone can do more research on this topic. Prophylax (talk) 23:52, 9 September 2024 (UTC)

Information repeated many times

This is one of the worst scientific articles I have ever seen on Wikipedia. Several facts are repeated in unnecessary fashion, and the divisions or headers should be combined or changed to a more logical order. — Preceding unsigned comment added by 68.3.72.196 (talk) 07:35, 8 January 2017 (UTC)

Information is now presented in a more logical order.Zesd (talk) 15:55, 8 March 2017 (UTC)

And I removed some duplicate information today.Zesd (talk) 18:30, 15 March 2017 (UTC)

Primary sources

Per WP:MEDRS we do not use primary sources for medical content. This section was supported nearly exclusively by primary sources.[1]

I have thus reverted this [2]. Doc James (talk · contribs · email) 21:16, 11 February 2019 (UTC)

agree w/ Doc James, should use MEDRS--Ozzie10aaaa (talk) 21:33, 11 February 2019 (UTC)

For @Zesd: "For biomedical content, primary sources should generally not be used. This is because primary biomedical literature is exploratory and often not reliable, and any given primary source may be contradicted by another. The Wikipedia community relies on guidance of expert reviews, and statements by major medical and scientific bodies. Text that relies on primary sources should usually have minimal undue weight, only be used to describe conclusions made by the source, and must describe these findings clearly so that all editors even those without specialist knowledge can check sources. Primary sources should never be cited in support of a conclusion that is not clearly made by the authors (see WP:Synthesis)." from WP:MEDRS. —Atcovi (Talk - Contribs) 21:50, 11 February 2019 (UTC)

@Doc James: @Ozzie10aaaa: @Atcovi: Okay then, but something more needs to be written about the impact on the immune system as there are strong indications that tonsillectomy does harm the immune system in the long run. Protecting the body against pathogens is the very purpose of the tonsils, so patients, or actually, their parents, should have an idea what the long term consequences of tonsil removal are. Zesd (talk) 05:26, 12 February 2019 (UTC)

You need to present high quality secondary sources such as literature reviews or positions statements by well respected medical organizations. Doc James (talk · contribs · email) 05:27, 12 February 2019 (UTC)

This 2015 JAMA Pediatrics review [3] seems to indicate that most studies have actually found no significant effects on a child's immune system post-tonsillectomy. A second 2015 review [4] agrees. A brief look at the literature shows the procedure even helps certain immune-mediated conditions on occasion. TylerDurden8823 (talk) 07:02, 12 February 2019 (UTC)

Thanks User:TylerDurden8823 have added those reviews. Doc James (talk · contribs · email) 16:13, 13 February 2019 (UTC)

• I agree that this content is not appropriate for this article. However, I also sympathize with the need for Wikipedia to develop and eventually have a process for summarizing research. The reason why this content does not belong in the article is because reporting the outcomes of primary research in a correct way is so difficult as to be nearly impossible in Wikipedia's medical articles. I could support an experimenting in starting a new article, something like "research on tonsillectomy", and clearly marking that article as a history and summary of research outcomes which no one should use to inform health decisions. Such information could be useful to track things like the history of medicine, social issues related to research, and general trends in research. I am not aware of good examples of such research articles existing. It would take a lot of work for someone to talk through the model of this, but this is where we are in Wikipedia. I can think of no way to go into this much detail on a general medical article without inappropriately communicating that there is some health insight to find in primary research, which would be a mistake. Blue Rasberry (talk) 18:01, 12 February 2019 (UTC)

Have reverted some recent readdition of these primary sources. Doc James (talk · contribs · email) 22:18, 12 February 2019 (UTC)

I am not persuaded that primary sources should never be cited. We teach medical students that where there are no relevant systematic reviews we look for primary evidence as the next best alternative. I am also not persuaded that "position statements" are particularly reliable as they can simply reinforce current opinion and ignore evidence. In relation to long term effects of tonsillectomy the Population of interest is children, the Exposure or Intervention of interest is tonsillectomy, the Comparison should be children who did not undergo tonsillectomy, the Outcome is subsequent illness or death years or decades later (not biomarker measurements or physiological variables). We should first look for systematic reviews of RCTs (there are not any), then systematic reviews of cohort studies (there are not any which look at illness outcomes), then primary cohort studies (there are a number).TTM314 (talk) 23:20, 16 May 2019 (UTC)

@TTM314: I agree with you that we should be allowed to use primary sources (especially if there is a lack of secondary sources) as long as those primary sources fulfil certain criteria. Those primary sources are peer reviewed and published in renowned journals such as The Lancet, so they are more reliable than position statements (which are often political).Zesd (talk) 17:53, 17 May 2019 (UTC)

I agree with this as well. Primary sources that meet certain criteria should be allowed to be included. What criteria would you propose? Prophylax (talk) 23:54, 9 September 2024 (UTC)

Immune function

I am not see the source that supports this "It remains controversial whether tonsillectomy affects long term immune function."

What the source says is "It is reasonable to say that there is enough evidence to conclude that tonsillectomy has no clinically significant negative effect on the immune system."[5]

Doc James (talk · contribs · email) 21:32, 16 February 2019 (UTC)

This is not a good summary "The long term impact of tonsillectomy on the immune system is still not fully understood." and is unreferenced. Not sure why the Lancet review form 2015 was removed? Doc James (talk · contribs · email) 04:32, 28 February 2019 (UTC)

@Doc James: The claim that the long term impact of tonsillectomy on the immune system is still not fully understood was based on the fact that there are several literature reviews that found an association between tonsillectomy an certain diseases (Crohn's disease, multiple sclerosis and polio). Those literature reviews are referenced in the article. So I put it back, but now with the argument that some studies did find an association whereas other studies did not. By the way, you used terms such as "appear" and "unclear", so you basically admit that it is still not clear what tonsillectomy does to the immune system. I also moved the information about the association between tonsillectomy and polio back to the complications section. I agree that polio is not really a concern anymore as it was in the forties and fifties, but that association is a potential indication that tonsillectomy does compromise the immune system in some way. I also put back that the increased risk of tonsillectomy on attracting multiple sclerosis is "small but statistically significant and clinically important" because this is what one of the articles literally says. Zesd (talk) 07:36, 2 March 2019 (UTC)

The polio bit is based on very old references, as such it belongs in the history section.

We already use the word "appear" and "unclear" the additional sentence "The long term impact of tonsillectomy on the immune system is still not fully understood" is simple not needed.

Also we generally paragraph rather than quote Doc James (talk · contribs · email) 02:22, 3 March 2019 (UTC)

I am afraid the cited source is very weak evidence as it does not measure outcomes of relevance to patients (illness, mortality) but instead measures levels of immunoglobulins; the follow up in most of the included studies is measured in months, not years; the combined number of patients in the 35 included studies is less than 2000. [6] It is misleading to suggest this rules out any future effects of tonsillectomy on health.TTM314 (talk) 23:25, 16 May 2019 (UTC)

Hodgkin lymphoma

User:Zesd added

"The Canadian Cancer Society mentions tonsillectomy as a possible risk factor for Hodgkin's lymphoma, although it stresses that more research is necessary."

Ref says:

"Unknown risk factors It isn’t known whether or not the following factors are linked with Hodgkin lymphoma previous surgery to remove the tonsils or the appendix"

One definitely does not equal the others. The source actually could be summarized as "There is no evidence that tonsillectomy is a risk factor for Hodgkin's lymphoma." Doc James (talk · contribs · email) 04:29, 6 March 2019 (UTC)

References

Text

Which text from the source supports this

"It is still controversial whether tonsillectomy is beneficial in case of frequent sore throats, compared with alternative treatments and watchful waiting. Because symptoms tend to improve with time, often spontaneously, most children recover without surgery."

