Volume 3, Issue 3 , Pages 120-123, September 2008
Pedunculated hamartomatous polyp of palatine tonsil in a child: A new presentation
Article Outline
- Summary
- 1. Introduction
- 2. Case report
- 3. Pathological findings
- 4. Discussion
- 5. Conclusions
- References
- Copyright
Summary
Pedunculated polyps of palatine tonsil are rare and have been described using various terms. Most of the cases have been reported in adults with varying presenting symptoms. We report a 13-year-old male child who presented with 2-year history of dry cough with complaint of recurrent vomiting for past 15 days. Clinical examination revealed a pedunculated polypoid mass arising from upper pole of left tonsil which was excised under general anesthesia. A diagnosis of pedunculated hamartomatous polyp of palatine tonsil was made based on histopathological findings. An unusual presentation of a rare condition in a pediatric patient has been discussed along with the histopathological findings.
Keywords: Hamartomatous polyp, Tonsil, Lymphangiomatous polyp, Recurrent vomiting
1. Introduction
Pedunculated polyps of the palatine tonsil are relatively rare [1]. Different terms like lymphangiectatic fibrous polyp [2], polypoidal lymphangioma [3], angiofibrolipoma [4], pedunculated squamous papillomas [5], hamartomatous tonsillar polyp [1], [6], [7], lipoma [8], [9], [10], lymphangiectatic fibrolipomatous polyp [11], lymphangiomatous polyp [12] have been used for these polyps. Most of the terms used are based on the histological constituents of the excised mass and the tissues of origin. Various symptoms associated with these polypoid masses are acute tonsillitis, recurrent sore throat, blood in sputum, dysphagia, mass in throat, slowing deglutition and lump in throat [12]. On internet search for similar cases with above mentioned names used in literature, majority of these cases have been reported in adults while an entity ‘lymphoid papillary hyperplasia’ or ‘papillary lymphoid polyp’ is reported exclusively in children [13], [14]. We report a case of 13-year-old child who complained of repeated episodes of cough and vomiting and clinical examination showed a pedunculated polypoid mass arising from the upper pole of left tonsil. On excision and histopathological examination, diagnosis of hamartomatous polyp of tonsil was established. Few cases of pedunculated hamartomatous polyp of palatine tonsil have been reported in pediatric age group (described under different names) and this is the first one presenting in a child with bouts of cough and vomiting.
2. Case report
A 13-year-old male child was brought to our department with complaint of chronic cough for past 2 years which was episodic in nature and history of recurrent vomiting for past 15 days. Cough was of insidious onset, dry and more frequent while taking food. Also present was a history of occasional vomiting associated with bouts of cough, but more frequently a retching sensation was there. There were no other associated symptoms. Patient was being treated symptomatically by local practitioners but with no improvement. On examination of oral cavity, a mucosa covered mass was found hanging along the left tonsil which was indistinguishable from the tonsil by color of the covering mucosa. Mass was pedunculated, mobile, touching the posterior part of tongue and posterior pharyngeal wall, its movements causing irritation resulting in bouts of cough. Site of origin of the mass was probed and it was found to be arising from the upper pole of the left palatine tonsil attached by a pedicle (Fig. 1). Excision biopsy of the mass was planned under general anesthesia. The mass was excised from the pedicle after tying with 1-0 vicryl and base was cauterized. The mass was sent for histopathological examination. Post-operative period was uneventful. There was no evidence of recurrence during the follow-up period of 1 year. The extirpated tissue was fixed in 10% formalin solution, and after fixation dissected for histopathological sectioning followed by dehydration with graded alcohols and embedding in paraffin. De-waxed sections were stained with hematoxylin and eosin stains.
Fig. 1.
Pedunculated mass arising from upper pole of left palatine tonsil (arrow head).
3. Pathological findings
Grossly the mass was 3.5
cm×1.5cm×1cm pedunculated polypoid structure with firm consistency and seemed to be covered with healthy pharyngeal mucosa (Fig. 2). Cut section was without any lumen. Microscopic examination revealed a covering of stratified squamous epithelium showing focal keratinisation. The subepithelial tissue showed a dense infiltrate of benign looking lymphocytes (Fig. 3) with evidence of focal nested epitheliotropism (inset). Deeper areas were formed of lobules of mature adipose tissue separated by dense network of intervening fibrous tissue and scattered lymphocytes and plasma cells. Scattered throughout the smear were plenty of small blood vessels and very few dilated lymphatics containing proteinacious fluid were seen (Fig. 4). Overall histological picture was suggestive of hamartomatous polyp of palatine tonsil.
Fig. 2.
Smooth-surfaced whitish mass excised from its pedicle.
Fig. 3.
Stratified squamous epithelium along with dense lymphocytic infiltrate, abundant fibrous and adipose tissue in deeper areas (H and E stain, 40×); nested epitheliotropism (inset, arrow head), (H and E stain, 400×).
Fig. 4.
Abundant adipose tissue, dilated vessels having RBC's and a single dilated lymphatic vessel (arrow head) with proteinacious fluid (H and E stain, 100×).
