THE JOURNAL OF PEDIATRICS • www.jpeds.

com ORIGINAL
ARTICLES
Pediatric Tonsil Cancer: A National and Institutional Perspective
Eelam A. Adil, MD, MBA1,2, Genevieve Medina, BA1, and Michael J. Cunningham, MD, FAAP1,2

Objective To evaluate childhood and adolescent tonsil cancer incidence and to identify the clinical characteris-
tics indicative of those patients who would benefit from urgent operative intervention.
Study design The Surveillance, Epidemiology and End Results 18 database, inclusive of national cancer sta-
tistics from 1973 to 2013, provided quantitative tonsil cancer incidence data. An institutional retrospective chart review
of pediatric patients diagnosed with tonsil malignancy from January 2013 to January 2017 identified supplemen-
tary qualitative clinical presentation information.
Results The Surveillance, Epidemiology and End Results 18 database included 138 pediatric patients with tonsil
cancer with an age-adjusted incidence rate of 0.021/100 000 patients per year. The majority of cases were unilat-
eral (79.7%), and there was both a male and Caucasian predominance. Non-Hodgkin lymphoma (84.1%) was the
most common malignancy, of which Burkitt lymphoma (31.1%), diffuse large B-cell lymphoma (26.8%), and fol-
licular lymphoma (10.1%) were the most common subtypes. Five tonsillar malignancy patients were identified upon
institutional chart review. The majority likewise had non-Hodgkin lymphoma and all shared a history of rapid ton-
sillar enlargement over ≤12 weeks. Significant tonsillar asymmetry was present in 4 patients. Four patients addi-
tionally exhibited prominent cervical lymphadenopathy.
Conclusions Pediatric tonsil cancer is rare, with non-Hodgkin lymphoma accounting for the majority of pediatric
tonsillar malignancies. A high index of suspicion is appropriate in children who present with relatively rapid tonsil
enlargement, tonsillar asymmetry characterized by a difference in tonsillar size of ≥2 degrees on the Brodsky scale,
or concurrent prominent cervical lymphadenopathy. (J Pediatr 2018;197:255-61).

See related article, p 309

pproximately 530 000 children undergo tonsillectomy in the US on an annual basis.1 The principal indications are

A obstruction (approximately 75%) and infection (approximately 25%). 2,3 A much smaller subset of pediatric
patients undergo tonsillectomy for a variety of other reasons, such as dysphagia, failure to thrive, pediatric autoim-
mune neuropsychiatric disorders associated with streptococcal infections, and periodic fever, aphthous stomatitis, pharyngitis,
and adenitis syndrome. The most concerning of the alternative indications for surgery is tonsillar asymmetry with suspicion
of malignancy.4
Although patients diagnosed with tonsillar malignancy typically exhibit asymmetrical tonsils, the majority of tonsillar asym-
metry is innocuous. Multiple studies have shown that the clinical observation of tonsillar asymmetry, alternatively termed uni-
lateral tonsillar enlargement (UTE), does not often reflect true asymmetric size when the tonsils are physically compared after
excision.5-7 This discrepancy is largely attributed to differences in tonsil position relative to the depth of the tonsillar fossa.7 In
view of the limited accuracy of the oropharyngeal examination in detecting truly asymmetric tonsils, the performance of ton-
sillectomy for UTE in the pediatric age group is controversial.4-9
Given the anesthesia exposure and complication risks of tonsillectomy, yet the significant concern of missing a tonsillar ma-
lignancy, we sought to examine pediatric tonsillar cancer from both a national and institutional perspective. The Surveillance,
Epidemiology and End Results (SEER) database provided the national perspective, and an institutional approach was used to
identify additional clinical presentation factors to help define which patients with UTE should undergo excision for patho-
logic examination purposes.