I am seeing "There was near consensus among the guideline update group that tonsillectomy should be an option for children who meet the eligibility criteria in this statement, but 1 member of the group felt that tonsillectomy should not be recommended, even with appropriate documentation." Doc James (talk · contribs · email) 13:11, 24 March 2019 (UTC)

@Doc James:Regarding controversy, the source says "Controversy persists regarding the actual benefits of tonsillectomy as compared with observation and medical treatment of throat infections.". And regarding spontaneous improvement without surgery: "Furthermore, 1 study explicitly observed children with recurrent throat infections and found high rates of spontaneous resolution over 12 months. Because of this tendency to improve with time, at least a 12-month period of observation is recommended prior to consideration of tonsillectomy as an intervention." and "A Cochrane review on the efficacy of tonsillectomy for recurrent tonsillitis also concluded that cases may resolve without surgery and that, after the first year, there were no or minimal differences between groups. A systematic review confirming earlier work reported that in all studies, the control group showed a spontaneous reduction of rates of recurrent infection." Zesd (talk) 14:00, 24 March 2019 (UTC)

Yes it says "Controversy persists regarding the actual benefits of tonsillectomy as compared with observation and medical treatment of throat infections."

And than says "A comparative effectiveness review from the Agency for Healthcare Research and Quality (AHRQ) reported that in children with recurrent throat infections undergoing tonsillectomy, the number of throat infections (moderate strength of evidence) and associated health care utilization and work/school absences (low strength of evidence) improved in the first postsurgical year. These benefits did not persist, and long-term results were lacking." So we can just state the conclusions.

Agree "Those with frequent throat infections often improve over a year without surgery" is supported and have added back. Doc James (talk · contribs · email) 14:17, 24 March 2019 (UTC)

Just to contextualise the "near consensus among the guideline update group". This is a guideline group from the USA which in international comparisons has one of the highest rates of tonsillectomy.

Tonsillectomy rates in Belgium, Finland and Norway are twice the UK rate, but in Spain, Italy and Poland rates are much lower. Childhood tonsillectomy rates in the USA are three times higher than in England., TTM314 (talk) 23:35, 16 May 2019 (UTC)

Most recent figures from the US are 289,000 childhood tonsillectomies per year. Median cost of a tonsillectomy in the US is $3585. $3585 x 289,000 = $1.036 billion. Childhood tonsillectomy is a billion dollar a year industry. I would therefore suggest we should be cautious about accepting the views of the industry on their current practice. By contrast the Cochrane review states "It is clear that some children get better without any surgery". This is illustrated in Analysis 1.1 which shows that in the five RCTs included, children assigned to the groups that did not undergo surgery averaged 3, 8, 3, 4 and 3 sore throats in the next year. Considerably fewer than previously. In good part this is likely to be Regression to The Mean, which is of course one of the reasons we need RCTs.TTM314 (talk) 13:44, 17 May 2019 (UTC)

@TTM314: And don't forget that there is a lot of confirmation bias! Zesd (talk) 18:07, 17 May 2019 (UTC)Zesd

Summary

Ref says "tonsillectomy for recurrent throat infections in severely affected children was shown, in a randomized controlled trial, to reduce the frequency and severity of infections in the 2 years following surgery"

This IMO is a reasonable summary:

"For those with frequent throat infections, surgery results in fewer sore throats in the following one to two years, but unclear long term benefits."

Doc James (talk · contribs · email) 08:53, 26 March 2019 (UTC)

@Doc James:How many fewer sore throats (on average)? Just "fewer" is too vague. Is it 20? 10? 5? 1? (per year) The sore throat section says "Children who undergo surgery on average have one fewer sore throat per year in the subsequent one or two years, compared to those who do not". This information should also be present in the introduction. Zesd (talk) 16:14, 26 March 2019 (UTC)

Fewer IMO is fine as that is the summary the source gives. The exact numbers can go in the body of the text. Doc James (talk · contribs · email) 16:22, 26 March 2019 (UTC)

agree w/ Doc James.... (BTW additional reverts Zesd are not wise at this point)--Ozzie10aaaa (talk) 22:38, 21 April 2019 (UTC)

@Doc James: @Ozzie10aaaa: One of the main points of this article is that the benefits of tonsillectomy are very modest at best. Therefore it needs to be in the introduction like in the abstract of a scientific study. I agree with @TTM314: that simply saying “fewer sore throats” is misleading. This is a medical article, so we really need to be careful, even in the introduction. I do not see what rule there would be violated, or what problem will be caused by mentioning a number or the fact that the reduction is minor. It would make the introduction more accurate by only adding a few extra words. And if we can say in the introduction for how long the decrease in sore throats persists, why can’t we say how big that decrease actually is? I also see some statistics regarding complications in the introduction, so why not about the reduction in the number of sore throats? Zesd (talk) 08:43, 22 April 2019 (UTC)

I dont agree w/your position/interpretation of the wording--Ozzie10aaaa (talk) 11:01, 22 April 2019 (UTC)

@Ozzie10aaaa:What exactly do you not agree with? Could you please tell me why you think that I am wrong? Just saying that you do not agree with me is not very helpful. Zesd (talk) 13:36, 22 April 2019 (UTC)

would refer you to both Doc James answers above, thank you--Ozzie10aaaa (talk) 15:49, 22 April 2019 (UTC)

It is in the body of the text. We could also say a 20% decrease. But the specifics are better in the body of the text. Doc James (talk · contribs · email) 17:13, 23 April 2019 (UTC)

Looks like the current statement now includes a number, which is nice for readers. Prophylax (talk) 23:57, 9 September 2024 (UTC)

Removal of reviews

User:Zesd Why did you remove the following reviews?

Sun W, Han X, Wu S, Yang C (June 2016). "Tonsillectomy and the risk of inflammatory bowel disease: A systematic review and meta-analysis". Journal of Gastroenterology and Hepatology. 31 (6): 1085–94. doi:10.1111/jgh.13273. PMID 26678358. Xiong, HF; Wang, B; Zhao, ZH; Hong, J; Zhu, Y; Zhou, X; Xie, Y (May 2016). "Tonsillectomy and inflammatory bowel disease: a meta-analysis". Colorectal Disease (Review). 18 (5): O145-53. doi:10.1111/codi.13323. PMID 26946482.

