Vol. 68, No. 6
525
Tonsillectomy: An Excision Biopsy ALBERT P. SELTZER, M.D., Department of Otolaryngology, St. Luke's and Chiildren's Medical Center, Phliladelphlia, Pennsylvania
EXTREME conservatism in regard to tonsillectomy is the trend at present, but it can reach the danger of neglect.1 At one time, not many years ago, tonsillectomy was the most common of all surgical procedures. Now, even in children, when a tonsillectomy is considered, it should be an excision biopsy when indicated. At the other extreme is the older patient, especially those past 65 years of age who complain of frequent sore throats and fever associated with signs of tonsillitis. Certainly, in the older patient, tonsillectomy is an excision biopsy. The pendulum continuously swings back and forth on what to do in many surgical and medical conditions. There were so many things done and continue to be carried out, not the same treatments, which were considered or thought to be medically indicated but are now outdated. You may recall the treatment of gonorrheal urethritis in the male, for example. We had these patients stand in stalls, like horses, and treated them with a solution of potassium permanganate that stained purple on contact. A rubber tube with a nozzle on the end was inserted deep into the affected urethra and the area irrigated with the potassium permanganate solution. Little did we realize that the infections were driven into the urinary bladder, frequently up the ureter with entry to the kidney. With the coming of sulfonamides and then antibiotics, the treatment changed completely. Treatment on tonsillitis also became different, and tonsillectomy far less frequent, despite better anesthesia, ready intubation and better trained otolaryngologists. The child needs his tonsils. He is three years old or older before these small rounded masses of lymphoid tissue are fully developed. However, when one or both are hypertrophied to the point of pharyngeal obstruc-
tion or when there are frequent recurrent tonsil infections, with or without peritonsillar abscesses and cervical lymphadenopathy, tonsillectomy is advisable. It is also recommended to prevent the recurrence of hearing loss and suppurative otitis media or both. A fetid mouth odor, other causes being excluded, may be due to an uncommon tonsillar infection, as the following two cases, in which tonsillectomy was done for excision biopsy, illustrate. CASE REPORTS
Case 1. A 26 year old male had a history of frequent sore throats and a foul breath odor for which no cause but a chronic tonsillitis was noted. Chest X-rays were negative. A tonsillectomy was done under local anesthesia on June 19, 1975. Pathological examination of the diseased tonsils revealed clusters of fungi consistent with actinomyces. His recovery was uneventful.
.7
,~~~~~~~~~~~~~
.-.
~
~
~
~
~
~
~
~
~
~
Fig. 1. Photomicrograph of ray fungus in the tonsil. Low power view, left. High power view, right.
Case 2. A 23 year old female complained of a cough and a bad odor on her breath for which no other source but a chronic tonsillitis was noted. Chest X-rays showed some type of lung infection. A tonsillectomy was done under local anesthesia on October 3, 1975. Pathological examination of the diseased tonsils revealed the presence of ray fungi (Fig. 1). She was also treated with anti-fungal antibiotics and the changes in her chest X-rays disappeared.
Actinomyces, a group of microorganisms, consists of three pathogenic species: 1) A.