Methods
The SEER 18 database (SEER*Stat software, version 18.0, National Cancer Insti-
tute; Bethesda, MD) was used to examine pediatric tonsil malignancy from a From the 1Department of Otolaryngology and
Communication Enhancement, Boston Children’s
Hospital; and 2Department of Otolaryngology, Harvard
Medical School, Boston, MA
The authors declare no conflicts of interest.
DLBCL Diffuse large B-cell lymphoma
SEER Surveillance, Epidemiology and End Results (database) 0022-3476/$ - see front matter. © 2018 Elsevier Inc. All rights
UTE Unilateral tonsillar enlargement reserved.
https://doi.org10.1016/j.jpeds.2018.01.022

255
THE JOURNAL OF PEDIATRICS • www.jpeds.com
national perspective. SEER data collection was initiated in 1973.
The first database, SEER 9, included 9 registries covering Atlanta,
Connecticut, Detroit, Hawaii, Iowa, New Mexico, San Francisco-
Oakland, Seattle-Puget Sound, and Utah. SEER subsequently
expanded its geographic range to enhance coverage of cancer
incidence in minority populations to represent more accu-
rately the general population. In 1992, SEER 13 was created
with the addition of registries from Los Angeles, San Jose-
Monterrey, and rural Georgia, as well as the Alaska native tumor
registry.
The most recent SEER 18 registry, established in 2001, in-
cludes additional data from the populations of greater Cali-
fornia, greater Georgia, Kentucky, Louisiana, and New Jersey.
The SEER 18 database reports data collected from 28% of the
US population, offering the most current and accurate cancer
incidence and national prevalence data from 1973 through
2014.10,11
The SEER 18 database was assessed for patients with ma-
lignancies diagnosed between 0 and 19 years of age. Using the
“Primary Site-Labeled” search option, patients with malig-
nancies of the “tonsillar fossa, tonsillar pillar, overlapping lesion
of the tonsil, tonsil, lateral wall of the oropharynx, or over-
lapping lesion of the oropharynx,” diagnosed between 1973 and
2013 were included. Patients were excluded if they were >19
years of age or if the specific oropharyngeal site of their tumor
was not specified.
To generalize the data gathered from the SEER registry to
the US pediatric population, incidence data were age ad-
justed and normalized to the 2000 US standard population
census. A ratio of the number of pediatric tonsil cancer cases
to the total number of patients aged 0-19 years in the SEER
database was calculated for each year. The data were then
weighted based on the proportion of patients in the SEER da-
tabase compared with the 2000 US standard population. These
annual incidence rates were averaged to obtain the final age
adjusted incidence rate.
In parallel, a comprehensive chart review of all patients di-
agnosed with tonsillar asymmetry and/or tonsillar malignan-
cies at our institution between January 2013 and January 2017
was also performed. Data collected included demographics,
clinical presentation, examination findings, laboratory studies,
imaging results, and histopathology. Tonsil size was standard-
ized using the Brodsky scale.12 In this classification system,
tonsils are referenced relative to the oropharyngeal midline and
graded on a 1-4 scale according to the fraction of the airway
space the tonsil obstructs.12 A tonsil size of 1+ corresponds with
≤25% oropharyngeal airway obstruction, 2+ means 50% of the
airway space is obstructed, grade 3+ represents ≤75% obstruc-
tion, and grade 4+ tonsils completely obstruct the airway
