OTOLARYNGOLOGY

Ann R Coll Surg Engl 2021; 103: 208–217

doi 10.1308/rcsann.2020.7030

Tonsillitis, tonsillectomy, and deep neck space

infections in England: the case for a new guideline
for surgical and non-surgical management
M Pankhania1, J Rees1, A Thompson2, S Richards1

1
The Rotherham Foundation Trust, Moorgate Road, Rotherham
2
Sheffield Teaching Hospitals, Glossop Road, Sheffield

ABSTRACT
Introduction Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network
(SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical
complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has
increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy
haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits.
Materials and methods A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics
data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance.
Results Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar
abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck
space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical
commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1–2%) has remained relatively constant at 46,299 (1999)
compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period.
Discussion The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical
commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase
tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck
space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the
complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy
haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at
£71 million with tonsillitis and its complications accounting for a further £8 million.

KEYWORDS
Tonsillectomy – Deep neck space infection – Abscess – Tonsillitis – Epidemiology
Accepted 5 July 2020
CORRESPONDENCE TO
Miran Pankhania, E: pank@doctors.org.uk

Introduction These guidelines were based on findings by Paradise et al,

Tonsillectomy is a commonly performed surgical procedure
with almost 50,000 surgeries performed in England alone
in 2017. The majority of tonsillectomies (60%) are
performed in the paediatric population. The chief
complication is haemorrhage, estimated to occur in 1–2%
post-tonsillectomy, although there is variation between
individual surgeons and method of tonsillectomy
performed.1 The risk of haemorrhage is known to correlate
with the age at which tonsillectomy is performed and is
thought to reflect the cumulative effects of recurrent
tonsillitis, such as scarring of the tonsillar fossae and
bacterial colonisation.1,2
The Scottish Intercollegiate Guidance Network (SIGN) and
the NHS introduced guidelines in 1998–1999 (SIGN 34).3
and aimed to improve patient selection, citing concerns
that too many tonsillectomies were being performed and
the associated complications such as haemorrhage
warranting admission or return to theatre required tighter
regulation.4–7 These guidelines were superseded in 2005 by
SIGN 117. Tonsillectomies were subsequently more tightly
regulated when procedures of limited clinical value were
introduced in 2011, following a report by the McKinsey
group. This report suggested a reduction of 10–90% in the
number of tonsillectomies performed, to save a predicted
£5–45 million per annum.8,9 There is, however, an
acceptance in SIGN 117 section 7 that the eligibility criteria
for tonsillectomy were arrived at arbitrarily and make no
distinction between children and adults.8

