A doctor responds to Seth Roberts' guest post about tonsillectomy

We recently ran a guest post by Seth Roberts, detailing the case against tonsillectomies as a regularly prescribed treatment for sore throats. I was able to read Roberts' post before it went up here, and comment on it. And Roberts made several changes to the post, which I had suggested, before it ran.

In general, I'm a big fan of basing medical treatment on evidence, rather than conjecture, tradition, or mythology. And, while I have a big problem with woo-woo (shorthand for attempts at medical treatment that are based primarily on conjecture, tradition, and mythology), I do think it's important to point out that woo-woo doesn't always come from hippies. Local doctors don't always follow the evidence, either. In fact, that's one big reason why "evidence-based medicine" has to be called that, rather than just medicine. So while I didn't agree with everything Roberts had to say, I thought his key point—tonsillectomy as a treatment for sore throats isn't actually strongly supported by evidence—was a valuable one.

That said, I R NOT A MEDICAL EXPERT. And neither is Roberts. Steven Novella, however, is a medical doctor and a clinical researcher. He has a very good blog post up that points out some important flaws in Roberts post. Here's the gist of what he has to say: Roberts seems to have misunderstood some of the studies he linked to, and assigned too much importance to others. "Evidence" can mean a range of different things. Some evidence is better than others. Just because a study was published doesn't mean it's evidence worth paying attention to. And it is very easy for people to get confused by this distinction when they start trying to treat themselves with the help of Google.

For instance, Roberts provided a laundry list of potential complications of tonsillectomy and asked why the evidence-based Cochrane Review didn't talk about any of them. The problem:

He seems to take the approach of listing any possible hypothesized risk as if it is established.

The links he uses to defend each risk he cites does not support the claims he is making. Once again he is lead to the conclusion that doctors are ignoring the risks and morbidity from tonsillectomy, while those alleged risks have not been established.

For example, he lists Hodgkins disease with links to evidence for an association with tonsillectomy. He does link to one article from 1972 and disputes the association, but did not link to a 1987 review that found no association between Hodgkins disease and tonsillectomy. As far as I can see this was the last word on the issue. Roberts still gets to list Hodgkins disease as a scary increased risk from tonsillectomy without fairly representing the state of the evidence.

He also lists variant Creutzfeld-Jacob disease, and links to two articles which do not establish a higher risk of developing the disease from tonsillectomy. Rather, the issue is about whether prion disease has an affinity for the tonsils, and whether tonsillar biopsy can be used for diagnosis. The correlation is about the natural history of prion disease, not a cause and effect from having a tonsillectomy. A deeper reading into the literature is needed in order to see this. Roberts, however, simply searched for tonsillectomy and complications and listed everything he found. In none of the cases is a cause and effect established. He wonders why doctors do not list all of the complications he found – that’s why.

You can read Steven Novella's full post at Science-Based Medicine

You can read Seth Roberts' response in the comments of Novella's post. Or read more at his blog

Image: T & A Journey, a Creative Commons Attribution Share-Alike (2.0) image from cjsorg's photostream


  1. This doctor is obviously a shill for Big Tonsillectomy.

    Some believe that removed tonsils are sold to the Blue Reptoids, who implant them in their young to give them eternal youth.


  2. “Apparently Gorski thinks animals (e.g., rats) and humans share no DNA.”

    That doesn’t follow. Humans share some DNA with basically everything that _has_ DNA. Asserting that trials in mice don’t always apply to humans is not the same as asserting that “mice and humans don’t share DNA.”

    1. Seth’s rebuttal (and in the comments) seemed to be the typical denial because it’s not what I believe and it’s coming from the ‘entrenched medical establishment’ stuff.

      This is pretty much why the only science info on Boing Boing I pay attention to is the stuff that Maggie writes herself.   When she’s wrong she’s not afraid to update with a correction.

      1. His argument seemed so weird that I spent 10 minutes trying to find a logical fallacy, until I realized there isn’t one.

        He’s saying “If studies showing an effect in mice don’t imply an effect in humans, then humans and mice don’t share DNA; the consequence is false, so the premise is false.” which is logically sound but complete nonsense.

        edit: on second thought it’s a classic campaign argument: my opponent said A. To say A, he must believe nonsensical thing B, so everything he’s saying is nonsense!

