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Lingual Tonsil Pseudolymphoma and Obstructive Sleep Apnea

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Lingual Tonsil Pseudolymphoma and Obstructive Sleep Apnea Braz J Otorhinolaryngol. 2009;75(3):469. CASE REPORT Lingual tonsil pseudolymphoma and obstructive sleep apnea Patrícia Eiko Yamakawa1, Elvis Henrique Santos Andrade2, Carlos Hirokatsu Watanabe-Silva3, Leopoldo Keywords: hyperplasia, obstructive sleep apnea, tongue, tonsil. Luiz Dos Santos Neto4 INTRODUCTION Videolaryngoscopy confirmed this finding dysphagia, chronic coughing, hoarseness, (Fig. 1). Facial sinus, thoracic and abdo- and recurring epiglottic abscesses.1,5 Lingual tonsils are the most neglec- minal computed tomography revealed no LTH is an uncommon cause of ted element of Waldeyer’s ring; they cannot significant findings. OSA.1,5 It may occur in children in associa- be visualized in a plain oropharyngeal A biopsy yielded an initial diagnosis tion with nocturnal pharyngeal collapse, es- examination. Lingual tonsillar hypertrophy of B immunophenotype non-Hodgkin’s pecially in Down’s syndrome.5 LTH-caused (LTH) is frequently asymptomatic and lymphoma, based on which the patient OSA is rare in adults; there are four such underdiagnosed, but may be associated underwent four chemotherapy sessions. reports in the literature.1,5,6 The authors with obstructive sleep apnea (OSA); it is A second review of the slide, however, suggest that significant LTH and obesity also included in the differential diagnosis 1,2 concluded that the lesion was in fact a led to OSA in this patient. of tongue base lymphoma. We present a reactional follicular lymphoid hyperplasia, Lingual tonsillectomy is recommen- case report and a review of the literature. and chemotherapy was discontinued. A ded in cases with any degree of airway obs- CASE REPORT bone marrow biopsy was normal. truction that impairs breathing, including The patient refused surgery; he was the treatment of OSA. Results are good in A male patient aged 36 years com- encouraged to lose weight. Up to the pre- these cases.5 plained of snoring and insomnia. There was sent, there has been no improvement. a history of nasal voice and serous otitis FINAL COMMENTS DISCUSSION media since childhood, including place- LTH is an uncommon and little ment of ventilation tubes (the last one in The pathophysiology of LTH is not diagnosed finding. It may, however, cause 2003). The patient underwent tonsillectomy yet clear; atopy, smoking, and chronic significant symptoms and affect the quality at age 7 years and adenoidectomy at age 33 lingual tonsil infection may contribute to of life of patients. LTH is part of the diffe- years. The patient smoked (15 years-pack) its development.1 The most commonly rential diagnosis of OSA and lymphomas but did not consume alcoholic beverages. admitted cause of LTH is compensating of the base of the tongue, and should be At the physical examination the patient was hyperplasia following tonsillectomy and/or taken into account when these cases are obese (BMI = 31.9 kg/m2), and there were adenoidectomy; two thirds of LTH patients investigated. no visible oropharyngeal signs. report having had these procedures.1 Polysomnography demonstrated A diagnosis of LTH requires an REFERENCES fragmented sleep with microawakenings assessment of the tongue base and hypo- 1. Golding-Wood DG, Whittet HB. The lingual and snoring; sleep efficiency was 77%; the pharynx with indirect laryngoscopy or an apnea-hypopnea index was 10 events per tonsil: A neglected symptomatic structure? J optic fiber laryngoscope. Image exams, Laryngol Otol. 1989;103(10):922-5. hour; minimum O2 saturation was 86%. such as MRI, are useful for detecting and A diagnosis of OSA was made based on 2. Lee ST, Jayalakshmi P, Raman R. Non- establishing the size of lingual tonsils. Hodgkins lymphoma of lingual tonsil-a case clinical and polysomnographic findings. The differential diagnosis of LTH in- Magnetic resonance imaging (MRI) de- report. Singapore Med J. 1987;28(4):363-5. 2 cludes an ectopic thyroid, thyroglossal duct 3. Graziadei G, Pruneri G, Carboni N, Luminari S, monstrated a hypopharyngeal 89 mm cysts, demoid cysts, angiomas, lymphan- nodule measuring 4 x 3.5 x 2.5 cm, located Targia ML et al. Low-grade MALT lymphoma giomas, adenomas, fibromas, papillomas, involving multiple mucosal sites and bone on the epiglottic valeculla and increasing squamous cell carcinomas, minor salivary the thickness of the epiglottis (Fig. 1). marrow. Ann Hematol. 1998;76(2):81-3. gland tumors of the base of the tongue, 4. Garcia Callejo FJ, Morant Ventura A, Tormos 1 and lymphomas. There are also reports in MM, Marco Algarra J. Upper dysphagia due the literature of non-Hodgkin’s lymphoma, to a chemotherapy resistant Burkitts lympho- Burkitt’s lymphoma, and MALT lymphoma ma in a lingual tonsil. Acta Otorrinolaringol 2-4 involving lingual tonsils. Esp. 2003;54(2):109-12. LTH in adults is often asympto- 5. Dundar A, Ozunlu A, Sahan M, Ozgen F. matic, and may be detected only during Lingual tonsil hypertrophy producing procedures involving the airway, causing obstructive sleep apnea. Laryngoscope. 1 difficult tracheal intubation. However, 1996;106:1167-9. lingual tonsils may be significantly incre- 6. Conacher LD, Meikle D, O’Brien C. Tracheos- ased, filling the valeculla and displacing tomy, lingular tonsillectomy and sleep-related Figure 1. Lingual tonsil hyperplasia - Laryngoscopic and magnetic the epiglottis posteriorly. LTH is also breathing disorders. BJA. 2002;88(5):724-6. resonance images demonstrating lingual tonsil hyperplasia. associated with dyspnea, odynophagia, 1 Medical student, Universidade de Brasilia - UnB. 2 Medical student, Universidade de Brasilia - UnB. 3 Medical student, Universidade de Brasilia - UnB. 4 Doctorate in molecular pathology, Universidade de Brasília. Adjunct professor of clinical medicine, Universidade de Brasília- UnB. Paper submitted to the BJORL-SGP (Publishing Management System – Brazilian Journal of Otorhinolaryngology) on May 8, 2007; and accepted on June 13, 2007. cod. 4507 BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY 75 (3) MAY/JUNE 2009 http://www.rborl.org.br / e-mail: [email protected] 469.
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