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PANKHANIA REES THOMPSON RICHARDS
In 2018, a research group from the University of
Birmingham retrospectively assessed the evidence base
for children undergoing tonsillectomy. This study found
that the UK performs half as many tonsillectomies as
other nations in Europe, including Belgium and Norway.
Within the UK, there is a seven-fold regional variation
in the number of tonsillectomies performed, with 37,000
paediatric tonsillectomies performed in England in 2016–
17 at a cost of £42 million.10
Quality of life studies suggest that tonsillectomy, in
those suffering recurrent sore throats, improves quality
of life in comparison with general population controls or
sore throat patients who did not undergo surgery.5–7,11–13
The economic and educational implications of nonoperative
management affect the staffing of businesses, time lost
in education and parental caring duties, and are not
necessarily accounted for in the literature. Minor
illnesses, including upper respiratory tract infections
such as tonsillitis, account for 27% of all sickness-related
absence in the UK.1,14 Concerns that the current
approach is incorrectly set against tonsillectomy have
been voiced by the Royal College of Surgeons of England.15
The release of SIGN 34 criteria foreshadowed a
significant decrease in tonsillectomy rate in England and
Wales in subsequent years. There was a concomitant
increase in hospital admission for tonsillitis and associated
complications such as deep neck space infections.
Increases in admission for tonsillitis and deep neck space
infections were not reciprocated in countries in which the
Paradise criteria and SIGN guidelines were not adopted,
where the tonsillectomy rate rose in line with population.
The population of England increased by an estimated
seven million from 48.8 million to 55.8 million over the
analysed period, with a sustained increase above 100,000
per annum in natural change (births minus deaths) after
2004, peaking in 2011 (255,000). By comparison, net
migration remained in excess of 150,000 per annum after
2001 with peaks in 2005 (335,000) and 2016 (345,000).1,7,16
Materials and methods
Hospital Episode Statistics (HES) online downloadable
spreadsheets were interrogated for relevant data on
admissions and interventions between 1998 and 2017.
Using healthcare resources group (HRG), International
Statistical Classification of Diseases and Related Health
Problems 10th revision (ICD-10) and HES codes,
data pertinent to adult and paediatric tonsillectomy
(CA60A and CA60B HRG codes, F34 HES/ICD-10
code), adenotonsillectomy (CA60Z), surgical arrest of
haemorrhage secondary to [adeno-] tonsillectomy
(F36.5), tonsillitis (J03), parapharyngeal, retropharyngeal
(J39.0), peritonsillar (J36.x), other neck and mediastinal
abscesses (J39.1 and J85.3 respectively) were gleaned and
tabulated. Demographic data such as age, mean age and
sex were tabulated, in addition to the total number of
admissions per annum, consultant episode bed days, and
the nature of the admission or intervention (eg daycase
TONSILLITIS, TONSILLECTOMY, AND DEEP NECK SPACE INFECTIONS
IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT
surgery, elective inpatient surgery, or emergency
admission and surgery; HES references + HRG access
dates etc).
A literature search was performed using search
terms ‘tonsillitis’, ‘tonsillectomy’, ‘peritonsillar’, ‘quinsy’,
‘parapharyngeal’, ‘retropharyngeal’, ‘mediastinitis’,
‘mediastinal’, ‘abscess’, ‘tonsillectomy’ and, ‘haemorrhage.’
Relevant papers were accessed via PubMed and the
Cochrane Library database. The respective SIGN,
McKinsey report and RCS guidelines and publications were
accessed online via their respective organisational
websites.2–9
Tabulated data on tonsillitis, deep neck space infections
and tonsillectomy were analysed statistically and
graphically using Microsoft Excel with the relevant
guidelines and interventions graphically superimposed.
Financial modelling using 2018 NHS tariffs for inpatient
and intensive care stays was done using a calculation
derived from average inpatient stay data obtained locally
(Table 1). These data are tabulated to create a lower limit
for the cost per admission and do not factor in the cost
per drug administered or for sundry items such as
venous access cannulas, catheters or investigations.
Workforce costs are also not included.
Results
The HES data obtained during the analysed time period
are detailed. To establish the need for separate paediatric
and adult criteria, demographic data have also been used.
Age
Acute tonsillitis and deep neck space infections both
appear to demonstrate bimodal age distribution, with
peaks in the paediatric and adult populations (Figure 1).
While the majority of admissions for acute tonsillitis are
seen in the paediatric population (50,538), typically at
primary school age, the adult population accounted for
28,589 cases requiring admission in 2016–17, with an
estimated 49,169 inpatient bed days accrued across both
populations. By contrast, fewer infections presented in
the paediatric population (1,700) than in the adult
population (11,164) in 2016–17. The peak age of incidence
is 20–24 years for both adult tonsillitis and deep neck
space infection. In 2016–17, deep neck space infections
accounted for 17,331 bed days of inpatient stay, including
time spent on intensive care. Acute tonsillitis and deep
neck space infections combined accounted for over
66,000 inpatient bed days.1
Since the introduction of SIGN guidance and associated
restrictions on tonsillectomy in the UK, the number
of tonsillectomies performed has plateaued, while the
number of admissions for tonsillitis and deep neck space
infections has increased. This is consistent across the
devolved nations of Scotland and Wales, as well as
England.17,18
Since 1998, the number of admissions for tonsillitis has
increased from 24,143 to 79,227 in 2017 (Figure 2).1 The
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IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT

