Talk:Tonsillectomy

message: -What's the source on the tonsils growing back after removal?  That's really very interesting.    --FMephit 05:11, 3 Dec 2004 (UTC)
replies: text: I think that's a confusion of the tonsils with the adenoids. The adenoids can grow back after an adenotomy, IIRC, but for sources on that, STFW... Dabljuh 21:42, 17 January 2006 (UTC)
thread_title: Growing back?

message: The section on Methods of Tonsil Removal was lifted wholesale from this site (http://www.entnet.org/KidsENT/tonsil_procedures.cfm) listed in the External Links section without appropriate citation.  Is this OK?
203.212.59.211 11:30, 10 December 2006 (UTC)
thread_title:  Citation concerns 

message: I personally don't think that the current picture of the article is very useful unless we have a "before" picture to go with it. Maybe someone who has very swollen tonsils could take a picture of them before they have them taken out and add them to the article. I think that would greatly improve the visual aspect of the article. --Emery 23:26, 10 January 2007 (UTC)
thread_title:  Pictures 

message: It would be help to add some information regarding after surgery recommendations for the patient and what to expect 10-15 days later.
Ryan Martin  —Preceding unsigned comment added by 65.186.208.223 (talk) 00:59, 27 September 2007 (UTC)
replies: text: I've not seen much in the texts covering that.  The focus is on the first 2 weeks.--RadioFan (talk) 14:38, 25 April 2009 (UTC)
thread_title:  Post-Surgery and Revovery 

message: I've removed the sentences which claim that North American physicians recommend a diet of soft foods while in the UK "crunchy" or "rough" foods are recommended to keep the tonsil beds "clean".  It was completely unreferenced and counters what is suggested in the references I'm finding.  The only mention I've found in texts to anything but soft foods being recommended was a study in 1992 which concluded that eating soft foods or rough foods after a tonsillectomy had no impact on recovery time, pain medication, etc.  Without some reference to the differing advice between the UK and the US/Canada, the information doesn't belong here.--RadioFan (talk) 14:38, 25 April 2009 (UTC)
thread_title:  Post-Op diet recommendations 

message: How about a section on side effects and results? I'd be interested to know if removal of tonsils has been correlated either positively or negatively with weight gain. 69.143.26.71 03:58, 23 October 2007 (UTC)
thread_title:  Side effects 

message: Should information about the tonsillolith be in the section about reasons for removal? I know some people do it just to stop it from happening, and I may have it done too. Any ideas? Montymintypie (talk) 08:38, 15 May 2008 (UTC)
replies: text: Tonsilloliths are listed as one of the indicators for the proceedure, what else did you want to see there?--RadioFan (talk) 14:42, 25 April 2009 (UTC)
thread_title:  Tonsillolith? 

message: I think it is important to note serious side effects such as a loss of taste, or metallic taste in the back of the mouth due to nerve damage caused during tonsillectomy. This issue seems to affect many adults who have had tonsillectomies. See here.  —Preceding unsigned comment added by 124.171.225.70 (talk) 05:48, 28 April 2009 (UTC)
thread_title:  Side Effect - Loss of Taste 

message: It was a very popular surgery for children in 80-es in USSR. Dissection and snare method was usually used without any kind of anesthesia.
In modern Russia less surgeries are performed and local or general anesthesia is often (but not always) used.
--Varnav (talk) 12:31, 18 December 2009 (UTC)
thread_title:  In Russia 

message: Lead sentence says it's been practiced for 2000 yrs, but further down it says it's been practiced for 3000 yrs. Maybe it was in clniical trials for the first 1000 yrs... Please check and update where needed. Oaktree b (talk) 15:55, 19 May 2010 (UTC)
thread_title: How Old?

message: Hi
I have just had my Tonsils removed 6 weeks ago, before the operation I was searching the net for information, but did not find what I was looking for, so here is the REAL truth about my operation on the N.H.S !!!
I am a 40 year old male, fit and healthy, do not smoke and not overwieght, I attend a gym 3 times a week. I had my Tonsils removed to hopefully stop me from Snoring!!
I was told I would need two weeks off work after the operation, which was an overnight stay in hospital, surely it can not be that bad I thought to myself??. I awoke after the operation with hardly any pain, but slowly during my overnight saty it became worse, I was taking pain killers and anti biotics every 6 hours, I left hospital the folowing morning and felt really drowsy..I could not return to work.
I was still taking loads of pain killers and anti biotics given to me by the Hospital, which I had to take every 6 hours for the next 21 days!!..after 5 days at home I returned to work..M<ASSIVE mistake, by day 7 I was in total agony, in all fairness the Doctor told me it gets  worse about 7 days after the ooperation, and man was he right!!!..all I could swallow was water and soup which was total agony, this went on for about 2 weeks, I felt terrible. Finally after approx 5/6 weeks I am now able to eat normal food and also taste the food.
All I can say is take 2 weeks off work to recover, and expect plenty of pain!!!..I lost 2 stone in 6 weeks with not eating correctly and had no energy whats so ever. 
But YES I have stopped SNORING so my Wife says it was well worth it.  —Preceding unsigned comment added by 81.144.178.190 (talk) 07:25, 1 June 2010 (UTC)
thread_title:  Just had my Tonsils REMOVED!!! 

