The Laryngoscope

© 2019 The American Laryngological,

Rhinological and Otological Society, Inc.

Long-Term Outcomes of Tonsillectomy for Recurrent Tonsillitis

in Adults

Sharon Tzelnick, MD, MPH ; Ohad Hilly, MD; Shlomo Vinker, MD; Gideon Bachar, MD;
Aviram Mizrachi, MD

Background: There is uncertainty regarding the effectiveness of tonsillectomy for recurrent tonsillitis in the adult population.
Several studies have described a reduced number and severity of tonsillitis episodes; however, the impact of tonsillectomy on
healthcare burden has yet to be studied. The aim of the present study was to evaluate the long-term outcomes of tonsillectomy in
the adult population.
Methods: A retrospective review of the central database of Clalit Health Services, Tel Aviv, Israel, between 2003 and
2009 was performed. The study included all adult patients (>18 years) who underwent tonsillectomy due to recurrent tonsilli-
tis. Clinical and epidemiological data from 3 years before and after surgery were collected and analyzed.
Results: A total of 3,701 patients were included in the study. Mean age was 37.4 years, and 42.9% were males. Following
surgery, there was a significant decrease in the total number of tonsillitis episodes, otolaryngologist clinic visits, consumption
of pertinent antibiotics, and respiratory complaints. Moreover, a reduced number of hospitalizations to the otolaryngology
department and shorter hospitalization duration were also noted. Although the total number of hospitalizations was unaffected,
there was an increase in the number of primary care office visits. Finally, a break-even time analysis revealed an average of
2.7 years following tonsillectomy.
Conclusion: Tonsillectomy for recurrent tonsillitis is effective in decreasing the number and severity of tonsillitis episodes
and might also have an economic benefit. The impact of tonsillectomy on general health needs to be further evaluated; however, it
appears that there is no increase in overall morbidity.
Key Words: Tonsillectomy, recurrent tonsillitis, health-related outcomes, adult population.
Level of Evidence: NA. Laryngoscope, 122:0000–0000, 2019
Laryngoscope, 9999:1–4, 2019

INTRODUCTION in adults is usually performed for chronic or recurrent ton-

Acute tonsillitis has a substantial impact on patients,
physicians, and healthcare systems. According to the
National Center for Health Statistics in the United States,1
more than 11 million patients with acute pharyngitis annu-
ally seek medical attention in the ambulatory care setting,
with a high antibiotic prescription rate ranging between 47%
and 73%.2–4 In 2007, an economic study regarding the bur-
den of pharyngitis management. Furthermore, antibiotic
resistance increased healthcare costs by 61% for each patient
encounter.5
Tonsillectomy is one of the most common procedures
performed by otolaryngologists. Although the majority of
cases are carried out in the pediatric population, a consider-
able number of surgeries are done in adults. Tonsillectomy
From the Department of Otorhinolaryngology Head and Neck
Surgery, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty
of Medicine, Tel Aviv University (S.T., O.H., G.B., A.M.); Department of
Family Medicine, Clalit Health Services, Central District (S.V.), Tel Aviv,
Israel.
Editor’s Note: This Manuscript was accepted for publication on
February 22, 2019.
The authors have no funding, financial relationships, or conflicts of
interest to disclose.
Send correspondence to Sharon Tzelnick, MD, MPH, Department of
Otolaryngology Head and Neck Surgery, Rabin Medical Center, 39 Jabotinsky
St., Petah Tikva, Israel. E-mail address: tzelnicksharon@gmail.com
DOI: 10.1002/lary.27928
sillitis. That said, there remains uncertainty regarding the
effectiveness of tonsillectomy for recurrent tonsillitis in the
adult population.
Based on two studies that examined the efficacy of
tonsillectomy in 156 adults,6,7 a 2014 Cochrane review con-
cluded that it is not clear whether tonsillectomy reduces
sore throat events in adult patients.8 However, it may seem
that patients undergoing tonsillectomy enjoy a higher qual-
ity of life (QOL) following surgery. In a recent systematic
review that examined QOL in adults who underwent tonsil-
lectomy, a long-standing improvement of patients’ physical
and general health was noted.9
Tonsillectomy complications in adults are not uncom-
mon, reaching up to 20%. Most complications are related
to postoperative pain, dehydration, and hemorrhage.
Post-tonsillectomy complications in adults have addi-
tional healthcare expenditures of thousands of dollars per
patient.10
The impact of tonsillectomy on the immune system has
been discussed because the tonsils are a part of Waldeyer’s
ring, which is an immunologically reactive lymphoid organ.
Previous studies that examined immunoglobulin and com-
plement levels did not show any postoperative compromise
of the immune system following tonsillectomy in the pediat-
ric population.11 It is unclear whether tonsillectomy in adults