They are not even 5 years old. And which words in the text support an increased risk of UC? Please provide a direct quote. The article is still in publication you added. We should wait until it is fully published. Doc James (talk · contribs · email) 17:01, 23 April 2019 (UTC)

@Doc James: On the 13th of February 2019 user TylerDurden8823 commented that studies from China are prone to academic fraud. Assuming that that is true, plus the fact there is now a good secondary source from Europe, I decided to replace the two Chinese sources by the one from Europe. This new source is quite clear on the link between tonsillectomy and Crohn’s disease (which is an IBD): ”We identified 9 factors that increase risk of IBD: smoking (CD), urban living (CD and IBD), appendectomy (CD), tonsillectomy (CD), antibiotic exposure (IBD), oral contraceptive use (IBD), consumption of soft drinks (UC), vitamin D deficiency (IBD), and non-Helicobacter pylori-like enterohepatic Helicobacter species (IBD).” Zesd (talk) 20:08, 23 April 2019 (UTC)

The article is currently in press.[7] We should wait until it is fully published. Do you have the full text? Doc James (talk · contribs · email) 02:49, 24 April 2019 (UTC)

@Doc James:Ok, I agree with you that we should wait for the final version although I don’t expect the conclusion to be much different. Zesd (talk) 21:29, 24 April 2019 (UTC)

Well first of all the abstract does not mention UC. Doc James (talk · contribs · email) 00:21, 27 April 2019 (UTC)

@Doc James:But the text of the article does, see https://www.gastrojournal.org/article/S0016-5085(19)36709-5/abstract under the Results section. Zesd (talk) 06:57, 1 May 2019 (UTC)

Can you quote the exact text you are looking at. Doc James (talk · contribs · email) 07:10, 1 May 2019 (UTC)

@Doc James:This is the text that says there is a link between tonsillectomy and Crohn’s Disease: “We identified 9 factors that increase risk of IBD: smoking (CD), urban living (CD and IBD), appendectomy (CD), tonsillectomy (CD), antibiotic exposure (IBD), oral contraceptive use (IBD), consumption of soft drinks (UC), vitamin D deficiency (IBD), and non-Helicobacter pylori-like enterohepatic Helicobacter species (IBD).“ The publication status of the study is “In Press Accepted Manuscript”, which means it is almost final. Once the publication status is final, we should no longer say that the link between tonsillectomy and Crohn’s disease is “unclear” as we will then have three secondary sources that confirm a link between tonsillectomy and Crohn’s disease. Zesd (talk) 20:09, 1 May 2019 (UTC)

We are talking about UC not CD. Doc James (talk · contribs · email) 20:18, 1 May 2019 (UTC)

@Doc James: According to those three secondary sources, tonsillectomy does not increase the risk of UC, but does increase the risk of CD. So, we can simply say that tonsillectomy increases the risk of CD (if citing three secondary sources is not sufficient, then what is?). In my opinion, there is no need to say that tonsillectomy does not increase the risk of UC.Zesd (talk) 05:37, 2 May 2019 (UTC)

Cochrane says "No obvious association between tonsillectomy and inflammatory bowel disease was identified in our meta-analysis."[8] Doc James (talk · contribs · email) 05:45, 2 May 2019 (UTC)

@Doc James: That may be, but other studies say: “This meta‐analysis demonstrates that tonsillectomy is associated with an increased risk of developing CD.” (https://onlinelibrary.wiley.com/doi/abs/10.1111/jgh.13273) and “We identified 9 factors that increase risk of IBD: (...) tonsillectomy (CD) (...)” (https://www.gastrojournal.org/article/S0016-5085(19)36709-5/abstract). Just because one study says that there is no link does not mean that all other studies that claim the opposite are wrong. Even that Cochrane review you are talking about says “The odds ratio for CD following a tonsillectomy was 1.194, 95% CI 0.992–1.437”, which means a slightly increased risk of CD. Based on the available medical literature, it is safe to say that tonsillectomy increases the risk of Crohn’s Disease. Please stop denying the obvious.Zesd (talk) 17:18, 6 May 2019 (UTC)

No that is not accurate. "he odds ratio for CD following a tonsillectomy was 1.194, 95% CI 0.992–1.437" does not mean a slight increase. It means no significant difference. Lets just wait for that paper to be fully published so that we can read it. Have you read the full copy yet? Doc James (talk · contribs · email) 23:20, 6 May 2019 (UTC)

@Doc James: Once the publication status of the study is final, we could say that according to most recent research, or according to the majority of the available research, tonsillectomy increases the risk of CD. Zesd (talk) 04:29, 7 May 2019 (UTC)

Once that study is fully published and we are able to read it we can figure out what we should say based on it.Doc James (talk · contribs · email) 09:52, 7 May 2019 (UTC)

Evidence for effectiveness of tonsillectomy for Obstructive Sleep Apnoea

I am concerned that the page as currently written misrepresents the evidence for tonsillectomy in Obstructive Sleep Apnoea

What Wikipedia says: "Tonsillectomy improves obstructive sleep apnea (OSA) in most people."

What the evidence says: Adults: no RCT evidence

Children: RCT evidence shows improvements in polysomnography parameters and in "quality of life, symptoms and behaviour as rated by caregivers". These are subjective outcomes rated by a third party in unblinded studies.

It is also observed that half of children improve without surgery - so it is hard to see how tonsillectomy can improve "most" chidren since half improve anyway.

There is no evidence in relation to children with OSA which is not confirmed by polysomnography.

There is no evidence relating to children aged under 5 years.

Exact wording of the Cochrane review:

In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time. For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.

Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG. We are unable to present data on the benefits of adenotonsillectomy in children with oSDB aged under five, despite this being a population in whom this procedure is often performed for this purpose. TTM314 (talk) 22:23, 16 May 2019 (UTC)

Statement applies to children. Adjusted to reflect that. Doc James (talk · contribs · email) 11:00, 19 May 2019 (UTC)

Long term effects - immune function versus autoimmune conditions

I am concerned that the current version is being distracted by measures of immune function which are not directly relevant to patients.

Wikipedia says: "Tonsillectomy does not appear to affect long term immune function" This is referenced to a meta-analysis of studies of biomarkers of immune function (Immunoglobulin levels - serum Ig's, SecIgA, cellular immunity, Ag specific Ig). But the fact that this is a secondary source is being given undue weight. It is a systematic review based on evidence from 35 small studies. Some studies included in the meta-analysis have no control group and are simply before and after studies, some are cohort studies. The total number of individuals in all the included studies was 1997, follow up testing was carried out at different time points but in most cases was less than a year (132 months in one study). This analysis is therefore not very long-term. It is much too small and too short term to compare future incidence of illness in children who have tonsillectomy and children who do not have tonsillectomy. In other words the study is underpowered to detect differences in disease incidence and is in any case only measuring biomarkers.

What the evidence says: I would suggest that future incidence of disease is of more interest to patients than changes in biomarkers. We don't have long term follow up with any RCT of tonsillectomy. It is inconceivable that we ever will have RCTs with years of follow up. The best we can do is a (retrospective) cohort study of children who did have tonsillectomy compared with those who did not.

There are three large retrospective cohort studies several orders of magnitude larger than the study cited above to support the suggestion that tonsillectomy may be associated with a higher risk of future illness. These appear to be being dismissed because they are primary sources, but they ask the right questions (about risk of illness, not biomarkers) and are very much larger than the entire 35 studies included in the cited secondary source.

One study included 1.2 million Danish children of whom over 40,000 underwent tonsillectomy, followed up for 1 to 21 years. This found a higher incidence of respiratory, infectious and allergic conditions later on in life in children undergoing tonsillectomy.

An Australian study followed up 8583 children for 37 years: 1238 underwent tonsillectomy and an increased mortality was observed in those who underwent tonsillectomy.

A study which followed up 179,875 Swedish patients who underwent tonsillectomy observed an increased risk of autoimmune conditions such as thyroid diseases, rheumatic diseases, inflammatory bowel disease and type 1 diabetes. The exact wording from the Abstract is:

A total of 179,875 individuals received a tonsillectomy in Sweden and 5357 of them were subsequently diagnosed with autoimmune diseases, giving an overall Standardised Incidence Ratio (SIR) of 1.34 (95%CI 1.30-1.37). For specific autoimmune diseases, 16 of them showed a significantly increased SIR, ranging between 1.21 and 2.97. The increased incidence was largely consistent irrespective of gender, age at operation, and underlying indications of tonsillectomy.

