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Risk-Stratified Bilateral Tonsillectomy for Unilateral HPV-Associated Tonsillar SCC: Oncologic and Functional
Tereza Vitkovska1, Crystal Z Zhou1, Ishna Pandey1
1Department of Head & Neck Surgery David Geffen School of Medicine Los Angeles California USA.
Objective:
To characterize synchronous and metachronous contralateral second primary malignancy (SPM) rates across preoperatively defined risk strata in patients with HPV-positive tonsillar squamous cell carcinoma (TSCC) undergoing unilateral versus bilateral tonsillectomy and to evaluate associated postoperative morbidity and functional outcomes.
Methods:
All patients with HPV-positive TSCC who underwent surgery between 2000 and 2023 were retrospectively reviewed. Fisher's exact test, Kaplan-Meier analysis, and log-rank tests were used to compare morbidity and survival, and multivariable regression models were employed to control for confounders, including patient demographics, substance use, tumor staging, and adjuvant therapy.
Results:
From 163 patients, 123 (75.5%) underwent unilateral tonsillectomy, 30 (18.4%) low-risk bilateral tonsillectomy, and 10 (6.1%) high-risk bilateral tonsillectomy. Across all patients undergoing bilateral tonsillectomy, synchronous tonsillar SPMs were identified in 10.0%, with rates of 6.7% in the low-risk bilateral group and 20.0% in the high-risk bilateral group. Of the 123 patients who underwent unilateral tonsillectomy, 0.8% developed a metachronous contralateral TSCC at 181.6 months. Among low-risk bilateral patients undergoing prophylactic contralateral tonsillectomy, the NNT for identification of one occult synchronous SPM was 14 (95% CI: 5-50). Bilateral tonsillectomy did not significantly alter discharge diet, postoperative length of stay, hemorrhage rates, return to the operating room, or 30-day emergency department visits. Disease-free survival did not differ significantly across risk-stratified groups.
Conclusion:
Contralateral second primary TSCC clustered disproportionately among high-risk patients. Bilateral tonsillectomy was not associated with significantly increased postoperative morbidity. These findings support a selective, risk-stratified approach to bilateral tonsillectomy in HPV-associated TSCC, balancing the potential benefit of occult contralateral disease detection against procedure-related morbidity through shared decision-making.
Level Of Evidence:
III.