Laryngoscope 00: 2019 Tzelnick et al.: Long-Term Outcomes of Tonsillectomy in Adults

1
affects immunologic status or is associated with increased TABLE II.
rates of other infectious or inflammatory diseases. Comparison of Epidemiological Data Before and After
The aim of the present study was to evaluate the Tonsillectomy.
outcomes of tonsillectomy in adults with recurrent tonsil- Before Surgery After Surgery P Value
litis and its impact on healthcare burden.
Total tonsillitis episodes 7,439 (999) 1,776 (851) <0.001
Average antibiotic 3.57 (0.65) 2.05 (0 .44) <0.001
MATERIALS AND METHODS prescriptions per patient
We performed a retrospective chart review of Clalit Health Total URTI episodes 11,214 (846) 5,107 (427) <0.001
Services (CHS) database, the largest healthcare provider in Israel, Average primary care 20.34 (3.20) 27.99 (4.09) <0.001
which serves approximately 50% of the population (around 4 million office visits per patient
people). We included all adult patients (>18 years) who underwent Average ENT office 1.68 (0.40) 1.45 (0.44) <0.001
tonsillectomy for recurrent tonsillitis between 2003 and 2009. We visits per patient
excluded patients who did not have a minimum follow-up of 3 years Total hospitalizations 9,104 (1,560) 9,770 (1,690) NS
before and after surgery. Average hospitalization 4 (1.97) 2.95 (0.86) <0.001
Clinical and epidemiological data from before and after sur- stay (days)
gery were collected, analyzed, and compared. Total hospitalizations 3,551 (700) 2,661 (580) <0.001
Data retrieved included the number of total hospitaliza- to the ENT department
tions, particularly hospitalization to the otolaryngology depart- Average ENT department 0.85 (0.27) 0.7 (0.22) <0.001
ment, number of hospitalization days, and total number of stay (days)
primary care physician and otolaryngology office visits. Diagno-
ses of tonsillitis were recorded as a physician clinical diagnosis. NS = nonsignificant; URTI = upper respiratory tract infection.
Upper respiratory tract infections that were diagnosed by physi-
cians were recorded as well. Additionally, prescriptions of perti- RESULTS
nent antibiotics were retrieved. All pharmacies in CHS are fully A total of 3,701 underwent tonsillectomy during the
computerized, and the documentation of all prescriptions is in study period. Of those, 187 (5.1%) patients had a documen-
this repository (systemic antibiotics). All drugs were identified by tation of obstructive sleep apnea and were excluded from
their generic name. the study. Mean age was 37.4 years (range: 21–66), and
In order to evaluate the long-term economic benefit of 42.9% of patients were males. Demographics and general
tonsillectomy, we performed a break-even time analysis. Break-
data are presented in Table I.
even time is the amount of time required for the discounted
cash flows generated by a project to equal its initial cost. First,
The comparison between different clinical parameters
we calculated the difference between the annual pre- and post- before and after tonsillectomy is presented in Table II.
operative average costs of tonsillitis episodes per patient, which Following surgery, there was a significant decrease in
included physician office visits, purchased antibiotics, and the total number of tonsillitis episodes (7,439 vs. 1,776,
absence from work that occurred during an episode. Next, we P < 0.001), (1.68 vs. 1.45, P < 0.001), otolaryngologist clinic
calculated the average cost of tonsillectomy per patient, which visits, consumption of pertinent antibiotics per patient (3.57
included the procedure itself, hospitalization, analgesics, and vs. 2.05, P < 0.001), and respiratory infection diagnoses
absence from work. Then, we divided the cost of tonsillectomy (11,214 vs. 5,107, P < 0.001) (Figs. 1–2). Moreover, there was a
by the average annual difference between pre- and postopera- reduction in the number of hospitalizations to the otolaryngol-
tive costs of tonsillitis. This resulted in the average time re-
ogy department (3,551 vs. 2,661, P < 0.001) as well as shorter
quired to cover the cost of tonsillectomy with the amount saved
by the procedure.
hospitalization duration following tonsillectomy (Fig. 3).
The institutional review board approved the study protocol. Interestingly, there was an increase in the number
Statistical analysis was performed with SPSS software, ver- of primary care office visits (20.34 vs. 28, P < 0.001) but no
sion 21.0 (IBM Corp.: Armonk, NY). Categorical variables are
described by frequency and percentage. Normally distributed
variables are described by mean and standard deviation. Associa-
tions with normally distributed variables were compared with the
paired t test and with nonparametric variables by the Wilcoxon
test. A P value of <0.05 was considered significant.