    2. I posted this over on the response site, but it’s been stuck in moderation so I may as well try here.

      I’m not sure why Seth thinks Gorski’s quote is conclusive evidence that he doesn’t think humans and mice/rats share any DNA. Gorski simply brought up the point that drugs/compounds/botanicals that produce a biologic effect in mice might not produce the same (or indeed any) biologic effect in humans. Mice and humans have many homologous genes, but rodents have massively different CYP450s than humans (these enzymes often help metabolize drugs). So it’s not at all unreasonable to ask for proof of efficacy in, you know, actual humans.

      Regarding the “contradiction,” it’s certainly possible for someone to point out that while evidence of drug efficacy in rodents is promising (hence why they are used for screening), it doesn’t mean that the drug is guaranteed to work in humans (even though we share TEH DNAZ).

      And yeah, if Seth couldn’t do a proper literature search/didn’t have an idea about how drugs are tested, he should probably refrain from bringing the snark when corrected by someone who actually knows something about the subject.

      1. I meant, Gorski saying “You can’t assert that there’s an effect in humans based on a couple of studies in mice.” doesn’t imply that Gorski believes that humans and mice don’t share DNA. This seems to be what Roberts is saying, which makes no sense.

        I’m pretty sure I’m agreeing with you, actually.

  3. I’m afraid that Seth makes a bit of fool of himself, on his blog, when he writes in response to criticism   “apparently Gorski thinks animals (e.g. rats) and humans share no DNA.”    This is either deliberately disingenuous or shows an incredible ignorance.  Gorski’s point is clearly that animal tests do not necessarily demonstrate efficacy on humans.   This is such a basic point, that I am stunned that Seth takes issue with it with his silly statement about sharing DNA.  Rats and humans are very different even though they share much DNA. Just two simple illustrations: rats don’t have gall bladders, humans do;  Humans can a feel satiated and full from eating, rats lack the gene for this and  would  literally eat themselves to death. 

    1. I had the same thought. It seems to me that Seth has had his ego hurt, and is now in damage control mode.

    2. rats lack the gene for this and  would  literally eat themselves to death.

      Really? Having caught relatively svelte rats in my parents’ grain store, this seems unlikely. Any more details?

    3. Last year I put a lot of compost in the ground and my carrots grew much bigger than they had before. Since humans and carrots share about 50% of their DNA, this implies that there is at least a 50% chance that putting a human in compost will cause them to grow bigger.

  4. I squee’d when I saw Novella’s name here on BoingBoing.  *swoon*

    Okay, what were we talking about, again?  Oh, right.  Tonsils.  Not sexy doctors.

  5. I’m not a fan of unnecessary surgery. In some cases, I think the potential risks of removing tonsils could be FAR outweighed by the benefits. It did for me. As a small child, I was sick so often that I was nearly held back in school. I spent more time sick than I did well. Until I had my tonsils removed. Don’t get me wrong, I still get sick, but not as severely or frequently as I did.

    By contrast, my kids are fairly healthy and have their tonsils. I have no plans to have them removed, and would not even consider it, unless and until it appears to impact their health as much as it did mine.

    Each case is individual and should be handled as such. A child who simply gets sick 6-7 times a year is not the same as one who coughs up tonsil stones 3-4 times a WEEK and has tonsillitis 15+ times a year for 3 years (as was my case).

    1. I probably should have had mine out. I was sick for years with recurrent infections in my throat throughout my youth. My tonsils are HUGE and to this day I clean them every day when I clean my teeth because if I don’t those things will just grow in there. I suspect that I have a mild immune disorder though.  Hashimoto’s thyroiditis would be likely since my mother, aunt, and cousin all have it.  I guess what I’m saying is, yes, case to case it varies and it’s really stupid to dig your feet in on something like that because you’re trying to be ideologically skeptical instead of just looking for the best response to the issue at hand.

      1. I was sick from yearly bouts of step throat as a child, but never had my tonsils out when I was young.  I wish I had.  After a series of bad throat and tonsil infections I did finally have to have them removed last year at the age of 37.  Unfortunately, undergoing tonsillectomy as an adult is SO MUCH WORSE than doing it as a kid.  Significantly more pain and much, much longer recovery period: the little slimy bastards apparently grow deeper into the tissue of the throat as you age requiring very extensive (*shudder*) cauterization to remove.  For that reason alone, I’d be tempted to get it out of the way during childhood if my kids showed a predisposition toward frequent strep.  