None of these three papers is utterly free from potential confounding but they measure incidence of disease and mortality, both of which are more important to patients than biomarkers (which have a more tenuous relationship to illness). All three papers are much larger, have longer follow up and more robust than the study which is currently cited in Wikipedia as evidence that tonsillectomy has no effect on the immune system.TTM314 (talk) 22:48, 16 May 2019 (UTC)

@TTM314: Exactly. Although it is interesting to look at biomarkers, it is the incidence of disease that really matters.Zesd (talk) 17:53, 17 May 2019 (UTC)

I would suggest that simply citing the findings of the large cohort studies would be more informative than the current meta-analysis. What does anyone else think? TTM314 (talk) 23:02, 16 May 2019 (UTC)

@TTM314: I fully agree with you. I found literally dozens and dozens of primary sources that indicate that tonsillectomy compromises the immune system, so secondary sources (which are based on primary sources!) that claim that there is no evidence that tonsillectomy compromises the immune system are simply wrong, especially if they only look at immunoglobulin levels a few months after surgery instead of the incidence of disease decades later. Furthermore, in the article no explanation is given on why removing its entire first line of defence would have no negative effect on the immune system. But most importantly, it’s a big shame that every year, thousands and thousands of young children are mutilated and have their life and health put at risk, just to avoid one or two sore throats. Zesd (talk) 17:53, 17 May 2019 (UTC)

You need to follow WP:MEDRS. Doc James (talk · contribs · email) 11:01, 19 May 2019 (UTC)

@Doc James: I think you are missing the point. There are some good reasons to doubt the quality of several of the cited secondary references here. As TTM314 said earlier, the fact that immunoglobulin or whatever other levels do not change after tonsillectomy does NOT mean that the immune system is not compromised as it is the incidence of disease that ultimately matters. So yes, we can mention that the level of (...) and the level of (...) remain unchanged after surgery, but the conclusion that tonsillectomy has no negative effect on the immune system would be premature. Furthermore, that there are no studies that demonstrate that tonsillectomy negatively affects the immune system is simply not true. This article cites multiple secondary sources that found an increase in the risk of Chrohn's Disease and Multiple Sclerosis. Besides that, there many primary sources that found strong indications that tonsillectomy does harm the immune system. I know we cannot use them here, but secondary sources should not ignore them. Zesd (talk) 15:17, 19 May 2019 (UTC)

The associations are for small differences of questionable clinical significance in the rates of these. Doc James (talk · contribs · email) 05:29, 20 May 2019 (UTC)

References

Immune function 2

There is a clear consensus for option 1: "Tonsillectomy does not appear to affect long term immune function."

Cunard (talk) 01:07, 30 June 2019 (UTC)

The following discussion is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

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How should we summarize the effect of tonsillectomy on immune function? Doc James (talk · contribs · email) 07:10, 24 May 2019 (UTC)

We have this 2015 review which says "It is reasonable to say that there is enough evidence to conclude that tonsillectomy has no clinically significant negative effect on the immune system."[9]

And we have this 2019 guideline which says "Nevertheless, there are no studies to date that demonstrate a significant clinical impact of tonsillectomy on the immune system."[10] Doc James (talk · contribs · email) 07:10, 24 May 2019 (UTC)

Not true: https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2683621 Zesd (talk) 04:07, 3 June 2019 (UTC)

Option 1

"Tonsillectomy does not appear to affect long term immune function."

• Support as proposer. We could also say "does not appear to meaningfully affect..." Doc James (talk · contribs · email) 07:10, 24 May 2019 (UTC)
• Support per MOS:JARGON. I'd also support an amalgamation of the two. (Something along the lines of "Tonsillectomy does not appear to affect long term immune function, with a number of biomarkers related to the immune system, such as secretory immunoglobulin A and antigen specific immunoglobulin levels, unaffected [insert MEDRS supported time frame] after the procedure.") Little pob (talk) 08:54, 24 May 2019 (UTC)
• support per above two editors rationale--Ozzie10aaaa (talk) 10:28, 24 May 2019 (UTC)
• Support as above. This follows the sources. TylerDurden8823 (talk) 11:18, 24 May 2019 (UTC)
• Support - Yes, "absence of proof is not proof of absence", but this version is much clearer, even if somewhat generalizing. The second version is trying to be more exact, but can also be confusing, leading readers to believe that while some biomarkers are not affected, others are, despite no hint of that being the case. PraiseVivec (talk) 16:33, 26 May 2019 (UTC)
• Support - based on discussion below, preponderance of evidence favours this statement imo. Ian Furst (talk) 10:01, 28 May 2019 (UTC)
• Support - This statement is more accessible and better for a wider audience; those interested in diving deeper on this topic can follow the source. Myoglobin (talk) 23:23, 1 June 2019 (UTC)
• Disagree - There are many good studies showing a link between tonsillectomy and a wide range of diseases and even a lower life expectancy. Not only primary sources, but also secondary sources (MS, CD and polio), so the 2019 guideline is simply wrong. There are also organisations that claim there is no climate change. A more careful wording is appropriate. We should at least add that there is uncertainty. Please keep in mind that many parents base their decisions on Wikipedia (although they should not). Zesd (talk) 16:49, 2 June 2019 (UTC)

Option 2

"Tonsillectomy does not appear to affect a number of biomarkers related to the immune system, such as secretory immunoglobulin A and antigen specific immunoglobulin levels."

• Support as above. This is what Bitar (2015) found, nothing more, nothing less. As the study does not consider the incidence of disease, the conclusion that the immune system remains unaffected is premature. Zesd (talk) 13:10, 24 May 2019 (UTC)

Discussion

"And we have this 2019 guideline which says "Nevertheless, there are no studies to date that demonstrate a significant clinical impact of tonsillectomy on the immune system."[11] Doc James (talk · contribs · email) 07:10, 24 May 2019 (UTC)"

The author does not provide any sort of evidence for that claim. Furthermore, that claim is obviously false as there are numerous articles that do demonstrate a negative effect on the immune system. Zesd (talk) 17:18, 24 May 2019 (UTC)

I'd favour the meta-analysis over the consensus conference on this one, as the consensus conference did not appear to take a regimented look at this specific question. From the meta, "Four studies (11.4%), including 406 patients (20.3%) found that tonsillectomy negatively affects the immune system." and "There is more evidence to suggest that tonsillectomy has no negative clinical or immunological sequalae on the immune system. Study limitations included heterogeneity in the diagnostic tools, timing of testing, indication for tonsillectomy and patients' age." I'd add a more nuanced, but general public friendly statement such as "Of the available scientific evidence, roughly 9 out of 10 studies show that tonsillectomy has no effect on the immune system. One in ten show that it negatively impacts the immune system. The consensus of experts in the field is that there is no effect." Wordy, but accurate. Ian Furst (talk) 19:51, 24 May 2019 (UTC)

I think the following four points should be mentioned:

• Most studies suggest there is no correlation between tonsillectomy and certain biomarkers related to immune function. Some studies however, do show a moderate correlation.
• There is a lack of literature reviews on the link between tonsillectomy and the incidence of disease, except for multiple sclerosis and Crohn's disease.
• The available literature reviews demonstrate a positive correlation between tonsillectomy and MS and between tonsillectomy and CD.
• Studies say more research is needed.

The 2019 guideline should not be used as it lacks sufficient argumentation. Zesd (talk) 22:29, 24 May 2019 (UTC)

One can nearly always say "more research is needed".

Are those correlations significant? Or simple small changes in rare diseases?

Which ref says there is a "lack of literature reviews"?

