Clinical significance of unilateral tonsillar enlargement

Act a Ot orrinolaringol Esp. 2009; 60(3): 194-8 Acta Otorrinolaringológica Española www. elsevier. es/ ot orrino ORIGINAL ARTICLE Clinical signiicance of unilateral tonsillar enlargement Susanna Tobias Gómez,* Víctor Palomar Asenjo, Montserrat Borràs Perera, Isabel Pérez Hernández, Antonio Ruiz Giner, and Víctor Palomar García Ser vi ci o de Ot or r i nol ar i ngol ogía, Hospi t al Uni ver si t ar i Ar nau de Vi l anova, Ll ei da, Spai n Received June 9, 2008; accept ed December 19, 2008 KEYWORDS Tonsillar asymmet ry; Tonsillect omy; Follicular lymphoid hyperplasia; Tonsillar cancer; Oropharynx cancer; Lymphoma Abst ract Int r oduct i on: Asympt omat ic unilat eral t onsillar enlargement is usually t reat ed wit h syst emat ic t onsillect omy under suspicion of malignancy. Due t o t he f act t hat most of t he cases are benign pat hologies, we set out t o st udy t he clinical signs t hat would help us in t he diagnosis in order t o avoid unnecessary t onsillect omies. Mat er i al and met hods: We reviewed 267 t onsillect omies perf ormed f rom 1996 t o 2006 and 30 of t hese were indicat ed because of asymmet ry. We evaluat ed risk f act ors f or malignancy: cervical lymphat ic node enlargement , sex, age, t onsillar enlargement not iced by t he pat ient , suspicious appearance, syst emic sympt oms, hist ory of malignancy, and immunocompromise. Resul t s: Hist opat hologic st udy revealed 80% t o be benign and 20% malignant . The risk f act ors wit h t he st rongest associat ion were enl argement of cervical l ymphat ic nodes and suspicious appearance of t he t onsil. Concl usi ons: St rict cont rol of a unilat eral t onsillar enlargement is possible, but it is mandat ory t o perf orm a t onsil l ect omy when t he appearance of t he t onsil raises suspicions or t here are enlarged lymphat ic nodes. © 2008 Elsevier España, S. L. All right s reserved. PALABRAS CLAVE Asimet ría amigdalina; Amigdalect omía; Hiperplasia f olicular linf oide; Cáncer de amígdala; Linf oma Signiicación clínica de la asimetría amigdalina Resumen Int r oducci ón: El aument o unilat eral asint omát ico de una amígdala palat ina suele t rat arse con amigdalect omía sist emát ica por sospecha de malignidad. Ant e la mayor f recuencia de procesos beni gnos, se est udi an dat os cl íni cos que puedan ser vi r como f act or es de r i esgo par a evi t ar amigdalect omías innecesarias. *Corresponding aut hor. E-mai l addr ess: st obiago@hot mail. com (S. Tobias Gómez). 0001-6519/ $ - see f ront mat t er © 2008 Elsevier España, S. L. All right s reserved. Clinical signiicance of unilateral tonsillar enlargement 195 Mat er i al y mét odos: Se revisan 267 amigdalect omías realizadas ent re 1996 y 2006, de las cuales 30 se i ndi car on por asi met r ía. Se val or an f act or es de r i esgo, como adenopat ías, ser var ón, mayor de 45 años, det ección por el mismo pacient e, aspect o sospechoso, cl ínica sist émica, historia de malignidad e inmunodeiciencia. Resul t ados: El resul t ado anat omopat ol ógico f ue de proceso benigno en el 80% de l os casos y maligno en el 20%. Los f act ores de riesgo que muest ran mayor relación con malignidad son las adenopat ías y el aspect o sospechoso. Concl usi ones: Se puede realizar cont rol est rict o ant e una asimet ría amigdalina, aunque cuando hay f act ores de riesgo debemos indicar amigdalect omía. © 2008 Elsevier España, S. L. Todos los derechos reservados. Introduction The unilat eral and asympt omat ic increase in size of t he palat ine t onsil (Figure 1) is usually t reat ed wit h syst emat ic t onsillect omy, due t o t he suspicion t hat it may be a malignancy. Alt hough t his palat ine t onsil may be harbouring a malignancy, such as a carcinoma or lymphoma, most of t en it is a benign process, such as t he varying dept h of t he t onsillar f ossa (most common cause), asymmet ry in t he anterior pillars, chronic inlammation, chronic infection (t uberculosis, syphilis, act ino-mycoses. . . ), granulomat ous diseases (sarcoidosis), 1 or benign t umours (papillomas) 2 (Figure 2). The most common malignancy f ound in t he palat ine t onsil is squamous cell carcinoma, which in most cases is present ed as a unilat eral increase in size of t he amygdala or as an ulcerat ion of t he mucosa coat ing it . Lymphomas represent t he second most common malignancy in t his area and of t en appear as a sub-mucosal mass which in it s growt h leads t o an asymmet rical increase in size of t he amygdala. 