ASYMMETRIC TONSIL HYPERTROPHY: CASE REPORT OF LYMPHANGIOMA OF THE TONSIL

Introduction

Lymphangiomas are benign lymphatic tumours typically compos of dilated lymphatic channels, which repeatedly occur subcutaneously in the head and neck region. Tonsillar lymphangiomas have been reported rarely in the literature and upon clinical examination are indistinguishable from malignant tonsillar tumours. Histological confirmation is essential for diagnosis. We report a case of lymphangioma of the tonsil in an otherwise well 22 year aged man and review the clinical and histological features of this rare tumour.

Case Report

A 22 year elderly man presented with a 2 month history of intermittent odynophagia, associated with left-sided otalgia and intermittent depressed grade fevers. He had been treated with several courses of oral antibiotics prior to his referral with no improvement. He reported constant left sided pharyngeal discomfort and described several episodes in the previous week of spitting on the outside fresh blood in his saliva. He was otherwise in eminent health, being a professional sportsman, with no other symptoms to report. He was a nonsmoker with les than 10g of alcohol consum by means of week.

Examination of his oropharynx revealed marked unilateral hypertrophy of his left tonsil, which was firm upon palpation with an area of shallow surface ulceration ~2cm in diameter with a marshy friable base. There was no associated trismus. The right tonsil was a great quantity [i]or[/i] amount of smaller in size with a normal appearance. There was no cervical lymphadenopathy palpable and filled head & neck examination find outed no other abnormal findings.

FBE and CXR were normal. An examination beneath anaesthesia and bilateral tonsillectomy was performed. No other sites of pathology were descryed He made an uncomplicated postoperative redemption and is clinically well 18 month after removal of the lesion. Histopathological examination of the specimen revealed a lymphangioma of the left tonsil, which was completely excised with no evidence of spread beyond the tonsillar capsule. Microscopy showed a large polypoidal mass containing multiple vascular spaces lined by means of endothelial cells and filled with lymph (Figures 1 & 2) The surrounding stroma was infiltrated through plasma cells and scattered aggregates of lymphocyte forming follicles with germinal midmost points The overlying mucosa was partially ulcerated on the other hand otherwise normal appearing stratified squamous epithelium. There were no atypical features or evidence of malignancy and the mass was environed by normal tonsillar tissue.

Discussion

Lymphangiomas are benign tumours which have been reported to appear rarely in the tonsil, with single 31 cases documented in the English literature (Medlinc 1966-2003) with 26 of these in a single scries from the Armed Forces Institute of Pathology (AFIP), in the US1-5 Lymphangiomas be met with in the head & neck region in ~90% of cases, being located primarily in the skin or subcutaneous tissue. They classically be met with in association with congenital malformations of the lymphatics, presenting in childhood as cystic masses (cystic hygroma). They may also be found in adults in varied locations including the oral cavity, tongue, larynx or parotid/' The majority of previously reported cases involving the palatine tonsils were pedunculated or polypoidal lesions with histological features consistent with those noted in this case. Surgical excision via tonsillectomy provides definitive management for these lesions, with patients undergoing an uncomplicated postoperative regaining There have been no reported instances of disease return after complete excision.

The differential diagnosis of unilateral tonsillar hypertrophy includes acute or chronic inflammation (including granulomatous change); malignant neoplasms, greatest in quantity commonly lymphoma or squamous confined apartment carcinoma; benign lesions including haemangiomas, papillomas or lymphangiomas or parapharyngeal masses which may give rise to apparent tonsillar enlargement to be paid to medial displacement of the tonsil. This case was clinically suggestive of a tonsillar malignancy and accurate diagnosis of a lymphangioma is sole possible with histological confirmation. Although histological diagnosis was straight forward in this case, these lesions may be difficult to differentiate from papilloma, fibroepithelial polyp or juvenile angiofibroma depending upon the degree of proliferation of vascular channels, fibrous stroma or lipomatous tissue.1

The veritable incidence of tonsillar lymphangiomas is difficult to determine from reviewing the literature with several authours suggesting these lesions may meet the eye more commonly than reported, possible accounting for 19% of all tonsillar tumours.1 Historically these tumours may have been reported as fibroangiomas or llbrolipomas depending upon the histological components seen. This particular case demonstrated prominent lymphatics with luminal proteinaccous fluid and lymphocyte within normal tonsillar tissue with no lipomatous tissue and a paucity of fibrous tissue.

The pathogenesis of tonsillar lymphangioma is uncertain. It has been propos that these lesions exhibit as a result of chronic inflammation interfering with lymphatic drainage- on the contrary this does seem unlikely given the rarity of these tumours in comparison to the oftenness of recurrent tonsillitis in the general population. Another possibility is that these lesions show harmartomatous proliferation of histological ultimate parts seen in normal tonsillar tissue which appears more probable.3