526
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
baudetii, an etiologic agent of actinomycosis in cats and dogs; 2) A. bovis, a non-acid fast anaerobic microorganism that occurs in cattle; and 3) A. israeli, a non-acid fast aerobic parasite in the mouth that proliferates in necrotic tissue, usually, and occurs as the etiologic agent in some cases of human actinomycosis. In these two patients, the excision tonsillar biopsies revealed A. israeli, a gram positive branching filament organism. It is less toxic than A. bovis because the oxidation-reduction potential is too high for multiplication. A. israeli is also seen in other areas of the oral cavity, such as the gums, and can spread to the lungs as well as to other parts of the body to become a serious infection. A. israeli may be characterized by suppuration, extension with necrosis, and fibrosis of the tonsils. Here, tonsillectomy is an excision biopsy that establishes the diagnosis. MALIGNANCY OF THE TONSIL
Lesions that lead to a suspicion of malignancy of the tonsil are benign hyperplasia or papilloma and recurrent leukoplakia or papillomatosis. Malignant tumors of the tonsil are squamous cell carcinoma in situ, lymphosarcoma, and the undifferentiated squamous cell carcinoma.28 Adenolymphoma, an adenoma of a lymph organ known as Warthin's tumor, usually benign, is an epithelial neoplasm with a gland like structure that may occur in the tonsil. It is logical to assume also that salivary tissue may well be included in lymphoid structures elsewhere in the head and neck. Thus, the presence of ectopic salivary tissue, especially the duct epithelium, within the tonsil can explain the development of an adenolymphoma there. Due to the current conservative attitude on tonsillectomy, how many cases of malignancy of the tonsil, especially in the over 65 patient, are being overlooked? Much as I have advised the older patients to have a tonsillectomy for excision biopsy purposes when indicated, the usual answer is, "Doctor, I'm too old to have my tonsils out."
NOVEMBER, 1976
Frequently, I would learn later from relatives of these patients that a malignancy was present, had spread to other organs, and the patients died from the metastases. To neglect the surgical procedure of tonsillectomy, when indicated, in older patients could be an invitation to disaster, especially when there is a long history of smoking or chewing tobacco or both. Examination of the tonsillar areas in such patients may reveal one tonsil much larger than its mate, perhaps with a finger-like projection from its surface. Even a patch of leukoplakia on one tonsil, free from any associated areas on the palate or pharynx, and no palpable cervical glands, should not only arouse suspicion of a malignancy, but calls for a tonsillectomy as an excision biopsy. This is the stage to determine if there is a squamous cell carcinoma of the tonsil for such a malignancy does not respect the anatomic boundaries of the tonsillar area for long. CASE REPORTS
Case A. A 67 year old male complained of a sore throat and dysphagia for many weeks. He had a history of frequent peritonsillar abscesses which had been treated on various occasions and he had been advised to have a tonsillectomy done. When I examined him, the left tonsil was twice the size of the right, causing almost complete obstruction of the pharynx. Finger palpation revealed a hard left tonsil, not painful. There were no submaxillary nodules and no glands palpable. Because of the size and firmness of the left tonsil, the patient was referred to an oncologist for treatment. Had the patient followed the earlier advice of having a tonsillectomy done, he might have had a better outlook. Case B. A 30 year old male had a tonsillectomy at another hospital by a general surgeon. A complete pathological examination of the tonsil specimens was not recorded. Two weeks later the patient bled from the tonsillar area and returned to the same surgeon; the bleeding was controlled. After six weeks, the patient was referred to me by the same surgeon. There was lingual tonsil tissue still present and a tonsillectomy was scheduled for biopsy purposes. Upon removing the lingual tonsil tissue under general anesthesia, the patient hemorrhaged and all efforts to control the bleeding by suturing failed. The removed tissue was disposed of by the 0 R nurse, but a careful search was made. While the patient remained on the 0 R table for four hours he was given three blood transfusions, and the tissue was found in discarded gauze on the 0 R (Concluded on page 460)
460
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
the pancreas was the site of infection with mumps virus. SUMMARY
An 11-year-old girl developed diabetes mellitus while she was suffering with acute parotitis secondary to mumps infection. Convincing clinical signs of mumps, plus positive complement fixation tests, suggest that the mumps virus may well have been the causative factor, probably as a result of concomitant involvement of the pancreas. ACKNOWLEDGMENTS
The authors are indebted to Mr. L. Westerman, Chief of Immunology Section, Tennessee Department of Public Health, Nashville, Tennessee, for his assistance in doing complement fixation tests, and to Mrs. C. B. Bell, Administrative Secretary, Department of Pediatrics, for her invaluable assistance. LITERATURE CITED
1. HINDEN, E. Mumps Followed by Diabetes. Lancet, 1:1381, 1962. 2. MCCRAE, W. M. Diabetes Mellitus Following Mumps. Lancet, 1:1300, 1963.