3 Several st udies have suggest ed t he possibilit y of maint aining a “ wait and see” at t it ude wit h t he aim of avoiding unnecessary surgery and it s complicat ions. Similarly, publicat ions have sought t o est ablish a set of crit eria in order t o limit t onsillect omy t o t hose cases wit h a high likelihood of a neoplast ic process. In t his regard, Spinou et al 2 f ound a relat ionship wit h malignancy in cases wit h ulcerat ion, weight loss, night sweat s, cervical lymphadenopat hy, age over 45 years and male gender. Furt hermore, Cinar 3 deines as risk f act ors t he suspicious appearance of t he amygdala, syst emic sympt oms, cervical lymphadenopat hy, hist ory of Figure 1 Pat i ent wi t h ver y mar ked asympt omat i c t onsi l l ar asymmet r y. It was deci ded t o moni t or i t s evol ut i on, wi t h no changes f or over 2 years. malignant disease or immunodeiciency. In our st udy we have at t empt ed t o est ablish t he clinical and exploratory data with the most signiicant relationship wit h malignant processes in pat ient s who come t o our consult at ion wit h t onsillar asymmet ry. Material and methods This is a ret rospect ive descript ive st udy, f or which we obt ained dat a f rom 267 consecut ive t onsillect omies carried out at t he ot olaryngology service of our cent re. Of all t hese, 30 were indicat ed due t o t onsillar asymmet ry. Among t he pat ient s operat ed on f or t onsillar asymmet ry, 21 were men and 9 women wit h an age range of 7-84 years (mean, 31. 96). Figure 2 A case of carcinoma of t he lef t amygdala in which we observed t onsil l ar asymmet ry, t oget her wit h ul cerat ion of t he upper part . 196 Tobias Gómez S et al Table 1 Crit eria f or suspicion of malignancy f ound in each case Adenopat hies Masculine gender >45 years Self -det ect ion Suspicious appearance Syst emic sympt oms Hist ory of malignant disease Immunodeiciency Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 + + + + + + — — — — — — — — — — — — — + + + + + + + + — — Ulcer Dysphagia, weight loss — — — Ulcer — — — Mass, ulcer Fever, dysphagia — — + + Mass — — — Af t er t he surgery, a pat hological st udy was perf ormed of t he specimens obt ained in all cases, bot h in t hose indicat ed due t o t onsillar asymmet ry and in t hose f or any ot her indicat ion. Wit h t he dat a obt ained f rom t he anamnesis and t he general physical and ot olaryngological examinat ion, we st udied a t ot al of 8 crit eria f or suspicion of malignancy, in order t o observe t heir relat ionship wit h malignancy. The crit eria considered are: presence of one or more palpable adenopat hies, demographic crit eria such as age and gender, asymmet ry must be st udied t horoughly, regardless of t he age at which it appears, because we can see an equal number of cases in pat ient s over 45 years of age as in t hose who are younger. Nevert heless, t he average age of pat ient s wit h a neoplast ic process is higher in t he case group (46. 8) t han in t he cont rol group (28. 3), alt hough dif f erences did not reach statistical signiicance (Mann-Whitney U, P=. 055) due t o t he small number of cases obt ained. From t he dat a obt ained in t he anamnesis, we not e t hat if it was the patient who had identiied the increased is not a f act t o be t aken int o account , since bot h crit eria were present in only 1 of our pat ient s and appear in a small number of pat ient s (16. 6%). Syst emic sympt oms report ed t onsillar size, suspicious appearance of t he amygdala (mass, ulcerat ion or changes in pigment at ion), syst emic sympt oms (f ever, night sweat s, dysphagia, weight loss), and prior history of malignant or immunodeicient disease. In addit ion t o t hese 8 crit eria, we st udied t he consumpt ion of t oxic subst ances such as t obacco and alcohol, as t hey are st rongly linked t o t he development of squamous cell carcinoma. Six cases are compared, all wit h asymmet rical growt h of t he palat ine amygdala due t o a malignant process and 24 cont rols wit h asymmet ric t onsillar growt h wit hout underlying neoplast ic disease. A dat abase was creat ed wit h t he inf ormat ion obt ained and t he st at ist ical package SPSS 11. 