Instruct: Given a question, retrieve relevant passages that answer the question.
Query: When was the first tonsillectomy?
Tonsillectomies have been practiced for over 2,000 years, with varying popularity over the centuries.[8] The procedure is claimed in some books as "Hindu medicine" about 1000 BCE (non-evidence based literature). Others refer to it as cleaning of tonsil using the nail of the index finger. Roughly a millennium later the Roman aristocrat Aulus Cornelius Celsus (25 BCE – 50 CE) described a procedure whereby using the finger (or a blunt hook if necessary), the tonsil was separated from the neighboring tissue before being cut out.[8] Galen (121–200 CE) was the first to advocate the use of the surgical instrument known as the snare, a practice that was to become common until Aetius (490 CE) recommended partial removal of the tonsil, writing "Those who extirpate the entire tonsil remove, at the same time, structures that are perfectly healthy, and, in this way, give rise to serious Hæmorrhage".[8] In the 7th century Paulus Aegineta (625–690) described a detailed procedure for tonsillectomy, including dealing with the inevitable post-operative bleeding. 1,200 years pass before the procedure is described again with such precision and detail.[8]
Tonsillectomy is controversial as its benefits are only modest and temporary whereas the operation has recognised hazards (including deaths). There are also strong indications that tonsillectomy compromises the immune system in the long run, especially when performed at a young age.[1][2] For example, there is evidence that tonsillectomy is associated with an increased risk of cancer, autoimmune diseases, infectious diseases, respiratory diseases, allergic diseases and is linked to higher mortality rates.[3][4][5][6]
For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding fascia, a so-called total, or extra-capsular tonsillectomy. Problems including pain and bleeding led to a recent resurgence in interest in sub-total tonsillectomy or tonsillotomy, which was popular 60–100 years ago, in an effort to reduce these complications.[130] The generally accepted procedure for 'total' tonsillectomy uses a scalpel and blunt dissection or electrocautery, although harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation by sutures, and the topical use of thrombin, a protein that induces blood clotting.
A 2010 study in England found the annual tonsillectomy rate per 100,000 between 2000 and 2005 was 754 in the highest region, the national average was 304 and the lowest region was 102. This means there is a seven-fold difference between the region with the highest tonsillectomy rate and the region with the lowest one.[36] In 2006, Chief Medical Officer Liam Donaldson revealed that unnecessary tonsillectomies and unnecessary hysterectomies combined cost the British National Health Service 21 million Pounds a year.[37]
Tonsillectomy can be considered as an industry with a market. In the USA there are 530,000 childhood tonsillectomies annually.[7] At an average of $3500 per operation this is an industry worth $1.855 billion yearly.[41] The rise in adenotonsillectomies for sleep apnoea in the USA has been much greater than the decline in tonsillectomies for sore throat.[42] This means that the tonsillectomy industry continues to grow, despite limited evidence that tonsillectomy confers significant benefits and increasing concerns in relation to long term safety. In 2009 US President Obama even remarked: "Right now, doctors, a lot of times, are forced to make decisions based on the fee payment schedule that's out there. So if they're looking and -- and you come in and you've got a bad sore throat, or your child has a bad sore throat, or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out.' Now, that may be the right thing to do. But I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies. Maybe they have something else that would make a difference."[43]
Moreover, these and other studies found correlation between a previous history of tonsillectomy and the following diseases:
Chronic cases can be treated with tonsillectomy (the surgical removal of tonsils) as a choice for treatment. Children have had only a modest benefit from tonsillectomy for chronic cases of tonsillitis.
In the US 77% of tonsillectomies in children are undertaken for obstructive sleep apnoea (usually adenotonsillectomies), but for this there is insufficient evidence to say if this is more effective than no surgery as even without treatment the condition tends to improve with time.[27][19][28] Because the effectiveness of tonsillectomy for breathing related problems is not known there are ongoing clinical trials to investigate whether it is effective.[29][30] The Cochrane review assessed evidence from randomised controlled trials, because these are less prone to bias than studies without a control group and concludes: “high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting”.[28] Data from the UK indicates that the vast majority (77.8%) of children with obstructive sleep apnoea do not ever undergo tonsillectomy, which casts doubt on whether surgery is really necessary.[31]
It is not known whether the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. But this is also the case for tonsillectomy for sleep apnea. There have been no randomised controlled trials of long term effectiveness of tonsillectomy for sleep apnea.[19][28]
In each of these studies it is not entirely clear if tonsillectomy caused the increased risk or whether it was merely an indicator of other factors which might be linked to poorer health such as poverty or exposure to smoking. Causation is difficult to prove anyway as correlation does not imply causation. However, many researchers argue that tonsillectomy is likely to be a causative factor because confounding variables are taken into account during research and because they claim that the tonsils act as the first line of defence in the immune system. Furthermore, research points out that the lower the age at which tonsillectomy is performed, the higher the probability of attracting certain diseases in adult life. This may be a strong indication that the tonsils play an important role in the development of the immune system.
