- Design
- Single-centre retrospective cohort
- Population
- 769 tonsillectomy specimens (307 children, 462 adults) at a US safety-net hospital
- Primary outcome
- Incidence of unexpected malignancy
- Effect
- 0 paediatric malignancies; 19 of 20 adult cancers anticipated; 1 unexpected (0.22% of adults)
A US safety-net hospital reviewed every tonsillectomy over three and a half years, 769 specimens: 307 children and 462 adults. Each cancer was classed as expected (biopsy-proven), suspected (clinical or radiological concern) or unexpected.
No child had a malignancy. Of 20 adult cancers, 13 squamous cell carcinomas and 7 haematological, 19 were expected or suspected before surgery. One mantle cell lymphoma was unexpected, about 0.2% of adult specimens removed without preoperative concern.
The population carried a high cancer risk and the hospital is a head and neck referral centre, yet clinical assessment before surgery picked up almost every cancer. The numbers are small, so the true rate of unexpected cancer could be up to about 1%.
For most units, this supports sending tonsils for histology selectively: asymmetry, a firm or ulcerated tonsil, neck nodes, systemic symptoms or a smoking and alcohol history in adults, rather than routinely in children having surgery for recurrent tonsillitis or sleep-disordered breathing.
- Send tonsils for histology when there is asymmetry, ulceration, firmness or neck nodes
- Send adult specimens when there are B symptoms or significant tobacco and alcohol exposure
- Routine histology in children with recurrent tonsillitis or obstructive sleep apnoea found no cancers here
- Agree a written risk-based protocol with your pathology department
Why it matters
It supports cutting routine pathology in low-risk tonsillectomy without missing cancers.
Don't overread it
With one unexpected cancer, the study cannot define how rare missed malignancy truly is.
The statistics, in plain English
Zero cancers in 307 children gives an upper 95% confidence limit of about 1.2%, so a small risk cannot be excluded. The same imprecision applies to the 0.2% adult unexpected rate.
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