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Are Histologic Studies of Adenotonsillectomy Really Necessary?

Abstract

Introduction

 In most ear, nose, and throat services, it is routine to send the material extracted from tonsillectomy for histologic study to research malignancy, to analyze suspect material, or to provide medical-legal documentation. Recent studies have shown that this routine analysis is dispensable.

Objective

 To evaluate the actual need and perform a cost–benefit analysis of routine histopathologic examination in tonsillectomy with no signs or symptoms of malignancy.

Methods

 A retrospective observational study evaluated the charts of patients undergoing adenotonsillectomy, tonsillectomy, or adenoidectomy from January 2008 to September 2009 at the Institute of Otorhinolaryngology CEMA-SP. Costs of this test for the public health system were analyzed and the literature reviewed.

Results

 We studied 281 patients between 2 and 22 years of age; 142 (50.5%) were male and 139 (49.5%) were female. Of the surgeries, 201 were adenotonsillectomies (71.5%), 41 were tonsillectomies (14.5%), and 39 were adenoidectomies (14%). The most common indication for surgery was recurrent infection (63.3%). None of study patients had clinical suspicion of malignancy. The tests showed a cost of R$20.03 per tonsil analyzed.

Conclusion

 Routine histopathologic examination in patients undergoing adenotonsillectomy with no signs or symptoms of malignancy is dispensable and increases the cost of the surgeries.

Keywords
tonsillar neoplasms; tonsillectomy; adenoidectomy


Introduction

Adenotonsillectomy is surgery to remove the tonsils and adenoids, and it is one of the most common and most frequently performed surgical procedures in the world.11 Randall DA, Martin PJ, Thompson LDR. Routine histologic examination is unnecessary for tonsillectomy or adenoidectomy. Laryngoscope 2007;117:1600-1604 , 22 Cinar F. Significance of asymptomatic tonsil asymmetry. Otolaryngol Head Neck Surg 2004;131:101-103 Its different indications can be divided into therapeutic, diagnostic, as well as access to other surgeries. Sleep apnea syndrome, hypertrophic tonsils and adenoids, chronic tonsillitis, halitosis, and suspicion of malignancy are indications for adenotonsillectomy, but the most frequent indication is recurrent tonsillitis.

Most otolaryngology services routinely send adenotonsillectomy specimens for histopathologic examination, whether for malignancy investigation, analysis of suspect material, or medicolegal documentation of surgical removal.11 Randall DA, Martin PJ, Thompson LDR. Routine histologic examination is unnecessary for tonsillectomy or adenoidectomy. Laryngoscope 2007;117:1600-1604 Recent studies have shown that routine histopathologic analysis of the tonsil is dispensable, because they have a very low probability of diagnosing occult malignancies. Unfortunately, this risk is still not zero, so the need for routine histopathology is still controversial.

Objective

Define the real need for routine histopathologic examination of adenotonsillectomy specimens and perform a cost–benefit analysis of its use in patients without risk factors for malignancy.

Materials and Methods

This retrospective observational study evaluated the records of all patients who had adenotonsillectomy, tonsillectomy, or adenoidectomy from January 2008 to September 2009 at the CEMA Institute of Otorhinolaryngology, São Paulo, Brazil. This project was approved by the Ethics and Research Institution under the protocol 17.205/2009. Patients or their guardians signed an informed consent form, shown in Appendix 1 Appendix 1 Model of the term of consent . Data analysis was performed using descriptive statistics, and the results are presented in absolute numbers.

We excluded patients with malignancy symptoms and signs. All patients underwent general anesthesia and tonsillectomy by extraction dissection technique. The pharyngeal tonsils were removed with a Beckmann curette. Specimens were immediately placed in sterile glass with 10% formalin and sent for histologic analysis. The tonsils were fixed in 10% formalin and embedded in paraffin, and sections were stained with hematoxylin-eosin. We studied the results of the histopathologic examinations, regardless of age, sex, and indication for surgery. We also analyzed the cost of this test for the public health system, and we reviewed the literature.

Results

A total of 281 patients were recruited, between 2 and 22 years old. Of them, 142 (50.5%) were male and 139 (49.5%) were female. Most patients had tonsil hypertrophy grade III according to the Brodsky classification and pharyngeal tonsil hypertrophy documented by nasofibrolaryngoscopy.

