When to remove tonsils/intersting case.

[danzman]

I am a recent med school graduate going into EM. My neighbor came over and asked for my advice on having her tonsils out. I normally give my stock " I cant help you, talk to your doctor" line, but this particular case struck me as interesting so I figured I would see if any of my ENT colleagues have an opinion on the matter.

23yr old female, no PMHX/PSHX, No FMHX, Meds or allergies. No smoking/drinking/drugs. Works around kids and at a bar on weekends.

Three months ago got a URI, chalked up to virus, got better in 3days. 2months ago had "pretty bad tonsillitis" went to urgent care, rapid strep neg, mono spot neg, chalked up to virus, got better in 5 days but had lingering lymphadenopathy. Went to urgent care because of swollen nodes on neck a few weeks later, did another strep and mono, and sent her for US of neck (?). Eventually she got two USs showing enlarged anterior nodes but they never changed size. Sent to ENT who noted unilateral swelling of tonsil and recommended tonsillectomy to "Rule out lymphoma."

This girl claims that she has felt great for the past 1.5 months, no sx at all, and didn't even notice that her tonsil was swollen. She claims that she was just worried about her swollen lymph nodes and is going to be out of the country for a few months pretty soon.

Part of the reason I ask this is because I know the ENT and he/she is known to jump at the chance to cut.

I, of course, told her that I couldn't help her and told her to talk to the ENT if she felt unsure about it.

But it does seem to strike me as a bit soon to yank out tonsils on a healty girl with two URIs, works around kids, has no R/F for cancer, and who has absolutly to Sx. So how long do you wait for swollen tonsils to go down before you start testing for stuff?


Tell me I'm wrong?


DanZ

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[OtoHNS]

Hard to say for sure based on what you've included here. Lymphoma can certainly present in young healthy people without symptoms.

I would want to examine her myself. Significant tonsillar asymmetry is a pretty reasonable indication for tonsillectomy though.

 

[danzman]

Hard to say for sure based on what you've included here. Lymphoma can certainly present in young healthy people without symptoms.

I would want to examine her myself. Significant tonsillar asymmetry is a pretty reasonable indication for tonsillectomy though.

Thats interesting.
I looked at her tonsils and noted a 1+ and a 2+ but was not really impressed with them. She did have pretty large anterior nodes and a couple of cervicals, but I certainly didn't examine her in depth. I did some looking into unilateral tonsillar enlargement, and I must admit, I wasn't aware of how high the correlation between it and H&N malignancies was. It kinda changes the way I look at lymphadenopathy in general. I was always under the impression that post infection, these things could kick around for months.

Forgive my ignorance on the subject as I have spent the last year in either the ED or the ICU.

 

[danzman]

http://www.elsevier.es/sites/default/files/elsevier/pdf/102/102v60n03a13138745pdf001_2.pdf


For anyone interested.

 

[resxn]

First, this is very very common. Tonsillectomy is probably on the aggressive side. They could always get a core-needle on a neck node to check for lymphoma. Much lower morbidity, faster recovery, and overall as accurate. FNA won't be effective, has to be core needle so they can get flow.

Overall unilateral tonsillar enlargement when asymptomatic is not concerning. However, enlarged lymph nodes does make it more interesting. I'd get the core-needle and if negative, simply f/u on the lymph nodes or tonsils--if they are enlarging, get them out. Depending on where she's travelling, she will need to have aggressive work-up now (perhaps overly aggressive) or just plan on returning if things are not going the right direction (increasing size, pain, or constitutional symptoms).

 

[danzman]

First, this is very very common. Tonsillectomy is probably on the aggressive side. They could always get a core-needle on a neck node to check for lymphoma. Much lower morbidity, faster recovery, and overall as accurate. FNA won't be effective, has to be core needle so they can get flow.

Overall unilateral tonsillar enlargement when asymptomatic is not concerning. However, enlarged lymph nodes does make it more interesting. I'd get the core-needle and if negative, simply f/u on the lymph nodes or tonsils--if they are enlarging, get them out. Depending on where she's travelling, she will need to have aggressive work-up now (perhaps overly aggressive) or just plan on returning if things are not going the right direction (increasing size, pain, or constitutional symptoms).

Thanks for all the info! Initially I wondered about the core biopsy also, and can only assume it was skipped because she is going to be out of the country for some time. After spending some time researching this it would seem to be the appropriate management. It always amazes me the thing I don't know about medicine.

 

[danzman]

If anyone was interested on this pt, she had surgery and biopsy was negative. Doing fine.

 

[resxn]

thanks for the f/u--it's good to let us know. Happy that all was neg.