message: This article does not cover the most talked-about after-effect of a tonsillectomy - possible voice change. There's a lot of talk about the extent to which a person can undergo a change of voice, post tonsillectomy. Some people, on the other hand, do not undergo any sort of voice-change. Can anybody shed more light about this? 59.184.164.16 (talk) 03:53, 2 June 2010 (UTC)
thread_title:  Tonsillectomy and voice-change 

message: This is one of the worst scientific articles I have ever seen on Wikipedia. Several facts are repeated in unnecessary fashion, and the divisions or headers should be combined or changed to a more logical order.  — Preceding unsigned comment added by 68.3.72.196 (talk) 07:35, 8 January 2017 (UTC)
thread_title:  Information repeated many times 

message: Per WP:MEDRS we do not use primary sources for medical content. This section was supported nearly exclusively by primary sources.
I have thus reverted this . Doc James (talk · contribs · email) 21:16, 11 February 2019 (UTC)
replies: text: agree w/ Doc James, should use MEDRS--Ozzie10aaaa (talk) 21:33, 11 February 2019 (UTC)
replies: text: For  "For biomedical content, primary sources should generally not be used. This is because primary biomedical literature is exploratory and often not reliable, and any given primary source may be contradicted by another. The Wikipedia community relies on guidance of expert reviews, and statements by major medical and scientific bodies. Text that relies on primary sources should usually have minimal undue weight, only be used to describe conclusions made by the source, and must describe these findings clearly so that all editors even those without specialist knowledge can check sources. Primary sources should never be cited in support of a conclusion that is not clearly made by the authors (see WP:Synthesis)." from WP:MEDRS. —Atcovi (Talk - Contribs) 21:50, 11 February 2019 (UTC)
replies: text:    Okay then, but something more needs to be written about the impact on the immune system as there are strong indications that tonsillectomy does harm the immune system in the long run. Protecting the body against pathogens is the very purpose of the tonsils, so patients, or actually, their parents, should have an idea what the long term consequences of tonsil removal are.  Zesd (talk) 05:26, 12 February 2019 (UTC)
replies: text: You need to present high quality secondary sources such as literature reviews or positions statements by well respected medical organizations. Doc James (talk · contribs · email) 05:27, 12 February 2019 (UTC)
replies: text: This 2015 JAMA Pediatrics review  seems to indicate that most studies have actually found no significant effects on a child's immune system post-tonsillectomy. A second 2015 review  agrees. A brief look at the literature shows the procedure even helps certain immune-mediated conditions on occasion. TylerDurden8823 (talk) 07:02, 12 February 2019 (UTC)
replies: text: Thanks User:TylerDurden8823 have added those reviews. Doc James (talk · contribs · email) 16:13, 13 February 2019 (UTC)

text: Have reverted some recent readdition of these primary sources. Doc James (talk · contribs · email) 22:18, 12 February 2019 (UTC)

text: I agree with you that we should be allowed to use primary sources (especially if there is a lack of secondary sources) as long as those primary sources fulfil certain criteria. Those primary sources are peer reviewed and published in renowned journals such as The Lancet, so they are more reliable than position statements (which are often political).Zesd (talk) 17:53, 17 May 2019 (UTC)
thread_title: Primary sources

message: User:Zesd added
"The Canadian Cancer Society mentions tonsillectomy as a possible risk factor for Hodgkin's lymphoma, although it stresses that more research is necessary."
Ref says:
"Unknown risk factors It isn’t known whether or not the following factors are linked with Hodgkin lymphoma previous surgery to remove the tonsils or the appendix"
One definitely does not equal the others. The source actually could be summarized as "There is no evidence that tonsillectomy is a risk factor for Hodgkin's lymphoma."
Doc James (talk · contribs · email) 04:29, 6 March 2019 (UTC)
thread_title: Hodgkin lymphoma

message: Ref says "tonsillectomy for recurrent throat infections in severely affected children was shown, in a randomized controlled trial, to reduce the frequency and severity of infections in the 2 years following surgery"
This IMO is a reasonable summary:
"For those with frequent throat infections, surgery results in fewer sore throats in the following one to two years, but unclear long term benefits."
Doc James (talk · contribs · email) 08:53, 26 March 2019 (UTC)
replies: text: How many fewer sore throats (on average)? Just "fewer" is too vague. Is it 20? 10? 5? 1? (per year) The sore throat section says "Children who undergo surgery on average have one fewer sore throat per year in the subsequent one or two years, compared to those who do not". This information should also be present in the introduction. Zesd (talk) 16:14, 26 March 2019 (UTC)
replies: text: Fewer IMO is fine as that is the summary the source gives. The exact numbers can go in the body of the text. Doc James (talk · contribs · email) 16:22, 26 March 2019 (UTC)