NOVEMBER, 1976
3. BURCH, G. E. and C. Y. Tsui, J. M. HARB, and G. L. COLCOLOUGH. Pathologic Findings in the Pancreas of Mice Infected with Coxsackie Virus B4. Arch. Int. Med., 128:40, 1971. 4. Tsui, C. Y. and G. E. BURCH, and I. M. HARB. Pancreatitis in Mice Infected with Coxsackie Virus B4. Arch. Path., 93:379, 1972. 5. COLEMAN, T. J. and . R. GAMBLE, and K. W. TAYLOR. Diabetes in Mice After Coxsackie B4 Virus Infection. Br. Md. J., 3:25, 1973. 6. STEINKE, J. and W. K. TAYLOR. Viruses and the Etiology of Diabetes. Diabetes, 23:631, 1974. 7. NELSON, L. L. and A. L. NOTKIN. Viral Infections and Diseases of the Endocrine System. J. Infect. Dis., 124:94, 1971. 8. GUNDERSON, E. Is Diabetes of Infectious Origin? J. Infect. Dis., 41:197, 1927. 9. CRAIGHEAD, J. E. News from the National Institutes of Health: Workshop on Viral Infection and Diabetes Mellitus in Man. J. Infect. Dis., 125:568, 1972. 10. MONIF, G. R. G. Can Diabetes Mellitus Result from an Infectious Disease? Hosp. Prac., 124, 1973. 11. SUITZ, A. H. and A. B. HART, and M. ZIELEZNY. Is Mumps Virus an Etiologic Factor in Juvenile Diabetes Mellitus? J. Pediat., 86:654, 1975.
(Seltzer, from page 526) LITERATURE CITED
floor. Biopsy of this tissue revealed a lymphosarcoma of the tonsil. A tracheotomy was done later, but the patient continued downhill during three weeks in the hospital and then expired. When first seen and during my surgery on him, I had given no thought of a malignancy of the tonsil, despite the history of bleeding following the original tonsillectomy which was not done as an excision biopsy.
The biopsy of any suspicious lesion is still the best way to diagnose an oral tumor. A tonsillectomy should be considered as an excision biopsy with full pathological examination of the removed tissue. Progress against cancer of the tonsil or any oral lesion need not wait basic discoveries; early detection is our best weapon. If the tonsillectomy, as an excision biopsy, reveals a malignant lesion, the patient may be referred to an oncologist for further treatment. If the malignancy is confined to the tonsil, the prognosis is good with surgery and other measures; if it extends beyond, the prognosis is poor.
1. BALL, S. Tonsillectomy: Never? Consultant, 13:30, 1973. 2. JAFEK, B. W. and R. C. HUNSICKER, and R. C. TINSLEY. Metastatic Melanoma Presenting as a Tonsil Polyp. Tran. Amer. Acad. Ophthal. and Otolaryngol., 80:431-433, 1975. 3. MALTZ, R. and D. A. SHUMRICK, B. S. ARON and K. A. WEICHERT. Carcinoma of the Tonsil: Results of Combined Therapy. Laryngoscope, 84:2172-2180, 1974. 4. NEAL, C. L. and J. B. SNOW, JR. and H. J. SEDA. An Analysis of Therapy for Carcinoma of the Tonsil. Trans. Amer. Acad. Ophthal. and Otolaryngol., 77:97-104, 1973. 5. PEREZ, C. A. and W. B. MILL, J. H. OGURA, and W. E. POWERS. Carcinoma of the Tonsil: Sequential Comparison of Four Treatment Modalities. Radiology, 94:649-659, 1970. 6. SCHULKIND, M. L. Tonsillectomy: A Cause of Immune Deficiency. Consultant, 13:95-97, 1973. 7. SELTZER, A. P. Lymphosarcoma: A Problem for the Nose and Throat Specialist. Ann. Oto. Rhinol. and Laryngol., 68:222-226, 1959. 8. SELTZER, A. P. Squamous Cell Carcinoma of the Tonsil, J. Natl. Med. Assoc., 25:486-488, 1965.
