648
WHY
I
& A
REMAINS
MOOT
T
ONSILLECFOMY is the most frequentlyperformed operation in the United
States; about 1,000,000 children are
sub-jected to this procedure annually.1 There
exists a general feeling among critical
ob-servers that the majority of these operations
may be unnecessary or actually harmful,
but even thoughtful and conscientious
pedi-atricians maintain divergent attitudes and
practices on the matter. Thus, some of
them, cognizant of potential anesthetic,
im-munologic, and psychologic risks, and of
widely publicized condemnations of the
procedure, almost routinely refuse to
con-sider tonsillectomy for any of their patients;
others, having cared for children who
appear to have been helped-sometimes
dra-matically-by tonsillectomy or
adenoidec-tomy or both, continue to recommend
surgery for selected patients. A recent poll
conducted among physicians in general
practice and in various specialties attests
to appreciable differences in attitudes and
practices regarding tonsil and adenoid
sur-gery.2
These differences in practice may to
some extent reflect disagreements among
authorities, or lack of specificity in their ad-vice. For example, one current, standard,
pediatric textbook’ questions whether any
indications for tonsillectomy exist, whereas
several others recommend the procedure for
“repeated” or “recurring” episodes of sore
throat, and in various other circumstances.4
Less disagreement exists concerning
ade-noidectomy: most authorities advocate such
surgery for children with recurrent or
chronic otitis media, and for those with
ad-enoid hypertrophy of such degree as to
in-terfere with nasal breathing. Other possible indications for adenoidectomy, e.g., recur-rent or chronic nasopharyngitis or sinusitis, have not received general agreement.
Inquiry as to the reasons for
disagree-ment among experts leads quickly to the
re-alization that, despite an immense clinical literature, conclusive studies of the indica-tions for, and results of, tonsillectomy and
adenoidectomy are lacking. Relevant
publi-cations have tended to fall into one of four categories:
1. Discussions of the indications for
sur-gery, based on the experience or opinions of
the authors.8’9
2. Reviews of published studies or
re-ports, often without adequate analysis of
their statistical shortcomings, by authors
who have not themselves participated in
the studies.bo2 Such “vicarious”
publica-tions tend to contain some of the strongest,
and in turn, most frequently quoted,
con-demnations of T & A.
3. Comparisons made, prospectively or
retrospectively, of certain aspects of the
health status of two population
groups-those who have received T & A, and those
who have not. If, as is usually the case, no
difference in favor of the operated group is
found, the value of the procedure is
im-pugned.’3’5 However, these studies have not
been controlled; there is no reason to
be-lieve that the operated and unoperated
groups were similar before surgery was
un-dertaken. Such studies are of very limited
value since the intent of surgery in the first place was to convert, as nearly as possible,
those in the operated group (whose health
status prior to surgery had presumably
been unsatisfactory) to the status of those
in the unoperated group (whose health
sta-tus was presumably so satisfactory that sur-gery was not deemed advisable). If surgery
had accomplished the desired effect
com-pletely, no difference ought to be found;
even a difference in favor of the unoperated
group would not rule out the possibility of
partial improvement in the operated group.
4. Controlled studies in which candidates
for surgery, having been identified on the
basis of certain indications, are divided into
operated and control groups, and their
subsequent courses compared.1620
Only
such studies can hope to provide valid and
generally applicable results, but, ironically,
none has been reported in the United
States since Kaiser’s pioneering study16
un-dertaken 50 years ago. Moreover, Kaiser’s
COMMENTARIES 649
language literature until 1963, when McKee
reported his careful and comprehensive
studies in England.17’18 Since then, only two other controlled studies, both similar to Mc-Kee’s, have been reported-one in England,1#{176} and one in New Zealand.’#{176}
Unhappily, the findings of all five of these
studies are open to question, since each of
them suffers from most if not all of the
fol-lowing limitations or flaws in experimental design:
a. The selection of patients for surgery was not random’6
b. Adenoidectomy, tonsillectomy, and
adenotonsillectomy were not considered as
separate procedures with separate
indica-tions and separate results.16,17,19,20
c. It is unclear to what extent
clin-ical severity might have varied within,
and between, the operated and control
groups.8’2#{176}
d. The indications for surgery were not
stringent, so that it is doubtful whether the
cumulative disability from illness in some
patients exceeded that which might be
expected from the operative procedure
it-self 1620
e. Children who appeared to the authors to be most in need of surgery (but whose
numbers, and whose indications for surgery
were not stated) were excluded from the
study and operated on, as it was considered “unethical” not to do so. This left for evalu-ation only those children in whom the
indi-cations appeared less compelling, or even
doubtful.1720
f. There was apparently limited clinical sophistication in the recognition and
treat-ment of middle ear disease. Thus, methods
for assessing the presence or severity of oti-tis media were not described,l?_20 or
consid-eration was limited to patients with
puru-lent otorrhea.16 Throughout, there was no
mention of serous otitis media,
myringot-omy, or tympanostomy tube insertion.16’#{176}
g. Post-operative evaluation was based
not on direct examination of the children,
but only on information obtained from
par-ents.18’8’2#{176}
h. The studies lacked, as additional
con-trols, a group of children not deemed
ap-propriate candidates for tonsil or adenoid surgery.169
Since none of the published studies
re-garding indications for T & A has been
de-signed so as to provide reliable clinical
guidelines, and since differences of opinion
among authorities have persisted over the
years, it is perhaps not surprising that some
practitioners, relatively unfamiliar or
un-concerned with underlying controversial is-sues, continue to advise or carry out surgery
for apparently insubstantial or irrelevant
medical reasons, or because of parental
pressure.