Doc James (talk · contribs · email) 08:03, 26 May 2019 (UTC)

The meta-analysis said that there "is enough evidence to conclude that tonsillectomy has no clinically significant negative effect", then went on to suggest standardized measurements for future studies. They looked at immune markers, not specific diseases. Wrt Crohn's, this large (7,045,288 individuals) Danish cohort concluded that people with shared heredity for IBD are more likely to need tonsillectomy. While it's accurate to say that, "...there is a positive correlation between tonsillectomy and crohn's...", it is misleading. Correlation is not causation, and the cause appears to be genetics, not tonsillectomy. We've all agreed to accept consensus conferences as a reliable source, as experts in the field have done a scholarly review of the literature. I don't think we should lead the readers (that tonsillectomy might cause autoimmune disease) when two high-quality sources say the opposite. Ian Furst (talk) 13:32, 26 May 2019 (UTC)

@Doc James: "Which ref says there is a "lack of literature reviews"?"

The only secondary sources I have found so far are about CD and MS. Therefore it seems likely that there are no other secondary sources between tonsillectomy and the incidence of disease (published in a language that I understand), but the whole problem of course is that it is impossible to know for sure that something does not exist. Maybe we could explicitly say that the studies on biomarkers did not look at the incidence of disease.

"Are those correlations significant? Or simple small changes in rare diseases?"

The increased risk of MS is statistically significant according to Lunny et al, 2013. The pooled OR for CD is 1.66 (Sun et al, 2016), which is also statistically significant.

Zesd (talk) 21:30, 26 May 2019 (UTC)

Statistical significance is not the same as clinical significance, Zesd. TylerDurden8823 (talk) 21:34, 26 May 2019 (UTC)

A reasonable compromise would be something like this:

Although some studies demonstrate a statistically significant alteration in biomarkers related to immune function following tonsillectomy, most studies do not. Those studies, however, do not consider the incidence of disease. Some studies found a statistically significant correlation between tonsillectomy and Crohn’s disease. Other studies found that tonsillectomy was followed by an increased risk of Multiple Sclerosis.

Zesd (talk) 16:09, 27 May 2019 (UTC)

That falls afoul of WP:SYNTH. Is that what the sources say or your own analysis of the sources? TylerDurden8823 (talk) 19:58, 27 May 2019 (UTC)

Agree with Tyler. Cherry picking two diseases that have shown correlation without causation (and not explicitly discussing it) is misleading imo. Also, way too much jargon. Personally, I think some detail about the immune system debate is interesting, but I think we need to be careful not to draw our own conclusions. Ian Furst (talk) 00:39, 28 May 2019 (UTC)

Disagree. It's entirely based on what the secondary sources say.Zesd (talk) 05:41, 28 May 2019 (UTC)

Really? Provide direct verbatim quotes. TylerDurden8823 (talk) 20:27, 28 May 2019 (UTC)

@TylerDurden8823: Although some studies demonstrate a statistically significant alteration in biomarkers related to immune function following tonsillectomy, most studies do not. --> 1. "However, some studies demonstrated minor alterations of Ig concentrations in the serum and adjacent tissues following tonsillectomy." (https://journals.sagepub.com/doi/10.1177/0194599818801757) --> 2. "Only Four studies (11.4%), including 406 patients (20.3%) found that tonsillectomy negatively affects the immune system." (https://doi.org/10.1016/j.ijporl.2015.05.016)

Those studies, however, do not consider the incidence of disease. --> 1. "We performed a separate meta-analysis on various reviewed humoral and cellular immunological parameters (e.g. total and specific serum Ig's, SecIgA, cellular immunity, and Ag specific Ig)." (https://doi.org/10.1016/j.ijporl.2015.05.016). So it's not about the incidence of disease. --> 2. Regarding the impact on the immune system, the 2019 guideline refers to an article that says "This brief review will focus on nasopharynx-associated lymphoid tissue as a unique inductive immune site for B cell responses and plasma cell generation." (https://www.karger.com/Article/Abstract/324588). So it's not about the incidence of disease.

Some studies found a statistically significant correlation between tonsillectomy and Crohn’s disease. --> "This meta‐analysis demonstrates that tonsillectomy is associated with an increased risk of developing CD." (https://onlinelibrary.wiley.com/doi/abs/10.1111/jgh.13273)

Other studies found that tonsillectomy was followed by an increased risk of Multiple Sclerosis. --> "We found a small but statistically significant and clinically important increased risk for developing multiple sclerosis, in those with tonsillectomy and appendectomy at ≤ 20 years of age. There was no convincing evidence to support the association of other surgeries and the risk for multiple sclerosis." (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651719/) Zesd (talk) 21:11, 28 May 2019 (UTC)

Zesd, the very articles you're citing explicitly state that it is reasonable to say that tonsillectomy has no clinically significant negative effect on the immune system. This article that you cited [12] says that verbatim. The first guideline you cite [13] also specifically says the following: "Nevertheless, there are no studies to date that demonstrate a significant clinical impact of tonsillectomy on the immune system." These articles do not say what you're quoting and do not support the text you're trying to include. I see no mention in these article saying "Those studies, however, do not consider the incidence of disease." when I search their text. That sounds like your analysis of those articles. If not, please point out exactly where this text is found in those articles. I am unable to find it. TylerDurden8823 (talk) 02:47, 29 May 2019 (UTC)

Additionally, this article [14] does indeed conclude that it found an association between tonsillectomy and a higher risk for Crohn's disease (it also found a protective effect on ulcerative colitis which you didn't mention). It also concludes "Further prospective studies are required to confirm the validity of these observations.", which strongly suggests it is not definitive (as one meta-analysis shouldn't be anyway). In contrast, this meta-analysis [15] did not find any such association. I wouldn't phrase it as some studies have found X. I think the way it was stated before (that whether any such association is present is currently unclear) was fine since results are mixed.

As for multiple sclerosis, the study you cite does say exactly what you said, but it appears to be the only such meta-analysis. It's also from observational data meaning it has many limitations (and it comes from a low-impact journal). Lastly, the same conclusion from that analysis says this: "Despite this significant finding, this in no way suggests or demonstrates causality, in that epidemiological studies can only provide etiological clues at best. More rigorous prospective studies, with high statistical power, are needed to prove an effect." So, I wouldn't phrase it the way you did above since I think a lot of readers would misinterpret that to mean tonsillectomy is definitively linked to a significantly (clinically speaking, that is) higher risk of multiple sclerosis. Based on the available evidence, this meta-analysis suggests that but given the limitations I don't think we can say that with great confidence at this time. TylerDurden8823 (talk) 03:02, 29 May 2019 (UTC)

@TylerDurden8823: There is a new study coming (it's not final yet) which confirms a link between tonsillectomy and Crohn's disease: "We identified 9 factors that increase risk of IBD: (...) tonsillectomy (CD) (...)" (https://www.gastrojournal.org/article/S0016-5085(19)36709-5/abstract)

Maybe this would be a better text:

Although some studies demonstrate a statistically significant alteration in biomarkers related to immune function following tonsillectomy, most studies do not. Other studies found that tonsillectomy is associated with an increased risk of both Crohn’s disease and Multiple Sclerosis.