525
Tonsillectomy: An Excision Biopsy ALBERT P. SELTZER, M.D., Department of Otolaryngology, St. Luke's and Chiildren's Medical Center, Phliladelphlia, Pennsylvania
EXTREME conservatism in regard to tonsillectomy is the trend at present, but it can reach the danger of neglect.1 At one time, not many years ago, tonsillectomy was the most common of all surgical procedures. Now, even in children, when a tonsillectomy is considered, it should be an excision biopsy when indicated. At the other extreme is the older patient, especially those past 65 years of age who complain of frequent sore throats and fever associated with signs of tonsillitis. Certainly, in the older patient, tonsillectomy is an excision biopsy. The pendulum continuously swings back and forth on what to do in many surgical and medical conditions. There were so many things done and continue to be carried out, not the same treatments, which were considered or thought to be medically indicated but are now outdated. You may recall the treatment of gonorrheal urethritis in the male, for example. We had these patients stand in stalls, like horses, and treated them with a solution of potassium permanganate that stained purple on contact. A rubber tube with a nozzle on the end was inserted deep into the affected urethra and the area irrigated with the potassium permanganate solution. Little did we realize that the infections were driven into the urinary bladder, frequently up the ureter with entry to the kidney. With the coming of sulfonamides and then antibiotics, the treatment changed completely. Treatment on tonsillitis also became different, and tonsillectomy far less frequent, despite better anesthesia, ready intubation and better trained otolaryngologists. The child needs his tonsils. He is three years old or older before these small rounded masses of lymphoid tissue are fully developed. However, when one or both are hypertrophied to the point of pharyngeal obstruc-
tion or when there are frequent recurrent tonsil infections, with or without peritonsillar abscesses and cervical lymphadenopathy, tonsillectomy is advisable. It is also recommended to prevent the recurrence of hearing loss and suppurative otitis media or both. A fetid mouth odor, other causes being excluded, may be due to an uncommon tonsillar infection, as the following two cases, in which tonsillectomy was done for excision biopsy, illustrate. CASE REPORTS
Case 1. A 26 year old male had a history of frequent sore throats and a foul breath odor for which no cause but a chronic tonsillitis was noted. Chest X-rays were negative. A tonsillectomy was done under local anesthesia on June 19, 1975. Pathological examination of the diseased tonsils revealed clusters of fungi consistent with actinomyces. His recovery was uneventful.
.7
,~~~~~~~~~~~~~
.-.
~
~
~
~
~
~
~
~
~
~
Fig. 1. Photomicrograph of ray fungus in the tonsil. Low power view, left. High power view, right.
Case 2. A 23 year old female complained of a cough and a bad odor on her breath for which no other source but a chronic tonsillitis was noted. Chest X-rays showed some type of lung infection. A tonsillectomy was done under local anesthesia on October 3, 1975. Pathological examination of the diseased tonsils revealed the presence of ray fungi (Fig. 1). She was also treated with anti-fungal antibiotics and the changes in her chest X-rays disappeared.
Actinomyces, a group of microorganisms, consists of three pathogenic species: 1) A.
