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Is diagnostic tonsillectomy indicated in all children with asymmetrically enlarged tonsils?
Anton C van Lierop1, C A J Prescott, Johannes J Fagan
1Division of Otorlaryngology, University of Cape Town, South Africa. antonv1@worldonline.co.za
Insights
Clinical tonsillar asymmetry in children is often not real and rarely indicates significant pathology. Diagnostic tonsillectomy is generally not necessary unless other concerning symptoms are present.
Area of Science:
- Otolaryngology
- Pediatric Surgery
- Pathology
Background:
- Tonsillar asymmetry is a common clinical finding in children.
- The necessity of diagnostic tonsillectomy for asymmetrical tonsils requires clarification.
- Accurate clinical assessment of tonsillar asymmetry is crucial for appropriate management.
Purpose of the Study:
- To evaluate the need for diagnostic tonsillectomy in children with asymmetrical tonsils.
- To assess the accuracy of clinical evaluation for tonsillar asymmetry.
- To guide the management of children presenting with clinical tonsillar asymmetry in resource-limited settings.
Main Methods:
- Prospective study at a children's hospital over 8 months.
- Clinical assessment of tonsil symmetry in children undergoing tonsillectomy/adenotonsillectomy.
- Histological examination and measurement of resected tonsil diameter and volume.
Main Results:
- Out of 172 patients, 13 (7.6%) had clinically asymmetrical tonsils with no significant pathology.
- True tonsillar asymmetry measurements (diameter and volume) were not significantly different between clinically asymmetrical and symmetrical tonsil groups.
- Abnormal pathological findings were rare in both groups.
Conclusions:
- Clinical tonsillar asymmetry is frequently apparent rather than indicative of true asymmetry.
- The incidence of significant pathology in children with asymptomatic, asymmetrical tonsils is low.
- Diagnostic tonsillectomy is reserved for cases with associated symptoms like constitutional issues, lymphadenopathy, or rapid enlargement.
Objectives:
The aims of the study were: (i) to determine the necessity for diagnostic tonsillectomy in children with asymmetrically enlarged tonsils; (ii) to determine the accuracy of clinical assessment of tonsillar asymmetry; and (iii) to determine how to manage children with clinical tonsillar asymmetry in a developing-world practice.
Methods:
A prospective study was carried out at Red Cross War Memorial Children's Hospital in Cape Town, over an 8-month period. All children undergoing tonsillectomy or adenotonsillectomy had a clinical assessment of tonsil symmetry done, and all tonsil and adenoid specimens were examined histologically. The maximum diameter and volume of the resected tonsils were measured. A comparison was done of true tonsil asymmetry in patients with asymmetrical tonsils and a subgroup of matched controls with symmetrical tonsils.
Results:
A total of 344 tonsils were analysed (172 patients). The 13 patients (7.6%) diagnosed as having clinically asymmetrically enlarged tonsils had no significant pathological diagnosis. In the patients with symmetrical tonsils there were 2 abnormal pathological findings (tuberculosis of the adenoids and T-cell lymphoma of the tonsils and adenoids). In the clinically asymmetrical tonsil group, true tonsillar asymmetry was 3 mm (maximum diameter), and 2.2 cm(3) (volume), compared with 1.9 mm and 1.5 cm(3) in the symmetrical tonsil group. When patients with clinical tonsillar asymmetry and symmetry were compared, the difference in maximum diameter (p = 0.62) and volume (p = 0.73) was not significantly different.
Conclusions:
Clinical tonsillar asymmetry is usually apparent rather than real. The incidence of significant pathology in children with asymptomatic, asymmetrical tonsils is low. Diagnostic tonsillectomy is indicated in children with asymmetrically enlarged tonsils associated with constitutional symptoms, cervical lymphadenopathy, rapid tonsil enlargement or significant tonsillar asymmetry.
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