        1. You have just perfectly described the reason why I have opted not to have them removed as an adult. In my case though I had strep several times a year well into my university days leading to an occasional hospital stay, etc. A combination of distrust for doctors and financial priorities I guess convinced my mother I was better off with them in (she never had hers removed). I do actually wonder if I wouldn’t be healthier if they’d just been removed. I’d definitely take that into consideration if I had a child. 

  6. Seth seems to miss key points of evidence and tie others together that are unrelated.  His wrapping of laboratory testing, DNA comparisons  and efficacy trials on animals all together without being able to differentiate between them is telling.

  7. Glad you posted Novella’s fisking of Roberts’ ill-informed post. Roberts’ sputtering reply on hs blog should serve as a lesson about the folly of not backing down in the face of greater evidence and knowledge. We’ve all been guilty of opining on things we didn’t understand as well as we should have (and anyone who says they haven’t is deluded). Being able to concede gracefully is an admirable and all too rare trait.

    Boing Boing might want to think twice before running a post on a medical topic by someone who doesn’t know what he or she is talking about without first seeking out the insight of someone who does. It’s one thing to bloviate about politics and whatnot, but extra caution is warranted around medical topics, for reasons too obvious to enumerate.

  8. BB lost a lot of credibility in my eyes by letting the original guest post through.  This post makes up for it a little, but the damage has already been done.  How many people that read the original post, re-posted, or spread it via other means, etc will read this update and pass it on?  Who’s next for a guest blog post?  Jenny McCarthy?

  9. It’s good to see you linked to Novella’s fisking of Roberts’ ill-informed post. Roberts’ sputtering response on his blog serves as a lesson about the importance of backing down in the face of better information and knowledge. Everyone has been guilty at one time or another of opining on a subject he or she didn’t understand as well as he or she should have (and anyone who says they haven’t been is pulling your leg or deluded) though judging from the rest of Roberts’ blog, he makes something of a full time job of it.

    It’s unfortunate Boing Boing ran the Roberts post in the first place. It’s one thing to bloviate about politics and whatnot, but when it comes to medical topics, a little more due diligence is, well, due, for reasons too obvious to enumerate.

  10. Thank you. I usually love my Boing Boing, but the original article had me questioning this blog’s place in my daily routine. This update satiates my skeptical hunger.

  11. Traditional Chinese medicine or BUST.
         Except when I get hit by an anvil, or cut a limb off or some other emergency, in which case… Western Evidence-Based medicine or BUST. ;)

  12. Where did you get the term ‘Woo-woo’?

    I’ve heard Brian Cox use it (Wikitionary and skepdic.com list it too), but the rest of the internet says its Sex on the Beach without orange*.

    I love the term, but where did it originate?

    * sounds like the best way to have it to me.

    1. I speculate that it is onomatopoeic with theramin sounds, related to the musical taste of a particular flavor of counterculture, or to suggest science fiction themes of the ’60’s. I have no evidence.

      RationalWiki suggests:
      “This is in turn believed to have come from the use of “woooooo!” as a reaction to dimmed lights or magic tricks.”

      1. I had always assumed it dated back early than that, maybe because quaintly old fashioned. Or maybe just because it’s so often used in discussion of the spiritualism and occult movements.

        Anyway I do know it was largely popularized by James Randy and people associated with him in general.

    2. In the amateur physics community, it tends to get shortened to ‘woo’, generally in reference to the free energy / cold fusion / Tesla conspired with aliens / $GENERIC_CONSPIRACY crap that gets brought up by those with less scientific rigor.

      I’ve also heard Adam Savage use it on Mythbusters.

  13. I had my tonsils removed as a child and they grew back. The doctor that operated on me seemed shocked that they grew back, but maybe he was just pretending (what do I know, I was 4). I’ve heard since then that it’s not that uncommon for tonsils to regenerate.

  14. It sickens me that the same fallacious logic used to tout autism’s link to vaccinations is being applied in more medical arena’s.

