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Journal of Rawalpindi Medical College (JRMC); 2013;17(2):262-264

Original Article

Frequency of Malignancy in Asymptomatic Unilateral


Enlarged Tonsil

Tallat Najeeb, * Rizwan Ullah Chattah**


*Department of ENT Islamabad Medical and Dental College ; **Department of ENT, Sargodha Medical College

Background:

Abstract

Currently frequency of carcinoma in asymmetrical


tonsil with normal mucosa is unknown 5. The study
aims to assess the frequency of carcinoma in patients
with UET both in children and adults. Removal of
tonsil for histopathological purposes to rule out
malignant tumour in asymmetric tonsil is one of the
definite indication for surgery.5,6 It has been standard
practice to perform diagnostic tonsillectomy to exclude
malignancy
when
tonsillar
asymmetry
is
unilateral
tonsillar
encountered.7Apparent
enlargement is often spurious and many unnecessary
tonsillectomies are performed when UET is taken as
indication for surgery in the absence of any other
suspicious feature.8.9 Present study will show how
much is important and beneficial of doing
tonsillectomy when indication is only asymmetry
without clinical features.

To determine frequency of
malignancy in unilateral enlarged tonsil (UET) in
different age groups without any other clinical
feature.
Method: In this descriptive cross sectional study
patients (n=70) who underwent tonsillectomy,for
tonsil asymmetry, were included. Group I, patients
were of 3-12 years and in group II, were of 13 and
above.All the patients were assessed clinically for
regional(otolaryngology) and systemic disease. After
tonsillectomy, difference in tonsils size was recorded
on gross pathology, then specimens were sent for
histopathology.
Results: In group I, 40 patients were of age 3 to 12
years. Clinically mild difference (+1) was noticed in
13(32%), moderate (+2) in 20 and
marked in
7(17.5%). In gross pathology after tonsillectomy, no
difference was noticed in +1 cases (0%), only in 13
(32%) in +2 and in 6 (15%) in +3, average was(19/40,
47.5%).Histopathology was either normal histology
or reactive hyperplasia. None of tonsil revealed any
type of malignancy.In group II 30 patients were of
13-56 years of age. Mild difference (+1) was in
5(16.66%),moderate (+2) was in 19(63.3%) and
marked was in 20(66.6%).In gross pathology no
difference in both tonsils in +1(<5mm), 5-10 mm
difference was noticed in +2 and >10mm difference
was noticed in +3 in all cases. Average was 83.3 %(
25/30).Histopathology was unremarkable except in
one, B cell lymphoma. Average was 3.3% (1/30).
Conclusion: In unilateral enlarged tonsils, no
malignancy was found in paediatric group, while in
adult group one patient showed malignancy
(Lymphoma).
Key Words: Unilateral tonsil enlargement

Patients and Methods

This descriptive cross sectional study was


performed in Social Security Hospital Islamabad
(allied with Islamabad Medical and Dental College),
from July 2006 to July 2012.Total of 70 patients were
studied who underwent tonsillectomy for purpose of
histological examination with only indication of
unilateral enlarged tonsil. Patients were divided into
two groups according to their age. In group I, pediatric
group we included (3-12 years of age). In group II,
adults (13 years and above) were included. All the
patients were assessed clinically for chronic sinusitis,
recurrent tonsillitis, and ulcers over the tonsils, chronic
nasal obstruction, dysphagia, any neck swelling, and
any significant cervical lymphadenopathy and
systemically
like
long
standing
fever
and
hepatosplenomegaly. Only those patients incidentally
diagnosed with UET were included in study for biopsy
purposes. Patients who themselves came for tonsil
asymmetry were also included. Exclusion criteria
included patients with no preoperative notes, where
histological reports were not available,and patients
having any of clinical features mentioned above,
immunocompromised patients, who had malignancy
at other sites already diagnosed and patients who had
received radiotherapy.Any difference noticed between

Introduction

Tonsils are encapsulated collection of lymphoid


tissue in lateral wall of oropharynx. Unilateral
enlarged tonsil may result from infection, chronic
inflammatory
response
or
neoplasm.
Tonsil
asymmetry may only be apparent in otherwise normal
individuals due to anatomical factors. 1-4

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Journal of Rawalpindi Medical College (JRMC); 2013;17(2):262-264


+3 group and B cell lymphoma, average was 3.3%
(1/30). Chi-square test was applied for frequency,
results were insignificant.

right and left sides was considered asymmetric.


Patients age, gender, right (R) and left (L) tonsil
asymmetry in size, neck examination, pathological
results and actual measured size of each tonsil on
gross pathology (width, depth and height). Clinically
enlarged tonsils were kept in three level;, mild
difference (+1), moderate difference (+2) and marked
difference
(+3).
After
doing
bilateral
tonsillectomy,difference between two sides was
recorded on gross pathology, then tonsils were sent for
histopathology.