Table 1 2018 Tariff costs

Combined Ordinary
Outpatient daycase/ Daycase Ordinary elective
HRG procedure ordinary elective spell tariff elective spell long-stay trim Nonelective
code HRG name tariff (£) spell tariff (£) (£) tariff (£) point (days) spell tariff (£)
CA60A Tonsillectomy, 19 years – – 1,084 977 5 1,658
and over
CA60B Tonsillectomy, 18 years – – 1,094 988 5 1,947
and under
CA61Z Adenotonsillectomy – – 1,195 1,078 5 2,385
CA01Z Complex neck – 10,019 – – 37 19,567
procedures
CA02A Very major neck – 6,342 – – 13 6,342
procedures with CC
score 2+
CA02B Very major neck – 4,831 – – 7 4,831
procedures with CC
score 0-1
CA03A Major neck procedures – 3,829 – – 9 3,829
with CC score 2+
CA03B Major neck procedures – 2,894 – – 5 2,894
with CC score 0-1
CA04A Intermediate neck – 2,087 – – 5 2,140
procedures, 19 years
and over
CA04B Intermediate neck – 2,087 – – 5 2,140
procedures, 18 years
and under
Daily inpatient ward cost 195
Daily ICU cost 1328
Incremental cost of ICU 1133

HRG, healthcare resources group; ICU, intensive care unit

length of stay has reduced from a mean of 1.4 days to 1.0
days over the same time period. The mean age has
increased slightly from 13 years to 15 years, explained in
part by an increase in adolescent and adult patients
presenting with tonsillitis. The elderly (60+ years of age)
account for less than 1% of all tonsillitis admissions.
Deep neck space infections have increased dramatically
over the analysed period, with 6,289 documented cases in
1998 compared with 12,898 in 2017. These infections
affected children in 5% of cases, while 7% were in the
elderly population in 2017. When peritonsillar abscesses,
representing the least serious infections, are excluded
from these figures, there were only 205 deep neck space
infections in 1998 across England, compared with a
six-fold increase to 1,272 in 2017 (Figures 3, 4).
During the analysed period, the net population of
England has increased by an estimated seven million,
primarily as a result of net international migration. It is
difficult to ascribe causality for the increasing rate of
deep neck space infections to either natural change
(births minus deaths) or net migration, as certain
demographic variables, such as age of migration and
therefore age at presentation, cannot be ascertained
(Figure 5). There may also be a lag phase to presentation.
Patients immigrating to England in one year cannot be
said to develop tonsillitis or its complications by virtue of
migration alone. Similarly, children born in a calendar
year may not present until several years later, or indeed
until adulthood.
Discussion
The changing face of tonsillitis and DNSIs
The incidence of tonsillitis and deep neck space infection
has increased dramatically since 1998, with successive
guidelines and interventions. This is against a background
of a relatively constant number of tonsillectomies per

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PANKHANIA REES THOMPSON RICHARDS TONSILLITIS, TONSILLECTOMY, AND DEEP NECK SPACE INFECTIONS
IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT

Figure 1 (Left axis) number of admissions for tonsillitis; (right axis) number of admissions for deep neck space infections; (horizontal axis) age of
admission

Figure 2 Change in admissions for tonsillitis and associated inpatient bed occupancy displayed against number of tonsillectomies performed per
annum and associated incidence of post-tonsillectomy haemorrhage. Dates of implementation of SIGN 34 (1999), SIGN 117 (2004) and procedures
of limited clinical value (2011) superimposed

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PANKHANIA REES THOMPSON RICHARDS TONSILLITIS, TONSILLECTOMY, AND DEEP NECK SPACE INFECTIONS
IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT

Figure 3 Admissions for peritonsillar abscess 1998–2017. Dates of implementation of SIGN 34 (1999), SIGN 117 (2004) and procedures of
limited clinical value (2011) superimposed

Figure 4 Incidence of deep neck space infections 1998–2017. Dates of implementation of SIGN 34 (1999), SIGN 117 (2004) and procedures of
limited clinical value (2011) superimposed

