Volume 3, Issue 2 , Pages 68-70, March 2008
Lingual tonsillitis presenting as hemoptysis
Article Outline
Summary
To the best of our knowledge, hemoptysis caused by hemorrhagic lingual tonsils has not been reported. We describe a case of hemoptysis caused by bleeding from inflamed, hypertrophied lingual tonsils. Treatment with antibiotics did not resolve the bleeding. Carbon dioxide laser lingual tonsillectomy was curative.
Keywords: Lingual tonsils, Hemoptysis, Lingual tonsillitis
Hemoptysis may be caused by several different etiologies, many of which are in the lower respiratory tract. These include inflammatory, infectious and neoplastic pathologies. Cardiopulmonary processes such as pulmonary embolism and pulmonary hypertension also are culprits. On occasion a pharyngeal source of bleeding can masquerade as hemoptysis. Hemorrhagic palatine tonsillitis has been well described. We describe a child with hemoptysis secondary to friable hypertophic, inflammed lingual tonsils.
1. Report of a case
An 8-year-old boy was seen in the emergency room with a 1-week history of hemoptysis consisting of bloody tinged saliva following an upper respiratory tract infection. There was no accompanying hematemesis, epistaxis or melena. No prior history of trauma was elicited. The birth history was remarkable for maternal intravenous drug abuse but was otherwise uncomplicated. All immunizations were up-to-date. His grandparents, who were his acting legal guardians, did note halitosis present since birth. Medical history was notable for an adenotonsillectomy performed 4 years previously. There was no family or personal history of bleeding disorders. The patient denied ingestion of NSAIDs or anticoagulants. The otolaryngology service was consulted to evaluate the upper aerodigestive tract.
On examination, the patient was comfortable and in no respiratory distress. Head and neck examination was unrevealing. Anterior/posterior and lateral chest radiographs were normal. Flexible laryngoscopy was performed finding no source of bleeding. Esophagoduodenoscopy as well as an upper GI radiology series were performed by the gastroenterology service with no etiology identified for the bleeding. The patient was instructed to return to the otolaryngology outpatient clinic for follow-up in 2 weeks.
In the otolaryngology clinic, a complete head and neck exam was performed by the attending physician. Careful evaluation of the nasal cavity and nasopharynx using endoscopy found no source of bleeding. The oral cavity and oropharynx were clear. Flexible laryngoscopy revealed moderate lingual tonsillar hypertrophy and inflammation with a friable, bleeding area on the left side without exudates (Fig. 1). The patient expectorated blood-tinged saliva numerous times during the examination. The remainder of the exam was normal. CT of the neck with contrast found mild left upper cervical adenopathy. Coagulation studies were negative. We made a presumptive diagnosis of lingual tonsillitis. A 2-week course of amoxicillin/clavulanic acid was prescribed. The patient's hemoptysis persisted in smaller amounts. Subsequent fiberoptic laryngoscopic examinations found continued lingual tonsil bleeding. He was brought to the operating room for endoscopic evaluation and lingual tonsillectomy. Microlaryngoscopy and bronchoscopy confirmed the flexible laryngoscopic exam findings. No other lesions explaining the bleeding were found. A CO2 laser lingual tonsillectomy was performed. Histological analysis of the lingual tonsil specimen revealed lymphoid hyperplasia. The patient was followed in clinic with resolution of the hemoptysis and cervical adenopathy. He has been free of hemoptysis and other complaints for 2 years following his procedure.
Figure 1.
Lingual tonsil bleeding found on microlaryngoscopy.
2. Comment
Historically, the lingual tonsils were neglected due to their anatomic location and ambiguous constellation of symptoms. Lingual tonsillar hypertrophy (LTH) is the most common abnormality of the lingual tonsil [1] and has been noted in up to 70% of patients following adenotonsillectomy [2]. This hypertrophy is postulated to result as a compensatory process [1]. Hyperplasia has also been noted in patients with allergies [2], excessive smoke exposure [3], & bulimia nervosa [4]. More recently, LTH in the pediatric population has been found to be associated with extra-esophageal reflux disease (EERD) [5]. Parham and Newman reported a case of recurrent lingual tonsil hyperplasia suspected to be facilitated by reflux [6]. LTH may be responsible for a variety of pharyngeal symptoms, including a sore or irritable throat, dysphagia, fever, lethargy, globus sensation, speech change, otalgia, submandibular referred pain, obstructive sleep apnea, chronic tickling cough, dyspnea, halitosis and choking on food. Rarely, LTH may cause life-threatening airway obstruction, and unrecognized LTH may also complicate airway intubation [7], [8].
To the best of our knowledge, no case of bleeding as a symptom of lingual tonsillar hypertrophy or lingual tonsillitis has been reported in the recent literature. There is a recent report of significant bleeding from hypertrophic lingual tonsils following intubation for tonsillectomy and postoperatively [8]. Cohen in 1917 and Elfman in 1949 reported bleeding from ruptured varices at the base of the tongue in cases with increased varicosity of the lingual tonsil and tongue base, with or without the presence of lingual tonsils, but otherwise hemoptysis as a symptom of LTH has not been mentioned [1], [9].
Treatment of LTH consists of control of any inciting or aggravating factors such as EERD or infections. A trial of a proton-pump inhibitor or H2-receptor blocker as well as control of any infections may suffice in the control of LTH. Lingual tonsillectomy performed under general anesthesia may be indicated for other patients. This can be accomplished by various techniques including sharp dissection, tonsil snares, cryosurgery, electrocautery or the CO2 laser, with generally good results.
We present a case of an otherwise healthy 8-year-old white male with a history of hemoptysis and enlarged lingual tonsils on examination. He was diagnosed with lingual tonsillitis and treated by CO2 laser lingual tonsillectomy with successful resolution of his symptoms. Hemoptysis as a symptom of LTH in the absence of varices has not been mentioned in the recent literature to the best of our knowledge. We feel that successful resolution of symptoms with lingual tonsillectomy in our patient suggest that LTH and lingual tonsillitis should be kept in the differential for clinicians evaluating hemoptysis in children.
References
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- . Lingual tonsils. Laryngoscope. 1949;59:1016–1025
- . Life-threatening tonsil hyperplasia probably induced by severe bulimia nervosa: a case report. Int. J. Eat. Disord. 2001;29:100–103
- . Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease. Laryngoscope. 2000;110:1560–1562
- . Recurrent lingual tonsil hyperplasia. Arch. Otolaryngol.-Head Neck Surg. 2003;129:1010–1012
- . Asymptomatic lingual tonsillar hypertrophy and difficult airway management: a report of three cases. Can. J. Anesth. 2001;48:1020–1024
- . Lingual tonsil hypertrophy with difficult airway and uncontrollable bleeding. Anaesthesia. 2003;58:390–391
- . The lingual tonsil: general consideration and its neglect. Laryngoscope. 1917;27:671–700
PII: S1871-4048(07)00086-X
doi:10.1016/j.pedex.2007.10.008
© 2007 Elsevier Ireland Ltd. All rights reserved.
Volume 3, Issue 2 , Pages 68-70, March 2008
