New Evidence in Recurrent Acute Tonsillitis in Adults Shows Benefit of Tonsillectomy Over Antibiotics

Sore throat is one of the symptoms present in uncomplicated tonsillitis (inflammation of the tonsils), pharyngitis (inflammation of the pharynx), and tonsillopharyngitis (inflammation of the pharynx, tonsils, or both). Tonsillopharyngitis is a common diagnosis and constitutes approximately 15% of all office visits to primary care physicians, contributing to high antibiotic prescribing and overprescribing rates in adult populations.1 Tonsillopharyngitis is generally self-limiting, but approximately 12% of adult patients experience recurrent tonsillitis with debilitating episodes that impair daily functioning and overutilize health care resources.^2,3

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Although only 30% of tonsillitis cases are because of bacterial infection, the signs and symptoms of bacterial and viral infections are similar, so it is important to perform laboratory testing to identify etiologies that warrant antibiotics.⁴ Management of tonsillitis includes conservative management (watch and wait), antibiotics, or tonsillectomy.²

Antibiotic Use in Tonsillitis

The highest antibiotic prescribing and overprescribing rates in adult populations were for throat indications, including tonsillitis, according to the literature.5 Data show 53% of clinicians prescribed antibiotics without a strep test in a typical visit. To compound this in the virtual setting, a database study of more than 118 million patient records demonstrated that before the COVID-19 pandemic (March 2017-March 2020), only about 10,510 telemedicine visits were for complaints of sore throat.⁶ During the pandemic (March 2020-June 2021), 216,877 visits were for sore throat and 90.6% of these virtual visits resulted in an antibiotic prescription without testing. Similarly, antibiotic prescribing without testing increased before and after the pandemic in urgent care centers and telephone visits.⁶ Antibiotics are not benign and often repeated, and longer courses may contribute to resistance development.⁷

Tonsillectomy in Recurrent Infections

Tonsillectomy criteria have not changed in the past 40 years. Infectious Diseases Society of America guidelines suggest that “tonsillectomy may be considered in the rare patient whose symptomatic episodes do not diminish in frequency over time and for whom no alternative explanation for recurrent GAS [group A streptococci] pharyngitis is evident.”⁴ However, these recommendations were extrapolated from pediatric clinical trials, and the current body of evidence is insufficient to inform recommendations.^3,8 Additionally, it is unclear as to the severity of disease at which it becomes cost-effective to perform tonsillectomy on adults with recurrent tonsillitis compared with conservative management.²

In a 2014 Cochrane Review, the authors concluded the evidence for tonsillectomy in adults was of low quality. Only 2 studies were identified, with 156 participants. Results showed the number of sore throat days was 10.6 days less in patients receiving tonsillectomy than those treated conservatively 6 months post follow-up. However, this did not account for postoperative sore throat days.⁹ Results from the national randomized controlled trial NATTINA (ISRCTN55284102) investigating tonsillectomy in adults recently published in The Lancet addressed this evidence gap.¹⁰

NATTINA was conducted in 27 hospitals in the United Kingdom and included individuals 16 years or older with recurrent acute tonsillitis. Participants had to meet UK guidelines for tonsillectomy, which included sore throat episodes that prevented healthy functioning and 7 or more clinically significant sore throat episodes in the preceding year, 5 or more episodes in each of the preceding 2 years, and 3 or more episodes in each of the preceding 3 years. Patients were randomly assigned 1:1 to receive tonsillectomy or conservative management. Conservative management consisted of self-administered analgesia plus ad hoc primary care prescription of antibiotics or attendance at emergency departments. Participants in the tonsillectomy group received elective surgery within 8 weeks after assignment. The primary outcome was the number of sore throat days collected during the 24 months after assignment. Secondary outcomes included patient-reported, disease-specific, quality-of-life questionnaires (Tonsil Outcome Inventory-14 [TOI-14]), economic evaluation outcomes, and adverse events.

In the primary intention-to-treat population, 429 patients were included (224 in the tonsillectomy group and 205 in the conservative management group). The median age of participants was 23 years with 355 (78%) female and 407 (90%) White patients. The incident rate ratio of total sore throat days in the immediate tonsillectomy group compared with the conservative management group was 0.53 (95% CI, 0.43-0.65; P < .0001). TOI-14 scores improved during the 24 months in both treatment groups, with more pronounced and earlier improvement in the tonsillectomy group compared with the conservative management group (mean, 4.7 [2.9-6.4] in 99 participants [42%] vs 15.4 [12.0-18.8] in 100 [45%]; P < .0001). Tonsillectomy was nonsignificantly more costly and more effective than conservative management. When participant costs were factored, tonsillectomy was less costly than conservative management and more effective.

The most common adverse effect (AE) in the tonsillectomy group was bleeding, with 19% of participants having any bleeding event occur, which resulted in 37 hospital readmissions. In total, 191 AEs occurred in 39% of participants and were deemed related to tonsillectomy. Two patients admitted to the hospital with acute tonsillitis had not undergone tonsillectomy. No deaths occurred during the study.

Based on these data, NATTINA adds evidence to a 40-year research gap and demonstrates tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. However, patients should still consider the increased risk of postoperative events compared with reduced symptoms of tonsillitis.

References

1. Cheng AG. Tonsillopharyngitis. Merck Manual. Updated September 2022. Accessed August 6, 2023. https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/oral-and-pharyngeal-disorders/tonsillopharyngitis

2. Powell J, O’Hara J, Carrie S, Wilson JA. Is tonsillectomy recommended in adults with recurrent tonsillitis? BMJ. 2017;357:j1450. doi:10.1136/bmj.j1450

3. Guntinas-Lichius O. Tonsillectomy in adults—to do or not to do. Lancet. 2023;401(10393):2015-2017. doi:10.1016/S0140-6736(23)00673-6

4. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):1279-1282. doi:10.1093/cid/cis847

5. Dekker ARJ, Verheij TJM, van der Velden AW. Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Fam Pract. 2015;32(4):401-407. doi:10.1093/fampra/cmv019

6. Gerhart J, Butler S. Overprescription of antibiotics for sore throat surged during the COVID-19 pandemic. NEJM Catalyst. Published online December 1, 2021. doi:10.1056/CAT.21.0366

7. Guillemot D, Carbon C, Balkau B, et al. Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA. 1998;279(5):365-370. doi:10.1001/jama.279.5.365

8. Mandavia R, Schilder AGM, Dimitriadis PA, Mossialos E. Addressing the challenges in tonsillectomy research to inform health care policy. JAMA Otolaryngol Head Neck Surg. 2017;143(9):943-947. doi:10.1001/jamaoto.2017.0964

9. Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or adenotonsillectomy versus nonsurgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014;2014(11):CD001802. doi:10.1002/14651858.CD001802.pub3

10. Wilson JA, O’Hara J, Fouweather T, et al. Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial. Lancet. 2023;401(10393):2051-2059. doi:10.1016/S0140-6736(23)00519-6

About the Authors

Diandra Ruidera, PharmD, BCPS, BCIDP, is a medical science liaison for infectious diseases and anti-infectives at GSK in San Diego, California.

Stuart Greaser, PharmD, BCIDP, is a clinical pharmacy specialist in infectious diseases at Saint Francis Medical Center in Cape Girardeau, Missouri.