Zesd (talk) 20:46, 29 May 2019 (UTC)

Based on the Danish cohort study, it does not look like tonsillectomy is associated with an increase of Crohn's, but that if you're predisposed to Crohn's, you're more likely to need your tonsils out. How do they know? Because if your 2nd-degree relative get's their tonsils out, you're more likely to get IBD. Tonsillectomy doesn't seem to cause it, it's a symptoms of immune mediated disease in the GI tract. Ian Furst (talk) 21:17, 29 May 2019 (UTC)

Zesd, I think the language you're proposing is too strong/definitive. You cited multiple reviews that say overall the literature does not show a significant clinical effect on the immune system (as well as the biomarkers). The studies about Crohn disease are mixed and few. I think the current language in the article (that any relationship with IBD is unclear) is appropriate. TylerDurden8823 (talk) 02:33, 30 May 2019 (UTC)

Disagree. I only said that there is a correlation, which is obviously true. We could add that it is not certain yet whether this correlation is the result of causality. Furthermore, I doubt how important the link between tonsillectomy and biomarkers is. Not only because it is the incidence of disease that really matters, but also because the immune system could be affected without any effect on biomarkers. This is especially true because the tonsils are likely to act as a filter by catching and destroying pathogens. Zesd (talk) 13:24, 31 May 2019 (UTC)

@Ian Furst: That Danish cohort study is a primary source and therefore cannot be used here.Zesd (talk) 19:32, 31 May 2019 (UTC)

If tonsillectomy had no effect on the immune system, this would mean the tonsils serve no purpose at all. So, all articles that state that the tonsils are part of the immune system are wrong? Zesd (talk) 21:02, 31 May 2019 (UTC)

Not true. Only that we have no consensus (among experts) that the long-term effect on the immune system is clinically significant when weighed against the near-term risks of retaining chronically infected tonsils (including repeated abx, deep neck infection, etc...). Notwithstanding your opposition to large matched cohorts, I would also point readers tothis cohort which used the same data set, and the match showed correlation with increased risk of URTI(triple), allergy related illness, COPD, and smaller risk of a host of other diseases. It claims to be the first study to look at the long-term risk (2018, vs the one I quoted above on the lack of correlation with crohn's which was 2019). They did not control for familial disease trends. Given that two big studies have come out in a year (with conflicting conclusions), I think we need to redress this in another year, but in the mean time, follow expert consensus. We are just at the beginning of good research into the longer-term effects tonsillectomy (beyond the local, beneficial ones) and we need a Cochrane or meta-analysis for just this reason. Ian Furst (talk) 21:26, 31 May 2019 (UTC)

I used that same study from Denmark about a year ago in this article (amongst many other similar studies showing a link between tonsillectomy and a broad range of diseases), but it was removed by Doc James because primary sources are not allowed here. I strongly doubt the necessity of tonsillectomy as patients who do not get the procedure still seem to be in good health years later. Most studies suggest the benefits of tonsillectomy are modest anyway. As long as we are not absolutely sure that the absence of the tonsils does not harm the immune system, the safest option is to say that there is no consensus.Zesd (talk) 11:00, 1 June 2019 (UTC)

Agree that a single study like this should not be used; I don't agree with the 'no consensus' (because there is), but I do feel it's worthwhile watching the topic in a year. Thanks for the links Zesd. Ian Furst (talk) 12:55, 1 June 2019 (UTC)

I think this article describes very well the controversy and uncertainty regarding the impact of tonsillectomy on the immune system:

Although the discussions on the role and importance of tonsils for the immune response are controversial, a significant contribution of the tonsil palatina to immunity is supported by a number of studies, which described an association between tonsillectomy and increased susceptibility to infections. (...) In contrast to the previous reports a number of studies and meta-analysis did not observe significant immune alterations following tonsillectomy. (...) Despite all these appreciations, there is an ongoing debate as to the net benefit of tonsils as a functional lymphoid organ and their contribution to infection control in humans. This controversy is not least fostered by the paucity of solid experimental data on the immunological status of tonsillar immune cells in the context of the various inflammatory conditions that can afflict the tonsil.

Zesd (talk) 21:04, 2 June 2019 (UTC)

It is a primary source. Doc James (talk · contribs · email) 04:02, 10 June 2019 (UTC)

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The discussion above is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

Discussion on incentives for removal

I think we should consider merging the financial incentives and parental pressure sections into the "reasons" area. The stated "reason" for removal is [surgeon/health facility] "financial incentive" but the references don't support it. Ref#48, is a single study by a single author. Ref#49 is 51 years old, and a lot has changed, but even then i can't even see a summary anywhere (plus it was a preliminary report). Ref #51 is Obama's quote where he mentions T&A as an example of FFS influencing decisions.

A proper study would compare the level of reimbursement (e.g the fee paid) and T&A rate with contemporary indications for removal. Comparing FFS vs salary, is a separate issue, as is 1960's indications vs modern ones. Even though the parental pressure ref#52 is a commentary, it's actually a good summary of the entire situation imo. Also, wrt financial incentives, no mention is made of populations that can't afford private pay treatment. Do they suffer more? Both sides of the coin should be examined if we create an entire section on it. Ian Furst (talk) 13:53, 26 June 2019 (UTC)

@Ian Furst:Thanks. I will take a look at it this weekend and edit the article if necessary. But for now I can say this: 1) No child has ever asked to be knocked out and have two or three of its organs removed. 2) It is abundantly clear that even in severe cases the benefits of tonsillectomy are modest at best. 3) There are strong indications that tonsillectomy increases the incidence of a broad range of diseases. Yet every year, hundreds of thousands, if not millions, of young children worldwide have their tonsils taken out. This can only be because surgeons get paid for doing this procedure or because of their biased views and / or parents want to have this procedure done because of psychological reasons. Furthermore, I believe the argument of "undertreatment" is simply not credible. Although tonsillitis (especially if it is chronic or recurrent) may be very disturbing, it is not life threatening, nor is it likely to cause any serious any long term health risks. Tonsillectomy rates vary considerably between similar countries, yet I have not heard of large numbers of children experiencing serious health issues because their tonsils have not been taken out in countries where tonsillectomy rates are low. Zesd (talk) 22:40, 26 June 2019 (UTC)

I'm happy to have a discussion about contemporary indications for tonsillectomy, and whether they're used globally. But statements like, "This can only be because surgeons get paid for doing this procedure or because of their biased views..." and "No child has ever asked to be knocked out and have two or three of its organs removed." are hyperbolic imo. I've seen the other side of this issue, with deep neck infections, and life-threatening outcomes from non-treatment. At the end of the day, we just need to ensure that any information that is put on Wikipedia is neutral, and supported by MEDRS Ian Furst (talk) 12:30, 27 June 2019 (UTC)

@Ian Furst: Sorry for my language. That was inappropriate, even on a talk page. I will be more careful in the future. Zesd (talk) 13:30, 27 June 2019 (UTC)

@Ian Furst: The financial incentives and parental pressure sections have been merged into the reasons section. I have added an extra reference that contains the conclusions of the 1968 Canadian report. I will look for more studies on the relation between surgeon's incomes and surgery / tonsillectomy rates when I have more time. Zesd (talk) 09:05, 29 June 2019 (UTC)

Parental pressure

Several references mention parental pressure, but none quoted so far address the specific effect. I think we have two separate issues; (1) does parental pressure make it more likely for the tonsils to come out, and (2) does it increase the chance of referral to ENT. Poor references keep getting inserted, last one was a ?dissertation in Dutch. Another was a commentary. Will look through guidelines for a better reference. I suspect it's addressed somewhere in a consensus paper or something Ian Furst (talk) 18:51, 3 July 2019 (UTC)