TABLE I.
Demographic and Clinical Data.
Feature N

Mean age (range) 37.4 (21–66)

Gender (%)
Males 1,586 (42.9)
Females 2,115 (57.1)
Indication for surgery (%)
Recurrent tonsillitis 3,514 (94.9)
Obstructive sleep apnea 187 (5.1)
Fig. 1. Total tonsillitis episodes.

Laryngoscope 00: 2019 Tzelnick et al.: Long-Term Outcomes of Tonsillectomy in Adults

2

Fig. 2. Average antibiotics prescriptions per patient.
change in the number of hospitalizations (other than to the
ear, nose, and throat [ENT] department), and there was a
decrease in the total number of hospitalization days follow-
ing tonsillectomy.
Finally, we performed a break-even time analysis.
The average annual cost of recurrent tonsillitis per patient
was $876 before tonsillectomy. Following surgery, this cost
declined to $137, which translates to an average annual
saving of $739 per patient. The average cost of tonsillec-
tomy was $2,000 per patient, which resulted in a break-
even time of 2.7 years.
DISCUSSION
The effectiveness of tonsillectomy in the adult popula-
tion has been previously questioned. To the best of our
knowledge, this is the largest study conducted on tonsillec-
tomy outcomes in adults. We found that patients with
Fig. 3. Total hospitalizations to the ENT department.ENT = ear,
nose, and throat.
Laryngoscope 00: 2019
recurrent tonsillitis who underwent tonsillectomy had a
75% decrease in the total number of tonsillitis episodes
and a 57% decrease in the consumption of pertinent antibi-
otics due to tonsillitis events. Moreover, it seems that the
severity of the events, which is reflected by the number of
ENT hospitalizations and days of hospitalization both to
the ENT and non-ENT departments, has also decreased.
Several studies have tried to investigate the out-
comes of tonsillectomy in the adult population from differ-
ent perspectives. Two randomized studies by Alho et al.6
and Koskenkorva et al.7 compared tonsillectomy with
observation for recurrent tonsillitis. Although considered
to be low-quality studies in the Cochrane’s 2014 review due
to the short duration of follow-up (6 months), both studies
have shown a decline in number of episodes and days of sore
throat. There was no data regarding antibiotic purchase
in those studies. Other studies examined the effectiveness of
tonsillectomy for recurrent tonsillitis based on patient-
completed questionnaires.12–22 These studies have shown
that tonsillectomy is an effective treatment that improves
QOL and reduces the number of sore throat events, as well
as the consumption of healthcare services costs, need for
antibiotics and analgesics, and number of days of absence
from work. Although tonsillectomy did not completely pre-
vent sore throat, the majority of patients expressed satisfac-
tion with its outcomes.19,22,23 Moreover, there is uncertainty
about the natural course of tonsillitis. A study that compared
preventive antibiotic regimen with placebo in patients with
recurrent tonsillitis showed that about half of the patients
who were treated with placebo alone had no further events
at a 1-year follow-up.24 Our study did not include patient-
reported outcomes but rather tried to use objective parame-
ters such as primary care and ENT diagnoses of tonsillitis.
Furthermore, we tried to address overall morbidity
expressed as primary care visits, number of hospitaliza-
tions, and respiratory infection diagnoses. It seems that,
despite a 30% increase in the number of primary care
office visits, there was a 50% decrease in respiratory in-
fectious diagnoses following tonsillectomy. That said, it
should be noted that objective laboratory data such as
immunological parameters were not retrieved.
In a recent publication by Byars et al.25 regarding the
long-term disease risks associated with adenoidectomy, ton-
sillectomy, and adenotonsillectomy in children, a population-
based cohort study of almost 1.2 million children in Denmark
was conducted. In their study, over 50 thousand children
underwent surgical removal of adenoids and tonsils and
were followed for 20 years postsurgery. They reported a two-
to threefold increase in diseases of the upper respiratory
tract and a higher risk for infectious and allergic diseases,
but on a smaller scale. Earlier studies have shown that ton-
sils and adenoids, as a part of the lymphatic system, play a
