Reply

To the Editor:

We thank Bharti et al for their interest in our article,1 and we completely share the sentiment of the provocative title of their Letter to the Editor. The impasse is not over yet!

Nevertheless, we have also some concerns about the criticisms made to our article, because, in our view, some of them require additional considerations. First, the failure rate of surgery is not 37%. In fact, even if complete resolution was obtained in 63% of children, it is noteworthy that a marked improvement of symptoms was also documented in the remainders. Second, the role of cimetidine has yet to be proved. To our knowledge, there are no randomized controlled trials supporting its benefits.2, 3, 4 It cannot be considered the gold standard of treatment, and for this reason we do not agree that cimetidine therapy should be used as a comparator. Third, adenotonsillectomy is a commonly performed intervention with a low rate of complication.5 Considering the dramatic impact of PFAPA syndrome on the quality of life of the children and their families, we do not believe that the topic of complications deserve the utmost consideration that Bharti et al give to this point. Fourth, Kaplan-Meier analysis is not crucial given the outcome chosen (complete resolution). We, however, performed that analysis, as well as nonparametric comparisons, and confirmed that all reported differences remain statistically significant. Finally, we agree with Bharti et al regarding all the additional clarifications required (superiority of combined adenotonsillectomy over tonsillectomy alone, appropriate age of surgical intervention, and incremental cost-effectiveness in terms of costs per episode averted). As stated above, the impasse is not over yet. However, the resolution of these points requires specific investigations and was beyond the scope of our contribution.