As tonsillectomy is most often performed on young children for whom the surgery and its aftermath may be a traumatic and very painful experience, there may be a depression and behavioural changes that last for several weeks.[67][68]
Tonsillectomy appears to be more painful in adults than children, although there will be individual variations in response.[148]
There are a great many more clinical trials comparing different ways of undertaking tonsillectomies and how to manage patients who undergo tonsillectomy than there are studies investigating whether they are effective in the first place. A single dose of the corticosteroid drug dexamethasone may be given during surgery to prevent post-operative vomiting.[72] A systematic review found that a dose of dexamethasone during surgery can prevent vomiting in one out of every five children who receives the drug.[72] The review also found that these children return to a normal diet more quickly and have less post-operative pain.[72]
In 2012, 28 years after the original Paradise clinical trial, the American Academy of Otolaryngology & Head and Neck Surgery (AAO-HNS) guidelines adopted the Paradise criteria, stating tonsillectomy is indicated as follows:
For example, a study of 43,207 Danish children who underwent tonsillectomy found a significantly increased risk of respiratory, infectious, and allergic conditions later on in life; the increased risk of respiratory diseases was two to threefold, which means that for every five tonsillectomies, one extra case of respiratory disease will be caused.[5] An Australian study observed a 50% increased mortality rate in young adults if surgery took place before the age of seven.[6] And a study of 179,875 Swedish patients observed an increased risk of autoimmune conditions such as thyroid disease, rheumatic diseases, inflammatory bowel disease and type 1 diabetes.[4]
Despite being a common childhood operation it is difficult to find accurate estimates of serious complications and deaths following tonsillectomy.[2] The morbidity rate associated with tonsillectomy is 2% to 4% due to post-operative bleeding; in the US 3.6% of children are readmitted to hospital following tonsillectomy, mainly because of dehydration or bleeding.[19][69] Haemorrhage after tonsillectomy affects about 4.2% of patients.[70] This would be about 22,260 (4.2% of 530,000) children annually in the USA.[7] Mortality has been reported as between 1 in 7,132 and 1 in 170,000 patients. A more recent estimate from Sweden suggests 1 in 40,000 patients die as a result of tonsillectomy.[2] In the USA the mortality rate is 1 in 15,000, due to bleeding, airway obstruction, or anesthesia complications.[71]
Watchful waiting for recurrent throat infection if there have been fewer than 7 documented episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years; Assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; Asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems; Counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; Counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; Advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and Clinicians who perform tonsillectomy should determine their rate of primary and secondary post-tonsillectomy hemorrhage at least annually.
A study, led by professor of pediatrics Jack Paradise and published in 1984, identified that children suffering from frequent, severe sore throats benefitted modestly from tonsillectomy.[10] This meant at least:
Furthermore, research indicates that tonsillectomy may also lead to the following:
During the First World War its name was changed to Willesden Municipal Hospital. When it joined the National Health Service in 1948 it had 200 beds. A newly refurbished theatre block was opened in 1949 with 16 beds for tonsillectomy patients.
There are significant variations in tonsillectomy rates, both between and within countries. As it is unlikely that recurrent sore throats vary in frequency between countries it suggests that many, tonsillectomies may in fact be done without sufficient medical justification.[19][34] In 2015, tonsillectomy rates in the Netherlands, Belgium, Finland and Norway were at least twice those in the UK but rates in Spain, Italy and Poland were at least a quarter lower.[35] Childhood tonsillectomy rates in the USA are among the highest in the world and are three times higher than in England.[19][7] Tonsillectomy rates vary considerably between even quite similar countries: rates are three times higher in Croatia than Slovenia.[35]
These recommendations, were made by a body whose members derive a substantial part of their income from undertaking tonsillectomies, which may explain the delay of 28 years (and 14 million childhood tonsillectomies - 28 years x 530,000 per year) before recommending that practice followed the evidence. The claims that tonsillectomy improves poor school performance, bedwetting (enuresis), or behavioural problems are based on "observational before-and-after studies", (i.e. case series), which are prone to bias and very weak evidence.[7][16][17]
By 1996, roughly a half million children underwent some surgery on their adenoid and/or tonsils in both outpatient and inpatient settings. This included approximately 60,000 tonsillectomies, 250,000 combined tonsillectomies and adenoidectomies, and 125,000 adenoidectomies. By 2006, the total number had risen to over 700,000 but when adjusted for population changes, the tonsillectomy "rate" had dropped from 0.62 per thousand children to 0.53 per thousand. A larger decline for combined tonsillectomy and adenoidectomy was noted - from 2.20 per thousand to 1.46. There was no significant change in adenoidectomy rates for chronic infectious reasons (0.25 versus 0.21 per 1000).
Treatment can also be given while a patient is under anesthesia, but this is usually reserved for children or anxious patients. Tonsillectomy can be indicated if a patient has recurring peritonsillar abscesses or a history of tonsillitis. For patients with their first peritonsillar abscess most ENT-surgeons prefer to "wait and observe" before recommending tonsillectomy.
There are several indications that far too many tonsillectomies have been performed worldwide .