combined cost the British National Health Service 21 million pounds a year. The rise in adenotonsillectomies for sleep apnea in the USA has been greater than the decline in tonsillectomies for sore throat. Evidence-based indications In 2018, a study of the medical records of 1.6 million UK children found 15,760 had sufficient sore throats to justify tonsillectomy and 13.6% (2,144) underwent surgery. The same study found 18,281 children who had undergone tonsillectomy, and of these only 11.7% (2,144) had evidence-based indications (i.e. frequent enough sore throats to justify surgery). The majority of tonsillectomies were undertaken for indications which did not have an evidence-base: five to six sore throats in one year (12.4%), two to four sore throats in one year (44.6%), sleep disordered breathing (12.3%), or obstructive sleep apnoea (3.9%). In the UK therefore, most children who undergo tonsillectomy probably do not benefit and most children who might benefit do not undergo tonsillectomy. The study concluded that 32,500 (close to 90%) out of the 37,000 children who have their tonsils removed annually "are unlikely to benefit" and that surgery therefore may do more harm than good to those children. Tonsillectomy rates are lower in the UK than in most other western European countries. Table: Numbers of children (from 1.6 million children between 2005 and 2016 in the UK) identified with possible indications for tonsillectomy and the numbers who subsequently undergo tonsillectomy. Source: Šumilo et al. 2018 Financial incentives According to a study from 2009, surgery rates on average increase by 78% when surgeons are paid fee-for-service reimbursements instead of a fixed salary. Regarding tonsillectomy, a 1968 Canadian study pointed out that ENT specialists working on a fee-for-service programme were twice as likely to perform a tonsillectomy than those who were not. In 2009 then US President Obama remarked: History Tonsillectomies have been practiced for over 2,000 years, with varying popularity over the centuries. The earliest mention of the procedure is in "Hindu medicine" from about 1000 BCE. Roughly a millennium later, the Roman aristocrat Aulus Cornelius Celsus (25 BCE–50 CE) described a procedure whereby using the finger (or a blunt hook if necessary), the tonsil was separated from the neighboring tissue before being cut out. Galen (121–200 CE) was the first to advocate the use of the surgical instrument known as the snare, a practice that was to become common until Aetius (490 CE) recommended partial removal of the tonsil,