Objective: To determine the incidence of carcinoma in patients with asymmetrical tonsillar enlargement. Study Design: A clinical retrospective case series based on medical records of our medical complex. Results: During a two-year period, 990 patients underwent tonsillectomy at Salmaniya Medical Complex (SMC). 59 (5.9%) of those patients had asymmetrical enlargement of their tonsils, three of whom had suspicious clinical findings at presentation. The latter were found to have tonsillar malignancy on histopathological testing. Malignancy was excluded in all other specimen. Conclusions: Since the incidence of malignancy in asymmetrical tonsils is negligible in the absence of other associated risk factors, watchful waiting may be appropriate prior to any surgical intervention. Diagnostic tonsillectomy is indicated in patients with asymmetrical tonsillar enlargement with associated suspicious clinical findings, including cervical lymphadenopathy and rapid tonsillar enlargement.
Tonsils are lymphoid tissue collections located at either side of the oropharynx. They are primarily made of B lymphocytes and are lined by stratified squamous epithelium. They lack afferent lymphatic channels. Their main function is to production antibodies, lymphokines and gamma interferon. There are several etiologies behind unilateral tonsillar enlargement, including tuberculosis, actinomycoses, syphilis and sarcoidosis [
Tonsillectomy is among the most commonly performed operations in otorhinolaryngology (ORL). The indications are classified into absolute and relative indications. Malignant tumors of the tonsil are one of the definitive indications for tonsillectomy. Suspected tonsillar malignancy cannot be confirmed except after biopsy is done, usually tonsillectomy.
Tonsillar malignancy has different presentations. It could present as ulcerated tonsillar mucosa as in squamous cell carcinoma of the tonsil. However, a normal tonsillar mucosa does not exclude tonsillar malignancy. For example, nonepidermoid malignancy of the tonsil can present with asymmetrical tonsillar enlargement with normal mucosa. The aim of this study is to determine the incidence of malignancy in patients with asymmetrical tonsillar enlargement.
Patients who underwent tonsillectomy in the period of January 2002 until December 2003 were included in the study. We conducted a clinical retrospective review of our institution’s experience with unilateral tonsillar enlargement in the mentioned period. All of the preoperative clinical findings were reviewed. The size of each tonsil was documented in patient’s medical records using a clinical assessment scale (CAS) of 0, +1, +2, +3, +4. This scale evaluates tonsillar hypertrophy relative to the midline (0 = absent, 1+ = small within the tonsillar fossa, 2+ extends beyond the tonsillar pillar, 3+ = enlarged tonsils but not touching the midline, 4+ = enlarged tonsils touching the midline). Asymmetric tonsils included all tonsils with different CAS between the right and left sides. The patient’s age, gender, tonsil size, associated symptoms, suspicious findings and pathology results were entered for all patients. Tonsil size was measured in histopathology laboratory postoperatively, the three-dimensional volume being calculated. Ethical clearance to review the medical records of our patients was approved by the Ministry of Health, Salmaniya Medical Complex, Bahrain. There were no missing data or data outliers for our subjects. Limitations for our study included small sample size and ethnicity; since all the patients were Bahraini, our findings may not translate to patients of other ethnicities.
Data were recorded and analyzed using SPSS version 20 software.
During the two-year period, 990 patients underwent tonsillectomy at SMC. 59 (5.9%) of those patients had asymmetrical enlargement of their tonsils. Of the 59 patients, 33 were male and 26 were female patients (
Tonsillar size (CAS) | |||||
---|---|---|---|---|---|
Frequency | Percent | Valid percent | Cumulative percent | ||
+1 | 20 | 33.9 | 33.9 | 33.9 | |
+2 | 27 | 45.8 | 45.8 | 79.7 | |
+3 | 12 | 20.3 | 20.3 | 100.0 | |
Total | 59 | 100.0 | 100.0 |
the 59 patients did not have a diagnosis of asymmetry on histopathological testing as compared to the CAS. All the patients had CAS difference between tonsils. 20 patients had a difference of 1+, 27 patients had a difference of 2+ and 12 patients had a difference of 3+ between the CAS for each tonsil (
Three (5%) of the 59 patients had benign lesions on their unilaterally-enlarged tonsil (
Gender | |||||
---|---|---|---|---|---|
Frequency | Percent | Valid percent | Cumulative percent | ||
Male | 33 | 55.9 | 55.9 | 55.9 | |
Female | 26 | 44.1 | 44.1 | 100.0 | |
Total | 59 | 100.0 | 100.0 |
Histopathology | |||||
---|---|---|---|---|---|
Frequency | Percent | Valid percent | Cumulative percent | ||
Lymphoid hyperplasia | 53 | 89.8 | 89.8 | 89.8 | |
Malignant tumor | 3 | 5.1 | 5.1 | 94.9 | |
Benign tumor | 3 | 5.1 | 5.1 | 100.0 | |
Total | 59 | 100.0 | 100.0 |
According to the American Academy of Otolaryngology-Head and Neck Surgery Clinical Indicator Compendium [
In a similar study [
Another study [
Tonsillar size on histopathology | |||||
---|---|---|---|---|---|
0 | +1 | +2 | +3 | ||
Count | Count | Count | Count | ||
Tonsillar size on examination (CAS) | +1 | 10 | 10 | 0 | 0 |
+2 | 0 | 7 | 20 | 0 | |
+3 | 0 | 0 | 6 | 6 |
percentage of patients have undergone a “needless” surgery. But up till now, tonsillectomy is still necessary and is the only definitive way to confirm tonsillar malignancy.
Furthermore, 10 (16.9%) of the patients did not have actual asymmetry after the pathology test results were known (
Since the incidence of malignancy in asymmetrical tonsils is negligible in the absence of other associated risk factors, watchful waiting may be appropriate prior to any surgical intervention. Diagnostic tonsillectomy is indicated in patients with asymmetrical tonsillar enlargement with associated suspicious clinical findings, including cervical lymphadenopathy and rapid tonsillar enlargement. Imaging modalities could be helpful in assessing the asymmetry of the tonsils when suspecting such finding on clinical examination.
Al Marzooq, J., Abdulla, J. and Al Sindi, M. (2017) Incidence of Malignancy in Asymmetrical Tonsillar Enlargement. International Journal of Otolaryngology and Head & Neck Surgery, 6, 6-10. http://dx.doi.org/10.4236/ijohns.2017.61002