Squamous malignancy is not usually a factor in paediatric care and therefore guidelines for adults do not apply.
An estimated 1.7% of asymptomatic children are thought to have tonsillar asymmetry.
Tonsils react to systemic infections in childhood and, in particular after URTIs or tonsillitis, can present as enlarged and asymmetrical.
The observation and grading of tonsil size is very imprecise. Tonsils may look asymmetrical because of their relative position in the oropharynx. At surgery, weight differences are often not significant.
The reason for referral, even though seldom stated, is presumed to be concern of tonsillar lymphoma.
Several case studies have not been able to identify a single tonsillar lymphoma if the only presenting sign was tonsillar asymmetry.
In the majority of lymphoma cases children will present with further systemic symptoms or new, rapid onset obstructive signs.
Red Flags are:
- Unexplained weight loss
- Drenching night sweats.
- Persistent unexplained lethargy/malaise
- Supraclavicular or axillary nodes.
- Hepato- or splenomegaly.
- Pallor or bruising
- Rapidly enlarging node without obvious underlying cause/infection
- Persistent unexplained bone pain
- Unexplained bruising, petechiae or unusual bleeding.
Tonsillar enlargement in tonsillar lymphoma does usually occur rapidly (within 6 weeks).
In view of the relatively high number of asymmetrical tonsils and the zero diagnostic yield if tonsillectomy is carried out for asymmetry alone, we do not advocate tonsillectomy for this patient group.
Who to refer:
Children with rapidly enlarging, asymmetrical tonsils, new onset of obstructive symptoms and new systemic symptoms (under 6 weeks duration) should be referred to both ENT and paediatric/haemato-oncology.
Please see red flag indications above.
Who NOT to refer:
Asymptomatic children with incidental finding of tonsillar asymmetry.
Longstanding, stable tonsillar asymmetry.
Children with acute asymmetry and underlying acute infection.
Reassurance, unless Red Flag Symptoms. If these are present, refer to ENT and paediatric/haemato-oncology (consider urgent discussion with on call team).