5 f or Windows was used f or it s analysis. Results Out of a t ot al of 267 t onsillect omies included in t he st udy, we observed t hat in 30 cases, t he indicat ion f or t his t echnique was t onsillar asymmet ry, which represent s 11. 2% of t he t ot al. The pat hologic examinat ion of t he specimens obt ained showed 80%of cases in which t he asymmet ry was not due t o a neoplast ic process, but t o f ollicular lymphoid hyperplasia in 23 cases (76. 7%) and a ret ent ion cyst of t he palat ine t onsil (3. 3%). Thus, we f ound t hat only 20% of pat ient s operat ed on wit h t his indicat ion were af f ect ed by a neoplasia; we obt ained 5 cases (16. 7%) of non-Hodgkin lymphoma and 1 case (3. 3%) of squamous cell carcinoma. On analyzing t he crit eria f or suspicion of malignancy t hat we int ended t o st udy in t hese pat ient s (Table 1), it was not ewort hy t hat all pat ient s wit h cancer were male. Similarly, 70% of t he t onsillect omies were perf ormed in males, a signiicantly higher percentage (c2, P=. 028) t han in women. In addit ion, it can be observed t hat t he t onsillar the previous history of malignancy or immunodeiciency by patients do seem to relate more signiicantly with the possibility of inding a neoplastic process underlying the t onsillar asymmet ry, as we f ound it in 2 of our 6 pat ient s (33. 3%). We did not observe t hat any of t he pat ient s perceived t he t onsillar asymmet ry by t hemselves bef ore at t ending t he consult at ion. Regarding t he crit eria derived f rom t he physical examinat ion, we not ed t hat many pat ient s wit h t onsillar asymmet ry and concomit ant neoplast ic disease also present ed palpable cervical lymphadenopat hies. We observed t his in 5 pat ient s (83. 3%). Similarly, t he pharyngoscopy showed dat a which was suspicious of malignancy in 4 (66. 7%) of our cases. Palat ine t onsil ulcerat ion st ands out in 50% of t hem. Only 1 pat ient (16. 67%) had a previous hist ory of malignant disease (lymphoma) and, therefore, immunodeiciency. Wit h regard t o exposure t o t oxic subst ances, we f ound more relat ionship wit h alcohol int ake (33. 3%) t han wit h t he consumpt ion of t obacco (20%). The odds rat io of t he dif f erent f act ors st udied are given in Table 2. Discussion Tonsillar asymmet ry is a clinical sit uat ion which can cover an underlying malignancy; t onsillect omy is t he generally proposed t reat ment . Nevert heless, t he maj orit y of pat ient s who have cancer do not have t his neoplast ic condit ion, so it can be accept able t o carry out monit oring in cases where t here are no risk f act ors. 2 For t his reason, we believe t hat it is interesting to deine which criteria must be considered as risk f act ors, and t hus lead t o t he indicat ion f or t onsillect omy in t his group of pat ient s. In t he work by Spinou et al, 2 it was not ed t hat t he crit eria in relat ion t o a higher incidence of underlying malignant Clinical signiicance of unilateral tonsillar enlargement disease were age >45 years, male gender, weight loss, night sweat s and t onsillar ulcerat ion or cervical lymphadenopat hy in t he clinical examinat ion of t he pat ient . No relat ion was f ound wit h t he consumpt ion of t obacco or persist ent pain. In anot her work, Cinar 3 concludes t hat t here are a number of f act ors t hat should make us suspect a neoplasm in cases of t onsillar asymmet ry, such as t he suspicious appearance of t he palat ine t onsil (by mass, ulcerat ion or areas of abnormal pigment at ion), t he onset of syst emic sympt oms (f ever, night sweat s, dysphagia, or weight loss), signs of possible regional ext ension by indicat ive cervical lymphadenopat hy, or personal hist ory of t he pat ient , such as immunosuppression or previous malignant diseases. However, in cases where t hese crit eria do not appear, a clinical monit oring of pat ient s could be carried out and t heref ore it would not be necessary t o conduct a syst emat ic t onsillect omy. In