Parotidectomy in Cape Town - a review of pathology and management

Background: The spectrum of parotid disease in southern Africa has not previously been reported. Methods: A review of all parotidectomies performed by a single surgeon over a period of 10 years (1994 - 2004) in Cape Town, South Africa, is presented. Data were collected from a retrospective chart review. Results: One hundred and ninety-nine parotidectomies were performed and 196 pathology reports were reviewed. Pleomorphic adenoma was the most common benign tumour and metastatic cutaneous squamous cell carcinoma (SCC) was the most common malignancy. Warthin's tumour had an equal gender distribution. Forty-five per cent of parotid tumours in males were malignant. The sensitivity, specificity and accuracy of fine-needle aspiration cytology (FNAC) in diagnosing malignancy were 73%, 98% and 94% respectively. Conclusions: In South African males almost half of parotid tumours are malignant. Warthin's tumours are less common in Africa than in the West, and did not show a male preponderance. FNAC is a highly reliable method of excluding malignancy

Is routine pathological examination required in South African children undergoing adenotonsillectomy?

Objective. We aimed to determine the incidence of abnormal pathological findings in the tonsils and/or adenoids of children undergoing tonsillectomy and/or adenoidectomy, and the incidence of tuberculosis of the tonsils and adenoids; suggest criteria to identify children at risk for adenotonsillar tuberculosis; and investigate the association between HIV and adenotonsillar abnormality, the cost-effectiveness of routine pathological examination of adenotonsillectomy specimens, and criteria to decide which specimens to send for histological examination. Methods. We undertook an 8-month prospective study on all children (≤12 years) undergoing consecutive tonsillectomy or adenotonsillectomy (T&A) at Red Cross War Memorial Children’s Hospital. Patients were assessed pre-operatively and tonsil sizes graded pre- and intra-operatively. Blood was taken for HIV testing, and all tonsils and adenoids were examined histologically. A cost-benefit analysis was done to determine the cost-effectiveness of adenotonsillectomy routine pathology. Results. A total of 344 tonsils were analysed from 172 children (102 boys, 70 girls); 1 patient had nasopharyngeal tuberculosis, and 1 lymphoma of the tonsils; 13 (7.6%) patients had clinically asymmetrically enlarged tonsils but no significant abnormal pathological finding. The average cost of detecting a clinically significant abnormality was R22 744 (R45 488 ÷ 2 abnormalities). Conclusions. The following criteria could improve cost-effectiveness of pathological examination of adenotonsillectomy specimens: positive tuberculosis contact at home, systemic symptoms of fever and weight loss, cervical lymphadenopathy >3 cm, suspicious nasopharyngeal appearance, HIV-positive patient, rapid tonsillar enlargement or significant tonsillar asymmetry. On our evidence, routine pathological investigation for South African children does not seem to be justified

Is routine pathological examination required in South African children undergoing adenotonsillectomy?

Objective We aimed to determine the incidence of abnormal pathologic findings in the tonsils and/ or adenoids of children undergoing tonsillectomy +/- adenoidectomy; incidence of tuberculosis of the tonsils and adenoids, and suggest criteria to identify children at risk for adenotonsillar tuberculosis; association between HIV and adenotonsillar abnormality; and the cost-effectiveness of routine pathological examination of adenotonsillectomy specimens, and criteria to decide which specimens to send for histology. Methods This was an 8 month prospective study on all children (≤ 12 years) undergoing consecutive tonsillectomy or adenotonsillectomy (T&A) at Red Cross War Memorial Children’s’ Hospital (RCH). Patients were assessed pre-operatively and tonsil sizes graded pre- and intra-operatively. Blood was taken for HIV testing and all tonsils and adenoids had histological examinations. A cost-benefit analysis was done to determine the cost- effectiveness of adeno- tonsillectomy routine pathology. Results A total of 344 tonsils were analysed on 172 children (102 males, 70 females); one patient had nasopharyngeal tuberculosis and another lymphoma of the tonsils; 13 (7.6%) patients had clinically asymmetrically enlarged tonsils but no significant abnormal pathological finding. The average charge to detect a clinically significant abnormality was R22 744 (R45 488 ÷ 2 abnormalities). Conclusions The following criteria could improve cost-effectiveness of pathological examination of adenotonsillectomy specimens: positive tuberculosis contact in the house, systemic symptoms of fever and weight loss, cervical lymphadenopathy >3cm, suspicious nasopharyngeal appearance, HIV positive patients, rapid tonsillar enlargement or significant tonsillar asymmetry. On our evidence routine pathology on South African children does not seem to be justified

Is total glossectomy for advanced carcinoma of the tongue justified?