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PANKHANIA REES THOMPSON RICHARDS
Figure 5 Logarithmic chart showing change in incidences over time alongside population and migration. Dates of implementation of SIGN 34
(1999), SIGN 117 (2004) and procedures of limited clinical value (PCLV; 2011) superimposed
annum, despite an increase in the population of England
and a move towards daycase surgery for those eligible
patients.
Adult tonsillitis has increased as a proportion of the total
number of admissions for tonsillitis over the analysed
period, suggesting that the current bimodal distribution of
tonsillitis could be accounted for by nonoperative
management at an earlier age. This could similarly
explain the increase in deep neck space infections as a
delayed effect of fewer tonsillectomies being performed.
The almost four-fold increase in admissions for
tonsillitis has brought with it a 69% increase in bed days
in the same period, while the number of admissions has
doubled for peritonsillar abscesses, increased five-fold for
deep neck space infections excluding mediastinitis and
ten-fold for mediastinitis itself. While bed days have
reduced for tonsillectomy, any gain in bed space has been
offset by admissions for infection.
Koshy et al performed a large study with up to six years
of follow-up, and demonstrated that there was a statistically
significant reduction in acute sore throats among those
children with low sore throat consultation rates who
underwent tonsillectomy compared with those who did
not, suggesting that tonsillectomy may be of benefit in the
paediatric population.19 This echoes the findings from the
Paradise studies performed in 1976 and 1984.4–7
TONSILLITIS, TONSILLECTOMY, AND DEEP NECK SPACE INFECTIONS
IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT
A national audit conducted in 2002 on the management
of peritonsillar abscesses by 101 ear, nose and throat
consultants in the UK concluded that 61% preferred
needle aspiration compared with 25% preferring formal
incision and drainage. Aspiration was, however,
accompanied by a higher risk of recurrence (23.26% vs
4.0%), so ‘hot tonsillectomy’ has been advocated by some
clinicians to prevent abscess progression, although the
procedure remains controversial. Collin and Beasley also
proposed an algorithm for recognition and management
of deep neck space infections to pre-empt the associated
morbidity and increasing need for surgical
intervention.20 This algorithm has been adapted for
up-to-date practice (Table 2). More recently, the
INTEGRATE team in the UK published the national
prospective cohort study of peritonsillar abscess
management and outcomes: the Multicentre Audit of
Quinsies study. This study looks at peritonsillar abscess
management across 42 centres over a two-month period.
Results suggest that rates of recurrence did not vary
significantly between needle aspiration and formal
incision and drainage.20,21
Progression from peritonsillar abscess to deep neck
space infection and/or mediastinitis can occur in 1.8% of
cases, while progression of deep neck space infection to
mediastinitis occurs in approximately 10%. The reported
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IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT

Table 2 Assessment and management of acute tonsillitis and deep neck space infections

Level of infection Signs and symptoms Investigations Management

Tonsillitis Pyrexia FBC IV antibiotics
Odynophagia CRP Dexamethasone
Purulent tonsil U&E Analgesia
Lymphadenopathy (Monospot/PB)
Peritonsillar abscess As above +: As above As above + incision and drainage
Trismus
Unilateral peritonsillar swelling
Contralateral deviation of uvula
Bulging of soft palate
Deep neck space As above +: As above +: As above + oropharyngeal ± cervical incision and
infection Cervical cellulitis Flexible endoscopy drainage (ICU)
Neck swelling/crepitus CT neck + contrast
As above +: As above +: Combined care with cardiothoracic surgeons
Dyspnoea CT Thorax + contrast ICU
Chest pain ECG Repeat imaging
Muffled heart sounds Echocardiogram
Pericardial rub

CRP, C-reactive protein; CT, computed tomography; ECG, electrocardiogram; FBC, full blood count; ICU, intensive care unit; IV, intravenous; PB, Paul
Bunnell glandular fever test; U&E, urea and electrolytes