(Figure; available at www.jpeds.com). We defined “signifi-
cant” tonsil asymmetry as tonsils that differed in size by ≥2
grades on the Brodsky scale. Volumetric data were calculated
using the formula for ellipsoid volume (V = 4/3pabc) for pa-
tients who underwent bilateral tonsillectomy. A paired t test
was used to compare tonsil volume between specimens taken
from the same patient. Prominent cervical lymphadenopa-
thy was defined as having ≥1 enlarged lymph node ≥1 cm
256
Volume 197 • June 2018
within one of the cervical chains. Patients who underwent ton-
sillectomy because of concern regarding post-transplant
lymphoproliferative disorder were excluded from this review.
The Boston Children’s Hospital Institutional Review Board
approved this retrospective study prior to data acquisition. In-
stitutional Review Board guidelines were followed.
Results
SEER Data
Pediatric patients with a tonsillar malignancy (N = 138) were
identified using the SEER 18 database.11 The overall age ad-
justed incidence rate was 0.021/100 000 per year. There were
25 children <5 years of age, of which only 2 were <12 months
of age. The majority of patients were in the 5- to 19-year-old
age categories, with nearly equal distributions between 5-9, 10-
14, and 15-19 years of age. Patients were primarily Caucasian
(n = 112; 81.2%). There were more than twice as many males
(n = 94; 68.1%) as females.
Non-Hodgkin lymphoma was the most common malig-
nancy, constituting 87.0% of cases (n = 120) (Table I). Burkitt
lymphoma was the most common subtype (n = 43; 31.1%),
followed by diffuse large B-cell lymphoma (DLBCL; n = 37
[26.8%]) and follicular lymphoma (n = 14; 10.1%). Rhabdo-
myosarcoma (n = 5; 3.62%), synovial sarcoma (n = 2; 1.44%),
and plasmacytoma (n = 3; 2.2%) were comparatively rare SEER
cohort diagnoses.
Among the 110 patients whose malignancies were unilat-
eral, the incidence of malignancy was nearly equal between the
right (n = 49; 35.5%) and left (n = 61; 44.2%) tonsils. In 16.0%
of patients (n = 22), the primary malignancy was bilateral. Lat-
erality was not specified for 6 cases.
Institutional Data
Data regarding the institutional tonsil malignancy cases are
summarized in Table II. These data are consistent with the SEER
findings in that 3 of the 5 children in our institutional cohort
had Burkitt lymphoma; the other 2 children notably had acute
lymphoblastic leukemia. Similar to the SEER cohort, 4 of the
5 children were male, all were Caucasian, and all were between
the ages of 3 and 10 years. In 4 of the 5 children, their diag-
nosis was ascertained by tonsillectomy; tonsillectomy was de-
ferred in 1 child because flow cytometry of a peripheral blood
sample had already confirmed the diagnosis.
Of the 5 cases of tonsillar malignancy in the institutional
cohort, 2 presented with obstructive sleep-disordered breath-
ing manifestations. One of the 2 children who presented with
obstructive symptoms also exhibited unilateral tonsillar asym-
metry. Of the 4 patients who presented with unilateral ton-
sillar hypertrophy, 3 underwent bilateral tonsillectomy. The
median tonsil volume was 20.3 cm3 (range, 12.4-36.8 cm3) in
the affected tonsil compared with 2.7 cm3 (range, 1.2-3.2 cm3)
in the contralateral tonsil. Prominent cervical lymphadenopa-
thy was present in 4 of the 5 children on initial examination.
Symptom duration before presentation ranged from 3 to 12
weeks. There was preoperative concern for malignancy in all
of these patients.
Adil, Medina, and Cunningham
June 2018 ORIGINAL ARTICLES