previous st udies in adult s, such as t hat conduct ed by Beat y et al, 4 discussing t he risk f act ors f or malignancy, such as t onsillar asymmet ry, palpable or visible lesion in t he amygdala, cervical mass, unexplained weight loss, syst emic sympt oms (ast henia, night sweat s, f ever, and anorexia), and previous hist ory of malignancy, it was f ound t hat all risk factors were signiicantly correlated with malignancy and t hat a higher number of f act ors is associat ed wit h an increased risk of malignancy. In our st udy, we have analyzed all t he f act ors which, in t he cont ext of t onsillar asymmet ry, should make us suspect malignancy, and we f ound t hat t he most commonly associat ed f act ors are lymphadenopat hy and suspicious appearance of t he amygdala. In a subsequent st udy, Oluwasanmi et al 5 f ound 2 cases of lymphoma among 87 t onsillect omies by asymmet ry, wit hout ot her alt erat ions and wit hout risk f act ors f or cancer, bot h cases were people over 50 years of age and one was male. Tonsillect omy was recommended whenever an abnormally enlarged amygdala was f ound, especially in people over 40 and in t hose wit h no hist ory of repeat ed t onsillit is. In cont rast , in our st udy, t he underlying malignancy t o an asymmet ry does not seem t o be relat ed t o t he age of t he pat ient . However, Oluwasanmi et al 5 compiled t he result s of Reit er et al, which included 31 individuals wit h t onsillar asymmet ry in a prospect ive st udy over 7 years, and excluded pat ient s wit h obvious mass or ulcerat ion, but not t hose pat ient s wit h lat erocervical lymphadenopat hy, dysphagia, const it ut ional sympt oms, unexplained weight loss, or unilateral symptoms or signs, inding 2 cases (6.5%) of malignancy, and also t hose of Syms et al, who f ollowed 49 pat ient s f or 5 years, excluding pat ient s wit h changes in t he mucosa, lat erocervical adenopat hy, hist ory of malignancy, or focal mass in the amygdala and inding 2 cases (4.1%) of non-Hodgkin lymphoma. As f or t he paediat ric popul at ion, t here are several st udies t hat examine t he conduct t o be f ol l owed wit h t his cl inical sign. In t heir st udy of t onsil l ar asymmet ry in chil dren, Spinou et al 6 st udied 47 chil dren under 16 years of age wit h an indicat ion of t onsil l ect omy f or t onsil l ar asymmet ry 197 Table 2 Odds ratio (OR) and 95% conidence intervals (CI) f or each risk f act or Cases Cont rols Adenopat hies Male gender More than 45 years of age Self -det ect ion Suspicious appearance Syst emic sympt oms Hist ory of malignancy Immunodeiciency Tobacco Alcohol OR (95% CI) 5/ 6 6/ 6 3/ 6 6/ 24 14/ 24 4/ 24 15 (1. 45-155. 3) 1. 43 (1. 07-1. 9) 5 (0. 73-34. 3) 0/ 6 4/ 6 2/ 6 1/ 6 1/ 6 2/ 6 1/ 6 0/ 24 1/ 24 5/ 24 1/ 24 0/ 24 5/ 24 1/ 24 — 46 (3. 3-634. 9) 1. 9 (0. 27-13. 5) 4. 6 (0. 24-86. 6) 1. 2 (0. 84- 1. 72) 1. 9 (0. 27-13. 5) 4. 6 (0. 24-86. 6) the beneits and risks of intervention should be taken into account . Dolev et al 7 reviewed 20 000 t onsillect omies and f ound only 6 cases of lymphoma; only in 2 of t hese was t he t onsillar asymmet ry t he only sign of present at ion. In conclusion, t hey argue t hat alt hough t onsillect omy in pat ient s wit h tonsillar asymmetry is probably not justiied due to cost and perf ormance reasons, all children present ing t his sign must be closely monit ored unt il a diagnosis of lymphoma is ruled out . They cit e ot her st udies which reach similar conclusions, including that of Berkowitz and Mahadevan who reviewed t he case hist ories of 46 children wit h t onsillar asymmet ry without inding any disease and conclude that systematic tonsillectomy in these cases is not justiied in the absence of risk f act ors; or t hat of Harley, who conduct ed a prospect ive st udy wit h 258 children wit h t onsillar asymmet ry and compared them with controls, inding no malignancy and reaching t he same conclusions. Prim et al 8 st udied t he incidence of lymphoprolif erat ive processes of Waldeyer’s ring in paediat ric pat ient s. In t heir work, t hey syst emat ically indicat ed t onsillect omy in immunocompet ent children present ing recent and progressive unilat eral growt h of t he palat ine t onsil and in any kind of