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Asymmetric Tonsil Size in Children
Earl H. Harley, MD
Arch Otolaryngol Head Neck Surg. 2002;128:767-769.
ABSTRACT
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Objective To assess the clinical implications of asymmetrically enlarged tonsils
in children.
Design A prospective controlled study of asymmetric tonsil size in children
scheduled for tonsillectomy with or without adenoidectomy. Data were recorded
on tonsil size and position, tonsillar fossa depth, degree of asymmetry, and
pathological findings. Control patients were matched for age, sex, race, diagnosis,
and surgical procedure.
Patients A total of 258 children, aged 2 to 18 years, scheduled for tonsillectomy
with or without adenoidectomy during a 27-month period.
Setting A tertiary care academic medical center.
Results Forty-seven children (18.2%) were determined to have asymmetric tonsils.
There were 43 matched controls with symmetric tonsils. Three-dimensional quantitative
measurements of the resected tonsils revealed little or no actual asymmetry
in tonsil size even though preoperative intraoral observations gave the impression
that one tonsil was larger than the other. Statistically, tonsillar asymmetry
was more apparent than real. When measured by volume, there was asymmetry
in both groups. However, there was no statistical difference in the degree
of asymmetry between the groups (P = .50). A difference
in the depth of the tonsil fossa contributed to the putative asymmetry (P<.001). No malignant neoplasms were identified on microscopic
examination in either group.
Conclusions Tonsillar asymmetry in children may often be an illusion secondary to
a difference in the depth of the tonsillar fossa. Tonsillar asymmetry in children
in the absence of other findings such as ipsilateral cervical adenopathy or
other constitutional symptoms may not indicate a malignancy.
INTRODUCTION
LYMPHOID TISSUE in the Waldeyer ring is sparse at birth. This is followed
by a period of proliferation and eventual involution.1
The proliferation is a true hyperplasia induced by immunologic activity, notably
expansion of B cells.1-2 Occasionally
there is unilateral tonsillar enlargement or asymmetry. Significant asymmetry
of the tonsils, especially if there is rapid enlargement, may portend a serious
underlying disorder such as lymphoma, lipid storage disease, or Langerhan
cell histiocytosis.2-5
In adults, there is a fair degree of consensus on the need for tonsillectomy
with microscopic examination of an asymmetric or unilaterally enlarged tonsil.5-7 The evaluation and treatment
of children with asymmetrically enlarged tonsils continues to be an area of
debate. This study seeks to elucidate and further the discussion by prospectively
examining comparative tonsil size in a cohort of children who have indications
for surgery other than a suspected tumor.
PATIENTS AND METHODS
Prospective data were recorded on children aged 2 to 18 years undergoing
tonsillectomy with or without adenoidectomy during the study period. Children
with an asymmetric tonsillar presentation were eligible to be included in
the study group. Children with a history of human immunodeficiency virus–acquired
immunodeficiency syndrome, immunosuppression, transplantation, suspected current
or previously treated malignancy, and Down syndrome or other craniofacial
disorders were excluded. A history and preoperative physical examination results
were recorded on all children. Demographic information was collected, including
age, sex, and race. The indication for surgery was recorded. After patients
were under anesthesia, they were placed in suspension using Crowe-Davis or
a McIvor mouth gag. Once the child was suspended, details of tonsillar size
were noted using the classification method of Brodsky: 4+ if the tonsils occupied
greater than 75% of the airway, 3+ if they occupied 50% to 75% of the airway,
2+ if they occupied 25% to 50% of the airway, and 1+ if they occupied less
than 25% of the airway.2 Tonsillar asymmetry
was determined to be present when there was at least a +1 difference in the
2 tonsils. Also, the degree of tonsillar fossa depth was assessed.
All tonsils were removed by a cautery technique. The resected specimens
were labeled as to the proper side and submitted in a fresh state for pathological
examination. All specimens were measured for length, width, and depth. Both
gross and microscopic features were recorded.
A control group of children with apparent symmetric tonsils who were
undergoing tonsillectomy with or without adenoidectomy was matched by age,
sex, race, indications for surgery, and surgical procedure performed. Similar
measurements and pathologic assessments were made for the control group.
Statistical analysis was performed with a commercially available software
package (Instat2, San Diego, Calif). P<.05 was
determined to be significant.
RESULTS
Two hundred fifty-eight children underwent tonsillectomy with or without
adenoidectomy during the study period. Forty-seven children were determined
to have some degree of tonsillar asymmetry (18.2%). The age range for the
study group was 2 to 13 years. There were 23 boys aged 2 to 10 years with
a mean age of 5.3 and a median age of 5 years. There were 24 girls aged 2
to 13 years with a mean age of 5.9 and a median age of 5.5 years.
The indications for surgery for the boys and girls in the asymmetric
group were similar. Fourteen boys and 15 girls had surgery for airway symptoms
(62%), 6 boys and 6 girls had surgery for a combination of airway symptoms
and recurrent tonsillitis (26%), while only 3 girls and 3 boys had surgery
for recurrent tonsillitis (13%).
There were 43 matched controls who had the same indications for surgery
and underwent the same procedures during the study period. Children in the
control group were aged 2 to 11 years. There were 24 girls aged 2 to 11 years
with a mean age of 5.8 years and a median age 5.5 years. There were 19 boys
aged 2 to 11 years with a mean age of 5.2 years and a median age of 5 years.
Fifteen girls and 14 boys had surgery for airway symptoms (67%), 7 girls and
2 boys had surgery for a combination of airway symptoms and recurrent tonsillitis
(21%), while 2 girls and 3 boys had surgery for recurrent tonsillitis (12%).
