The histopathology of routine tonsillectomy specimens: Results of a study and review of literature.

Abstract

Controversy continues to attend the routine histologic examination of tonsillectomy specimens. We performed a retrospective evaluation of 400 tonsil specimens removed from 200 patients. We found that 68.3% of the specimens contained reactive lymphoid hyperplasia, 13.5% had follicular hyperplasia, 10.0% represented acute or chronic tonsillitis, and 7.5% were normal. Only one case of malignancy was detected: a non-Hodgkin's lymphoma in one tonsil of a patient who was a cigarette smoker and who had asymmetric tonsils. The results of our study, taken in combination with data already published in the literature, indicate that routine histologic examination of tonsillectomy specimens is unnecessary and results only in added costs and a loss of man-hours. However, in patients who have certain preoperative risk factors, a histopathologic evaluation of tonsillar specimens remains mandatory.

Introduction

Tonsillectomy is performed for a wide range of indications, including recurrent infection, peritonsillar abscess, obstructive sleep apnea, snoring, and evaluation of suspected malignancy. [1] Regardless of the indication, tonsillectomy specimens are routinely sent for histopathologic evaluation because of the concern that the tonsils might harbor malignancy or, especially in developing countries, a serious infection such as tuberculosis. In certain countries, medicolegal issues dictate that a histopathologic evaluation be made of all specimens obtained from routine tonsillectomy procedures.

However, little has been published regarding the risks of tonsillar malignancy in patients who undergo routine tonsillectomy. As efforts are being intensified to reduce medical costs, especially in developing countries where patients often pay for their own healthcare, the necessity for this routine evaluation is now being questioned.

In this article, we describe our retrospective evaluation of 400 tonsillectomy specimens performed at The Aga Khan University Hospital in Karachi, Pakistan, to assess the role of histopathologic examination in routine tonsillectomy surgeries.

Materials and methods

We performed a retrospective chart review of 220 patients who had undergone tonsillectomy surgery for various indications at The Aga Khan University Hospital between January 1994 and December 1997. Twenty charts were excluded from our evaluation because of a lack of adequate followup. Information was compiled on each patient's age, sex, indication for surgery, type of surgical procedure, and history of tobacco, alcohol, or betel nut use.

The defined risk factors for malignancy are tonsil asymmetry, a visible tonsillar lesion, a neck mass, a history of cancer, constitutional symptoms (unexplained weight loss, fatigue, fever, night sweats, loss of appetite), and a history of tobacco, paan leaf, or betel nut use. The presence of any of these risk factors was documented. Data were entered and analyzed with the statistical analysis package Epidemiologic Information (EpiInfo) V6.0.

Results

A total of 200 patients--aged 4 to 49 years (mean: 15.8), including 111 males (55.5%)--fulfilled our criteria and were included in this study. Most (183 [91.5%]) had been admitted to the inpatient service, while the remaining 17 (8.5%) underwent day-care surgery. The length of stay for the admitted patients ranged from 1 to 3 days (mean: 1.68).

The most common indications for tonsillectomy were quinsy, sleep disorders, and snoring. Only one patient underwent tonsillectomy to rule out malignancy. A tonsillectomy alone was performed on 195 (97.5%) patients; the remaining five patients (2.5%) underwent both tonsillectomy and adenoidectomy. Electrocautery was performed on 119 patients (59.5%), while 79 (39.5%) had tonsillectomy by the dissection method and two patients (1%) received a combination of both.

Perioperative, postoperative, and late complications were evaluated. Thirty-six patients (18%) experienced complications, which included hemorrhage, otalgia, and infection. Only 23 patients were smokers, and only three had a history of alcohol use.

All 400 specimens were submitted for gross and microscopic histologic evaluation. Most specimens (68.3%) contained reactive lymphoid hyperplasia; follicular hyperplasia (13.5%), acute chronic tonsillitis (10.0%), and normal tonsillar tissue (7.5%) were also found (table). Only one malignancy was found: a non-Hodgkin's lymphoma in one tonsillar specimen of a patient who had a marked asymmetry of his tonsils and a history of smoking.