text: agree w/ Doc James.... (BTW additional reverts  Zesd are not wise at this point)--Ozzie10aaaa (talk) 22:38, 21 April 2019 (UTC)
replies: text:   One of the main points of this article is that the benefits of tonsillectomy are very modest at best. Therefore it needs to be in the introduction like in the abstract of a scientific study. I agree with  that simply saying “fewer sore throats” is misleading. This is a medical article, so we really need to be careful, even in the introduction. I do not see what rule there would be violated, or what problem will be caused by mentioning a number or the fact that the reduction is minor. It would make the introduction more accurate by only adding a few extra words. And if we can say in the introduction for how long the decrease in sore throats persists, why can’t we say how big that decrease actually is? I also see some statistics regarding complications in the introduction, so why not about the reduction in the number of sore throats? Zesd (talk) 08:43, 22 April 2019 (UTC)
replies: text: I dont agree w/your position/interpretation of the wording--Ozzie10aaaa (talk) 11:01, 22 April 2019 (UTC)
replies: text: What exactly do you not agree with? Could you please tell me why you think that I am wrong? Just saying that you do not agree with me is not very helpful. Zesd (talk) 13:36, 22 April 2019 (UTC)
replies: text: would refer you to both Doc James answers above, thank you--Ozzie10aaaa (talk) 15:49, 22 April 2019 (UTC)
replies: text: It is in the body of the text. We could also say a 20% decrease. But the specifics are better in the body of the text. Doc James (talk · contribs · email) 17:13, 23 April 2019 (UTC)
thread_title: Summary

message: User:Zesd Why did you remove the following reviews?
They are not even 5 years old. And which words in the text support an increased risk of UC? Please provide a direct quote. The article is still in publication you added. We should wait until it is fully published. Doc James (talk · contribs · email) 17:01, 23 April 2019 (UTC)
replies: text: On the 13th of February 2019 user TylerDurden8823 commented that studies from China are prone to academic fraud. Assuming that that is true, plus the fact there is now a good secondary source from Europe, I decided to replace the two Chinese sources by the one from Europe. This new source is quite clear on the link between tonsillectomy and Crohn’s disease (which is an IBD): ”We identified 9 factors that increase risk of IBD: smoking (CD), urban living (CD and IBD), appendectomy (CD), tonsillectomy (CD), antibiotic exposure (IBD), oral contraceptive use (IBD), consumption of soft drinks (UC), vitamin D deficiency (IBD), and non-Helicobacter pylori-like enterohepatic Helicobacter species (IBD).” Zesd (talk) 20:08, 23 April 2019 (UTC)
replies: text: The article is currently in press. We should wait until it is fully published. Do you have the full text? Doc James (talk · contribs · email) 02:49, 24 April 2019 (UTC)
replies: text: Ok, I agree with you that we should wait for the final version although I don’t expect the conclusion to be much different. Zesd (talk) 21:29, 24 April 2019 (UTC)
replies: text: Well first of all the abstract does not mention UC. Doc James (talk · contribs · email) 00:21, 27 April 2019 (UTC)
replies: text: But the text of the article does, see https://www.gastrojournal.org/article/S0016-5085(19)36709-5/abstract under the Results section. Zesd (talk) 06:57, 1 May 2019 (UTC)
replies: text: Can you quote the exact text you are looking at. Doc James (talk · contribs · email) 07:10, 1 May 2019 (UTC)
replies: text: This is the text that says there is a link between tonsillectomy and Crohn’s Disease: “We identified 9 factors that increase risk of IBD: smoking (CD), urban living (CD and IBD), appendectomy (CD), tonsillectomy (CD), antibiotic exposure (IBD), oral contraceptive use (IBD), consumption of soft drinks (UC), vitamin D deficiency (IBD), and non-Helicobacter pylori-like enterohepatic Helicobacter species (IBD).“ The publication status of the study is “In Press Accepted Manuscript”, which means it is almost final. Once the publication status is final, we should no longer say that the link between tonsillectomy and Crohn’s disease is “unclear” as we will then have three secondary sources that confirm a link between tonsillectomy and Crohn’s disease. Zesd (talk) 20:09, 1 May 2019 (UTC)
replies: text: We are talking about UC not CD. Doc James (talk · contribs · email) 20:18, 1 May 2019 (UTC)
replies: text:  According to those three secondary sources, tonsillectomy does not increase the risk of UC, but does increase the risk of CD. So, we can simply say that tonsillectomy increases the risk of CD (if citing three secondary sources is not sufficient, then what is?). In my opinion, there is no need to say that tonsillectomy does not increase the risk of UC.Zesd (talk) 05:37, 2 May 2019 (UTC)