No child was determined to have more than 25% degree of asymmetry as
measured by the method of Brodsky.2 When measured
by volume, there were no statistical differences in the size of the tonsils
in the 2 groups (P = .50). The apparent asymmetry
resulted from the depth of the tonsillar fossae (P<.001).
No child was determined to have significant cervical adenopathy or hepatosplenomegaly.
All children underwent tonsillectomy with or without adenoidectomy.
Neither group demonstrated malignancy or unusual pathological findings
on histologic examination. Actinomyces species were
noted in both the study group and the control group specimens, but there was
not a statistical difference.
COMMENT
The central issues in children with asymmetric or unilateral tonsillar
enlargement are the possibility of a significant underlying disorder and whether
tonsillectomy is warranted. Certain children are predisposed to tonsillar
malignancy. These include immunosuppressed children and those who have undergone
transplantation. There is no argument that in such patients any tonsillar
asymmetry may portend serious pathological conditions. Also, if the tonsil
has an unusual color or appearance, tonsillectomy is prudent. The dilemma
exists when a child is healthy except for symptoms related to recurrent throat
infections or obstructive breathing.
In the present study there were no cases of significant unilateral tonsillar
enlargement. Only mild tonsillar asymmetry was demonstrated. Asymmetry appeared
to be more a function of the depth of the tonsillar fossa instead of an indication
of a true difference in size. Comparison of the study patients (asymmetric
group) with the control patients (symmetric group) illustrated this phenomenon
effectively. Furthermore, even in tonsils that clinically appeared symmetric,
there often was some asymmetry. When comparing the clinically asymmetric group
with the clinically symmetric group, there was no statistical difference in
the degree of asymmetry. Asymmetry occurred in children whose indications
for surgery were both infection as well as obstruction. The only difference
was in the relative size of the tonsils. It was also observed that children
whose only indication for surgery was infection had small but asymmetric tonsils,
while children with obstructive symptoms with or without a history of recurrent
infection had moderated to marked enlargement of the tonsils. These findings
were noted in both the control and study groups. No evidence of lymphoma or
other significant disorder was noted in either group.
The possibility of a lymphoma is the greatest concern in assessing children
with asymmetric tonsils. Most lymphomas of the tonsils are the non-Hodgkin
type. These are usually B cell in origin. Rarely are patients with tonsillar
lymphoma asymptomatic. The symptoms include sore throat, dysphagia, and otalgia.
Cervical adenopathy is also often present. In a retrospective study of children
aged 2 to 13 years, Berkowitz and Mahadevan3
failed to find any lymphoma in the absence of significant systemic symptoms,
cervical adenopathy, or hepatosplenomegaly. They reviewed the records of 46
Australian children with unilateral tonsil enlargement who underwent tonsillectomy
for the purpose of biopsy. They compared these 46 children with 7 children
who had tonsillar lymphoma. Fewer than one half of the 46 had any otolaryngologic
symptoms and none had systemic symptoms or cervical adenopathy. In contrast,
86% of the children with lymphoma showed symptoms. These included night sweats,
fevers, significant cervical adenopathy, and hepatosplenomegaly.3
Reiter et al6 reviewed 1280 patients 18 years
and older who underwent tonsillectomy. In 31 cases of tonsillar asymmetry
there were 2 cases of malignant lymphoma. Dohar and Bonilla5
reviewed 2012 adenotonsillectomies or tonsillectomies and discovered only
1 case of lymphoma. The lymphoma was suspected before surgery because of "dramatic
asymmetry between the right and left tonsils."5
In a retrospective study of adults and children, Alvi and Vartanian7 did not find any significant disease in 3 cases of
tonsillar asymmetry. Their study revolved around the issue of microscopic
examination of resected tonsils. They concluded that microscopic examinations
should be carried out only in cases of gross asymmetry.
CONCLUSIONS
Tonsillar asymmetry is usually secondary to benign hyperplasia. The
asymmetry is often an illusion created by a difference in the depth of the
tonsillar fossae. However, rapid onset of unilateral tonsillar enlargement
which is associated with fever, weight loss, night sweats, symptoms in the
aerodigestive tract, significant cervical adenopathy, and/or hepatosplenomegaly
may indicate a serious underlying disorder such as lymphoma or other serious
disease processes. Children with unusual circumstances such as having had
transplantation or with immunosuppression may be at higher risk for tonsillar
disorders.
RECOMMENDATIONS
Based on these conclusions, the following recommendations are suggested:
- Children may be observed if there is only mild asymmetry and there
are no other indications for surgery such as recurrent tonsillitis or obstructed
breathing.
- Tonsillectomy should be strongly considered in children who have
significant tonsillar asymmetry associated with rapid onset of enlargement,
prominent cervical adenopathy, and/or hepatosplenomegaly with or without constitutional
symptoms such as weight loss, fever, and night sweats.
- Children with unilateral tonsillar enlargement who have significant
dysphagia and other aerodigestive symptoms should be considered for tonsillectomy.
- Surgery is warranted for any tonsillar asymmetry or rapid tonsillar
enlargement in transplant recipients or immunosuppressed patients.
AUTHOR INFORMATION
Accepted for publication December 5, 2001.
This study was presented in part at the American Society of Pediatric
Otolaryngology meeting, Palm Desert, Calif, April 29, 1999.
Corresponding author and reprints: Earl H. Harley, MD, Georgetown
University Hospital, Department of Otolaryngology–Head and Neck Surgery,
3800 Reservoir Rd NW, Washington, DC 20007 (e-mail: Harleye{at}gunet.georgetown.edu).
From the Department of Otolaryngology–Head and Neck Surgery,
Georgetown University Hospital, Washington, DC.
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