  15. While I didn’t have recurrent infections as a kid, I’ve had some pretty bad ones recently, and my tonsils are also enormous. I sort of wish I could have them out, but on the other hand, maybe they are doing more good than bad. Just wanted to mention because you might not have an immune disorder. I had to start gargling alcohol-free mouthwash at least once a day to keep the suckers in line.

    1. I have this and am considering getting my tonsils removed because it is so irritating (and gross)

  16. In the 50’s & 60’s tonsillectomies were the treatment of choice for sore throats of any sort.  Far fewer are now conducted because the procedure is simply not indicated 
     in many cases, as the original post noted. And all surgeries have risk. The fact that unnecessary surgeries are frequently conducted on less-than-informed patients should be well established by now.  Just consider the # of hysterectomies, cholesystectomies (gall bladder removal), and prostatectomies each year against the indications and current research and it’s an impossible trend to miss. We’ve enthusiastically turned medicine into competitive business, and this is the natural and logical result.  Prostatectomies, for example, are the single biggest income “pop” for Urologists. A real gold-mine. The article doesn’t even look at each medical specialty, and all have their “popular” and widely “promoted” surgical solutions. It also doesn’t factor-in the competition between specialties for the profits produced by surgical procedures. For example, interventional radiologists are now doing a lot of procedures that used to be conducted by other specialties.  It’s a market-made mess of the first caliber. Let the patient beware.

  17. Let’s assume it’s true that animal results tell us nothing about what will happen with humans. Can you think of another plausible explanation for this pattern of results besides zero DNA overlap?

    UH… I can think of several. o_O

  18. “In general, I’m a big fan of basing medical treatment on evidence, rather than conjecture, tradition, or mythology.”

    Then I do not understand why you still propose bicycle helmets as a must have device. Evidence is that they increase the risk of serious injury and death (and this is already known since Rodgers published his paper in 1988 (see http://cyclehelmets.org/1146.html )

  19. “detailing the case against tonsillectomies as a regularly prescribed treatment for sore throats”
    I’m a bit… distressed… about the intro to this article. I do understand that this is in reference to the original article, but, it makes it sound like this was actually a stated fact instead of a strawman. The original article, and this one for that matter, should have first established that the premise is actually true. I have no facts myself to back up either side, but I have _never_ _ever_ heard on any parenting board I frequent that their kids would have gotten their tonsils removed due to sore throats. Quite on the contrary, many parents have had to fight their doctors to get tonsils or adenoids removed, even when their children are snoring like crazy and having sleep apnea. Actually, the only reason nowadays for removing tonsils or adenoids seems to be _very_ heavy snoring and/or sleep apnea, or difficulty with eating (anecdotal data, again). So, I would say the pendulum has swung pretty heavily to the other direction.

    I had my adenoids removed in the 70’s (I was 9) for pretty light reasons. I was ill, they were swollen, so out with them. Seems like the author to the original article still lives in those days.

  20. My wife had throat infections each year until she eventually decided, based on doctor’s advice, on having her tonsils removed.  Now she has chest infections every year at the times she used to have throat infections.

  21. wow.  I just had an intense response to the image at the top of this post. I had my tonsils taken out (along with my adnoids, which are like tonsils in your sinuses I guess.)  almost 30 years ago, when I was about seven.  The who process was a long series of blood tests, doctor visits and an eventual three hour drive to the hospital.  Before the procedure I was given a brochure about what was going to happen to me.  Not having much to read I probably leafed through that thing about 200 times.  I’m shaking here looking at that thing.  crazy.

  22. I’m pleased to learn my skepticism  with regards to the first article was well founded.

    Seth Roberts now shares a place in my kill file with the rest of the woo mongers.

  23. My tonsils and adenoids were removed when I was 6, and as a teenager, my dentist took a photo of my throat because he was surprised to hear they had been removed as they had grown back big time.  His photos were often published in medical books, so he was not being a weirdo by taking photos.  I haven’t had problems with tonsillitis as an adult, and probably a lot of my throat/ear infections as a child were at least in part related to growing up in a house with two parents who were heavy cigarette smokers.

  24. Ok, this guy spot-checked his inflated claims about risk.  But has anybody actually found any reasons for this surgery to be recommended as often as it is?  My pediatrician actually said I should have mine out “so I could eat meat” — has the reasoning improved?  I’d like a doctor to answer THAT!

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