What causes lingual tonsil hypertrophy?

Causes of Lingual Tonsil Hypertrophy

Lingual tonsil hypertrophy primarily results from lymphoid hyperplasia due to prior adenotonsillectomy, obesity, and/or laryngopharyngeal reflux. 1

Primary Causes

Lingual tonsil hypertrophy (LTH) can develop from several underlying factors:

1. Post-adenotonsillectomy lymphoid hyperplasia

   • Compensatory hypertrophy after removal of palatine tonsils 1
   • The lingual tonsil is part of Waldeyer's ring of lymphoid tissue and may enlarge after other lymphoid tissues are removed

2. Obesity

   • Strong association between excess weight and lingual tonsillar enlargement 1
   • Fat deposition in tongue base tissues contributes to hypertrophy

3. Laryngopharyngeal reflux (LPR)

   • Chronic acid exposure causes inflammation and subsequent hypertrophy 1
   • Often underdiagnosed contributor to LTH

Associated Conditions and Risk Factors

• Down syndrome: Highest prevalence of LTH among pediatric populations 1, 2
• Other comorbidities:
  • Mucopolysaccharidoses 2
  • Craniofacial abnormalities
  • Neuromuscular disorders

Clinical Presentation

LTH commonly presents with:

1. Obstructive sleep apnea (OSA)

   • Particularly persistent OSA after adenotonsillectomy 1, 2
   • Can cause posterior tongue prolapse leading to airway obstruction in up to 85% of affected children 1

2. Dysphagia

   • Mechanical interference with swallowing 3
   • Inhibition of laryngeal elevation and epiglottic inversion 3
   • Sensation of globus (feeling of something stuck in throat)

3. Airway management challenges

   • Often undetected in routine airway assessment 4, 5
   • Can cause unanticipated difficult intubation during anesthesia 4

Diagnostic Approach

LTH can be diagnosed through:

• Awake flexible endoscopy: Preferred method 1
• Drug-induced sleep endoscopy (DISE): Helpful for evaluating obstruction during sleep 1
• Imaging studies:
  • MRI studies (including cine MRI) 1
  • CT scan 2
  • Plain neck X-rays 1

Clinical Implications

LTH has significant implications for:

1. Persistent OSA management

   • Common cause of OSA that persists after adenotonsillectomy 2
   • May require lingual tonsillectomy for resolution 1

2. Anesthetic risk

   • Associated with difficult mask ventilation (29.6%) and difficult intubation (89.1%) 4
   • Can lead to failed intubation in 21.7% of cases 4
   • May require specialized airway management techniques including videolaryngoscopy 5

Treatment Considerations

For symptomatic LTH:

• Lingual tonsillectomy using:

  • Radiofrequency ablation (Coblation) 6, 3
  • Suction cautery 1
  • Microdebridement 1

• Perioperative risks:

  • Airway edema (19% of cases) 1
  • Bleeding 1
  • Dehydration 1

Important Caveats

1. Routine physical examination may miss LTH

   • Standard airway assessment often fails to identify this condition 4
   • Consider specialized evaluation in patients with persistent OSA symptoms

2. Surgical outcomes

   • Complete improvement occurs in approximately 60-70% of cases 2
   • Persistent symptoms may occur in patients with underlying comorbidities 2

3. Anesthetic management

   • Requires robust airway strategy with early consideration of advanced techniques 4
   • Awake intubation should be considered in known severe cases 4

Understanding the causes and implications of lingual tonsil hypertrophy is essential for appropriate management of this often underdiagnosed condition that can significantly impact airway patency and quality of life.