Regarding question #1: In this article from 1957 (a long time ago, I admit) the author says that of the 40 children who had their tonsils removed, 6 (15%) had the procedure done because of parental pressure. It is very likely that this has also happened elsewhere. About question #2: According to this article from 1972 (also a long time ago) which I find very interesting and credible, "Too often physicians scheduled [adenotonsillectomies] out of habit or in response to parental pressure". I would not say that the references I have found are "poor", although I admit that some are better than others. The Dutch source from 2009 for example, is not bad at all in my opinion. But I'm sure we can find more and better sources. When I enter "tonsillectomy" combined with "parental pressure" in Google, I get around 2.470 results, which probably excludes many other relevant pages (including those in other languages than English) that cannot be found using those exact terms. Zesd (talk) 21:39, 3 July 2019 (UTC)

Zesd, there's no reason to use these horrible references, when there is so much good data out there. that article from 1974 reported rates of 2,000 tonsillectomies per 100,000 children, which just isn't relevant anymore. Plus, it's a bookkeeping excercise and doesn't directly address the parental pressure issue. Imo, a parent is likely to read the lead of wikipedia, but caregivers (both formal and informal) are going to read the details. If we give them contemporary, evidence-based facts it has the potential to do the most good. There are great references out there, like the consensus statement that's quoted everywhere (including the dutch economics paper). [Here http://www.health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_tonsil.pdf] is a governmental review, that lists all kinds of meta-analysis, and even rates the quality of the references. Ian Furst (talk) 23:37, 3 July 2019 (UTC)

@Ian Furst: Those references I used in the parental pressure section are from renowned journals such as The British Medical Journal, International Journal of Epidemiology and the New England Journal of Medicine. I can hardly believe all those journals publish "horrible" or "poor" articles or commentaries. But anyway, could you maybe write a new section about parental pressure using the great references you have found so far? I'm looking forward to seeing it. Without a section about parental pressure, this article is simply incomplete. Zesd (talk) 19:43, 4 July 2019 (UTC)

I'd add that everyone agrees that 2,000 per 100,000 is too much, and 0 per 100,000 is too few. What is the proper rate? I don't know, but I do know that it will change with time, our understanding of the risks and benefits, and evolving technology. Appendectomy rates used to be higher, and 10% "healthy appendectomy" rates acceptable so that the risk of periotonitis was kept low on a populational bases. Ultrasound, CT, modern antibiotics, have all changed that. Ian Furst (talk) 23:41, 3 July 2019 (UTC)

@Ian Furst: I find it astonishing that so many parents opt for a medical procedure that is so ineffective and so potentially harmful, especially now we live in the information age. Tonsillectomy is an elective procedure, so the most important reason it happens is because the parents want it. By far, most children simply outgrow tonsil related diseases and those diseases are unlikely to be fatal, contrary to, for example, an appendicitis. Furthermore, I have found dozens and dozens of studies that prove that tonsillectomy does harm the immune system profoundly (increased risk of cancer, allergies, diseases in the upper respiratory tract, heart attack, autoimmune diseases and inflammatory diseases for example). And then there also the risks of general anaesthesia, such as cognitive disorders later in life. The benefits of tonsillectomy are in the vast majority of cases minor and temporary, whereas the drawbacks are forever and potentially profound as the procedure involves the permanent removal of the entire first line of defence of the immune system. Zesd (talk) 19:43, 4 July 2019 (UTC)

@Ian Furst: I also find the whole parental pressure section very interesting from a psychological point of view. Are there similarities with phenomena such as circumcision, castration and child abuse? Given the fact that tonsillectomised parents are more likely to opt for tonsillectomy for their children, may the desire to have the procedure done be some sort of "revenge"? Zesd (talk) 19:59, 4 July 2019 (UTC)

The two references I cut were this white paper (in dutch) published on the personal website of a "independent advisor health economics" and this commentary. Regarding the parents motive to seek care unless there is a proper MEDRS reference, it should not be in the article. The same as all other statements of fact. Ian Furst (talk) 21:59, 4 July 2019 (UTC)

@Ian Furst: You have deleted the parental pressure section again. I just checked the the page about MEDRS but could not find anything there that convinces me that a PhD dissertation is not MEDRS. Could you please let me know why a PhD dissertation is not MEDRS? Or maybe even better, could you write something about parental pressure yourself? Zesd (talk) 13:55, 10 July 2019 (UTC)

The source quotes two primary studies, both of which were small surveys of GP's in England (the doctoral candidate discusses the limitations of the studies in the dissertation). Neither a PhD submission, or the original science it quotes, is considered a generally accepted fact. Also, we've all agreed not to use primary research (a PhD dissertation is, by definition, original science). The fact you stated was "According to several studies, parental pressure sometimes plays a role in the decision-making of general practitioners and ENT consultants." under tonsillectomy rates. This is misleading imo because the source states that parental pressure influenced referral rates, not tonsillectomy rates. Between the misleading statement, and the poor reference I removed it. I can't find a contemporary MEDRS that states the surgeons tonsillectomy rates are influence by parental pressure. Ian Furst (talk) 14:16, 10 July 2019 (UTC)

@Ian Furst: Even if we cannot find good quality sources that confirm that parental pressure increases tonsillectomy rates, we could still say something about parental pressure. For example, we could say that parental pressure influences referral rates, but it is not clear whether those higher referral rates subsequently result in higher surgery rates (although it is extremely likely, especially if the surgeon is paid fee-for-service reimbursements). The whole parental pressure thing is an interesting psychological phenomenon anyway, so why not give it a bit of attention. Zesd (talk) 21:25, 10 July 2019 (UTC)

If we can't find good quality sources, it shouldn't be in the text. The community is clear that they don't want speculative facts peppering articles (and I agree). Ian Furst (talk) 12:52, 11 July 2019 (UTC)

Secondary sources

Can anyone explain to me why this article does not qualify as a secondary source? It is an advice from the American Association for Respiratory Care, so I would say it can be considered a position statement by a well respected medical organization. Zesd (talk) 19:43, 11 July 2019 (UTC)

Sure; WP:MEDRS stipulates that facts should be backed by consensus statements or position statements when coming from organizations. This is an anonymously authored web page with ?3 linked papers (one of which is extensively discussed in the the article already). I think you're claiming that it would qualify under this heading, but the AARC is not a major international organization, and the webpage was not some massive, well referenced consensus. Compare to something like this on dengue fever which is heavily referenced, and from the WHO. I'd also add that the statement of fact you claimed, "... several studies that demonstrate an association between tonsillectomy and certain diseases..." is vague, and arguably falls under the RfC the community agreed to previously. Ian Furst (talk) 03:04, 12 July 2019 (UTC)

Obstructive Sleep Disordered Breathing

Obstructive Sleep Disordered Breathing is an indication for adenotonsillectomy in children in the USA, and the majority of procedures in this country are performed for this reason.

The only place Obstructive Sleep Disordered Breathing is mentioned in this article is in the 2018 UK study reviewing indications for the procedure, indicating this is a frequent and non-indicated reason for the procedure in the UK. I practice in the USA and don't know if this is accurate or not.

The Section "Obstructive Sleep Apnea" under "Medical Uses" states that OSA is an indication for tonsillectomy without referencing any specific age group and then references the 2019 update to AAO-HNS Clinical Practice Guideline for Tonsillectomy *in Children*. This paragraph goes on to state that "The procedure is recommended for those who have OSA that has been verified by a sleep study.[1]" This is a distortion of this guideline, which states first that OSDB is a clinical diagnosis and an indication for adenotonsillectomy, and further that a sleep study may be indicated in specific patient populations, such as those without apparent obstructive anatomy.

