In Reference to Should the Contralateral Tonsil Be Removed in Cases of HPV‐Positive Squamous Cell Carcinoma of the Tonsil?

We read the recent publication titled “Should the Contralateral Tonsil Be Removed in Cases of HPV-Positive Squamous Cell Carcinoma of the Tonsil?” with interest. This addresses an important clinical question that is frequently encountered in practice. The authors reached the conclusion that it is best practice to routinely remove the contralateral tonsil in cases of unilateral human papillomavirus (HPV)–positive tonsillar squamous cell carcinoma (SCC). This recommendation is based on the existing literature, which consists of three case reports and two retrospective chart reviews, including a total of 16 patients with synchronous bilateral HPV-positive SCC of the tonsil. Although these data should appropriately lead to further investigation of the contralateral tonsil in HPV-positive oropharyngeal cancer, we caution that putting forth a formal recommendation of contralateral tonsillectomy is not sufficiently substantiated. Based on our experience and review of the cited studies, the truest number for incidental contralateral tonsillar cancer is likely less than 3%. In the Rokkjaer and Klug study, when contralateral tonsillectomy was routinely performed for all patients with known or suspected tonsillar cancer, 2.3% had contralateral disease. Finally, it is not evident that subclinical contralateral tonsil cancer would ultimately have clinical impact. A majority of patients receive adjuvant radiation and close post-treatment surveillance. Even the lower radiation dose at the contralateral tonsil could theoretically be therapeutic, and post-treatment imaging and examination regimens may catch contralateral tumors at earlier stages. None of the articles presented patients who developed contralateral tonsil cancer after previous treatment. We have had one patient who recurred with a contralateral (left) lingual tonsil cancer after initial right radical palatine tonsillectomy. Of note, this patient did not have adjuvant radiation as part of his initial treatment and was again successfully treated with surgery alone. This case highlights the concept of a “condemned Waldeyer’s ring” in HPV-positive oropharyngeal cancer. Should all patients with known palatine tonsil cancer undergo lingual tonsil resection as well? Should both palatine tonsils be removed when a patient presents with a base of tongue cancer? Finally, the article implies that morbidity is not increased with contralateral tonsillectomy. However, this is based on only 30 patients from a single study. Our experience suggests that patients with a bilateral tonsillectomy trend toward increased postoperative pain, dysphagia, bleeding, and readmissions. In our series, there was a trend toward patients who underwent contralateral tonsillectomy being more likely to have a postoperative bleed. Our recommendation is that the contralateral tonsil is carefully examined in every patient with oropharyngeal cancer and that there should be a low threshold for contralateral tonsillectomy based on examination or imaging findings. We do not recommend routine contralateral tonsillectomy and feel that it would only serve to increase morbidity in the vast majority of patients.