text: That may be, but other studies say: “This meta‐analysis demonstrates that tonsillectomy is associated with an increased risk of developing CD.” (https://onlinelibrary.wiley.com/doi/abs/10.1111/jgh.13273) and “We identified 9 factors that increase risk of IBD: (...) tonsillectomy (CD) (...)” (https://www.gastrojournal.org/article/S0016-5085(19)36709-5/abstract). Just because one study says that there is no link does not mean that all other studies that claim the opposite are wrong. Even that Cochrane review you are talking about says “The odds ratio for CD following a tonsillectomy was 1.194, 95% CI 0.992–1.437”, which means a slightly increased risk of CD. Based on the available medical literature, it is safe to say that tonsillectomy increases the risk of Crohn’s Disease. Please stop denying the obvious.Zesd (talk) 17:18, 6 May 2019 (UTC)
replies: text: No that is not accurate. "he odds ratio for CD following a tonsillectomy was 1.194, 95% CI 0.992–1.437" does not mean a slight increase. It means no significant difference. Lets just wait for that paper to be fully published so that we can read it. Have you read the full copy yet? Doc James (talk · contribs · email) 23:20, 6 May 2019 (UTC)
replies: text:   Once the publication status of the study is final, we could say that according to most recent research, or according to the majority of the available research, tonsillectomy increases the risk of CD. Zesd (talk) 04:29, 7 May 2019 (UTC)
replies: text: Once that study is fully published and we are able to read it we can figure out what we should say based on it.Doc James (talk · contribs · email) 09:52, 7 May 2019 (UTC)
thread_title: Removal of reviews

message: I am concerned that the page as currently written misrepresents the evidence for tonsillectomy in Obstructive Sleep Apnoea
What Wikipedia says:
"Tonsillectomy improves obstructive sleep apnea (OSA) in most people."
What the evidence says:
Adults: no RCT evidence
Children: RCT evidence shows improvements in polysomnography parameters and in "quality of life, symptoms and behaviour as rated by caregivers". These are subjective outcomes rated by a third party in unblinded studies. 
It is also observed that half of children improve without surgery - so it is hard to see how tonsillectomy can improve "most" chidren since half improve anyway.
There is no evidence in relation to children with OSA which is not confirmed by polysomnography. 
There is no evidence relating to children aged under 5 years.
Exact wording of the Cochrane review:
In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time.
''
For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.
Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG.
''
We are unable to present data on the benefits of adenotonsillectomy in children with oSDB aged under five, despite this being a population in whom this procedure is often performed for this purpose.
 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011165.pub2/full
TTM314 (talk) 22:23, 16 May 2019 (UTC)
replies: text: Statement applies to children. Adjusted to reflect that. Doc James (talk · contribs · email) 11:00, 19 May 2019 (UTC)
thread_title:  Evidence for effectiveness of tonsillectomy for Obstructive Sleep Apnoea 

message: I am concerned that the current version is being distracted by measures of immune function which are not directly relevant to patients.  
Wikipedia says:
"Tonsillectomy does not appear to affect long term immune function"
This is referenced to a meta-analysis of studies of biomarkers of immune function (Immunoglobulin levels - serum Ig's, SecIgA, cellular immunity, Ag specific Ig).Bitar MA, Dowli A, Mourad M. The effect of tonsillectomy on the immune system: A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. 2015 Aug;79(8):1184-91. doi: 10.1016/j.ijporl.2015.05.016. Epub 2015 May 27. doi: 10.1016/j.ijporl.2015.05.016. But the fact that this is a secondary source is being given undue weight. It is a systematic review based on evidence from 35 small studies. Some studies included in the meta-analysis have no control group and are simply before and after studies, some are cohort studies. The total number of individuals in all the included studies was 1997, follow up testing was carried out at different time points but in most cases was less than a year (132 months in one study). This analysis is therefore not very long-term. It is much too small and too short term to compare future incidence of illness in children who have tonsillectomy and children who do not have tonsillectomy. In other words the study is underpowered to detect differences in disease incidence and is in any case only measuring biomarkers.
What the evidence says:
I would suggest that future incidence of disease is of more interest to patients than changes in biomarkers. We don't have long term follow up with any RCT of tonsillectomy. It is inconceivable that we ever will have RCTs with years of follow up. The best we can do is a (retrospective) cohort study of children who did have tonsillectomy compared with those who did not. 
There are three large retrospective cohort studies several orders of magnitude larger than the study cited above to support the suggestion that tonsillectomy may be associated with a higher risk of future illness. These appear to be being dismissed because they are primary sources, but they ask the right questions (about risk of illness, not biomarkers) and are very much larger than the entire 35 studies included in the cited secondary source.
One study included 1.2 million Danish children of whom over 40,000 underwent tonsillectomy, followed up for 1 to 21 years. This found a higher incidence of respiratory, infectious and allergic conditions later on in life in children undergoing tonsillectomy. 
An Australian study followed up 8583 children for 37 years: 1238 underwent tonsillectomy and an increased mortality was observed in those who underwent tonsillectomy. 
A study which followed up 179,875 Swedish patients who underwent tonsillectomy observed an increased risk of autoimmune conditions such as thyroid diseases, rheumatic diseases, inflammatory bowel disease and type 1 diabetes. The exact wording from the Abstract is: 
A total of 179,875 individuals received a tonsillectomy in Sweden and 5357 of them were subsequently diagnosed with autoimmune diseases, giving an overall Standardised Incidence Ratio (SIR) of 1.34 (95%CI 1.30-1.37). For specific autoimmune diseases, 16 of them showed a significantly increased SIR, ranging between 1.21 and 2.97. The increased incidence was largely consistent irrespective of gender, age at operation, and underlying indications of tonsillectomy.
''
Ji J, Sundquist J, Sundquist K. Tonsillectomy associated with an increased risk of autoimmune diseases: A national cohort study. J Autoimmun. 2016 Aug;72:1-7. doi: 10.1016/j.jaut.2016.06.007. Epub 2016 Jun 22.
None of these three papers is utterly free from potential confounding but they measure incidence of disease and mortality, both of which are more important to patients than biomarkers (which have a more tenuous relationship to illness). All three papers are much larger, have longer follow up and more robust than the study which is currently cited in Wikipedia as evidence that tonsillectomy has no effect on the immune system.TTM314 (talk) 22:48, 16 May 2019 (UTC)
replies: text: Exactly. Although it is interesting to look at biomarkers, it is the incidence of disease that really matters.Zesd (talk) 17:53, 17 May 2019 (UTC)