One facet of the T & A problem has been addressed in a recent study which suggests
that the response to adenoidectomy of
chil-dren with recurrent otitis media may be
predictable on the basis of certain
dis-tinguishing clinical characteristics.2’ Two
categories of patients-those with nasal
al-lergy, and those in whom retrograde
ob-struction of the Eustachian tube could not
be demonstrated
roentgenographically-developed recurrences of otitis media soon
after adenoidectomy; by contrast, children
without allergy, and in whom retrograde
obstruction of the Eustachian tube had
been demonstrated preoperatively,
re-mained free of otitis media for periods up
to 9 months following adenoidectomy. The
findings of this study must be interpreted
cautiously, however, mainly because
con-trol groups of nonoperated children were
not studied simultaneously, and because the
post-operative observation periods were
relatively short.
In order to rationalize as fully as possible
the entire T & A issue, large-scale, compre-hensive studies are necessary. Potential
can-didates for adenoidectomy, or
tonsillec-tomy, or both, must be identified from
within a substantial population of children, using for each surgical procedure a discrete
set of stringent indications. Children with
congestive heart failure secondary to
naso-pharyngeal obstruction,22,23 and probably
certain others severely affected, should be
excluded from the clinical study and
oper-ated on promptly, but few such children
650 WHY T& A?
must then be classified appropriately, and
randomly divided into surgical and control
groups; a group of matched patients, not
considered appropriate surgical candidates,
must be added as additional controls. The
courses of all the study subjects must then
be followed closely over extended periods.
Controlled, prospective studies of this
kind should be carried out in a variety of
settings, ideally where turnover of
profes-sional personnel and mobility of patient
population are at a minimum. Private
pedi-atric practices, either solo or group, or
pre-paid group practice programs, might afford
the best opportunities for such studies, but they might also be carried out in teaching or community hospitals if sufficient
commit-ment exists. Collaboration between
pedia-trician and otolaryngologist would
obvi-ously be desirable in the case-by-case
identification of appropriate children for
study, and would help insure the accuracy
of clinical observations and interpretations.
In any case, if two or more physicians,
ir-respective of specialty, are involved in eval-uation, it will be necessary to establish and
maintain inter-observer reliability. As the
maintenance of follow-up is critical to the
success of any study of T & A, adequate
as-sistance from ancillary personnel, and
cor-respondingly adequate funding, must be
available.
The human and health care dimensions
of the T & A problem are so great, and its present status so confused and
unsatisfac-tory, that the need for resolution seems
compelling.
JACK L. PAJ1rnsE, M.D.
Departments of Pediatrics and
Community Medicine
University of Pittsburgh
Children’s Hospital of Pittsburgh
125 DeSoto Street
Pittsburgh, Pennsylvania 15213
REFERENCES
1. Surgical Operations in Short-Stay Hospitals for
Discharged Patients, United States-1965.
Public Health Service Publication No.
1000-Series 13-No. 7, U. S. Department of Health, Education, and Welfare, National Center for Health Statistics, p. 3, April,
1971.
2. Poll on medical practice. Modern Medicine, 37:
77, Feb. 10, 1969.
3. Einhorn, A. H. : In Barnett, H. L.: Pediatrics,
ed. 14. New York: Appleton-Century-Crofts,
pp. 1675-1677, 1968.
4. Eichenwald, H. F., and McCracken, C. H., Jr.:
In Nelson, W. E., Vaughan, V. C. III, and
McKay, R. J.: Textbook of Pediatrics, ed. 9.
