Is routine pathological examination required in South African children undergoing adenotonsillectomy?

ORIGINAL ARTICLES Is routine pathological examination required in South African children undergoing adenotonsillectomy? Anton C van Lierop, C A J Prescott Objective. We aimed to determine the incidence of abnormal pathological findings in the tonsils and/or adenoids of children undergoing tonsillectomy and/or adenoidectomy, and the incidence of tuberculosis of the tonsils and adenoids; suggest criteria to identify children at risk for adenotonsillar tuberculosis; and investigate the association between HIV and adenotonsillar abnormality, the cost-effectiveness of routine pathological examination of adenotonsillectomy specimens, and criteria to decide which specimens to send for histological examination. Methods. We undertook an 8-month prospective study on all children (≤12 years) undergoing consecutive tonsillectomy or adenotonsillectomy (T&A) at Red Cross War Memorial Children’s Hospital. Patients were assessed pre-operatively and tonsil sizes graded pre- and intra-operatively. Blood was taken for HIV testing, and all tonsils and adenoids were examined histologically. A cost-benefit analysis was done to determine the cost-effectiveness of adenotonsillectomy routine pathology. Tonsillectomy and adenotonsillectomy are commonly performed on children.1 The indications are recurrent tonsillitis, obstructive sleep apnoea, peritonsillar abscess or suspicion of a serious underlying disorder. Tonsillar lymphoma is the major pathology of concern, but in South Africa and other countries with a high incidence of HIV infection adenotonsillar tuberculosis must also be considered.2 Routine histological examination of tonsillectomy and adenoidectomy specimens is performed in many parts of the world so as not to miss rare but significant pathological findings, to serve as a quality control measure, and to teach pathology to residents and fellows.1,3,4 However, the costeffectiveness of this routine examination has been questioned.2-9 Most studies are in developed countries,3,5-9 where the tonsils and adenoids disease spectrum differs from that of developing countries. Because of financial constraints at Red Cross War Division of Otolaryngology, University of Cape Town Medical School Anton C van Lierop, MB ChB, FCORL (SA), MMed (ORL) Department of Paediatric Otolaryngology, University of Cape Town Medical School C A J Prescott, MB ChB, FRCS (Eng) Corresponding author: A C van Lierop () November 2009, Vol. 99, No. 11 SAMJ Results. A total of 344 tonsils were analysed from 172 children (102 boys, 70 girls); 1 patient had nasopharyngeal tuberculosis, and 1 lymphoma of the tonsils; 13 (7.6%) patients had clinically asymmetrically enlarged tonsils but no significant abnormal pathological finding. The average cost of detecting a clinically significant abnormality was R22 744 (R45 488 ÷ 2 abnormalities). Conclusions. The following criteria could improve cost-effectiveness of pathological examination of adenotonsillectomy specimens: positive tuberculosis contact at home, systemic symptoms of fever and weight loss, cervical lymphadenopathy >3 cm, suspicious nasopharyngeal appearance, HIV-positive patient, rapid tonsillar enlargement or significant tonsillar asymmetry. On our evidence, routine pathological investigation for South African children does not seem to be justified. S Afr Med J 2009; 99: 805-809. Memorial Children’s Hospital (RCH) in Cape Town, histological analysis is requested only if a high index of suspicion for significant pathology exists. The cost-effectiveness of routine histology on adenotonsillectomy specimens in South African children is unknown. The high prevalence of tuberculosis and HIV in RCH’s Western Cape drainage area make circumstances different to those in developed countries. An HIV-positive patient is 30 times more likely to develop active tuberculosis, once infected. In South Africa, 40% of tuberculosis patients are HIV-positive. The incidence of pulmonary tuberculosis in the Western Cape in 1998 was 430/100 000.10 This figure had risen to 832/100 000 in 2002, owing mainly to the rising incidence of HIV infection. The prevalence of HIV-infected individuals in 2002 in the Western Cape was 12%. At the turn of the previous century, before the advent of chemotherapy, 1.4% of all adenoids and 6.5% of all tonsils removed from asymptomatic patients were infected by tuberculosis.11 A high index of suspicion is needed to diagnose nasopharyngeal tuberculosis, owing to a lack of clinical signs. Criteria to identify adult patients at increased risk of tonsil malignancies have been suggested,7 and clinical criteria in the paediatric population to identify tonsillar lymphoma have been delineated.12 The risk of lymphoma in HIV-positive patients is 100 times that in the general population. Despite the high incidence of tuberculosis and HIV infection in the Western 805 ORIGINAL ARTICLES Cape, the incidence of HIV-related tonsillar abnormalities and adenotonsillar tuberculosis remains largely unknown. one clinically significant finding could be determined. Results were considered statistically significant if p<0.05. Objectives Results We aimed to: (i) describe the incidence of abnormal pathological findings in the tonsils and/or adenoids of children undergoing tonsillectomy or adenotonsillectomy at RCH; (ii) determine the incidence of tuberculosis of the tonsils and adenoids in children of the local population; (iii) suggest criteria to identify children at risk for adenotonsillar tuberculosis; (iv) determine the association between HIV and adenotonsillar abnormalities, including HIV-related lymphomas involving Waldeyer’s ring; and (v) determine the cost-effectiveness of routine pathological examination of adenotonsillectomy specimens in our setting, and to suggest criteria to decide which specimens to send for histological examination. A total of 344 tonsils were analysed, from 172 children (102 boys, 70 girls) who had had a tonsillectomy or adenotonsillectomy. The mean age was 5.6 years (range 1 - 12 years). Adenotonsillectomies were performed on 154 (89.5%) children and tonsillectomy alone on 18 (10.5%) children. The clinical findings are summarised in Table I. Ten (5.8%) children had tuberculosis contacts and 4 (2.2%) had been treated for prior pulmonary tuberculosis. Thirteen (7.6%) children had clinically asymmetrical tonsil enlargement. The most common indications for surgery were recurrent tonsillitis (41%), obstructive sleep apnoea (31%), and a combination of the above (19%) (Table II). Material and methods We conducted a prospective study on all children (≤12 years) undergoing routine consecutive tonsillectomy or adenotonsillectomy (T&A) at RCH during an 8-month period. We obtained approval from the University of Cape Town ethics committee, and informed consent was obtained for HIV testing. Patients were clinically assessed pre-operatively and the following data collected: indication for surgery, known tuberculosis contacts, constitutional symptoms (w (...truncated)