Table I. SEER database cancer subtypes

Cancer types/subtypes Total cases Subtype bilateral cases
Non-Hodgkin lymphoma
Burkitt lymphoma/leukemia 43 (31.2) 4 (9.3)
DLBCL, NOS 37 (26.8) 4 (10.8)
Follicular lymphoma 14 (10.1) 5 (35.7)
Non-Hodgkin lymphoma, NOS, unknown lineage 8 (5.8) 0 (0.0)
Lymphoid neoplasm, NOS 5 (3.6) 3 (60.0)
Precursor non-Hodgkin lymphoma, T-cell 4 (2.9) 1 (25.0)
Chronic/small lymphocytic leukemia/lymphoma 2 (1.4) 0 (0.0)
Extranodal marginal zone lymphoma, mucosa-associated lymphoid tissue type 2 (1.4) 1 (50.0)
Non-Hodgkin lymphoma, B-cell, NOS 2 (1.4) 1 (50.0)
Lymphoplasmacytic lymphoma 1 (.7) 0 (0.0)
Natural killer T-cell lymphoma, nasal type/aggressive natural killer leukemia 1 (.7) 0 (0.0)
Non-Hodgkin lymphoma, NOS, T cell 1 (.7) 1 (100.0)
Sarcoma
Rhabdomyosarcoma 5 (3.6) 0 (0.0)
Synovial sarcoma 2 (1.4) 0 (0.0)
Liposarcoma 1 (.7) 0 (0.0)
Kaposi's sarcoma 1 (.7) 1 (100.0)
Plasma cell neoplasms
Plasmacytoma 3 (2.2) 1 (33.3)
Hodgkin lymphoma
Nodular sclerosis 2 (1.5) 0 (0.0)
Unclassified carcinomas 4 (2.9) 0 (0.0)
Total 138 22

NOS, not otherwise specified.

Values are n (%).