Of the surgeries, 201 were adenotonsillectomies (71.5%), 41 were tonsillectomies (14.5%), and 39 were adenoidectomies (14%). The most common surgical indications were recurrent tonsillitis (63.3%) and obstructive sleep apnea syndrome (38.7%). None of the patients in our study had clinical suspicion of malignancy.

Results of the pathologic examinations of tonsils and adenoids are shown in Tables 1 and 22 Cinar F. Significance of asymptomatic tonsil asymmetry. Otolaryngol Head Neck Surg 2004;131:101-103. The tests cost R$20.03 per piece analyzed; the adenotonsillectomy surgery has three pieces, reaching a total of R$60.09 per surgery.

Table 1
Results of histopathologic examination of the tonsils
Table 2
Results of histopathologic examination of the pharyngeal tonsils

Discussion

Tonsils with malignant processes present different aspects than benign lesions on clinical examination; physical examination and medical history can be important guides. These lesions may start with nonspecific symptoms and insidious symptoms, and they are usually diagnosed in patients over 60 years old. Smoking and alcoholism are risk factors.

According Beaty et al,33 BeatyMM, Funk GF, Karnell LH, et al. Risk factors formalignancy in adult tonsils. Head Neck 1998;20:399-403 risk factors for tonsillar malignancy include history of head and neck cancer, tonsillar asymmetry, visible lesion, ulcerated or hard consistency on palpation of the tonsil, unexplained weight loss or constitutional symptoms, and cervical lymphadenopathy. Usually the patient starts with dysphagia without signs of acute infection with ipsilateral otalgia, difficulty in mobility of the tongue, nasal voice, halitosis, and nasal reflux. Symptoms such as changes in tone of voice, drooling, bloody saliva, and trismus indicate deep infiltration of the tumor.

Many authors have reported that tests with positive results for malignancy had a suspected diagnosis before surgery. The result of histopathologic exams on tonsil specimens correlates well with preoperative clinical impressions, and their findings rarely change the management of the patient.44 Ikram M, Khan MAA, Ahmed M, Siddiqui T, Mian MY. The histopathology of routine tonsillectomy specimens: results of a study and review of literature. Ear Nose Throat J 2000;79:880-882

Randall et al reported a prevalence of malignancy of 0.087% in routine examinations. In these patients, 88% had preoperative suspicion of malignancy. Among the tests, 0.011% had a positive result but no risk factor; the authors concluded that routine examination was unnecessary if there was no suspicion of malignancy.11 Randall DA, Martin PJ, Thompson LDR. Routine histologic examination is unnecessary for tonsillectomy or adenoidectomy. Laryngoscope 2007;117:1600-1604 Garavello et al noted a 0.18% incidence of positive histopathologic analysis without clinical suspicion in children, concluding that routine examinations were unnecessary.55 Garavello W, Romagnoli M, Sordo L, Spreafico R, Gaini RM. Incidence of unexpected malignancies in routine tonsillectomy specimens in children. Laryngoscope 2004;114:1103-1105 Felix et al found a 0.19% incidence of positivity; however, all of the patients had some risk factor for tonsillar malignancy. The examinations did not locate any hidden malignancies.66 Felippe F, Gomes GA, de Souza BP, Cardoso GA, Tomita S. Evaluation of the utility of histopathologic exam as a routine in tonsillectomies. Braz J Otorhinolaryngol 2006;72:252-255 Williams and Brown found 4,070 tonsils with malignancy on histopathology, and all of them had been diagnosed during preoperative evaluations.77 Williams MD, Brown HM. The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and younger. Hum Pathol 2003;34:1053-1057 A study by DellAringa et al showed no malignancy in the patients analyzed, finding a negative cost–benefit ratio for routine histopathologic exams.88 Dell'Aringa AR, Juares AJ, Melo Cd, Nardi JC, Kobari K, Perches Filho RM. Histological analysis of tonsillectomy and adenoidectomy specimens-January 2001 to May 2003. Braz J Otorhinolaryngol 2005;71:18-22 Younis et al presented research that showed none of the 2,099 pediatric patients undergoing tonsillectomy had malignancy found on histopathologic exam, but this incidence differed from the adult population.99 Younis RT, Hesse SV, Anand VK. Evaluation of the utility and costeffectiveness of obtaining histopathologic diagnosis on all routine tonsillectomy specimens. Laryngoscope 2001;111:2166-2169 Mohamad et al also found in their study that routine examination is not necessary in the pediatric population.1010 Mohamad I, Hassan S, Salim R. The routine histopathological examination of tonsillectomy specimens at hospital universiti sains Malaysia-retrospective study and its implication. Malays J Med Sci 2007;14:19-21 Many authors have showed that histopathologic exam of specimens from children is superfluous1111 Strong EB, Rubinstein B, Senders CW. Pathologic analysis of routine tonsillectomy and adenoidectomy specimens. Otolaryngol Head Neck Surg 2001;125:473-477 and that increasing age is a risk factor to be considered.1212 Erdag TK, Ecevit MC, Guneri EA, Dogan E, Ikiz AO, Sutay S. Pathologic evaluation of routine tonsillectomy and adenoidectomy specimens in the pediatric population: is it really necessary? Int J Pediatr Otorhinolaryngol 2005;69:1321-1325 This fact is due to very different indications for tonsillectomy in different age groups; in adults, the incidence of excisional biopsies and symptoms of malignancy are much higher than in pediatric patients.

