- Design
- Retrospective single-centre cohort
- Population
- 769 tonsillectomy specimens (307 children, 462 adults) at a US safety-net hospital
- Primary outcome
- Unexpected malignancy on histology
- Effect
- 0 of 307 children; 1 of 443 adults without preoperative concern (0.23%)
A retrospective cohort from a US safety-net hospital (The Laryngoscope, 15 September 2026) reviewed all 769 tonsillectomy specimens from 2022 to mid-2025, 307 from children and 462 from adults, sorting each cancer by whether it was expected, suspected or unexpected before surgery.
No child had a malignancy. Among adults there were 20 cancers, 13 squamous cell carcinomas and 7 haematological; 19 were expected or suspected before surgery. One mantle cell lymphoma was unexpected, 0.23% of the 443 adults operated on without any preoperative concern.
The numbers are small and the confidence intervals wide, so this cannot exclude a rare occult cancer. But it supports what many units now do: send tonsils for histology when there is a clinical reason, and not routinely in children with symmetrical tonsils.
- Send tonsils for histology when there is asymmetry, an ulcer, a neck mass, weight loss or another red flag.
- Consider omitting routine histology in children with symmetrical tonsils and no red flags.
- Remember that lymphoma can present as a tonsil that looks unremarkable; take a careful history in adults.
- Agree a written risk-based policy with your pathology department.
Why it matters
It supports focusing pathology resources on the patients where a cancer is plausible.
Don't overread it
With one unexpected cancer, the true rate of occult malignancy is very imprecise.
The statistics, in plain English
Finding no cancers in 307 children means the true rate is probably below about 1.2%, which is the upper end of the confidence interval. A single unexpected case in adults gives an interval from almost zero to about 1.25%.
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