text: I fully agree with you. I found literally dozens and dozens of primary sources that indicate that tonsillectomy compromises the immune system, so secondary sources (which are based on primary sources!) that claim that there is no evidence that tonsillectomy compromises the immune system are simply wrong, especially if they only look at immunoglobulin levels a few months after surgery instead of the incidence of disease decades later. Furthermore, in the article no explanation is given on why removing its entire first line of defence would have no negative effect on the immune system. But most importantly, it’s a big shame that every year, thousands and thousands of young children are mutilated and have their life and health put at risk, just to avoid one or two sore throats. Zesd (talk) 17:53, 17 May 2019 (UTC)
replies: text: You need to follow WP:MEDRS. Doc James (talk · contribs · email) 11:01, 19 May 2019 (UTC)
replies: text:  I think you are missing the point. There are some good reasons to doubt the quality of several of the cited secondary references here. As TTM314 said earlier, the fact that immunoglobulin or whatever other levels do not change after tonsillectomy does NOT mean that the immune system is not compromised as it is the incidence of disease that ultimately matters. So yes, we can mention that the level of (...) and the level of (...) remain unchanged after surgery, but the conclusion that tonsillectomy has no negative effect on the immune system would be premature. Furthermore, that there are no studies that demonstrate that tonsillectomy negatively affects the immune system is simply not true. This article cites multiple secondary sources that found an increase in the risk of Chrohn's Disease and Multiple Sclerosis. Besides that, there many primary sources that found strong indications that tonsillectomy does harm the immune system. I know we cannot use them here, but secondary sources should not ignore them. Zesd (talk) 15:17, 19 May 2019 (UTC)
replies: text: The associations are for small differences of questionable clinical significance in the rates of these. Doc James (talk · contribs · email) 05:29, 20 May 2019 (UTC)
thread_title:  Long term effects - immune function versus autoimmune conditions 

message: "Tonsillectomy does not appear to affect long term immune function."
*Support as proposer. We could also say "does not appear to meaningfully affect..." Doc James (talk · contribs · email) 07:10, 24 May 2019 (UTC)
thread_title: Option 1

message: "Tonsillectomy does not appear to affect a number of biomarkers related to the immune system, such as secretory immunoglobulin A and antigen specific immunoglobulin levels."
* Support as above. This is what Bitar (2015) found, nothing more, nothing less. As the study does not consider the incidence of disease, the conclusion that the immune system remains unaffected is premature. Zesd (talk) 13:10, 24 May 2019 (UTC)
thread_title: Option 2

message: I think we should consider merging the financial incentives and parental pressure sections into the "reasons" area.  The stated "reason" for removal is [surgeon/health facility] "financial incentive" but the references don't support it. Ref#48, is a single study by a single author.  Ref#49 is 51 years old, and a lot has changed, but even then i can't even see a summary anywhere (plus it was a preliminary report). Ref #51 is Obama's quote where he mentions T&A as an example of FFS influencing decisions.   
A proper study would compare the level of reimbursement (e.g the fee paid) and T&A rate with contemporary indications for removal.  Comparing FFS vs salary, is a separate issue, as is 1960's indications vs modern ones. Even though the parental pressure ref#52 is a commentary, it's actually a good summary of the entire situation imo.  Also, wrt financial incentives, no mention is made of populations that can't afford private pay treatment.  Do they suffer more?  Both sides of the coin should be examined if we create an entire section on it. Ian Furst (talk) 13:53, 26 June 2019 (UTC)
replies: text: Thanks. I will take a look at it this weekend and edit the article if necessary. But for now I can say this: 1) No child has ever asked to be knocked out and have two or three of its organs removed. 2) It is abundantly clear that even in severe cases the benefits of tonsillectomy are modest at best. 3) There are strong indications that tonsillectomy increases the incidence of a broad range of diseases. Yet every year, hundreds of thousands, if not millions, of young children worldwide have their tonsils taken out. This can only be because surgeons get paid for doing this procedure or because of their biased views and / or parents want to have this procedure done because of psychological reasons. Furthermore, I believe the argument of "undertreatment" is simply not credible. Although tonsillitis (especially if it is chronic or recurrent) may be very disturbing, it is not life threatening, nor is it likely to cause any serious any long term health risks. Tonsillectomy rates vary considerably between similar countries, yet I have not heard of large numbers of children experiencing serious health issues because their tonsils have not been taken out in countries where tonsillectomy rates are low. Zesd (talk) 22:40, 26 June 2019 (UTC)
replies: text: I'm happy to have a discussion about contemporary indications for tonsillectomy, and whether they're used globally.   But statements like, "This can only be because surgeons get paid for doing this procedure or because of their biased views..." and "No child has ever asked to be knocked out and have two or three of its organs removed." are hyperbolic imo. I've seen the other side of this issue, with deep neck infections, and life-threatening outcomes from non-treatment. At the end of the day, we just need to ensure that any information that is put on Wikipedia is neutral, and supported by MEDRS Ian Furst (talk) 12:30, 27 June 2019 (UTC)
replies: text:  Sorry for my language. That was inappropriate, even on a talk page. I will be more careful in the future. Zesd (talk) 13:30, 27 June 2019 (UTC)