526
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
baudetii, an etiologic agent of actinomycosis in cats and dogs; 2) A. bovis, a non-acid fast anaerobic microorganism that occurs in cattle; and 3) A. israeli, a non-acid fast aerobic parasite in the mouth that proliferates in necrotic tissue, usually, and occurs as the etiologic agent in some cases of human actinomycosis. In these two patients, the excision tonsillar biopsies revealed A. israeli, a gram positive branching filament organism. It is less toxic than A. bovis because the oxidation-reduction potential is too high for multiplication. A. israeli is also seen in other areas of the oral cavity, such as the gums, and can spread to the lungs as well as to other parts of the body to become a serious infection. A. israeli may be characterized by suppuration, extension with necrosis, and fibrosis of the tonsils. Here, tonsillectomy is an excision biopsy that establishes the diagnosis. MALIGNANCY OF THE TONSIL
Lesions that lead to a suspicion of malignancy of the tonsil are benign hyperplasia or papilloma and recurrent leukoplakia or papillomatosis. Malignant tumors of the tonsil are squamous cell carcinoma in situ, lymphosarcoma, and the undifferentiated squamous cell carcinoma.28 Adenolymphoma, an adenoma of a lymph organ known as Warthin's tumor, usually benign, is an epithelial neoplasm with a gland like structure that may occur in the tonsil. It is logical to assume also that salivary tissue may well be included in lymphoid structures elsewhere in the head and neck. Thus, the presence of ectopic salivary tissue, especially the duct epithelium, within the tonsil can explain the development of an adenolymphoma there. Due to the current conservative attitude on tonsillectomy, how many cases of malignancy of the tonsil, especially in the over 65 patient, are being overlooked? Much as I have advised the older patients to have a tonsillectomy for excision biopsy purposes when indicated, the usual answer is, "Doctor, I'm too old to have my tonsils out."
NOVEMBER, 1976
Frequently, I would learn later from relatives of these patients that a malignancy was present, had spread to other organs, and the patients died from the metastases. To neglect the surgical procedure of tonsillectomy, when indicated, in older patients could be an invitation to disaster, especially when there is a long history of smoking or chewing tobacco or both. Examination of the tonsillar areas in such patients may reveal one tonsil much larger than its mate, perhaps with a finger-like projection from its surface. Even a patch of leukoplakia on one tonsil, free from any associated areas on the palate or pharynx, and no palpable cervical glands, should not only arouse suspicion of a malignancy, but calls for a tonsillectomy as an excision biopsy. This is the stage to determine if there is a squamous cell carcinoma of the tonsil for such a malignancy does not respect the anatomic boundaries of the tonsillar area for long. CASE REPORTS
Case A. A 67 year old male complained of a sore throat and dysphagia for many weeks. He had a history of frequent peritonsillar abscesses which had been treated on various occasions and he had been advised to have a tonsillectomy done. When I examined him, the left tonsil was twice the size of the right, causing almost complete obstruction of the pharynx. Finger palpation revealed a hard left tonsil, not painful. There were no submaxillary nodules and no glands palpable. Because of the size and firmness of the left tonsil, the patient was referred to an oncologist for treatment. Had the patient followed the earlier advice of having a tonsillectomy done, he might have had a better outlook. Case B. A 30 year old male had a tonsillectomy at another hospital by a general surgeon. A complete pathological examination of the tonsil specimens was not recorded. Two weeks later the patient bled from the tonsillar area and returned to the same surgeon; the bleeding was controlled. After six weeks, the patient was referred to me by the same surgeon. There was lingual tonsil tissue still present and a tonsillectomy was scheduled for biopsy purposes. Upon removing the lingual tonsil tissue under general anesthesia, the patient hemorrhaged and all efforts to control the bleeding by suturing failed. The removed tissue was disposed of by the 0 R nurse, but a careful search was made. While the patient remained on the 0 R table for four hours he was given three blood transfusions, and the tissue was found in discarded gauze on the 0 R (Concluded on page 460)
460
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
the pancreas was the site of infection with mumps virus. SUMMARY
An 11-year-old girl developed diabetes mellitus while she was suffering with acute parotitis secondary to mumps infection. Convincing clinical signs of mumps, plus positive complement fixation tests, suggest that the mumps virus may well have been the causative factor, probably as a result of concomitant involvement of the pancreas. ACKNOWLEDGMENTS
The authors are indebted to Mr. L. Westerman, Chief of Immunology Section, Tennessee Department of Public Health, Nashville, Tennessee, for his assistance in doing complement fixation tests, and to Mrs. C. B. Bell, Administrative Secretary, Department of Pediatrics, for her invaluable assistance. LITERATURE CITED
1. HINDEN, E. Mumps Followed by Diabetes. Lancet, 1:1381, 1962. 2. MCCRAE, W. M. Diabetes Mellitus Following Mumps. Lancet, 1:1300, 1963.
