Dear Sirs
The above retrospective study is a welcome addition to the literature supporting the practice of tonsillectomy in appropriately selected individuals. It serves to highlight the impact of recurrent tonsillitis on the patient's quality of life, and suggests that tonsillectomy is a cost-effective treatment. The practice of cost containment within the National Health Service (NHS) has led many primary healthcare trusts to ration the funding for procedures such as tonsillectomy, their rationale being that there is a lack of high level evidence of effectiveness. Akgun and colleagues state that ‘level one and two evidence cannot easily be obtained [for tonsillectomy], given the ethical objections that would be generated when considering a suitable surgical control group in a randomised controlled trial’.Reference Akgun, Seymour, Qayyum, Crystal and Frosh1 Whilst this is debatable, the results of robust quality of life studies are important to otolaryngology as they provide some justification for our practice.
However, any questionnaire used to measure quality of life in a clinical setting must show validity, appropriateness and acceptability, reliability, sensitivity, and interpretability.Reference Higginson and Carr2 The tonsillectomy survey questionnaire used by Akgun et al. raises concern as to its validity, i.e. whether it measures what it claims to measure. We are surprised that the authors did not consider one of the available, well validated, generic questionnaires (e.g. the Child Health Questionnaire or the SF36). A previous, prospective, observational study validated the Child Health Questionnaire and compared children with adenotonsillar disease to healthy children and those with rheumatoid arthritis.Reference Georgalas, Tolley and Kanagalingam3 It would appear that the impact of adenotonsillar disease on the quality of life of both children and their families is quite significant.Reference Georgalas, Tolley and Kanagalingam3, Reference Georgalas, Barbara-Craig, Arora and Narula4
There are also some validated, disease-specific questionnaires for tonsillectomy, such as the Tonsil and Adenoid Health Status Instrument. If quality of life measures are to play a role in surgical decision-making for the future, it is imperative that we apply the same amount of diligence in their use as we would in more conventional randomised, controlled trials.
Authors' reply
Dear Sirs
Thank you for the opportunity to respond to the comments made by Miss Rennie and colleagues. We are delighted that they are in agreement with us regarding the importance of gathering evidence to demonstrate that tonsillectomy is a cost-effective treatment for recurrent tonsillitis, especially given the current economic climate in the NHS.
Our study, ‘Assessment of clinical improvement and quality of life before and after tonsillectomy’, was conducted as a retrospective survey. For this reason, we were not able to use a generic health questionnaire as suggested by Rennie et al., as we were enquiring about changes in symptomatology, in a cross-sectional manner, rather than comparing the quality of life scores at two separate time points and calculating the difference. Whilst the questionnaires suggested by Rennie et al. are valuable tools, attempting to retrospectively administer a pre-operative quality of life questionnaire would have given unreliable results. Existing validated questionnaires (specifically the SF36) were used to guide development of the questionnaire used in the study, but the retrospective nature of the study forced us to use a simple scoring system assessing only changes in symptoms.
This was a pilot study, and we intend to proceed to a more formal, prospective study of pre- and post-operative utility scores, using validated quality of life tools. We agree with Rennie and colleagues that such a prospective study would be a valuable piece of research in our quest to prove the efficacy of tonsillectomy, and we hope that this discussion will stimulate such efforts.