text:  The financial incentives and parental pressure sections have been merged into the reasons section. I have added an extra reference that contains the conclusions of the 1968 Canadian report. I will look for more studies on the relation between surgeon's incomes and surgery / tonsillectomy rates when I have more time. Zesd (talk) 09:05, 29 June 2019 (UTC)
thread_title: Discussion on incentives for removal

message: Several references mention parental pressure, but none quoted so far address the specific effect.  I think we have two separate issues; (1) does parental pressure make it more likely for the tonsils to come out, and (2) does it increase the chance of referral to ENT.  Poor references keep getting inserted, last one was a ?dissertation in Dutch.  Another was a commentary.  Will look through guidelines for a better reference.  I suspect it's addressed somewhere in a consensus paper or something Ian Furst (talk) 18:51, 3 July 2019 (UTC)
replies: text: Regarding question #1: In this article from 1957 (a long time ago, I admit) the author says that of the 40 children who had their tonsils removed, 6 (15%) had the procedure done because of parental pressure. It is very likely that this has also happened elsewhere. About question #2: According to this article from 1972 (also a long time ago) which I find very interesting and credible, "Too often physicians scheduled [adenotonsillectomies] out of habit or in response to parental pressure". I would not say that the references I have found are "poor", although I admit that some are better than others. The Dutch source from 2009 for example, is not bad at all in my opinion. But I'm sure we can find more and better sources. When I enter "tonsillectomy" combined with "parental pressure" in Google, I get around 2.470 results, which probably excludes many other relevant pages (including those in other languages than English) that cannot be found using those exact terms. Zesd (talk) 21:39, 3 July 2019 (UTC)
replies: text: Zesd, there's no reason to use these horrible references, when there is so much good data out there.  that article from 1974 reported rates of 2,000 tonsillectomies per 100,000 children, which just isn't relevant anymore. Plus, it's a bookkeeping excercise and doesn't directly address the parental pressure issue.  Imo, a parent is likely to read the lead of wikipedia, but caregivers (both formal and informal) are going to read the details.  If we give them contemporary, evidence-based facts it has the potential to do the most good.  There are great references out there, like the consensus statement that's quoted everywhere (including the dutch economics paper). [Here http://www.health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_tonsil.pdf] is a governmental review, that lists all kinds of meta-analysis, and even rates the quality of the references.  Ian Furst (talk) 23:37, 3 July 2019 (UTC)
replies: text:  Those references I used in the parental pressure section are from renowned journals such as The British Medical Journal, International Journal of Epidemiology and the New England Journal of Medicine. I can hardly believe all those journals publish "horrible" or "poor" articles or commentaries. But anyway, could you maybe write a new section about parental pressure using the great references you have found so far? I'm looking forward to seeing it. Without a section about parental pressure, this article is simply incomplete. Zesd (talk) 19:43, 4 July 2019 (UTC)

text: I'd add that everyone agrees that 2,000 per 100,000 is too much, and 0 per 100,000 is too few.  What is the proper rate?  I don't know, but I do know that it will change with time, our understanding of the risks and benefits, and evolving technology. Appendectomy rates used to be higher, and 10% "healthy appendectomy" rates acceptable so that the risk of periotonitis was kept low on a populational bases.   Ultrasound, CT, modern antibiotics, have all changed that. Ian Furst (talk) 23:41, 3 July 2019 (UTC)
replies: text:  I find it astonishing that so many parents opt for a medical procedure that is so ineffective and so potentially harmful, especially now we live in the information age. Tonsillectomy is an elective procedure, so the most important reason it happens is because the parents want it. By far, most children simply outgrow tonsil related diseases and those diseases are unlikely to be fatal, contrary to, for example, an appendicitis. Furthermore, I have found dozens and dozens of studies that prove that tonsillectomy does harm the immune system profoundly (increased risk of cancer, allergies, diseases in the upper respiratory tract, heart attack, autoimmune diseases and inflammatory diseases for example). And then there also the risks of general anaesthesia, such as cognitive disorders later in life. The benefits of tonsillectomy are in the vast majority of cases minor and temporary, whereas the drawbacks are forever and potentially profound as the procedure involves the permanent removal of the entire first line of defence of the immune system. Zesd (talk) 19:43, 4 July 2019 (UTC)