rate of mortality from mediastinitis is variable but may be
in excess of 30%.20 By comparison, the INTEGRATE study
only demonstrated concurrent deep neck space infection
in 0.6% of patients with peritonsillar abscess in the
two-month audit period.21
An unwitting effect of restrictions to tonsillectomy may
manifest in the incidence of oropharyngeal squamous
cell carcinoma later in life. While outside the scope
of this study, the authors recognise the importance of
oropharyngeal squamous cell carcinoma in the context of
tonsillectomy and would recommend a dedicated study
to this end, particularly as longer-term data emerge on
human papillomavirus, P16 status and the various related
treatment modalities. It is important to consider the role
of quadrivalent human papillomavirus vaccination, as
well as the potential for P16-positive oropharyngeal
squamous cell carcinoma to manifest in lingual tonsillar
tissue despite tonsillectomy, which may affect the
incidence of oropharyngeal squamous cell carcinoma in
years to come.
The rationale for a new guideline
Individual studies suggest that tonsillectomy reduces the
frequency of sore throats in the long term, although
meta-analysis by Morad et al suggests that these effects
are not sustained beyond the first post-surgical year. The
same group demonstrated in a separate meta-analysis
that tonsillectomy improves obstructive sleep
apnoea-related symptoms.21,23 Peritonsillar abscess after
tonsillectomy is uncommon. A systematic review by
Farmer et al suggests that there are as few as 11 reported
cases of peritonsillar abscess post-tonsillectomy in the
literature. These cases typically had multiple previous
admissions with tonsillitis and peritonsillar abscesses.
Tonsillectomy appears to be a useful intervention with
regards to peritonsillar abscess, but there is no specific
reference to other deep neck space infections.24
By contrast, Wang et al looked at over 108,000
Taiwanese patients in a retrospective cohort study,
comparing the incidence of deep neck space infection in
patients who had undergone tonsillectomy (34 deep neck
space infections, n = 9,915) with a control group (174 deep
neck space infections, n = 99,150); suggesting the absolute
risk of deep neck space infection was 1.71 times higher in
patients post-tonsillectomy after correcting for
demographics.25
Patients in the tonsillectomy cohort were more likely to
have had prior recurrent tonsillitis, and this may have
predisposed to a higher risk of future deep neck space
infections. Adult patients younger than 40 years were
also deemed to be at higher risk of deep neck space
infection compared with paediatric patients, suggesting
that nonoperative management of recurrent tonsillitis in
childhood may presuppose to deep neck space infections
in adulthood.
Risk stratifying patients by clinical indication suggests
that paediatric obstructive sleep apnoea was not
associated with a significantly higher risk of deep neck
space infection (absolute hazard ratio 1.90; range 0.71–
5.10) but having five or more episodes of recurrent
tonsillitis was significantly associated with a higher risk
of deep neck space infection despite tonsillectomy
(absolute hazard ratio 1.89; range 1.02–3.49). The
absolute risk increase is equivalent to 0.035% per