Discussion

Although unilateral enlargement results from


repeated tonsillitis, chronic tuberculosis, benign and
malignant tumours but it may also be due to
anatomical variations with changes in tonsillar fossa
depth or asymmetric anterior pillars. It is common
finding
during
clinical
otolaryngological
10,11
Unilateral tonsillar hypertrophy is
examination.
presumed to be neoplastic according to the American
Academy of otolaryngology.12 If tonsillectomy is being
done to evaluate a tonsil for malignancy, the validity
of physical examination to assess asymmetry needs to
be established.5 Present study determines whether
clinically assessed asymmetry is significant, when
tonsil size is measured in gross pathology after
tonsillectomy.
Actual tonsillar hypertrophy in gross pathology
after tonsillectomy was more significant in adults as
compared to children. In children it may be due to
anatomical variation with changes in tonsillar fossa
depth.Our study is comparable with one study
performed in adults above 18 years of age with UET.
46 patients were assessed for UET, 28 out of
49(57.14%) showed actual difference in size when
measured in gross specimens.5 It was noticed that
pathological enlargement is usually seen in+2 and +3.
No difference was seen in clinical and pathological
enlargement in +1 cases. It is also proved in previous
studies.5 In another study, 47 children with tonsil
asymmetry were studied. No statistical difference in
degree of asymmetry was found on clinical and
pathological examination (p=0.5). A difference in
depth of tonsillar fossa was identified.13More accurate
methods to assess the size of tonsil is CT scan. After
confirming the size of tonsil with CT scan clinician will
be better able to counsel the patients regarding need to
undergo tonsillectomy.5
Primary malignant tumour of tonsil represents 12%
of oral cavity neoplasm. Secondary malignancy is rare.
Squamous cell carcinoma accounts for 85-95% of
tonsillar malignancies. Lymphomas (10-15%), they are
most common malignant tumour of paediatric age
group. 14,15 Squamous cell carcinoma usually present
with ulcer over the tonsil and UET, lymphoma usually
with UET without ulceration of mucosa and with
painful cervical lymph adenopathy.14 Risk factors
associated with malignancy in children with tonsillar

Results

In group I number of patients were 40, age ranged


from 13- 12 years, mean age was 7.5. 25 (62%) were
male, 15 (43%) were female. Mild difference (+1) was
noticed in 13(32%), 5 on right(Rt) and 8 on left(Lt) side,
moderate (+2) in 20 (50%)15 on Rt side and 5 on Lt
side. Marked difference (+3) was in 7(17.5%). All were
of Lt side( Table I). In gross pathology after doing
tonsillectomy, no difference was noticed in volume,
height, width and length in +1 cases (0%), only in 13
(32%) in +2 and in 6 (15%) in +3, average is (19/40,
47.5%), difference in size in +2 was between 5-10mm,
and in +3cases was>10mm. t test was applied for
clinically enlarged tonsils and actual tonsil size in
gross pathology, P value < 0.05.Total average of
difference in size in all cases was 47.5% (Table
I).Histopathology of all tonsil specimens showed either
normal histology or reactive hyperplasia. None of
tonsil revealed any type of malignancy.In group II
number of patients was 30. Age ranged between 13-56
years, mean was 34.5years. 21(70%) were male, 9(30%)
were female. Mild difference (+1) was seen in
5(16.66%); 3 on Rt and 2 on Lt side. Moderate(+2)
difference was in 19(63.3%);9 on Rt and 10 on Lt, and
marked was in 20(66.6%); 9 on Rt and 11 on Lt(Table
I).In gross pathology no difference in both tonsils in
+1(<5mm), 5-10 mm difference was noticed in +2 and

Table I: Unilateral tonsils differences between


clinical and pathological enlarged tonsil
Size of tonsil

Mild(+1)
Moderate(+2)
Marked(+3)

Hypertrophy Hypertrophy in gross


Average
assessed
pathology
clinically
Group Group Group I Group II Group I Group
I
II
II
13
5
No
No
difference difference
20
7

19
6

13
6

19
7

47.5

83.3

>10mm difference was noticed in +3 in all cases.


Average was 83.3 %( 25/30) (Table I). T test was
applied, p value >0.05.Histopathology of enlarged
tonsil was unremarkable except in one. This was from

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Journal of Rawalpindi Medical College (JRMC); 2013;17(2):262-264


asymmetry are presence of enlarged cervical lymph
node and abnormal appearance of tonsil. 16, 17
In our study the only indication of tonsillectomy
was tonsillar asymmetry and none of the case showed
any malignancy in children but in adults one patient
with UET and intact mucosa showed B cell lymphoma
without cervical lymph node enlargement and any
systemic symptoms.In one retrospective study 33
patients with UET, none of patients was found to have
malignancy.5 In a study 476 patients with UET
underwent tonsillectomy, 25 patients were found to
have malignancy but it was seen that 23 patients had
two or more risk factors and two patients had one risk
factor.13 Incidence of malignancy in tonsils which
exhibit asymmetry with no other clinical features is
very low. In our study it is zero in children and 3.3% in
adults. Tonsillectomy itself carries risks so physician
must weigh the discomfort and risks associated with
tonsillectomy against risk of malignancy not being
diagnosed.13
Results also indicate that presence of certain
preoperatively identifiable risk factors associated with
malignancy such as mucosal ulceration, abnormal
appearance of tonsil, cervical lymphadenopathy,
progressive enlargement of tonsil and systemic
symptoms must be considered for diagnosis. 17 Further
absence of malignancy in tonsillectomy specimens of
patients with UET does not rule out loco-regional
primary lymphoma. Tonsillar enlargement may be
reactive response to nearby tumour.14 An alternative
approach to diagnose tumour without doing
tonsillectomies is positron emission tomography(PET)
imaging; that is detection of foci of increased
glycolysis which is an important sign of tumour
metabolism 14.In the absence of these facilities close
observation is essential.

1.
2.
3.

4.
5.

6.

7.
8.

10.
11.

12.

13.

14.
15.

Conclusion

1.Although tonsillectomy in UET is easier method to


rule out malignancy, physician must compare the risks
associated with tonsillectomies with risks of
undiagnosed malignancy.
2. By using CT scan and PET, unnecessary
tonsillectomies can be avoided

16.
17.

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