One Tonsil Larger than the Other a Sign of Cancer?

Not uncommonly, a patient will present to an ENT clinic with only ONE tonsil being unusually large compared with the other side. Typically, such patients have no pain, no sore throat,  no preceding illness, no trouble swallowing, etc. Really, no symptoms other than one tonsil being very large. The main concern from an ENT perspective is that this may suggest the possibility of cancer.

What is the risk of cancer in such a situation where an asymmetric tonsil hypertrophy is present? Depending on the study, it can be anywhere from 5-10% in an otherwise healthy patient without any other risk factors or symptoms. Of course, if other risk factors are present including smoking, alcohol use, neck mass, pain, sore throat, difficulty swallowing, etc, the risk of malignancy increases. Factors that decrease the possibility of cancer include being female and a child.

Cancers that commonly produce a unilateral enlarged tonsil include lymphomas and squamous cell carcinomas. Other more rare cancers include extramedullary plasmacytomas, Hodgkin's disease, leukemia, and metastatic neoplasms.

In order to diagnose whether cancer is present or not, the entire tonsil needs to be removed (tonsillectomy). Taking only a small superficial sample of the tonsil via incisional biopsy is NOT recommended as it may miss the cancer if it is occurring deep within the tonsil.

As such, tonsil removal is not just for recurrent infections, but also to evaluate for presence of cancer and should be undertaken in patients where one tonsil is significantly larger than the other. Indeed, ENT's are trained to consider unilateral tonsillar hypertrophy cancerous until proven otherwise and diagnostic tonsillectomy should be pursued.

Watch a video showing how a tonsillectomy is performed here!

References:

Unilateral tonsillar enlargement. Otolaryngol Head Neck Surg (1979). 1979 Nov-Dec;87(6):707-16.

Risk factors for malignancy in adult tonsils. Head Neck. 1998 Aug;20(5):399-403.

Incidence of carcinoma in incidental tonsil asymmetry. Laryngoscope. 2000 Nov;110(11):1807-10.

Significance of asymptomatic tonsil asymmetry. Otolaryngol Head Neck Surg. 2004 Jul;131(1):101-3.

Palatine Tonsils Asymmetry: 10 Years Experience of the Otorhinolaryngology Service of the Clinical Hospital of the Federal University of Paraná. Int. Arch. Otorhinolaryngol. 2011;15(1):67-71