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PANKHANIA REES THOMPSON RICHARDS
person-year. There was no mention of recurrent
peritonsillar abscess as a risk factor, distinct entity or
indication for tonsillectomy in this paper.
Wang et al’s large Taiwanese study demonstrates the
experience of a country that does not use the Paradise or
SIGN criteria.25 The increased risk of deep neck space
infection despite tonsillectomy, with five or more
episodes of tonsillitis, does however suggest that the
current arbitrarily defined SIGN criteria may be too
restrictive.
Kim et al performed a similar study in South Korea
comparing 5,299 people undergoing tonsillectomy with
21,196 controls.26 Those with surgery for suspected or
confirmed malignancy were excluded from analysis, as
were patients with previous deep neck space infections.
Patients were divided into adult and paediatric (less than
15 years of age) cohorts. The adjusted hazard ratio of
deep neck space infection after tonsillectomy was 1.87 in
adolescents and adults (95% confidence interval, CI, 1.43–
2.45, p < 0.001) compared with 1.12 in children (95% CI
0.86–1.47, p = 0.390). Patients were matched for
demographics, including the frequency of prior upper
respiratory infections (mean 5.56, standard deviation
5.31). The mean time to deep neck space infection in
patients post-tonsillectomy was 53.0 ± 30.0 months.
Patients were not subdivided by indication for surgery as
they were in the study by Wang et al, while ICD-10 was
used to identify patients with retropharyngeal and
parapharyngeal abscesses, there is no mention in the
study by Kim et al of peritonsillar abscess or mediastinitis.
Hurley et al analysed deep neck space infection over a
four-year period in western Scotland in one of the most
detailed analyses of deep neck space infection in the
UK.18 The most common origin of infection was tonsillar
(40.8%), with 18.9% of patients having consulted their
general practitioner for recurrent tonsillitis in the past,
although 5.4% had tonsillectomy performed in the past.
Dental infection was the second most common origin in
37.8% of patients.
Over 50% of patients with deep neck space infection
consumed tobacco or alcohol. Oral antibiotic prescription
prior to admission was seen in 70.8% of patients. The
mean length of stay for deep neck space infection was 11
days, with 27% requiring intensive care admission (mean
2 days, range 0–30 days). Admission to a high-dependency
unit was required by 28.4% of patients (mean 1 day, range
0–20 days), with 21.6% requiring both high-dependency
and intensive care admissions. Deep neck space infections
were most common in the parapharyngeal space (60.8%)
but as many as 12.6% had evidence of deep neck space
infection in multiple neck spaces. More than one surgical
procedure was required by 14.8% of patients. Hurley et al
estimated the mean cost of treating deep neck space
infection at £5,699.94 inclusive of investigations and
treatment (range £332.06 to £46,700.24).18 Extrapolation
to include the rest of Scotland estimated the total cost
over the analysed time period was £1,749,881.58,
accounting for 307 patients’ care. The cost of admission
for a single deep neck space infection can be estimated at
TONSILLITIS, TONSILLECTOMY, AND DEEP NECK SPACE INFECTIONS
IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT
£5,700 compared with the cost of elective tonsillectomy
(in Scotland) at £1,416 (£1,084 in England).18
Using the Scottish data from Hurley et al, it is possible to
estimate the total all-inclusive cost in England for 12,898
deep neck space infections in 2016–17, at £73.5 million.
When compared with the combined tariff-only cost of
tonsillectomy and management of postoperative
haemorrhage (£53.2 million), there is still a difference of
£20 million. For context, the tariff-only cost of admissions
for tonsillitis for 2016–17 was £15.5 million and for deep
neck space infections £19.7 million. Including antibiotics
and investigations, this rises to £30.8 million, and when
including peritonsillar abscesses, rises further to £40.1
million. Thus, the prevention of deep neck space infection
comes with a potential economic benefit to the taxpayer,
and in the form of fewer sick days to the patient.
Had the 12,898 patients with deep neck space infection
undergone childhood tonsillectomy, the cost for
comparison of performing tonsillectomy on this number
of patients is £13.9 million, representing a significant
long-term saving, assuming paediatric tonsillectomy to
be protective.
The all-inclusive cost of investigating and treating deep
neck space infection is far in excess of the predicted
tariff-only costs described in this paper of £19.7 million,
hence the additional costs of prolonged treatment impact
significantly and may have been overlooked by the
McKinsey consultation. Indeed, the predicted cost of
treating deep neck space infection exceeds the savings
from reducing the number of tonsillectomies performed
estimated by the McKinsey report. Table 3 estimates the
equivalent cost per patient in England using Scottish data.
Conclusions
This is the largest national analysis of deep neck space
infection in UK literature and makes a direct comparison
with tonsillectomy, haemorrhage and tonsillitis. There is
growing evidence of the financial implications of both
admissions for recurrent tonsillitis and deep neck space
infection on the health service. This has wider economic
repercussions for patients and businesses with regards to
lost time and earnings, specifically loss of time in
education for children, thus falling behind peers, as well
as the associated time off work for adults and parents.
Restricting tonsillectomy may result in increasing
admissions for tonsillitis and deep neck space infection
requiring antibiotic treatment, the mainstay of which
may be penicillin based but is guided by both local
resistance trends and patient hypersensitivity profiles.
Deep neck space infections are frequently polymicrobial
and may require a multitude of antibiotics for treatment,
which in an age of increasing antibiotic resistance could
run the risk of mortality from untreatable deep neck
space infection without sensible or proactive antibiotic
stewardship. Due consideration should also be given to
the role of microbial virulence as a factor in deep neck
space infection.18
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IN ENGLAND: THE CASE FOR A NEW GUIDELINE FOR SURGICAL AND
NON-SURGICAL MANAGEMENT

