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Effectiveness of tonsillectomy depends on stringency of indications
  1. J L Paradise1
  1. 1Children’s Hospital of Pittsburgh, Pennsylvania, USA;

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The meta-analysis of adenotonsillectomy trial results reported by van Staaij and colleagues,1 from which they concluded that the operation confers “an additional, but small, reduction of sore throat episodes...compared to watchful waiting”, falls short on numerous counts and misleads the unwary reader.

Their analysis of the trials conducted between the 1920s and 1960s not only overlooks previously published critiques of those trials,2–4 but fails to incorporate the sense of those critiques’ most telling criticisms, namely: the exclusion from most of the trials, on ethical grounds, of children thought to be severely affected; the inclusion of children who were only mildly affected and in whom, therefore, the benefits of surgery could at best be modest; and the limited nature of follow up procedures and, accordingly, of ascertainment of the numbers and types of succeeding episodes of throat infection. Relatedly, their analysis of trials conducted since the 1960s5,6 (each of which I led) omits mention of key elements and, most importantly, misconstrues the trials’ results and consequently their clinical implications.

The main single shortcoming of the meta-analysis is its failure, by considering only pooled risk differences across studies, to relate the outcomes of individual randomised trials to the stringency of the indications used in determining trial eligibility. Although the authors note that “the …

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