What Is the Best Management of Asymptomatic Unilateral Tonsillar Enlargement?

by Michelle S. Hwang, BS, Kathryn E. Kaye, BS, Jonathan A. Waxman, MD, PhD, and Michael Friedman, MD •

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.

Background

Lymphoma is the most common pediatric cancer of the head and neck, typically involving the cervical lymph nodes. However, primary tonsillar lymphoma accounts for <1% of head and neck cancer. It is generally believed that tonsillectomy is indicated to treat unilateral tonsillar enlargement (UTE), due to concern for lymphoma in the enlarged tonsil. This is particularly true in the setting of suspicious symptoms such as constitutional symptoms or cervical lymphadenopathy. Yet many patients with isolated UTE, with no associated symptoms, are still treated surgically. However, recent research suggests that treating asymptomatic UTE with tonsillectomy may be unnecessarily invasive, because clinical assessment of asymmetric tonsils may be inaccurate and because very few enlarged tonsils actually contain malignancies.

Best Practice

In spite of traditional dogma that a UTE always requires tonsillectomy to rule out lymphoma, there is little evidence to support this. Pediatric studies demonstrated no higher incidence of lymphoma in asymmetric compared to symmetric tonsils, and showed that the clinical diagnosis of asymmetric tonsil hypertrophy can itself be unreliable. Studies on asymptomatic UTE in adults similarly showed low incidence of malignancy. As such, there is no clear evidence that UTE demands tonsillectomy, but also no clear evidence that tonsillectomy is not indicated. Decisions must be made on an individual basis by the treating clinician. Clearly, when UTE is associated with generalized lymphadenopathy, rapid growth, or systemic symptoms, tonsillectomy is indicated (Fig. 1). In isolated asymptomatic UTE, periodic (suggested follow-up every 4 weeks for 3 months) monitoring of the patient along with noninvasive means of ruling out malignancy seems reasonable (Laryngoscope. 2015;125:2438–2440).