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Background material by Professor Omar Hasan Kasule Sr. for Year 1 Semester 1 PPSD session on 29th October 2008
Rosni Julaihi was uncomfortable with the advice given by Dr Harni that her daughter undergoes tonsillectomy. She looked up information on tonsillitis from Encyclopedia Brittanica and pubmed.
Tonsillitis (Encyclopedia Britannica 2004)
Tonsillitis is inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms, usually hemolytic streptococci or viruses. The symptoms are sore throat, difficulty in swallowing, fever, malaise, and enlarged lymph nodes on both sides of the neck. The infection lasts about five days. The treatment includes bed rest until the fever has subsided, isolation to protect others from the infection, and warm throat irrigations or gargles with a mild antiseptic solution. Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications.
The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. The infection may extend upward into the nose, sinuses, and ears or downward into the larynx, trachea, and bronchi. Locally, virulent bacteria may spread from the infected tonsil to the adjoining tissues, resulting in a peritonsillar abscess. More serious are two distant complications—acute nephritis (kidney inflammation) and acute rheumatic fever, with or without heart involvement. Repeated acute infections may cause chronic inflammation of the tonsils, evidenced by tonsillar enlargement, repeated or persistent sore throat, and swollen lymph nodes in the neck. The treatment in this case is surgical removal (tonsillectomy). Scarlet fever, diphtheria and trench mouth may also produce acute tonsillitis. In diphtheria the tonsils are covered with a thick, whitish, adherent membrane; in trench mouth, with a grayish membrane that wipes off readily.
Liaw KL, Adami J, Gridley G, Nyren O, Linet MS. Risk of Hodgkin's disease subsequent to tonsillectomy: a population-based cohort study in Sweden. Int J Cancer. 1997 Sep 4;72(5):711-3
Although some studies have linked excess of Hodgkin's disease (HD) to tonsillectomy, the findings have not been consistent. In particular, risk of HD by age at tonsillectomy has not been fully evaluated, despite the notable change in immunologic function of the tonsils between childhood and adulthood. To evaluate the risk of HD and other lymphomas, associated with tonsillectomy according to age at surgery, a population-based cohort study was conducted. Using nationwide Swedish hospitalization records, 55,169 patients undergoing tonsillectomy with/without adenoidectomy (T/A) were identified during the period 1964-1983. By linkage with the nationwide Total Population, Migration, Cancer and Causes-of-Death registries, these patients were followed up for as long as 25 years. After exclusion of the first post-operative year, a total of 533 first primary-cancer cases was identified between 1965 and 1989. Small excess risk was
observed for HD (20 cases, SIR = 1.4, 95% CI 0.9-2.2). HD risk was more pronounced among patients tonsillectomized before age 12 (7 observed vs. 1.7 expected, SIR = 4.1, 95% CI 1.6-8.4), but declined significantly with older ages at T/A. While our data suggest a small increase in HD among all patients undergoing T/A and a significant excess for those under age 12 at surgery, we cannot exclude the possibility that the excess may be due to factors underlying the disorders that led to surgery.
Bonelli L, Vitale V, Bistolfi F, Landucci M, Bruzzi P. Hodgkin's disease in adults: association with social factors and age at tonsillectomy. A case-control study. Int J Cancer. 1990 Mar 15;45(3):423-7.
The relationship between socio-economic characteristics, previous tonsillectomy, family history of cancer and risk of Hodgkin's disease (HD) was investigated in a case-control study. One hundred and sixty patients, aged 15-78, with histologically confirmed HD, and 185 hospital controls were interviewed. A statistically significant decrease in risk of HD was observed among subjects with large sibship size (RR = 0.63, C.I. 0.46-0.86) and among those who underwent tonsillectomy prior to the age of 10 (RR = 0.46, C.I. 0.22-0.94). High educational level was associated with an increased risk of HD (RR = 6.68, C.I. I.94-23.08). Analysis by age-group (15-39 yrs and 40 yrs or more) confirmed the role of high educational level as a risk factor in both young and old subjects, while the protective effect of tonsillectomy at an early age seems to be confined to young subjects. Analysis by histological subtype showed a statistically significant decrease in risk of HD in large sibship size for both nodular sclerosis (NS) and mixed-cell subtypes; the role of education and tonsillectomy was observed only for NS. These data confirm the role of social factors in HD risk and suggest a protective effect of tonsillectomy performed early in life that needs to be confirmed in larger population-based studies.
Mueller N, Swanson GM, Hsieh CC, Cole P. Tonsillectomy and Hodgkin's disease: results from companion population-based studies. J Natl Cancer Inst. 1987 Jan;78(1):1-5.
The question of whether persons with a history of tonsillectomy are at increased risk of Hodgkin's disease (HD) in adulthood was evaluated in companion population-based case-control studies conducted in the eastern Massachusetts and the Detroit metropolitan areas. These studies compared the history of tonsillectomy among incident cases with that of all their siblings by matched analysis controlling for confounding by childhood social class, family size, and birth order. Among young adults (15-39 yr) there is substantial evidence that tonsillectomy is not a risk factor and the relative risk (RR) is 1.0 (95% confidence interval, 0.72-1.4). Among middle-aged persons (40-54 yr) the RR is not significantly elevated, 1.5 (0.67-3.3), and the direction of the association differs between the sexes, consistent with the hypothesis of no association. Among older persons, the RR is significantly elevated, 3.0 (1.3-6.9), but the data are sparse. On the basis of these data, it appears unlikely that prior tonsillectomy is a causal factor in the development of HD in young and middle-aged adulthood. Whether it is a risk factor for the malignancy occurring late in life is unclear.
Discussion issues
- List ethical arguments for and against tonsillectomy using relevant ethical theories and principles;
- Explain how evidence-based medicine can help resolve ethical controversies in this case.