The National Institute for Clinical Excellence is examining laser-assisted serial tonsillectomy and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about laser-assisted serial tonsillectomy.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the preliminary recommendation
• the identification of factual inaccuracies
• additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare draft guidance, which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales and Scotland.

For further details, see the Interim Guide to the Interventional Procedures Programme, which is available from the Institute's website (www.nice.org.uk/ip).

Closing date for comments: 23 March 2004

Target date for publication of guidance: June 2004

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of laser-assisted serial tonsillectomy does not appear adequate for this procedure to be used without special arrangements for consent and for audit or research.

Clinicians wishing to undertake laser-assisted serial tonsillectomy should take the following action.

• Inform the clinical governance leads in their Trusts.
• Ensure that patients understand the uncertainty about the procedure's safety and efficacy and provide them with clear written information. Use of the Institute's Information for the Public is recommended.
• Audit and review clinical outcomes of all patients having laser-assisted serial tonsillectomy. Publication of safety and efficacy outcomes will be useful in reducing the current uncertainty. The Institute may review the procedure upon publication of further evidence.

Laser-assisted serial tonsillectomy is used to treat recurrent or chronic tonsillar infection, chronic sore throat, airway obstruction or chronic halitosis.

Standard treatment is tonsillectomy using a scalpel or electrocautery to remove the tonsils, under general anaesthetic.

Laser-assisted serial tonsillectomy is an outpatient procedure performed under local anaesthetic. A carbon dioxide laser is swept several times over the tonsil. During each sweep, the patient exhales and smoke is mechanically extracted to prevent inhalation. The procedure takes about 20 minutes, but may be repeated over the course of several visits, especially in patients with deep tonsillar crypts or large tonsils.

Only one small case series study was identified, in which methods and outcomes were poorly reported. In this study, 60% (52/86) of patients required one session of the procedure, and 37% (32/86) of patients required two. Two percent (2/86) of patients refused a second session and chose to undergo conventional tonsillectomy, but the reasons for this were not specified. In total, 98% (84/86) of patients were reported to be relieved of their symptoms. For more details, refer to the sources of evidence (see Appendix).

One Specialist Advisor considered there to be a lack of evidence demonstrating the efficacy of the procedure.

The identified study reported no peri-operative or anaesthesia-related complications, no early or delayed bleeding, and 'minimal' post-operative pain. For more details, refer to the sources of evidence (see Appendix).

The Specialist Advisors considered the safety concerns to be no different to those associated with standard tonsillectomy (reactionary and secondary haemorrhage, wound infection) and diathermy (laser burns or injury to the eye, fire if flammable anaesthetics or sterilising fluids are used). One Specialist Advisor reported that pain may be greater after this procedure than with conventional tonsillectomy.

Data are very limited and patients studied were all adults.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

• Interventional procedure overview of laser assisted serial tonsillectomy, October 2002

Available from www.nice.org.uk/ip057overview