Philadelphia: W. B. Saunders Company, pp.
895-897, 1969.
5. Shore, S.: In Cellis, S. S., and Kagan: B. M.:
Current Pediatric Therapy-4. Philadelphia:
W. B. Saunders Company, pp. 162-164,
1970.
6. Hughes, J. C.: Synopsis of Pediatrics, ed. 3. St.
Louis, C. V. Mosby Company, pp. 375, 376,
1971.
7. Proctor, D. F.: In Cooke, R. E.: The Biologic
Basis of Pediatric Practice. New York:
Mc-Craw-Hill Book Company, p. 279, 1968.
8. Reid, J. M., and Donaldson, J. A.: The
indica-tions for tonsillectomy and adenoidectomy.
Otolaryngologic Clin. North Amer., 3:339,
1970.
9. Haggerty, R. J.: Diagnosis and treatment:
Ton-sils and adenoids-A problem revisited.
PE-DIATRICS, 41:815, 1968.
10. Bakwin, H.: The tonsil-adenoidectomy enigma.
J. Pediat., 52:339, 1958.
11. Evans, H. E.: Tonsillectomy and
adenoidec-tomy: Review of published evidence for and
against the T and A. Clin. Pediat., 7:71, 1968.
12. Bolande, R. P.: Ritualistic surgery-circumci-sion and tonsillectomy. N. Eng. J. Med., 280:
591, 1969.
13. Paton, J. H. P.: Tonsil-adenoid operation in
re-lation to health of group of school girls.
Quart. J. Med., 12:119, 1943.
14. McCorkle, L. P., Hodges, R. C., Badger, C. F.,
Dingle, J. H., and Jordan, W. S., Jr.: A
study of illness in a group of Cleveland
fam-ilies VIII. Relation of tonsillectomy to
inci-dence of common respiratory disease in chil-dren. N. Eng. J. Med., 252:1066, 1955.
15. Chamovitz, R., Rammelkamp, C. H.,
Wanna-maker, L. W., and Denny, F. W., Jr.: The
effect of tonsillectomy on the incidence of
streptococcal respiratory disease and its complications. PEDIATRICS, 26:355, 1960.
16. Kaiser, A. D.: Results of tonsillectomy: A
com-parative study of 2200 tonsillectomized
chil-dren with an equal number of controls three
and ten years after operation. J.A.M.A., 95:
837, 1930.
17. McKee, W. J. E.: A controlled study of the
effects of tonsillectomy and adenoidectomy in children. Brit. J. Prey. Soc. Med., 17:49, 1963.
18. McKee, W. J. E.: The part played by
ton-COMMENTARIES 651
sillectomy with adenoidectomy; Second part of a controlled study in children. Brit. J.
Prey. Soc. Med., 17:133, 1963.
19. Mawson, S. R., Adlington, P., and Evans, M.:
A controlled study evaluation of
adeno-ton-sillectomy in children. J. Laryngol. Otol., 81:
777, 1967.
20. Roydhouse, N.: A controlled study of
adeno-tonsillectomy. Arch. Otolaryngol., 92:611, 1970.
21. Bluestone, C. D., Wittel, R. A., Paradise, J. L.,
and Felder, H.: Eustachian tube function as
related to adenoidectomy for otitis media.
Trans. Amer. Acad. Ophthal., to be
pub-lished.
22. Menashe, V. D., Farrehi, C., and Miller, M.:
Hypoventilation and cor pulmonale due to
chronic upper airway obstruction. J. Pediat.,
67:198, 1965.
23. Macartney, F. J., Panday, J., and Scott, 0: Cor
pulmonale as a result of chronic
nasopharyn-geal obstruction due to hypertrophied tonsils
and adenoids. Arch. Dis. Child., 44:585, 1969.
ST. AUGUSTINE ON HIS CHILDHOOD
Gradually I came to know where I was, and
I tried to express my wants to those who could gratify them, yet could not, because my wants were inside me, and they were outside, nor had they any power of getting into my soul. And so
I made movements and sounds, signs like my
wants, the few I could, the best I could, for they
were not really like my meaning. And when I
was not obeyed, because people did not
under-stand me, or because they would not do me
harm, I was angry, because elders did not
sub-mit to me, because freemen would not slave for
me and I avenged myself on them by tears.1
NOTED BY T. E. C., JR., M.D.
REFERENCE
1. St. Augustine. In Auden, W. H.: A Certain
World: A Commonplace Book. New York:
