- Design
- Retrospective cohort, single safety-net hospital
- Population
- 769 tonsillectomy specimens (307 children, 462 adults)
- Primary outcome
- Unexpected malignancy on routine histology
- Effect
- 0 paediatric; 1/462 unexpected adult malignancy (0.22%)
A US safety-net hospital reviewed all 769 tonsillectomy specimens from 2022 to 2025 (307 children, 462 adults). As a head and neck cancer referral centre, the series included tonsillectomies done for known or suspected cancer.
No paediatric malignancy was found (0%, 95% CI 0% to 1.19%). There were 20 adult malignancies — 13 squamous cell carcinomas and 7 haematological — of which 19 were expected or suspected before surgery. One mantle cell lymphoma was unexpected: 0.22% of adult specimens and 0.23% of those without preoperative concern.
Even in a higher-risk population, preoperative assessment predicted nearly all cancers. That supports sending tonsils for histology selectively — asymmetry, adult age, neck nodes, systemic symptoms — rather than routinely, especially in children.
- Document tonsil symmetry, neck nodes and B symptoms before tonsillectomy.
- Send histology for adults with asymmetry, nodes, ulceration or suspicious history.
- Consider omitting routine histology in children with symmetrical tonsils and no red flags.
- Agree a written local policy with pathology.
Why it matters
It supports risk-based rather than routine tonsil histology, saving pathology resources without missing expected cancers.
Don't overread it
One unexpected cancer in 462 adults means the true rate is imprecise, possibly up to about 1 in 80.
The statistics, in plain English
The upper limit of 1.2% for unexpected adult malignancy shows how uncertain a single event is. For children, zero in 307 means the true rate is probably below about 1 in 85.
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