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To the Editor.—
The article by Doctors Paradise, Bluestone, and colleagues,1 which discourages tonsillectomies and adenotonsillectomies (T&As) yet again, is commendable for making readers think about criteria and outcome. But insufficient data and loose criteria make it difficult to evaluate pre- versus postsurgery study groups, or versus control patients.
As a concatenation of partial sets of observation and data, versus controls, the clinical trials studied:
Numbers 1, 2 and 3 above are contained within the "2-way trial." Readers would learn more if enrollment culture data and postoperative surveillance regarding otitis media and nasal passage obstruction were provided.
Number 4 is incomplete, lacking enrollment incidence of culture-positive ß streptococcal infection for the 3-way trial. With enough data, including number 5 might help show what percentage of children undergo T&A or tonsillectomy based on all episodes of pharyngeal illness (primarily viral) from enrollment information. The authors justifiably argue for strict criteria. Using "suspected strep episodes" or "counting episodes" does not account for physicians’ proven high error rate in diagnosing strep throat without culturing. The looseness of "qualifying units" presumably includes viral illness. How much surgery is being performed for infection of the upper respiratory tract, most not proven ß strep (per manuscript appendix, as low as 1 or 2 in 6 being ß strep in the prior year)? It is hard to avoid that implication. Otitis media concerns aside, I had been taught that it was only repeated group A ß-hemolytic strep infection that made tonsillitis/adenotonsillitis/pharyngitis of concern. You know, the rheumatic fever thing.
The authors refer to Table 2 in which, although the overall number of episodes was small, control children experienced about 2 to 4 times as many ß strep infections compared with children who had adenotonsillectomy. Perhaps this is partly why 20% to 25% of control patients went on to have T&As or tonsillectomy? Excluding strict otitis/obstructing-adenoid criteria, does that also suggest that only 20% to 25% of operated patients needed surgery if it were based on more strict strep culture criteria beforehand?
About 29% of children operated upon in the 3-way trial were ages 3 to 6 years, versus about 50% of patients operated on in the 2-way trial. The implication is that otitis media and/or obstructing adenoids in that age group were, understandably, more of a problem than pharyngitis. Should throat culture criteria be stricter for tonsil-oriented surgery, especially in children 3 to 6 years of age?
REFERENCE
Howard E. Rockette, PhD
Department of Biostatistics
Graduate School of Public Health
University of Pittsburgh
Pittsburgh, PA 15261
The main purpose of the trial, as part of a broader study of indications for tonsillectomy and adenoidectomy (T&A), was specifically to determine the efficacy of tonsillectomy and of adenotonsillectomy in preventing recurrent episodes of throat infection in children with histories of recurrent episodes that met defined criteria.1
Because children were not ill at the time of enrollment, it is not clear how enrollment culture data would have been instructive. It is likely that some of the children had harbored ß-hemolytic streptococci—as carriers—at the time of enrollment, but randomization would have ensured that the numbers of such children were reasonably evenly distributed across treatment groups.
Follow-up surveillance regarding otitis media and nasal obstruction was, in fact, conducted, but data were not included in the report because they seemed tangential to the main purpose of the trial. Previously we have reported separately on the efficacy of adenoidectomy and of adenotonsillectomy for recurrent and persistent otitis media in children who had, or had not, undergone tympanostomy tube insertion earlier.2,3 We hope soon to be reporting the results of a randomized, clinical trial of adenoidectomy in children with adenoidal nasal obstruction.
Our report included data concerning the total numbers of episodes of throat infection during follow-up and the numbers that were specifically streptococcal. The difference between those numbers presumably represented viral illnesses. In previous clinical trials we have shown that, in children more severely affected than the children in this trial, tonsillectomy was effective in reducing the numbers both of streptococcal episodes and of nonstreptococcal episodes.4 It is not only streptococcal infection that occasions concern in children with recurrent sore throats; it is also the case that the morbidity associated with viral episodes, while not dangerous, can be quite discomfiting and disruptive.
We did state explicitly in our report that the control children who underwent surgery generally did so because they were continuing to have episodes of throat infection. And we added, "Thus, they were coming to meet the eligibility criteria of our earlier trials and thereby, in our view, would become reasonable candidates for surgery."1
Throat cultures should be performed in children whenever episodes of throat infection occur, irrespective of the question of tonsillectomy. The prior occurrence of documented streptococcal episodes is 1 factor, but not the only appropriate factor, in the surgical decision-making process.4
REFERENCES
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