I am going to make an edit to the paragraph to clarify this but would welcome others' thoughts. — Preceding unsigned comment added by Apcpa (talk • contribs) 18:11, 15 July 2019 (UTC)

@Apcpa: Because of the historic over prescription of tonsillectomy, and current wide variation between regional rates there is a lot of debate within this article. As such, we look for very strong evidence to include in the indications sections. Either consensus statement, meta-analysis or cochrane study to support each statement of fact. I'll take a look at the specific guideline too. Is there a consensus statement about diagnostic criteria for which OSDB patients receive T&A? Ian Furst (talk) 18:32, 15 July 2019 (UTC)

Questions that need to be answered in the article

In my opinion, the article is missing some crucial information. I would like to see the following three questions answered:

• If tonsillectomy is effective in treating OSAS and recurrent / chronic tonsillitis, is generally safe and does not harm the immune system in any way, then why have tonsillectomy rates decreased so drastically over the past decades in most countries?
• If the tonsils are important and serve as the first line of defence in the immune system, then why does tonsillectomy not compromise the immune system?
• What is the role of parental pressure in the decision process whether the tonsils need to be taken out?

Can anyone give an answer to each of these three questions, backed up by secondary sources? I would be very grateful. Zesd (talk) 20:34, 2 August 2019 (UTC)

Commentary

This is from a commentary on a primary source not a review

"In reaction to a 2018 study from Denmark that demonstrated a positive association between childhood tonsillectomy and around twenty diseases later in life, the American Academy of Otolaryngology–Head and Neck Surgery commented that this study may be biased because of unmeasured confounding variables, reverse causation, selection bias and measurement bias. However, it also said:

[It] is certainly a provocative and well executed study that may add some nuance to how we counsel parents when this all-too-common question comes up.

" Doc James (talk · contribs · email) 00:42, 4 October 2019 (UTC)

Were does the ref support

"There are variations in tonsillectomy rates, both between and within countries." Doc James (talk · contribs · email) 20:23, 7 October 2019 (UTC)

Here:

https://ec.europa.eu/eurostat/statistics-explained/index.php/Surgical_operations_and_procedures_statistics#Number_of_surgical_operations_and_procedures (search for "tonsillectomy")

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1749-4486.2010.02086.x

I just corrected the references in the article. Zesd (talk) 04:33, 8 October 2019 (UTC)

Range of deaths

Per source

"Current US reported mortality rates for tonsillectomy are 1 per 2360 and 1 per 18,000 in inpatient and ambulatory settings, respectively,46,47 while the province of Ontario, Canada, reported a combined inpatient/outpatient setting mortality rate of 1 per 56,000 for the years 2002 to 2013. A prospective audit reported only 1 postoperative death after 33,921 procedures in England and Northern Ireland."

So the death rate in the US is not actually 1 in 2360. Doc James (talk · contribs · email) 01:24, 11 December 2019 (UTC)

2019 Consenus statement and the section on sore throat

I'd like to proposed that we blow-up most of the section on sore throat (which has been melded from multiple sources) and harmonize it with Statements 2 and 3 from the consensus conferences. "Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. Optionbased on systematic reviews of randomized controlled trials, with a balance between benefit and harm." and the other statement already blockquoted. Ian Furst (talk) 19:02, 2 January 2020 (UTC)

We could remove the 2011 guideline (we now have a more up to date guideline from 2019) and "The panel also recommended..." part (most of it is not about sore throat). For the rest it is better to leave it as it is in my opinion. Zesd (talk) 19:08, 3 January 2020 (UTC)

perhaps it would be proper for an encyclopedia to keep a history of guidelines and not remove the earlier one from the record when a new one comes out. 89.134.199.32 (talk) 14:46, 22 February 2020 (UTC).

But then it should be concise, in the form of a table or something like that. The content about the 2011 guidelines was too long. Zesd (talk) 21:39, 25 February 2020 (UTC)

section "tonsillectomy rates"

has this text: "This means there is a seven-fold difference between the region with the highest tonsillectomy rate and the region with the lowest one.[13] In 2006, English Chief Medical Officer Liam Donaldson revealed that unnecessary tonsillectomies and unnecessary hysterectomies combined cost the British National Health Service 21 million pounds a year.[44]"

-i dont see the reason the "sevenfold" difference between regions needs to be italicized as it is in the current article text, since the section title is about the rates, and not the SIGNIFICANCE attributed to those rates. an emphasis would be reasonable if the section was to make an argument to change the rates of tonsillectomy, but at the current title it is supposed to remain neutral and just list the numbers without emphasizing on what is 7 times higher. it is actually degrading to read a text that supposes that i cant see for myself that 7000 per 100 000 (or something similar) is SEVENFOLD higher than 1000 per 100 000.

Ok. Changed it.Zesd (talk) 18:26, 25 February 2020 (UTC)

-on the other hand i would welcome a change of title for the section because as it reads now, section 5, 5.1, and 5.2 are not really about the rates and its subsections but rather on the same logical level, so perhaps it would be better to rename section 5 to something like "controversy about recommendation" and put the text from section 5, 5.1 and 5.2 under subsections 5.1, 5.2 and 5.3 . this citation: "English Chief Medical Officer Liam Donaldson revealed that unnecessary tonsillectomies " shows that the intent of the text is criticism of the (frequent application of the) procedure and not just collecting data on the rates of procedure in different regions. so it would be more honest to title the section accordingly.

This has been edited many times, so for now I would like to keep it as it is.Zesd (talk) 18:26, 25 February 2020 (UTC)

-at the same time this: "English Chief Medical Officer Liam Donaldson revealed that unnecessary tonsillectomies and unnecessary hysterectomies combined cost" citation raises questions:

-- why the opinion of the chief med officer about financing is taken as a fact and given weight in the article that is not about the financing side of this procedure. also the talk about COMBINED costs shows that the whole Med Chief opinion cited is more of a rhetorical acomplishment than a logical inquiry of reasoning - so perhaps it would be best to find a reliable source that is not talking about pears and apples when your article needs to focus on apples.

I agree with you that the source you are referring to is far from perfect because indeed it 1) focuses on costs rather than numbers of surgeries and 2) it simply adds up tonsillectomies and hysterectomies (which are completely unrelated to each other). However, it is still a strong indication that the number of tonsillectomies performed in the UK is way too high, which is especially interesting because it is a country where tonsillectomy rates are relatively low. Furthermore, by mentioning hysterectomies, it is made clear that the problem of overtreatment extends beyond tonsillectomies.Zesd (talk) 18:26, 25 February 2020 (UTC)

And if you have better sources... you are more than welcome to use them in the article!Zesd (talk) 18:26, 25 February 2020 (UTC)

-- also while i myself all in for the likelihood of the complete uselessness of tonsillectomy, the cited words of the Med Chief seem to have no backing on what he considers UNNECESSARY and by what evidence he refers to that. 89.134.199.32 (talk) 15:06, 22 February 2020 (UTC).

True, but medicine is not only a matter of science, but also of opinion. And it is important to know that tonsillectomy is controversial. Zesd (talk) 18:26, 25 February 2020 (UTC)

Apparent copyright violation by third party

While searching for sources to support a claim that I ultimately removed from the article, I came across Tonsillectomy-Comparative Study of Various Techniques and Changing Trend (Ravinder Verma) in the Indian Journal of Otolaryngology and Head & Neck Surgery, published by Springer. Parts of the Discussion section seem to have been copied and pasted from the History section of this Wikipedia article. The linked article was published in late 2017, whereas the Wikipedia article has had the text since at least 2016. --Joshua Issac (talk) 15:59, 9 May 2020 (UTC)