There were 206 pediatric patients diagnosed with UTE in
our institutional series who met the inclusion criteria; there-
fore, the incidence of tonsil malignancy in patients with UTE
in our series was 1.9% (Table III). Upon review of final pa-
thology reports, there was no significant difference in tonsil
volume between the enlarged tonsil and the contralateral speci-
men in patients with UTE who did not have tonsil malig-
nancy (4.6 cm3 vs 3.0 cm3; P = .17). The Brodsky size difference
between specimens taken from the same patient ranged from
0.5 to 1.5 in the UTE group without tonsil cancer. None of these
patients were reported to have prominent cervical
lymphadenopathy.
Discussion
Pediatric tonsil cancer is rare with the existent literature largely
limited to small case series (Table III). To expand on current
knowledge, the SEER database was used to provide population-
based observational data. This comprehensive source of na-
tional cancer data includes demographics, cancer stage at
diagnosis, primary site, and cancer subtype, allowing esti-
mates of these measures on a national level. From a national
perspective, 138 pediatric patients with tonsillar malignancy
were identified in the 1973-2013 study period, translating to
an age-adjusted population incidence rate of 0.021/100 000 pe-
diatric patients per year. An evident male predominance is re-
flective of prior literature demonstrating male sex to be a risk
factor for non-Hodgkin lymphoma, the most common ton-
sillar malignancy identified.14
Analysis of the SEER database reveals non-Hodgkin lym-
phoma to be the most common tonsillar malignancy (n = 120;
Pediatric Tonsil Cancer: A National and Institutional Perspective
87.0%), with Burkitt lymphoma being the most common non-
Hodgkin lymphoma subtype (n = 43; 31.2%). This observa-
tion reflects the prevalence of Burkitt lymphoma in the pediatric
population at large, reported in 1 institutional review to rep-
resent approximately 60.7% of all pediatric non-Hodgkin lym-
phoma cases.15 Burkitt lymphoma is considered an aggressive
subtype in which translocation of the c-myc proto-oncogene
is seen in the majority of cases, leading to rapid unregulated
cell growth.16 Treatment is intensive chemotherapy, based on
risk stratification.17-19
DLBCL is the second most common lymphoma subtype in
the SEER cohort (n = 37; 26.8%). This is consistent with the
reported prevalence of DLBCL as the second most common
subtype of pediatric non-Hodgkin lymphoma, representing
about 21.4% of pediatric non-Hodgkin lymphoma cases.15 Al-
though patients with DLBCL present typically with abdomi-
nal disease, adenotonsillar lymphatic tissue is the second most
common primary site.20 Similar to Burkitt lymphoma, DLBCL
is considered an aggressive non-Hodgkin lymphoma subtype
requiring intensive chemotherapy as treatment.
The third most common tonsillar malignancy in the SEER
database is follicular lymphoma (10.1%). Follicular lym-
phoma represents only 1%-2% of all pediatric non-Hodgkin
lymphomas with a notable 3 to 1 male to female
predominance.21,22 Translocations of BCL2, characteristic of
adult follicular lymphoma, are not frequently observed in chil-
dren, perhaps accounting for the much more favorable prog-
nosis of pediatric patients with follicular lymphoma.23,24 The
vast majority of pediatric follicular lymphoma cases occur in
the head and neck region and are detected at an early stage;
in 2 separate series, 85% and 86% of pediatric patients with
follicular lymphoma had either stage I or stage II disease.25,26
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Table II. Institutional review of patient clinical and histopathologic data
Preoperative Duration of Time before Right Left
Ages Other suspicion for Other indications symptoms office visit tonsil tonsil Laterality of
(y) Gender Chief complaint signs/symptoms malignancy for tonsillectomy (wk) (wk) Final pathology Laterality size* size* pathology
3 Male Obstructive sleep- Bilateral cervical Yes, owing to rapid Obstructive airway 8 6 Acute lymphoblastic Bilateral 4+ 4+ Both tonsils and
disordered lymphadenopathy, tonsillar enlargement symptoms leukemia (T cell) adenoid:
breathing elevated white blood and abnormal T-lymphoblastic
cell count (53.16 K laboratory tests leukemia/lymphoma
cells/µL, 58% blast)
4 Male Obstructive sleep- Bilateral cervical Yes, owing to rapid Obstructive airway 3 3 Burkitt lymphoma Unilateral 4+ 1+ Right tonsil: Burkitt
disordered lymphadenopathy tonsillar enlargement symptoms lymphoma; left tonsil:
breathing/ no pathology
enlarged right
tonsil
7 Male Neck pain/enlarged Right cervical Yes, owing to rapid Snoring without 12 12 Burkitt lymphoma Unilateral 4+ 0 Right tonsil: Burkitt
right tonsil lymphadenopathy tonsillar enlargement dysphagia lymphoma;
and lymphadenopathy left tonsil: no pathology
7 Female Enlarged right tonsil Bilateral cervical Yes, owing to unilateral Obstructive airway 12 12 Acute lymphoblastic Unilateral 4+ 1+ Right tonsillectomy
lymphadenopathy tonsillar hypertrophy symptoms leukemia (T cell) deferred given blasts
(predominantly the and abnormal on peripheral smear
right) laboratory tests and flow cytometry
from peripheral blood
consistent with T-cell
acute lymphoblastic
leukemia
9 Male Recurrent tonsillitis/ No palpable cervical Yes, owing to rapid Dysphagia 4 4 Burkitt lymphoma Unilateral 4+ 2+ Right tonsil: non-
enlarged right lymphadenopathy, tonsillar enlargement Hodgkin lymphoma,
tonsil B-cell lymphoma; left
tonsil: no pathology
Adil, Medina, and Cunningham

*Brodsky Grading Classification Scale.

