Tonsillectomy for recurrent tonsillitis: the NATTINA trial
Authors: Chun-Kang Liao
Journal: The Lancet (2024)

The publication by Janet Wilson and colleagues1Wilson 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: 2051-2059Summary Full Text Full Text PDF PubMed Google Scholar captivated my attention. This pioneering randomised controlled trial enhances our comprehension as otolaryngologists, offering crucial evidence for tonsillectomy's efficacy in adults with recurrent tonsillitis.2Powell J O'Hara J Carrie S Wilson JA Is tonsillectomy recommended in adults with recurrent tonsillitis?.BMJ. 2017; 357j1450 PubMed Google Scholar Nevertheless, specific nuances are unaddressed in this study, evoking curiosity. Identifying the opportune time for tonsillectomy presents a frequent clinical conundrum. We ponder whether outcomes would vary if the procedure was done amidst an acute tonsillitis episode or postponed until the resolution of the acute phase. This dilemma echoes in the management of peritonsillar abscess, in which immediate or interval surgery often stirs debate.3Tsikopoulos A Fountarlis A Tsikopoulos K et al.Immediate or interval abscess tonsillectomy? A systematic review and meta-analysis.Eur Arch Otorhinolaryngol. 2022; 279: 2245-2257Crossref Scopus (6) Google Scholar, 4Page C Chassery G Boute P Obongo R Strunski V Immediate tonsillectomy: indications for use as first-line surgical management of peritonsillar abscess (quinsy) and parapharyngeal abscess.J Laryngol Otol. 2010; 124: 1085-1090Crossref PubMed Google Scholar Such clarification could considerably augment our decision-making process. Furthermore, conventional belief posits larger tonsils as a more significant infection risk, thus indicating surgery.5Webb CJ Osman E Ghosh SK Hone S Tonsillar size is an important indicator of recurrent acute tonsillitis.Clin Otolaryngol Allied Sci. 2004; 29: 369-371Crossref PubMed Scopus (16) Google Scholar Could the NATTINA trial illuminate this conjecture? Does tonsil size indeed correlate with surgical outcomes? Another issue to be addressed is the potential immortal time bias inherent in the comparison between the surgical and conservative management groups. I am particularly interested in observing the resultant data upon the application of robust statistical corrections, including but not limited to time-varying adjustment methodologies. Although the NATTINA trial has indisputably propelled us towards more evidence-based tonsillitis management, a further analytical delve into these aspects could fine-tune our clinical strategy and optimise patient care. I keenly await future insights that this seminal research could yield. I declare no competing interests. Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trialCompared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. Full-Text PDF Open AccessTonsillectomy for recurrent tonsillitis: the NATTINA trial – Authors' replyWe welcome the enthusiasm of fellow researchers to explore other aspects of recurrent tonsil disease in adults and comment on our Article.1 Christopher R Jones and colleagues highlight the putative association between tonsillectomy rates, tonsillitis admission, and invasive group A streptococcus incidence in children.2 It is impossible for us to suggest how improved and timely access to tonsillectomy could affect societal levels of invasive group A streptococcus but the trends in tonsillectomy rates are clear. Full-Text PDF