Spending with microscopic examinations by tonsil varies greatly in the studies, ranging from US $12.85 to US $90.00. Annual spending in the United States is approximately US $35,467,080.00. For the Brazilian government, spending on each piece is R$20.03.

Conclusion

Routine histopathologic examination in pediatric adenotonsillectomy specimens is dispensable, with a negative cost–benefit ratio. Despite all these studies showing that such tests burden the public purse as well as private health systems, surgeons are required to apply for the pathologic study because health plans require its result for the payment of the surgery.

We emphasize the importance of a thorough history and clinical examination in all patients undergoing adenotonsillectomy. In children, the chance of occult malignancy is very low. In patients with risk factor present in clinical ear, nose, and throat examination, this exam is indispensable. With more careful preoperative assessment, we could save millions of dollars per year.

References

  • 1
    Randall DA, Martin PJ, Thompson LDR. Routine histologic examination is unnecessary for tonsillectomy or adenoidectomy. Laryngoscope 2007;117:1600-1604
  • 2
    Cinar F. Significance of asymptomatic tonsil asymmetry. Otolaryngol Head Neck Surg 2004;131:101-103
  • 3
    BeatyMM, Funk GF, Karnell LH, et al. Risk factors formalignancy in adult tonsils. Head Neck 1998;20:399-403
  • 4
    Ikram M, Khan MAA, Ahmed M, Siddiqui T, Mian MY. The histopathology of routine tonsillectomy specimens: results of a study and review of literature. Ear Nose Throat J 2000;79:880-882
  • 5
    Garavello W, Romagnoli M, Sordo L, Spreafico R, Gaini RM. Incidence of unexpected malignancies in routine tonsillectomy specimens in children. Laryngoscope 2004;114:1103-1105
  • 6
    Felippe F, Gomes GA, de Souza BP, Cardoso GA, Tomita S. Evaluation of the utility of histopathologic exam as a routine in tonsillectomies. Braz J Otorhinolaryngol 2006;72:252-255
  • 7
    Williams MD, Brown HM. The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and younger. Hum Pathol 2003;34:1053-1057
  • 8
    Dell'Aringa AR, Juares AJ, Melo Cd, Nardi JC, Kobari K, Perches Filho RM. Histological analysis of tonsillectomy and adenoidectomy specimens-January 2001 to May 2003. Braz J Otorhinolaryngol 2005;71:18-22
  • 9
    Younis RT, Hesse SV, Anand VK. Evaluation of the utility and costeffectiveness of obtaining histopathologic diagnosis on all routine tonsillectomy specimens. Laryngoscope 2001;111:2166-2169
  • 10
    Mohamad I, Hassan S, Salim R. The routine histopathological examination of tonsillectomy specimens at hospital universiti sains Malaysia-retrospective study and its implication. Malays J Med Sci 2007;14:19-21
  • 11
    Strong EB, Rubinstein B, Senders CW. Pathologic analysis of routine tonsillectomy and adenoidectomy specimens. Otolaryngol Head Neck Surg 2001;125:473-477
  • 12
    Erdag TK, Ecevit MC, Guneri EA, Dogan E, Ikiz AO, Sutay S. Pathologic evaluation of routine tonsillectomy and adenoidectomy specimens in the pediatric population: is it really necessary? Int J Pediatr Otorhinolaryngol 2005;69:1321-1325

Appendix 1 Model of the term of consent

Publication Dates

  • Publication in this collection
    2013

History

  • Received
    08 June 2013
  • Accepted
    11 July 2013
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