Suspending Tonsillectomy: The Effects On Primary And Secondary Acute Care In Scotland

 H Mehanna, D Rejali*, A Murray+

Department of Otolaryngology, Head & Neck Surgery, Green Lane Hospital, Auckland, New Zealand

*Department of Otolaryngology –Head & Neck Surgery, Stobhill Hospital , Glasgow

+Department of Otolaryngology –Head & Neck Surgery, Crosshouse Hospital, Kilmarnock

Correspondence to: Andrew Murray, Consultant, Dept of Otolaryngology –Head & Neck Surgery, Crosshouse Hospital, Kilmarnock, KA2 0BE. Tel: 01563 521133 Fax: 01563 577979 e-mail: andrew.murray@aaaht.scot.nhs.uk

  SMJ 2004 49(4): 144-145

Abstract

For the first six months of 2001, tonsillectomy operations were effectively suspended in Scotland. This was due to concern regarding the potential transmission of vCJD prions by surgical instruments, and the subsequent gradual introduction of disposable instruments. The number of patients awaiting tonsillectomy therefore increased and theoretically there should have been an increase in the number of tonsillitis episodes in the community, or even in the number of tonsillitis-related complications seen in secondary care. We examined for these effects using available national data sources which record primary and secondary care activity. No increases in the incidences of acute tonsillitis or tonsillitis-related complications were found for this period. The reasons and implications are discussed. Key words: Tonsillectomy, acute tonsillitis, peritonsillar abscess 

Introduction

From January–June 2001, tonsillectomy operations were effectively suspended in Scotland because of the potential risk of transmitting variant Creutzfeld Jacob disease (vCJD) prions by reusable surgical equipment. This increased the number of patients awaiting tonsillectomy locally (Fig 1) and nationally,1 and could have produced an increase in the incidence of tonsillitis in the community for this six month period,2 as more patients waited longer for surgery. The decision to delay tonsillectomies may also have resulted in an increase of tonsillitis-related complications presenting to acute hospital services. The aim of this study was to examine for these potential effects from the enforced change in practice, using available national data sources. 

Materials and methods

The following data was obtained from the Information and Statistics Division of NHS Scotland for the period January 1999 – June 2001: 

1 Tonsillectomy operation rates

2 Hospital admissions for acute tonsillitis

3 Hospital admissions for peritonsillar abscesses

Rates of GP consultations for acute and chronic tonsillitis were obtained for the same period from the Continuous Morbidity Recording (CMR) practices, covering a population of approximately 300,000 patients. The six months from January to June 2001 were designated the study, or referent, period, as this corresponded to the main period of non-operating. This data was compared with the preceding two years divided into similar six-month periods, which acted as controls. 

Results 

The reduction in the number of tonsillectomies performed was confirmed over the referent period (Fig 2 and Table I). Within each control year the number of primary care consultations for tonsillitis was noted to vary. No attempt was made to place this data in a seasonal context, therefore the exact nature of this variation is uncertain. However, in both control years, the period of July-December had a significantly lower number of tonsillitis consultations when compared to the January-June period of the same year (1999 RR= 0.81,CI=0.77-0.84, p<0.001, 2000 RR=0.83, CI=0.80-0.87, p<0.001, Poisson regression). 

Table I 

More importantly however, comparing the referent period to the corresponding January-June periods of the previous two years showed no statistically significant increase in the numbers of acute or chronic tonsillitis consultations in primary care. Similarly, acute secondary care saw no statistically significant rise in admissions due to acute tonsillitis in comparison with either of the control January- June periods. No significant variation in the rate of admission to hospital for peritonsillar abscess was seen at any time. 

Discussion

The suspension of tonsillectomy operations in Scotland did not significantly affect either GP consultations for acute or chronic tonsillitis in the community, or the incidence of acute tonsillitis and peritonsillar abscess admissions to hospital (Fig 2, Table I). 

The latter finding suggests that patients on a waiting list for tonsillectomy are not the same patient group who attends hospitals as an emergency with severe tonsillitis and related complications. The reason for this is that the pathogenesis of the different clinical pictures of tonsil infections is believed to be different.3 An increased rate of consultations for tonsillitis in primary care could have been expected for the period of tonsillectomy suspension, as patients waited longer for their operations.2 This has not been confirmed by this study. The reason is multi-factorial. Firstly, the natural remission rate for recurrent acute or chronic tonsillitis remains unknown2 and patients on the waiting list may have considerably fewer attacks than we assume. This raises the need to re-evaluate patients before surgery4 and reminds us that tonsillectomy remains a scientifically unproven procedure.2 Secondly, a patient’s knowledge that they are on the waiting list for a procedure may lead to an increase in their symptom tolerance, and threshold for consulting their GP.5 Finally, the available methods of data collation may have been too imprecise to detect the size of effects we were looking for. However, if current guidelines were being adhered to2 for selection of these waiting list patients, with particular reference to the number of attacks of tonsillitis these patients should be experiencing, then our power calculations showed there should have been a clear and statistically significant rise in the recorded episodes of recurrent acute tonsillitis for the national population as a whole over this period, compared with previous years. 

Conclusion

A prospective cohort study would have been the ideal model to examine the problems that these patients did or did not experience while they were on an extended waiting list. In the absence of such a study, we have tried to answer the same question from a different perspective, using nationally collated data, with the conclusion that suspending tonsillectomy more or less completely for a six month period, appears to have created no increase in tonsillitis or tonsillitis related problems in the population as a whole.

ACKNOWLEDGEMENTS: The authors would like to thank Mr Gordon Thomson and Ms Lindsey Harkins of the Information and Statistics Division (ISD) of the Common Services Agency of NHS Scotland for their assistance in providing the data Paper presented at Scottish Otolaryngological Society Summer meeting 2002 Mr H Mehanna and Mr D Rejali now at Department of Otorhinoloaryngology - Head and Neck Surgery, University Hospitals Coventry & Warwickshire, Coventry. 

REFERENCES

1 Anonymous. Waiting list rises after surgery ban. The Times. 2001;11 Aug.

2 Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. SIGN Guidelines. 1999;34 :1-23

3 Bussi M, Carlevato MT, Pannizut B, Omede P, Cotesina G. Are recurrent and chronic tonsillitis different entities? An immunological study with specific markers of inflammatory stages. Acta Otolaryngol Suppl. 1996;532:112-4

4 Woolford TJ, Ahmed A, Willatt DJ, Rothera MP. Spontaneous resolution of tonsillitis in children on the waiting list for tonsillectomy. Clin Otolaryngol. 2000;25(5):428-30

5 Howie JG, Porter AM, Forbes JF. Quality and the use of time in general practice ; widening the discussion. Br Med J. 1989;298:1008-10.

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