Discussion

It is common throughout the world to routinely send tonsillectomy specimens for histologic examination to screen for occult malignancy. This concern over cancer has traditionally been supported in the literature, which indicates that younger patients with lymphomas of Waldeyer' s ring can have tonsillar abnormalities and that in older patients, tonsillar findings or a neck mass might be associated with primary tonsillar carcinoma. [2] However, microscopic examination of tonsil specimens generally correlates well with preoperative clinical impressions, and pathology findings rarely alter patient management.

To investigate the issue of pathologic examination of routine tonsillectomy specimens, Dohar and Bonilla conducted a nationwide survey of members of the American Society of Pediatric Otolaryngology (ASPO). [3] They received a wide range of opinions and arrived at no definite consensus. Explanations for the practice included institutional protocol and better medicolegal cover. Their final analysis of details provided by members revealed only one malignancy among 2,012 specimens. Although the ASPO members reached no consensus at the national level, Dohar and Bonilla nevertheless recommended that histopathologic evaluation be conducted routinely if only to detect rare, unsuspected malignancies.

Likewise, Alvi and Vartanian found only one malignancy in a pathologic review of 526 post-tonsillectomy specimens [4] They concluded that routine evaluation is not necessary and results in a waste of both money and pathologist man-hours. Beaty et al, in their retrospective review of adult tonsillectomy tissue, found a higher rate of positive specimens: 25 malignant tumors in 476 samples. [5] However, these 25 samples had been obtained from patients with several definite and identifiable risk factors that had already been detected prior to surgery. Based on their findings, Beaty et al recommended that evaluation be performed only on specimens of patients who had certain risk factors.

Arguments in favor of microscopic examination of all tonsillectomy specimens are found in certain isolated anecdotal reports. [6,7] Cases involving an unsuspected diagnosis of lymphoma or teratoma are two such examples.

Our own institution's policy requires the routine histopathologic evaluation of all surgically removed tissue. Even so, the results of this study, combined with evidence gathered from our review of the literature, lead us to conclude that in the absence of certain preoperative risk factors (tonsillar asymmetry, a neck mass, a visible tonsillar lesion, a history of cancer, constitutional symptoms, or a history of tobacco, paan leaf, or betel nut use), routine histologic examination of tonsillectomy specimens is not necessary and serves only to increase costs and divert man-hours.

From the Department of Otolaryngology--Head and Neck Surgery, Aga Khan University Hospital, Karachi, Pakistan.

Reprint requests: Mubasher Ikram, FCPS, Department of Otolaryngology--Head and Neck Surgery, Aga Khan University Hospital, Stadium Rd., Box 3500, Karachi 74800, Pakistan. Phone: [phone], ext. 4761; fax: [phone]; e-mail: [e-mail]

References

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(2.) Szeremeta W, Novelly NJ, Benninger M. Postoperative bleeding in tonsillectomy patients. Ear Nose Throat J 1996;75:373-6.

(3.) Dohar JE, Bonilla JA. Processing of adenoid and tonsil specimens in children: A national survey of standard practices and a five-year review of the experience at the Children's Hospital of Pittsburgh. Otolaryngol Head Neck Surg 1996;115:94-7.

(4.) Alvi A, Vartanian AJ. Microscopic examination of routine tonsillectomy specimens: Is it necessary? Otolaryngol Head Neck Surg 1998;119:361-3.

(5.) Beaty MM, Funk GF, Karnell LH, et al. Risk factors for malignancy in adult tonsils. Head Neck 1998;20:399-403.

(6.) Kraus M, Fliss DM, Argov S, et al. Burkitt's lymphoma of the tonsil. J Laryngol Otol 1990;104:991-4.

(7.) Batsakis JG, el-Naggar AK, Luna MA. Teratomas of the head and neck with emphasis on malignancy. Ann Otol Rhinol Laryngol 1995;104:496-500.