key role both in the normal development of the immune sys-
tem and in pathogen screening during childhood and early
life.26 However, their influence on adults remains unclear.
A meta-analysis by Lunny et al.27 examined the connection
between surgery and multiple sclerosis. They found that
removal of the palatine tonsils in children was associated
with increased risk of developing multiple sclerosis in adult-
hood. Interestingly, surgical intervention in the adult popu-
lation did not show the same correlation. Similarly, a study
Tzelnick et al.: Long-Term Outcomes of Tonsillectomy in Adults
3
by Janszky et al.28 has shown an increased risk for acute
myocardial infarction in patients who underwent tonsillec-
tomy during their childhood, with no similar association in
adults who underwent the same surgical procedure. Further-
more, Weigel et al.29 managed to isolate functioning T-cells
from the palatine tonsils of three adults, although the clini-
cal implications and the influence on the immune system are
still not clear.
Earlier studies have addressed the cost-effectiveness
of tonsillitis and tonsillectomy. A cost-of-illness study,
which was based on the National Ambulatory Care Survey
data, estimated the annual expenditures of pharyngitis in
adults.5 In that study, an annual total cost of $1.2 billion
for pharyngitis management was reported. Other studies
compared preoperative to operative financial costs. In a
study by Bhattacharyya et al.,30 a break-even time analysis
was performed in order to evaluate the economic impact
and influence of tonsillectomy in adults. They reported a
short break-even time of 2.3 years for the recovery of ton-
sillectomy cost compared to the economic burden of physi-
cian visits, antibiotic consumption, and absence from work.
Similarly, a study by Fujihara et al.31 reported a break-
even time of 2.5 years for adult patients who underwent
tonsillectomy in Japan. We conducted a break-even time
analysis as well and found a similar recovery time for ton-
sillectomy cost of 2.7 years. This data suggests there might
be an economic benefit for tonsillectomy.
Interestingly, although we have shown a significant
decline in tonsillitis events following surgery, a tonsillitis
diagnosis was still noted for patients who underwent ton-
sillectomy. In a procedure with a high complication rate
of up to 20% and a 25% risk of additional episodes after
surgery, surgeons should discuss the advantages and dis-
advantages with their patients, as well as set up the
expectations regarding the outcomes of tonsillectomy.
The present study has several limitations. First, this
is a retrospective observational study. Although tonsillitis
diagnosis was taken from patients’ medical charts, we have
no laboratory documentation for the presence of group-A
streptococcus infection. Moreover, as mentioned above, we
did not include immunological or inflammatory data on the
post-tonsillectomy immune status of the patients.
CONCLUSION
It appears that tonsillectomy is effective in decreas-
ing the number and severity of tonsillitis episodes and
might also have an economic benefit. The impact of tonsil-
lectomy on general health does not appear to result in
increased overall morbidity.
BIBLIOGRAPHY
1. Schappert SM, Burt CW. Ambulatory care visits to physician offices, hospi-
tal outpatient departments, and emergency rooms: United States,
2001–2002. National Center for Health Statistics. Vital Health Stat 2006;
13:1–66.
Laryngoscope 00: 2019
4
2. Linder JA, Chan J, Bates DW. Evaluation and treatment of pharyngitis in
primary care practice. Arch Intern Med 2006;166:1374–1379.
3. Ladd E. The use of antibiotics for viral upper respiratory tract infections: an
analysis of nurse practitioner and physician prescribing practices in
ambulatory care, 1997–2001. J Am Acad Nurse Pract 2005;17:416–424.
4. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by
community care physicians. A national survey, 1989–1999. JAMA 2001;
286:1181–1186.
5. Salkind AR, Wright JM. Economic burden of adult pharyngitis: the payer’s
perspective. Value Health 2008;11:621–627.
6. Alho OP, Koivunen P, Penna T, Teppo H, Koskela M, Luotonen J. Tonsillec-
tomy versus watchful waiting in recurrent streptococcal pharyngitis in
adults: randomised controlled trial. BMJ 2007;334:939.
7. Koskenkorva T, Koivunen P, Koskela M, Niemela O, Kristo A, Alho OP.