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June 2018
Table III. Literature summary regarding the incidence of malignancy in patients with UTE
Authors Year Patient population
4
Berkowitz et al 1999 Pediatric
Syms et al8 2000 Nonpediatric
Spinou et al6 2002 Pediatric
Harley et al7 2002 Pediatric
Cinar et al13 2004 Nonpediatric
Oluwasanmi et al9 2006 Nonpediatric
Van Lierop et al5 2007 Pediatric
Adil et al (current study) 2018 Pediatric
Localized stage 1 BCL2-negative follicular lymphoma is typi-
cally managed with surgical resection alone.23,24,27,28
Rhabdomyosarcoma (n = 5; 3.6%) and plasmacytomas
(n = 3; 2.2%) were comparatively rare tumors in the SEER
cohort. The rhabdomyosarcoma neoplasms likely originated
in the adjacent oropharyngeal musculature and involved the
tonsils by direct extension. Multimodality therapy including
chemotherapy, radiotherapy, and possibly additional surgery
is typically required in such cases.29,30 Owing to local aggres-
siveness and a propensity to metastasize, surgical resection alone
is rarely curative for tonsillar rhabdomyosarcoma.29,31
Extramedullary plasmacytoma is a soft tissue neoplasm of
monoclonal plasma cells. Tonsillar plasmacytomas are ex-
tremely rare, even within the nonpediatric population.32 Sur-
gical resection alone, with or without radiotherapy, is sufficient
to cure this disease. Effective local control can be achieved in
≤100% of cases of monoclonal extramedullary plasmacy-
toma; postoperative radiotherapy is recommended when com-
plete resection is not possible.33
It is noteworthy there were no cases of squamous cell car-
cinoma in the SEER cohort, because squamous cell carci-
noma is the most common oropharyngeal malignancy in adults.
The increasing prevalence of human papilloma virus-related
cancers in otherwise healthy young men and women sug-
gests future increases in the frequency of this human papil-
loma virus-associated tonsillar malignancy among younger
patients may be anticipated.34
Because the SEER data attest to the overall rarity of pedi-
atric tonsillar malignancy, identifying clinical factors that may
help to stratify patients with UTE is clearly necessary. This need
is highlighted further by the fact tonsillar asymmetry is not
an uncommon finding, manifesting in about 1.7% of the pe-
diatric population.35 The reported prevalence of tonsillar ma-
lignancy among patients with UTE in the literature ranges from
0% to 4%, and the overall rate of malignancy in patients of
all ages who undergo tonsillectomy for UTE is 1.4%
(Table III).4-9,13 The lack of a correlation between UTE and ton-
sillar malignancy is explained by the limited accuracy of the
oropharyngeal examination in detecting truly asymmetric
tonsils. In our series, there were 202 patients with UTE who
underwent tonsillectomy and did not have tonsil malignancy
based on final pathology review. The difference in Brodsky score
ranged from 0.5 to 1.5 in these patients, with no significant
difference in tonsil volume (P = .17), indicating the per-
Pediatric Tonsil Cancer: A National and Institutional Perspective
ORIGINAL ARTICLES
Patients with UTE (n) Malignant cases (n) Malignancy (%)
46 0 0
48 2 4.1
47 0 0
57 0 0
53 0 0
87 2 2.3
13 0 0
206 4 1.9
557 8 1.4
ceived asymmetry was due to other factors. Similarly, a pro-
spective, controlled study comparing tonsil size and fossa depth
in 47 patients with clinically asymmetrical tonsils compared
with 43 patients with clinically symmetrical tonsils found no
significant difference in 3-dimensional quantitative measure-
ments of resected tonsil specimens.7 The perceived tonsillar
asymmetry was closely associated with a difference in the depth
of the tonsillar fossa (P < .001).7 Notably, the specific amount
or degree of clinically observed asymmetry is typically not de-
scribed in prior studies investigating UTE in the pediatric
population.4-6 The exception is the study outlined herein, in
which all reported cases of asymmetry were described as “mild.”7
Although the majority of tonsil asymmetry is benign, most
patients with tonsillar malignancy exhibit UTE. This finding
was first reported in a small case series in which 6 of 7 pa-
tients with tonsillar malignancies had UTE.4 A subsequent sys-
tematic review and meta-analysis confirmed this observation,
documenting 52 of 71 patients (72.7%) with tonsillar lym-
phoma to have had clinically apparent asymmetry.36 Simi-
larly, a review of 6 pediatric patients with palatine tonsil
lymphomas reported all to exhibit UTE.37 Our institutional