NOVEMBER, 1976
3. BURCH, G. E. and C. Y. Tsui, J. M. HARB, and G. L. COLCOLOUGH. Pathologic Findings in the Pancreas of Mice Infected with Coxsackie Virus B4. Arch. Int. Med., 128:40, 1971. 4. Tsui, C. Y. and G. E. BURCH, and I. M. HARB. Pancreatitis in Mice Infected with Coxsackie Virus B4. Arch. Path., 93:379, 1972. 5. COLEMAN, T. J. and . R. GAMBLE, and K. W. TAYLOR. Diabetes in Mice After Coxsackie B4 Virus Infection. Br. Md. J., 3:25, 1973. 6. STEINKE, J. and W. K. TAYLOR. Viruses and the Etiology of Diabetes. Diabetes, 23:631, 1974. 7. NELSON, L. L. and A. L. NOTKIN. Viral Infections and Diseases of the Endocrine System. J. Infect. Dis., 124:94, 1971. 8. GUNDERSON, E. Is Diabetes of Infectious Origin? J. Infect. Dis., 41:197, 1927. 9. CRAIGHEAD, J. E. News from the National Institutes of Health: Workshop on Viral Infection and Diabetes Mellitus in Man. J. Infect. Dis., 125:568, 1972. 10. MONIF, G. R. G. Can Diabetes Mellitus Result from an Infectious Disease? Hosp. Prac., 124, 1973. 11. SUITZ, A. H. and A. B. HART, and M. ZIELEZNY. Is Mumps Virus an Etiologic Factor in Juvenile Diabetes Mellitus? J. Pediat., 86:654, 1975.
(Seltzer, from page 526) LITERATURE CITED
floor. Biopsy of this tissue revealed a lymphosarcoma of the tonsil. A tracheotomy was done later, but the patient continued downhill during three weeks in the hospital and then expired. When first seen and during my surgery on him, I had given no thought of a malignancy of the tonsil, despite the history of bleeding following the original tonsillectomy which was not done as an excision biopsy.
The biopsy of any suspicious lesion is still the best way to diagnose an oral tumor. A tonsillectomy should be considered as an excision biopsy with full pathological examination of the removed tissue. Progress against cancer of the tonsil or any oral lesion need not wait basic discoveries; early detection is our best weapon. If the tonsillectomy, as an excision biopsy, reveals a malignant lesion, the patient may be referred to an oncologist for further treatment. If the malignancy is confined to the tonsil, the prognosis is good with surgery and other measures; if it extends beyond, the prognosis is poor.
1. BALL, S. Tonsillectomy: Never? Consultant, 13:30, 1973. 2. JAFEK, B. W. and R. C. HUNSICKER, and R. C. TINSLEY. Metastatic Melanoma Presenting as a Tonsil Polyp. Tran. Amer. Acad. Ophthal. and Otolaryngol., 80:431-433, 1975. 3. MALTZ, R. and D. A. SHUMRICK, B. S. ARON and K. A. WEICHERT. Carcinoma of the Tonsil: Results of Combined Therapy. Laryngoscope, 84:2172-2180, 1974. 4. NEAL, C. L. and J. B. SNOW, JR. and H. J. SEDA. An Analysis of Therapy for Carcinoma of the Tonsil. Trans. Amer. Acad. Ophthal. and Otolaryngol., 77:97-104, 1973. 5. PEREZ, C. A. and W. B. MILL, J. H. OGURA, and W. E. POWERS. Carcinoma of the Tonsil: Sequential Comparison of Four Treatment Modalities. Radiology, 94:649-659, 1970. 6. SCHULKIND, M. L. Tonsillectomy: A Cause of Immune Deficiency. Consultant, 13:95-97, 1973. 7. SELTZER, A. P. Lymphosarcoma: A Problem for the Nose and Throat Specialist. Ann. Oto. Rhinol. and Laryngol., 68:222-226, 1959. 8. SELTZER, A. P. Squamous Cell Carcinoma of the Tonsil, J. Natl. Med. Assoc., 25:486-488, 1965.