4. Discussion
Pedunculated polypoid lesions of tonsil, although reported using various types of nomenclature, are relatively rare lesions [1]. In the literature, different types of nomenclatures have been used for these lesions like lymphangiectatic fibrous polyp [2], polypoid lymphangioma [3], angiofibrolipoma [4], hamartomatous tonsillar polyp [1], [6], [7], lymphangiomatous polyp [12]. Although head and neck are most common sites [15], tonsil remains a rare and uncommon location for this type of lesion [15] and this rarity explains the abundance of names.
Different types of clinical presentations have been reported in the literature ranging from acute tonsillitis, recurrent sore throat, blood in sputum, dysphagia, mass in throat, slowing deglutition and lump in throat with most of the cases in adults [12] but this is the first case presenting with complaint of cough and vomiting in a child. Pedunculated lesion hanging in pharynx and irritating the posterior pharyngeal wall may explain the bouts of cough and occasional vomiting in the present case.
The main histological components of these lesions are an epithelial covering of squamous or respiratory type along with varying proportions of adipose tissue, fibrous tissue, blood vessels, dilated lymphatics and varying amount of lymphoid infiltrate, which in some cases may even show follicle formation [12]. These components are normal constituents of this site, except that these are arranged in a different pattern, that is why these lesions are considered hamartomatous [12]. If the lymphoid tissues were removed from the normal tonsil, the components noted above would remain as a polypous lesion reported here except for fatty tissue. This is another reason these lesions are considered hamartomatous in nature [1]. In fact a hamartomatous origin of these lesions has been suggested in the literature [6], [7], [11]. All these components were present in the present case but with a paucity of dilated lymphatics (Fig. 4), thereby making hamartomatous polyp rather than lymphangiomatous polyp or lymphangioma as the appropriate diagnosis.
Abundance of fatty tissue in the present lesion can be explained based on the suggestion that the fatty tissue is because of ischemic change as a result of degeneration or tissue metaplasia during the long clinical course [1]. As in the present case, long history of more than 2 years points towards a protracted course of the lesion. The histogenesis of these lesions remains unclear, though according to some authors, it appears to be preceded by polyps in the original tonsil, such as hamartomatous tonsillar tissue similar to that found in normal tonsil [16]. Judging from these findings, these lesions are non-neoplastic rather than neoplastic [1]. The diagnosis of such lesions does not require ancillary studies but according to literature, immunoprofile of these lesions shows that the endothelial tissue is uniformly reactive for the factor VIII related antigens and lymphocytes for CD 4 5RB, CD 3 and CD 20 [12].
Although the differential diagnosis include juvenile angiofibroma, fibroepithelial polyps, papillomas and lymphangioma but it remains pertinent to always exclude the possibility of juvenile angiofibroma especially in male adolescents as it needs to be treated much more aggressively to prevent recurrence or associated morbidity. Histologically, angiofibromas have a more cellular stroma, stellate and plump cells along with staghorn-like thin vascular channels while the hamartomas contain varying amounts of lymphoid infiltrate, adipose tissue, fibrous tissue and dilated vessels [12].
5. Conclusions
We have reported a polypoid lesion arising from upper pole of left palatine tonsil unusually presenting in a child with symptoms like bouts of cough and vomiting for which the term pedunculated hamartomatous polyp appears to be the appropriate diagnosis based on histological picture.
References
- . A pedunculated hamartomatous polyp of the palatine tonsil. Biomed. Res. 2006;17(3):155–158
- . Lymphangiectatic fibrous polyp of the palatine tonsil. A report of three cases. J. Laryngol. Otol. April 1985;99(4):403–409
- . Polypoid lymphangioma of the tonsil: report of two cases and review of the literature. J. Laryngol. Otol. August 1985;99(8):819–823
- . Angiofibrolipoma of the tonsil. Laryngol. Rhinol. Otol. 1986;65:355–356
- . Pedunculated squamous papillomas of laryngopharynx. J. Laryngol. Otol. February 1989;103(2):209–210
- . Hamartomatous tonsillar polyp. J. Laryngol. Otol. December 1991;105(12):1089–1090
- . Benign hamartomatous polyp of the palatine tonsil. J. Laryngol. Otol. November 1993;107(11):1073–1075
- . Polypoid lipoma of the palatine tonsil. J. Laryngol. Otol. June 1993;107(6):556–558
- . Lipoma of the left tonsillar fossa. J. Laryngol. Otol. June 1994;108(6):507–508
- . Tonsillar lipoma: a case report. J. Laryngol. Otol. July 1995;109(7):662–664
- . Lymphangiectatic fibrolipomatous polyp of the palatine tonsil. Indian J. Pathol. Microbiol. October 2000;43(4):449–451
- . Tonsillar lymphangiomatous polyps: a clinicopathologic series of 26 cases. Mod. Pathol. October 2000;13(10):1128–1133
- . Papillary lymphoid polyp of the palatine tonsil. Ear Nose Throat J. May 1985;64(5):243–245
- . Lymphoid papillary hyperplasia of the palatine tonsils. Am. J. Surg. Pathol. September 1983;7(6):579–582
- . Cystic hygroma-lymphangioma: a rare and still unclear entity. Laryngoscope. October 1989;99(10Pt 2 Suppl. 49):1–10
- . Torsion of the palatine tonsil. J. Laryngol. Otol. September 1996;110(9):891–892
PII: S1871-4048(08)00004-X
doi:10.1016/j.pedex.2008.01.002
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 3, Issue 3 , Pages 120-123, September 2008
