Cost and Value of Routine Histopathologic Analysis after Adenoidectomy and Tonsillectomy

THIEME Original Research Cost and Value of Routine Histopathologic Analysis after Adenoidectomy and Tonsillectomy Berit Hackenberg1 Magdalena Pölzl1 Christoph Matthias1 1 Department of Otolaryngology and Head and Neck Surgery, University Hospital Mainz, Mainz, Germany Julian Künzel1 Address for correspondence Julian Künzel, MD, Head and Neck Surgery, University Hospital of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany (e-mail: ). Int Arch Otorhinolaryngol 2020;24(4):e429–e433. Abstract Keywords ► tonsillectomy ► adenoidectomy ► pathology ► neoplasms Introduction Tonsillectomy and adenoidectomy are common procedures. Most surgeries in children and young adults are recommended due to recurring infections or obstructive constraints. However, occult malignant findings are reported in the literature. The clinical guidelines still refrain from recommending routine histopathologic analyses when discussing these procedures. Objective The present study aims to define the value of a routine histopathologic analysis after tonsillectomy, adenoidectomy and tonsillotomy. Methods We conducted a prospective survey including all German ear, nose and throat (ENT) departments, asking physicians about their current clinical practice and opinion. Furthermore, we reviewed all patients attending our department for tonsillectomy/adenoidectomy/tonsillotomy or a combination of these procedures between 2011 and 2016. In addition to this, a cost analysis was conducted to assess the financial burden of a routine histopathologic analysis. Results Most German ENT departments perform a routine histopathologic analysis after tonsillectomy/adenoidectomy/tonsillotomy. Despite this, only a minority deemed this approach necessary. Our retrospective review of the histopathologic analysis after tonsillectomy/adenoidectomy/tonsillotomy in our department rendered a cohort size of 2,157 patients. Within this group, there were no occult malignant findings. We found a yearly burden of 2,509,401€ for routine histopathologic analyses in patients under the age of 15 years in Germany in 2016. Conclusion We found a divergence between the physicians opinions and their current clinical practice concerning the question of whether to conduct routine histopathologic analyses. Even though there was no occult malignant finding in our cohort, unsuspected malignant findings are reported in the literature. Therefore, we call for a discussion on clinical practice guidelines. Introduction Tonsillectomy (TE) and adenoidectomy (AE) are two of the most common surgeries conducted on a daily basis in Germany.1 There are many reasons to indicate these procedures. The tonsils and adenoids belong to the lymphoid tissue, and they are known as Waldeyer tonsillar ring. As the body’s received March 3, 2019 accepted November 11, 2019 DOI https://doi.org/ 10.1055/s-0039-3402493. ISSN 1809-9777. first defense against antigens and pathogens entering the aerodigestive tract, they play a key role in the development of a competent immune system. Therefore, the diseases prone to attack this tissue start affecting the patients from an early age. In children, tonsillar hyperplasia can be a common cause of obstructive sleep apnea, difficulties in swallowing, and Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil 429 430 Routine Histopathology after Tonsillectomy Hackenberg et al. general growth retardation.2–5 Moreover, adenoid hyperplasia can restrict middle ear ventilation and lead to effusions, conductive hearing loss, and, eventually, a delay in the child’s speech development.6,7 Furthermore, infectious diseases of the tonsils are common in all age groups, with a peak in incidence in early school ages and among young adults.8 Acute tonsillitis can be caused by a variety of viruses and bacteria, and the bacterial form can lead to the formation of abscesses and require emergency surgery. With increasing age, the tonsils, albeit decreasing in size and function, are prone to be the sight of oropharyngeal tumors. While squamous cell carcinomas are mostly restricted to older patients, malignant diseases of the lymphatic tissue can occur in all age groups.9 When the clinical signs of malignancy are lacking, sometimes these tumors are diagnosed only through a thorough histopathologic investigation. Retrospective reviews regarding occult malignancies (defined as malignant findings in the histopathologic analysis without a clinical suspicion prior to surgery) after TE, AE and tonsillotomy (TT) present cohort sizes ranging from 61 to 15,120 patients.10,11 In 1 study,12 the rate of occult malignant findings was as high as 2.3%. Despite the frequency of TE and AE, the question of whether to examine the specimen histopathologically – especially in young patients and without suspicion of a malignant disease – seems to remain unclear, and is not discussed in the current clinical practice guidelines.8,13–15 The present article seeks to answer this question through a retrospective review of all tonsillectomies and adenoidectomies conducted in children and adults at the Department of Otolaryngology of a German university hospital in Mainz between 2011 and 2016 regarding the histopathological reports. In addition, a prospective survey was sent to all German ear, nose and throat (ENT) departments asking for their proceedings and opinion. Method Prospective Survey of ENT departments in Germany A prospective survey was conducted including all German ENT departments. Names and addresses of all departments were provided by the German Society of Otorhinolaryngology and Head and Neck Surgery (Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e.V., Bonn, DGHNO-KHC).16 A questionnaire developed by the authors was sent to all departments, and it contained five questions with many subitems. The first three questions were on the ENT departments standard procedure concerning routine histopathologic analyses of the specimens after TE and TT in children or adults, and after AE in children. In the fourth item, the ENT doctors were asked about their opinion concerning routine histopathologic analyses of the specimens after AE in children and after TT or TE in children or adults. All items asked explicitly about surgeries with inconspicuous anamnesis and without clinical findings to focus on routine procedures. The questions were dichotomous, and could be answered with yes or no. A fifth item asked for individual comments and was International Archives of Otorhinolaryngology Vol. 24 No. 4/2020 phrased as an open question. The original questionnaire is provided in the appendix. Retrospective Review of Histopathologic Reports in University Hospital Mainz A retrospective review of histopathologic reports in the ENT department at University Hospital Mainz was completed by searching the department’s electronic medical records (EMRs) for all AE, TT and TE procedures performed during January 2011 and N (...truncated)