clinical experience is consistent with these results as 4 of 5 pa-
tients (80%) exhibited UTE.
It is important to note, however, that 16.0% of patients in
the SEER database had bilateral malignancies. This finding was
true of 1 case in our institutional cohort as well, a child who
was eventually diagnosed with acute lymphoblastic leuke-
mia. A previously published, prospective, controlled study re-
ported no cases of malignancy in their “asymmetric tonsil”
population, but 1 case of malignancy in a patient with dra-
matically enlarged tonsils bilaterally.5 These findings suggest
that clinical concern for malignancy should include patients
with rapidly enlarging tonsils, whether in symmetrical bilat-
eral or asymmetric unilateral fashion.
Because the 2 most common pediatric tonsillar malignan-
cies are aggressive subtypes, it is critically important that cases
of malignancy be diagnosed as early as possible so that che-
motherapy may be initiated promptly. Our institutional cohort
experience indicates that rapid tonsillar enlargement over ≤12
weeks, marked asymmetry, and prominent cervical lymph-
adenopathy are important signs of tonsillar malignancy. All cases
of UTE of neoplastic origin on institutional review mani-
fested relatively rapid tonsillar enlargement over a 3- to 12-
week time course. The literature regarding pediatric tonsil
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cancer is limited given its rarity, but several case reports de-
scribe similar rapid tonsillar enlargement over a time course
of days to weeks in pediatric patients who were later diag-
nosed with malignant UTE.38-40 In our 4 cases of UTE sec-
ondary to tonsil malignancy, each had one 4+ tonsil, with all
4 of these patients demonstrating a difference in tonsil size score
of at least two on the Brodsky scale. Volumetric analysis also
confirmed a dramatic difference in size between affected and
unaffected tonsils (20.3 versus 2.7 cm3). This more signifi-
cant degree of asymmetry lessens the ambiguity that true volu-
metric asymmetry is present.
Last, prominent cervical lymphadenopathy was present in
80% of our patients with tonsil malignancy. A prior system-
atic review likewise indicated cervical lymphadenopathy to be
the third most common sign/symptom of tonsillar malig-
nancy, documented in 30.3% of the patients reviewed.41
There are several notable limitations to our study. The SEER
database captures the incidence of cancer among only ap-
proximately 28% of the population.10 Age-adjusted popula-
tion data were necessary to calculate a national incidence rate;
our estimates as a result may slightly overestimate or under-
estimate this rate. Some patients’ tumors were categorized as
“oropharynx, not otherwise specified” and were excluded from
the analysis because there was no indication as to what oro-
pharyngeal subsite was involved. It is, therefore, possible that
some patients with tonsillar malignancies may have been ex-
cluded inadvertently. Finally, as with any retrospective study,
the data obtained on institutional chart review were origi-
nally collected from a patient care rather than a study per-
spective. Any data incorrectly documented or omitted could
alter our results.
In summary, tonsillar malignancy is the underlying etiol-
ogy of only a very small percentage of pediatric UTE. In our
practice, clinical suspicion is increased and tonsillectomy is war-
ranted when there has been relatively rapid tonsillar enlarge-
ment within a several week time frame, particularly if the degree
of asymmetry corresponds with a difference in score on the
Brodsky scale of ≥2. Concurrent prominent cervical lymph-
adenopathy further increases the concern for malignancy. Ton-
sillectomy for excisional biopsy purposes should be performed
conservatively, bearing in mind that a proactive diagnosis is
important, because the majority of pediatric tonsillar malig-
nancies are aggressive non-Hodgkin lymphoma subtypes. ■
Submitted for publication Aug 24, 2017; last revision received Dec 13, 2017;
accepted Jan 10, 2018
Reprint requests: Eelam A. Adil, MD, MBA, Department of Otolaryngology and
Communication Enhancement, Boston Children’s Hospital, 300 Longwood
Avenue, BCH_3129, Boston, MA 02115. E-mail: Eelam.Adil@
childrens.harvard.edu
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Figure. Brodsky tonsil size grading classification system. Reprinted from Pediatric Clinics of North America, Vol. 36, No. 6,
Linda Brodsky MD, Modern.

261.e1 Adil, Medina, and Cunningham