Total glossectomy (with or without total laryngectomy) followed by postoperative radiotherapy remains the principal treatment method for advanced base of tongue carcinoma. The procedure remains controversial owing to poor cure rates and the inevitable functional deficits associated with it. However, even though total glossectomy is a major surgical procedure that impacts on speech, deglutition and quality of life, it may offer patients the best chance of cure in many centres, especially in the developing world. Methods: We did a retrospective chart review of all patients at Groote Schuur Hospital, Cape Town, who had undergone total glossectomy, with or without total laryngectomy, for stage IV squamous cell carcinoma (SCC) of the tongue between 1998 and 2004. Results: Eight patients had a total glossectomy performed during the study period. At 2, 3 and 5 years 63%, 38% and 25% of patients respectively were alive without disease. No patient required permanent nasogastric or gastrostomy feeding, and all returned to a full oral diet. Three of 5 patients who had laryngeal preservation and could be assessed for speech had intelligible speech. All but 1 patient (88%) reported pain relief following surgical excision. Perineural invasion was present in 75%, and 38% had positive resection margins. Five patients had recurrence, 2 cervical, 1 local, and 2 local and cervical. Conclusion: Advanced SCC of the tongue is a devastating disease causing severe pain and disorders of speech and swallowing. Total glossectomy (with or without total laryngectomy) and postoperative radiotherapy is a reasonable treatment option, particularly in the developing world setting. It has cure rates superior to primary radiotherapy, and provides motivated patients with excellent pain relief and a reasonable quality of life

Is diagnostic tonsillectomy indicated in all children with asymmetrically enlarged tonsil?

Objectives. The aims of the study were: (i) to determine the necessity for diagnostic tonsillectomy in children with asymmetrically enlarged tonsils; (ii) to determine the accuracy of clinical assessment of tonsillar asymmetry; and (iii) to determine how to manage children with clinical tonsillar asymmetry in a developing-world practice. Methods. A prospective study was carried out at Red Cross War Memorial Children’s Hospital in Cape Town, over an 8-month period. All children undergoing tonsillectomy or adenotonsillectomy had a clinical assessment of tonsil symmetry done, and all tonsil and adenoid specimens were examined histologically. The maximum diameter and volume of the resected tonsils were measured. A comparison was done of true tonsil asymmetry in patients with asymmetrical tonsils and a subgroup of matched controls with symmetrical tonsils. Results. A total of 344 tonsils were analysed (172 patients). The 13 patients (7.6%) diagnosed as having clinically asymmetrically enlarged tonsils had no significant pathological diagnosis. In the patients with symmetrical tonsils there were abnormal pathological findings (tuberculosis of the adenoids and T-cell lymphoma of the tonsils and adenoids). In the clinically asymmetrical tonsil group, true tonsillar asymmetry was 3 mm (maximum diameter), and 2.2 cm3 (volume), compared with 1.9 mm and 1.5 cm3 in the symmetrical tonsil group. When patients with clinical tonsillar asymmetry and symmetry were compared, the difference in maximum diameter (p = 0.62) and volume (p = 0.73) was not significantly different. Conclusions. Clinical tonsillar asymmetry is usually apparent rather than real. The incidence of significant pathology in children with asymptomatic, asymmetrical tonsils is low. Diagnostic tonsillectomy is indicated in children with asymmetrically enlarged tonsils associated with constitutional symptoms, cervical lymphadenopathy, rapid tonsil enlargement or significant tonsillar asymmetry