text:  I also find the whole parental pressure section very interesting from a psychological point of view. Are there similarities with phenomena such as circumcision, castration and child abuse? Given the fact that tonsillectomised parents are more likely to opt for tonsillectomy for their children, may the desire to have the procedure done be some sort of "revenge"? Zesd (talk) 19:59, 4 July 2019 (UTC)
replies: text: The two references I cut were this white paper (in dutch) published on the personal website of a "independent advisor health economics" and this commentary.  Regarding the parents motive to seek care unless there is a proper MEDRS reference, it should not be in the article.  The same as all other statements of fact.  Ian Furst (talk) 21:59, 4 July 2019 (UTC)
replies: text:  You have deleted the parental pressure section again. I just checked the the page about MEDRS but could not find anything there that convinces me that a PhD dissertation is not MEDRS. Could you please let me know why a PhD dissertation is not MEDRS? Or maybe even better, could you write something about parental pressure yourself? Zesd (talk) 13:55, 10 July 2019 (UTC)
replies: text: The source quotes two primary studies, both of which were small surveys of GP's in England (the doctoral candidate discusses the limitations of the studies in the dissertation). Neither a PhD submission, or the original science it quotes, is considered a generally accepted fact.  Also, we've all agreed not to use primary research (a PhD dissertation is, by definition, original science). The fact you stated was "According to several studies, parental pressure sometimes plays a role in the decision-making of general practitioners and ENT consultants." under tonsillectomy rates. This is misleading imo because the source states that parental pressure influenced referral rates, not tonsillectomy rates.  Between the misleading statement, and the poor reference I removed it.  I can't find a contemporary MEDRS that states the surgeons tonsillectomy rates are influence by parental pressure. Ian Furst (talk) 14:16, 10 July 2019 (UTC)
replies: text:   Even if we cannot find good quality sources that confirm that parental pressure increases tonsillectomy rates, we could still say something about parental pressure. For example, we could say that parental pressure influences referral rates, but it is not clear whether those higher referral rates subsequently result in higher surgery rates (although it is extremely likely, especially if the surgeon is paid fee-for-service reimbursements). The whole parental pressure thing is an interesting psychological phenomenon anyway, so why not give it a bit of attention.  Zesd (talk) 21:25, 10 July 2019 (UTC)
replies: text: If we can't find good quality sources, it shouldn't be in the text.  The community is clear that they don't want speculative facts peppering articles (and I agree).  Ian Furst (talk) 12:52, 11 July 2019 (UTC)
thread_title:  Parental pressure 

message: Can anyone explain to me why this article does not qualify as a secondary source? It is an advice from the American Association for Respiratory Care, so I would say it can be considered a position statement by a well respected medical organization. Zesd (talk) 19:43, 11 July 2019 (UTC)
replies: text: Sure; WP:MEDRS stipulates that facts should be backed by consensus statements or position statements when coming from organizations.  This is an anonymously authored web page with ?3 linked papers (one of which is extensively discussed in the the article already).  I think you're claiming that it would qualify under this heading, but the AARC is not a major international organization, and the webpage was not some massive, well referenced consensus.  Compare to something like this on dengue fever which is heavily referenced, and from the WHO.  I'd also add that the statement of fact you claimed, "... several studies that demonstrate an association between tonsillectomy and certain diseases..." is vague, and arguably falls under the RfC the community agreed to previously. Ian Furst (talk) 03:04, 12 July 2019 (UTC)
thread_title:  Secondary sources 

message: Obstructive Sleep Disordered Breathing is an indication for adenotonsillectomy in children in the USA, and the majority of procedures in this country are performed for this reason.
The only place Obstructive Sleep Disordered Breathing is mentioned in this article is in the 2018 UK study reviewing indications for the procedure, indicating this is a frequent and non-indicated reason for the procedure in the UK.  I practice in the USA and don't know if this is accurate or not.  
The Section "Obstructive Sleep Apnea" under "Medical Uses" states that OSA is an indication for tonsillectomy without referencing any specific age group and then references the 2019 update to AAO-HNS Clinical Practice Guideline for Tonsillectomy *in Children*.  This paragraph goes on to state that "The procedure is recommended for those who have OSA that has been verified by a sleep study.[1]"  This is a distortion of this guideline, which states first that OSDB is a clinical diagnosis and an indication for adenotonsillectomy, and further that a sleep study may be indicated in specific patient populations, such as those without apparent obstructive anatomy.  
I am going to make an edit to the paragraph to clarify this but would welcome others' thoughts.  — Preceding unsigned comment added by Apcpa (talk • contribs) 18:11, 15 July 2019 (UTC)
replies: text: Because of the historic over prescription of tonsillectomy, and current wide variation between regional rates there is a lot of debate within this article.  As such, we look for very strong evidence to include in the indications sections.  Either consensus statement, meta-analysis or cochrane study to support each statement of fact. I'll take a look at the specific guideline too.  Is there a consensus statement about diagnostic criteria for which OSDB patients receive T&A? Ian Furst (talk) 18:32, 15 July 2019 (UTC)
thread_title:  Obstructive Sleep Disordered Breathing 