Table 3 Cost of treating deep neck space infections in Scotland and estimated costs in England

Mean cost per Frequency per Total cost for Estimated cost
Individual item patient (£) patient all patients for all patients
Item Cost (£) (Scotland) (Scotland) (Scotland) (£) (England)
ICU bed day 411 766.67 1.87 56,733.58 9,888,509.66
HDU bed day 212 214.46 1.01 15,870.04 2,766,105.08
Ward bed day 195 2,601.19 13.34 192,488.06 33,550,148.62
Theatre cost per hour 1000 1,306.97 1.31 96,715.78 16,857,299.06
FBC 2.60 22.31 8.58 1,650.94 287,754.38
Biochemistry 6.80 58.17 8.55 4,304.58 750,276.66
CRP 0.68 5.57 8.19 412.18 71,841.86
Group & save 7.20 5.94 0.83 439.56 76,614.12
Coagulation screen 4.12 12.25 2.97 906.5 158,000.5
Chest x-ray 25 38.18 1.53 2,825.32 492,445.64
CT unit cost 225 361.82 1.61 26,774.68 4,666,754.36
MRI unit cost 430 34.86 0.08 2,579.64 449,624.28
Flexible nasendoscopy 33 59.76 1.81 4,422.24 770,784.48
IV antibiotic dose Variable 183.86 13,605.64 2,371,426.28
Enoxaparin 7.23 9.28 1.28 686.72 119,693.44
Rivaroxaban 1.80 6.45 3.58 477.3 83,192.1
Tracheostomy tubes Variable 13.03 964.22 168,060.94
Total 5700.76 421,856.22 73,528,531.46

CRP, C-reactive protein; CT, computed tomography; FBC, full blood count; HDU, high dependency unit; ICU, intensive care unit; IV, intravenous; MRI,
magnetic resonance imaging

There are potentially financial savings to be made by
preventing deep neck space infection as the cost of
treating 12,898 patients in England is almost as expensive
as treating 60,000 patients with tonsillitis. Prior to the
availability of antibiotics, deep neck space infections of
tonsillar origin were more common than odontogenic.18
These benefits are only evident in the longer term and
require a significant change in practice.
There appears to be a difference between paediatric and
adult populations, with regards to indications for
tonsillectomy and the long-term postoperative sequelae.
Consideration could be given to review of the current
criteria for tonsillectomy, with a view to modification to
reflect this, while bearing in mind the approximately 2%
risk of haemorrhage following tonsillectomy.1
While data from Korea and Taiwan do not support adult
tonsillectomy as preventative of deep neck space infections
in those with recurrent tonsillitis, it suggests that paediatric
tonsillectomy for recurrent tonsillitis carries no increased
risk of deep neck space infection when patients are
followed up for up to 10 years post-tonsillectomy. Their
large data sets demonstrate an increased risk of deep
neck space infection in all patients with more than five
previous episodes of tonsillitis, however.24,25
Causation for the increased number of deep neck space
infections cannot be definitively attributed to the
restriction of tonsillectomy in the UK. More research in
this area could support or refute a change in
tonsillectomy criteria for infective episodes. It would be
inappropriate to amend the criteria for tonsillectomy for
obstructive sleep apnoea and sleep-disturbed breathing,
particularly in the paediatric population, based on the
findings of this study. In light of the increased relative
risk of deep neck space infection in adults and
adolescents in other studies, we would recommend a
long-term UK-based study to assess the risk of deep neck
space infection from operative and nonoperative
management of tonsillitis on the background of SIGN
criteria, with specific consideration given to the cohort of
patients with a history of peritonsillar abscesses and their
deep neck space infection risk. This could then guide any
evidence-based future changes to adult tonsillectomy
criteria using contemporary data. The evidence of a
peritonsillar abscess following tonsillectomy is low and,
based on the reviewed contemporary literature, the
authors recommend reducing the number of episodes of
tonsillitis per annum to five in a single year or three per
annum for two or more years before triggering a

216 Ann R Coll Surg Engl 2021; 103: 208–217

PANKHANIA REES THOMPSON RICHARDS
referral, rather than the current recommendations by
SIGN.23
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