Are Histologic Studies of Adenotonsillectomy Really Necessary?

Original Article Are Histologic Studies of Adenotonsillectomy Really Necessary? Giseli Rebechi1 Thiago Euênio Pontes1 Cícero Matsuyama1 Elias Lobo Braga1 1 Setor de Otorrinolaringologia, Instituto CEMA, São Paulo/SP, Brasil Int Arch Otorhinolaryngol 2013;17:387–389. Abstract Keywords ► tonsillar neoplasms ► tonsillectomy ► adenoidectomy Fernando Rebechi1 Address for correspondence Giseli Rebechi, Avenida Indianópolis, 740, Bairro, Moema, CEP 04062-001, São Paulo/SP, Brasil (e-mail: ). Introduction In most ear, nose, and throat services, it is routine to send the material extracted from tonsillectomy for histologic study to research malignancy, to analyze suspect material, or to provide medical-legal documentation. Recent studies have shown that this routine analysis is dispensable. Objective To evaluate the actual need and perform a cost–benefit analysis of routine histopathologic examination in tonsillectomy with no signs or symptoms of malignancy. Methods A retrospective observational study evaluated the charts of patients undergoing adenotonsillectomy, tonsillectomy, or adenoidectomy from January 2008 to September 2009 at the Institute of Otorhinolaryngology CEMA-SP. Costs of this test for the public health system were analyzed and the literature reviewed. Results We studied 281 patients between 2 and 22 years of age; 142 (50.5%) were male and 139 (49.5%) were female. Of the surgeries, 201 were adenotonsillectomies (71.5%), 41 were tonsillectomies (14.5%), and 39 were adenoidectomies (14%). The most common indication for surgery was recurrent infection (63.3%). None of study patients had clinical suspicion of malignancy. The tests showed a cost of R$20.03 per tonsil analyzed. Conclusion Routine histopathologic examination in patients undergoing adenotonsillectomy with no signs or symptoms of malignancy is dispensable and increases the cost of the surgeries. Introduction Adenotonsillectomy is surgery to remove the tonsils and adenoids, and it is one of the most common and most frequently performed surgical procedures in the world.1,2 Its different indications can be divided into therapeutic, diagnostic, as well as access to other surgeries. Sleep apnea syndrome, hypertrophic tonsils and adenoids, chronic tonsillitis, halitosis, and suspicion of malignancy are indications for adenotonsillectomy, but the most frequent indication is recurrent tonsillitis. Most otolaryngology services routinely send adenotonsillectomy specimens for histopathologic examination, whether received June 8, 2013 accepted July 11, 2013 Willian Maduel Matos1 for malignancy investigation, analysis of suspect material, or medicolegal documentation of surgical removal.1 Recent studies have shown that routine histopathologic analysis of the tonsil is dispensable, because they have a very low probability of diagnosing occult malignancies. Unfortunately, this risk is still not zero, so the need for routine histopathology is still controversial. Objective Define the real need for routine histopathologic examination of adenotonsillectomy specimens and perform a cost–benefit analysis of its use in patients without risk factors for malignancy. Copyright © 2013 by Thieme Publicações DOI http://dx.doi.org/ Ltda, Rio de Janeiro, Brazil 10.1055/s-0033-1353441. ISSN 1809-9777. 387 388 Are Histologic Studies of Adenotonsillectomy Really Necessary? Materials and Methods Table 1 Results of histopathologic examination of the tonsils This retrospective observational study evaluated the records of all patients who had adenotonsillectomy, tonsillectomy, or adenoidectomy from January 2008 to September 2009 at the CEMA Institute of Otorhinolaryngology, São Paulo, Brazil. This project was approved by the Ethics and Research Institution under the protocol 17.205/2009. Patients or their guardians signed an informed consent form, shown in Appendix 1. Data analysis was performed using descriptive statistics, and the results are presented in absolute numbers. We excluded patients with malignancy symptoms and signs. All patients underwent general anesthesia and tonsillectomy by extraction dissection technique. The pharyngeal tonsils were removed with a Beckmann curette. Specimens were immediately placed in sterile glass with 10% formalin and sent for histologic analysis. The tonsils were fixed in 10% formalin and embedded in paraffin, and sections were stained with hematoxylin-eosin. We studied the results of the histopathologic examinations, regardless of age, sex, and indication for surgery. We also analyzed the cost of this test for the public health system, and we reviewed the literature. Results A total of 281 patients were recruited, between 2 and 22 years old. Of them, 142 (50.5%) were male and 139 (49.5%) were female. Most patients had tonsil hypertrophy grade III according to the Brodsky classification and pharyngeal tonsil hypertrophy documented by nasofibrolaryngoscopy. Of the surgeries, 201 were adenotonsillectomies (71.5%), 41 were tonsillectomies (14.5%), and 39 were adenoidectomies (14%). The most common surgical indications were recurrent tonsillitis (63.3%) and obstructive sleep apnea syndrome (38.7%). None of the patients in our study had clinical suspicion of malignancy. Results of the pathologic examinations of tonsils and adenoids are shown in ►Tables 1 and 2. The tests cost R$20.03 per piece analyzed; the adenotonsillectomy surgery has three pieces, reaching a total of R$60.09 per surgery. Discussion Tonsils with malignant processes present different aspects than benign lesions on clinical examination; physical examination and medical history can be important guides. These lesions may start with nonspecific symptoms and insidious symptoms, and they are usually diagnosed in patients over 60 years old. Smoking and alcoholism are risk factors. According Beaty et al,3 risk factors for tonsillar malignancy include history of head and neck cancer, tonsillar asymmetry, visible lesion, ulcerated or hard consistency on palpation of the tonsil, unexplained weight loss or constitutional symptoms, and cervical lymphadenopathy. Usually the patient starts with dysphagia without signs of acute infection with ipsilateral otalgia, difficulty in mobility of the tongue, nasal voice, halitosis, and nasal reflux. Symptoms such as changes in tone of voice, drooling, bloody saliva, and trismus indicate deep infiltration of the tumor. International Archives of Otorhinolaryngology Rebechi et al. Vol. 17 No. 4/2013 Exam result Number of tonsils Percentage CT with LH 282 58.3 CT with LH and suppurative foci 96 19.9 CT with LH with areas of surface erosion 44 9 CT with LH with colonies of actinomyces 46 9.6 CT with LH and submucous fibrosis 2 0.4 CT with recent hemorrhage 4 0.8 Nonspecific CT 6 1.2 Papilloma squamous cells 4 0.8 Total 484 100 Abbreviations: CT, chronic tonsillitis; LH, lymphatic hyperplasia. Table 2 Results of histopathologic examination of the pharyngeal tonsils Exam (...truncated)