June 09, 2018

Potential Increased Long-Term Risk of Diseases with Tonsillectomy and Adenoidectomy

The New York Times published a story on June 7, 2018 publicizing a Danish 2018 study that suggested that children under 9 years old undergoing tonsillectomy and/or adenoidectomy are at increased long-term risk of respiratory, infectious, and allergic diseases. (Adults undergoing this surgery were not investigated.)

All prior studies evaluating for any adverse affects from surgical intervention looked more at any unusual immunological changes after surgery; these studies did not show any obvious deleterious affect.

But this study instead looked at health outcomes over a period of decades. This study involved over 1 million children of which 17 460 underwent adenoidectomy, 11 830 tonsillectomy, and 31 377 adenotonsillectomy. 1 157 684 were in the control group.

Adenoidectomy and tonsillectomy were associated with a 2- to 3-fold increase in diseases of the upper respiratory tract. Smaller increases in risks for infectious and allergic diseases were also found of which adenotonsillectomy was associated with a 17% increased risk of infectious diseases corresponding to an absolute risk increase of 2.14% because these diseases are relatively common (12%) in the population.

What these numbers mean as it pertains to a particular child that may be easier to understand is that on average, ONE out of every ~38 children undergoing surgery is associated with more long-term problems (this number is called NNT or number needed to treat). But do keep in mind that association does not mean causation.

The conclusion reached overall is that tonsillectomy and/or adenoidectomy should NOT be performed if the disease condition being treated is not severe.

Well... what exactly does "not severe" mean?

Typically, tonsillectomy and/or adenoidectomy is performed for obstructive sleep apnea and chronic tonsillitis.

Surgery should be performed for these conditions if the severity is bad enough to warrant the potential downsides of surgical intervention.

For sleep apnea, that means snoring alone is not a good enough reason for surgical intervention. Children should exhibit additional symptoms of sleep apnea adversely affecting health including restless sleep, witnessed apneas, adverse behavioral changes, bedwetting, excessive daytime sleepiness, etc. Certainly, if a sleep study documents sleep apnea, surgery intervention is also warranted. Medical intervention could also be tried prior to pursuing surgery (typically, steroid nasal sprays and singulair).

For chronic tonsillitis, clear guidelines have been produced that outline when severity is bad enough to warrant surgical intervention. The guidelines state that a child must suffer at least:

• 7 episodes of tonsillitis within the past 12 months OR
• 5 or more episodes of tonsillitis in EACH of the past 2 years OR
• 3 or more episodes of tonsillitis in EACH of the past 3 years

With respect to adults desiring tonsillectomy, there are no studies that suggest any long-term adverse risks to health (here's more info), though again, due to significant pain and morbidity during recovery, should be reserved for instances where the disease condition is severe enough to warrant intervention.

Click to watch a video of tonsillectomy here!

Tonsillectomy Risks May Outweigh Benefits. NYT 6/7/18

Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood. JAMA Otolaryngol Head Neck Surg. Published online June 7, 2018. doi:10.1001/jamaoto.2018.0614
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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