adenoamygdaline growt h in immunocompromised children. Alt hough t he occurrence of lymphoprolif erat ive processes had a very low incidence, t hey advised excision f or biopsy of t he t onsils in cases of unilat eral growt h, regardless of t he immune condit ion of t he pat ient . In t he st udy by Beat y et al, 4 a statistically signiicant relat ionship was f ound f or t he risk f act ors of exposure t o t oxic subst ances such as alcohol and t obacco. There are f ew ref erences on t he rol e of t onsil l ar biopsy in t he l it erat ure. In a work by Shah et al , 9 it is st at ed that ine needle aspirative biopsy (FNAB) is a safe and ef f ect ive t echnique in t he diagnosis of l ymphoma and squamous cell carcinoma. They ind a sensitivity of 93% and a speciicity of 86% in intraoral FNAB as compared to convent ional biopsy. They report t hat t he convent ional without inding any form of malignancy. Similarly, they technique is best for supericial squamous cell carcinoma observed no dif f erence in size in t he t onsil s removed in 36% of cases. They argue t hat an observat ion t ime is wise, since it is uncommon f or a mal ignant disease t o become est abl ished on a singl e asymmet rical amygdal a and t hat l esions, whil e FNAB is bet t er f or sub-mucosal l esions, where conventional techniques are dificult to perform or are limited by chronic supericial inlammation. They perf ormed 6 FNAB and f ound onl y 2 cases of squamous cel l 198 carcinoma; 1 of t he 2 cases had onl y a part ial af f ect at ion of t he amygdal a, which coul d have l ed t o a misdiagnosis. Due t o t he consequences ent ail ed by a f al se negat ive, t hey recommend carrying out a t onsil l ect omy f or biopsy. They st udied visibl e inj uries, but do not ment ion carrying out FNAB in apparent l y heal t hy t issue, as woul d be t he case of an isol at ed t onsil l ar asymmet ry. In our st udy, t he crit eria for suspicion of malignancy t hat appear wit h most frequency are male gender, concomit ant adenopat hies and suspicious appearance of t he palat ine t onsil in conduct ing t he clinical examinat ion. The fact t hat in no case had t he pat ient s t hemselves been t he ones t o observe t he asymmet ric growt h of t he amygdala should be highlight ed. Upon st udying t he dat a obt ained in t he sub-group of pat ient s (asymmet ric growt h of t he palat ine t onsil by a neoplast ic process) and in t he sub-group of cont rol subj ect s (asymmet ric growt h wit hout underlying malignant disease), we not e t hat t he risk f act or most associat ed wit h neoplast ic disease is a suspicious appearance of t he palat ine t onsil (odds rat io [ OR] =46), f ollowed by a palpable adenopat hy on clinical examinat ion (OR=15). We not e t hat t he most commonly observed crit erion f or suspicion (male gender) loses st rengt h of associat ion when bot h groups are compared, since t here is also a predominance of males in t he cont rol group. Wit h regard to exposure to toxic substances, there is a signiicant relat ionship wit h alcohol abuse (OR=4. 6) and, alt hough minor, wit h t obacco consumpt ion (OR=1. 9) due t o it s relat ionship wit h t he appearance of squamous cell carcinoma. Conclusions — The asymmet ry in t he size of t he palat ine t onsils should alert us t o t he possibilit y t hat an underlying malignancy may exist . — This asymmet ry should not syst emat ically imply an indicat ion of t onsillect omy. Tobias Gómez S et al — St rict monit oring should be carried out on t onsillar asymmet ry cases wit hout suspicion of malignancy. — Special at t ent ion should be paid and t onsillect omy should be indicat ed if t here are risk f act ors, part icularly in t hose wit h suspicious appearance in t he clinical examinat ion and concomit ant cervical lymphadenopat hy. References 1. Compadret t i GC, Nannini R, Tasca I. Isolat ed t onsillar sarcoidosis manif est ed as asymmet ric pal at ine t onsil s. Am J Ot ol aryngol . 2003; 24: 187-90. 2. Spi nou C, Kubba H, Konst ant i ni di s I, Johnst on A. Rol e of t onsil l ect omy in hist ol ogy f or adul t s wit h unil at eral t onsil l ar enlargement. Br J Oral Maxillofac Surg. 2005;43:144-7. 3. Ci nar F. 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