Short-term outcomes of tonsillectomy in adult patients with recurrent
pharyngitis: a randomized controlled trial. CMAJ 2013;185:E331–E336.
8. Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or
adenotonsillectomy versus non-surgical treatment for chronic/recurrent
acute tonsillitis. Cochrane Database Syst Rev 2014;11:CD001802.
9. Andreou N, Hadjisymeou S, Panesar J. Does tonsillectomy improve quality
of life in adults? A systematic literature review. J Laryngol Otol 2013;127:
332–338.
10. Seshamani M, Vogtmann E, Gatwood J, Gibson TB, Scanlon D. Prevalence
of complications from adult tonsillectomy and impact on health care
expenditures. Otolaryngol Head Neck Surg 2014;150:574–581.
11. Kaygusuz I, Alpay HC, Godekmerdan A, et al. Evaluation of long-term
impacts of tonsillectomy on immune functions of children: a follow-up
study. Int J Pediatr Otorhinolaryngol. 2009;73:445–449.
12. Senska G, Ellermann S, Ernst S, Lax H, Dost P. Recurrent tonsillitis in
adults: quality of life after tonsillectomy. Dtsch Arztebl Int 2010;107:
622–628.
13. Koskenkorva T, Koivunen P, Penna T, et al. Factors affecting quality-of-life
impact of adult tonsillectomy. J Laryngol Otol 2009;123:1010–1014.
14. Richards AL, Bailey M, Hooper R, Thomson P. Quality-of-life effect of tonsil-
lectomy in a young adult group. ANZ J Surg 2007;77:988–990.
15. Fox R, Temple M, Owens D, Short A, Tomkinson A. Does tonsillectomy lead
to improved outcomes over and above the effect of time? A longitudinal
study. J Laryngol Otol 2008;122:1197–1200.
16. Witsell DL, Orvidas LJ, Stewart MG, et al. Quality of life after tonsillec-
tomy in adults with recurrent or chronic tonsillitis. Otolaryngol Head
Neck Surg 2008;138(suppl):S1–S8.
17. Akgun D, Seymour FK, Qayyum A, Crystal R, Frosh A. Assessment of clini-
cal improvement and quality of life before and after tonsillectomy.
J Laryngol Otol 2009;123:199–202.
18. Schwentner I, Hofer S, Schmutzhard J, Deibl M, Sprinzl GM. Impact of ton-
sillectomy on quality of life in adults with chronic tonsillitis. Swiss Med
Wkly 2007;137:454–461.
19. Hsu AP, Tan KL, Tan YB, Han HJ, Lu PK. Benefits and efficacy of tonsillec-
tomy for recurrent tonsillitis in adults. Acta Otolaryngol 2007;127:62–64.
20. Baumann I, Kucheida H, Blumenstock G, Zalaman IM, Maassen MM,
Plinkert PK. Benefit from tonsillectomy in adult patients with chronic
tonsillitis. Eur Arch Otorhinolaryngol 2006;263:556–559.
21. Bhattacharyya N, Kepnes LJ, Shapiro J. Efficacy and quality-of-life impact
of adult tonsillectomy. Arch Otolaryngol Head Neck Surg 2001;127:
1347–1350.
22. Faulconbridge RV, Fowler S, Horrocks J, Topham JH. Comparative audit of
tonsillectomy. Clin Otolaryngol Allied Sci 2000;25:110–117.
23. Blair RL, McKerrow WS, Carter NW, Fenton A. The Scottish tonsillectomy
audlt. The Audit Sub-Committee of the Scottish Otolaryngological Society.
J Laryngol Otol Suppl 1996;20:1–25.
24. Lildholdt T, Doessing H, Lyster M, Outzen KE. The natural history of recur-
rent acute tonsillitis and a clinical trial of azithromycin for antibiotic pro-
phylaxis. Clin Otolaryngol Allied Sci 2003;28:371–373.
25. Byars SG, Stearns SC, Boomsma JJ. Association of long-term risk of respi-
ratory, allergic, and infectious diseases with removal of adenoids and ton-
sils in childhood. JAMA Otolaryngol Head Neck Surg. 2018;144:594–603.
26. Ramos SD, Mukerji S, Pine HS. Tonsillectomy and adenoidectomy. Pediatr
Clin North Am 2013;60:793–807.
27. Lunny C, Knopp-Sihota JA, Fraser SN. Surgery and risk for multiple sclero-
sis: a systematic review and meta-analysis of case-control studies. BMC
Neurol 2013;13:41.
28. Janszky I, Mukamal KJ, Dalman C, Hammar N, Ahnve S. Childhood
appendectomy, tonsillectomy, and risk for premature acute myocardial
infarction—a nationwide population-based cohort study. Eur Heart J
2011;32:2290–2296.
29. Weigel C, Geissler K, Markwart R, et al. Isolation of viable and functional
T-cells from human palatine tonsils. J Immunol Methods 2015;427:66–72.
30. Bhattacharyya N, Kepnes LJ. Economic benefit of tonsillectomy in adults
with chronic tonsillitis. Ann Otol Rhinol Laryngol 2002;111:983–988.
31. Fujihara K, Koltai PJ, Hayashi M, Tamura S, Yamanaka N. Cost-
effectiveness of tonsillectomy for recurrent acute tonsillitis. Ann Otol
Rhinol Laryngol 2006;115:365–369.
Tzelnick et al.: Long-Term Outcomes of Tonsillectomy in Adults