message: In my opinion, the article is missing some crucial information. I would like to see the following three questions answered: 
* If tonsillectomy is effective in treating OSAS and recurrent / chronic tonsillitis, is generally safe and does not harm the immune system in any way, then why have tonsillectomy rates decreased so drastically over the past decades in most countries?
* If the tonsils are important and serve as the first line of defence in the immune system, then why does tonsillectomy not compromise the immune system?
* What is the role of parental pressure in the decision process whether the tonsils need to be taken out?
Can anyone give an answer to each of these three questions, backed up by secondary sources? I would be very grateful.
Zesd (talk) 20:34, 2 August 2019 (UTC)
thread_title:  Questions that need to be answered in the article 

message: This is from a commentary on a primary source not a review
"In reaction to a 2018 study from Denmark that demonstrated a positive association between childhood tonsillectomy and around twenty diseases later in life, the American Academy of Otolaryngology–Head and Neck Surgery commented that this study may be biased because of unmeasured confounding variables, reverse causation, selection bias and measurement bias. However, it also said:[It] is certainly a provocative and well executed study that may add some nuance to how we counsel parents when this all-too-common question comes up." Doc James (talk · contribs · email) 00:42, 4 October 2019 (UTC)
thread_title: Commentary

message: Per source
"Current US reported mortality rates for tonsillectomy are 1 per 2360 and 1 per 18,000 in inpatient and ambulatory settings, respectively,46,47 while the province of Ontario, Canada, reported a combined inpatient/outpatient setting mortality rate of 1 per 56,000 for the years 2002 to 2013. A prospective audit reported only 1 postoperative death after 33,921 procedures in England and Northern Ireland."
So the death rate in the US is not actually 1 in 2360. Doc James (talk · contribs · email) 01:24, 11 December 2019 (UTC)
thread_title: Range of deaths

message: I'd like to proposed that we blow-up most of the section on sore throat (which has been melded from multiple sources) and harmonize it with Statements 2 and 3 from the consensus conferences.   
"Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. Optionbased on systematic reviews of randomized controlled trials, with a balance between benefit and harm." and the other statement already blockquoted. Ian Furst (talk) 19:02, 2 January 2020 (UTC)
replies: text: We could remove the 2011 guideline (we now have a more up to date guideline from 2019) and "The panel also recommended..." part (most of it is not about sore throat). For the rest it is better to leave it as it is in my opinion. Zesd (talk) 19:08, 3 January 2020 (UTC)
replies: text:  perhaps it would be proper for an encyclopedia to keep a history of guidelines and not remove the earlier one from the record when a new one comes out. 89.134.199.32 (talk) 14:46, 22 February 2020 (UTC)
replies: text:  But then it should be concise, in the form of a table or something like that. The content about the 2011 guidelines was too long. Zesd (talk) 21:39, 25 February 2020 (UTC)
thread_title: 2019 Consenus statement and the section on sore throat

message: has this text: "This means there is a seven-fold difference between the region with the highest tonsillectomy rate and the region with the lowest one.[13] In 2006, English Chief Medical Officer Liam Donaldson revealed that unnecessary tonsillectomies and unnecessary hysterectomies combined cost the British National Health Service 21 million pounds a year.[44]"
-i dont see the reason the "sevenfold" difference between regions needs to be italicized as it is in the current article text, since the section title is about the rates, and not the SIGNIFICANCE attributed to those rates. an emphasis would be reasonable if the section was to make an argument to change the rates of tonsillectomy, but at the current title it is supposed to remain neutral and just list the numbers without emphasizing on what is 7 times higher. it is actually degrading to read a text that supposes that i cant see for myself that 7000 per 100 000 (or something similar) is SEVENFOLD higher than 1000 per 100 000. 
:Ok. Changed it.Zesd (talk) 18:26, 25 February 2020 (UTC)
replies: text: This has been edited many times, so for now I would like to keep it as it is.Zesd (talk) 18:26, 25 February 2020 (UTC)

text: I agree with you that the source you are referring to is far from perfect because indeed it 1) focuses on costs rather than numbers of surgeries and 2) it simply adds up tonsillectomies and hysterectomies (which are completely unrelated to each other). However, it is still a strong indication that the number of tonsillectomies performed in the UK is way too high, which is especially interesting because it is a country where tonsillectomy rates are relatively low. Furthermore, by mentioning hysterectomies, it is made clear that the problem of overtreatment extends beyond tonsillectomies.Zesd (talk) 18:26, 25 February 2020 (UTC)

text: And if you have better sources... you are more than welcome to use them in the article!Zesd (talk) 18:26, 25 February 2020 (UTC)

text: True, but medicine is not only a matter of science, but also of opinion. And it is important to know that tonsillectomy is controversial. Zesd (talk) 18:26, 25 February 2020 (UTC)
thread_title:  section "tonsillectomy rates" 

message: While searching for sources to support a claim that I ultimately removed from the article, I came across Tonsillectomy-Comparative Study of Various Techniques and Changing Trend (Ravinder Verma) in the Indian Journal of Otolaryngology and Head & Neck Surgery, published by Springer. Parts of the Discussion section seem to have been copied and pasted from the History section of this Wikipedia article. The linked article was published in late 2017, whereas the Wikipedia article has had the text since at least 2016. --Joshua Issac (talk) 15:59, 9 May 2020 (UTC)
thread_title:  Apparent copyright violation by third party