Treatment of Hyperplastic Lymphoid Tissue in the Throat
Hyperplastic lymphoid tissue in the throat is typically a benign, reactive process that requires observation only, with surgical excision reserved for cases causing obstructive symptoms, diagnostic uncertainty, or failure to resolve after addressing underlying inflammatory triggers.
Initial Diagnostic Approach
The first priority is distinguishing benign lymphoid hyperplasia from malignancy or infection-related processes:
Document clinical context: Look specifically for symptoms of chronic irritation (gastroesophageal reflux, smoking, chronic sinusitis), viral upper respiratory infections, or HIV status, as these are common triggers for reactive lymphoid hyperplasia 1, 2, 3
Assess for concerning features: Rapid growth, unilateral presentation, firm consistency, fixation to underlying structures, or systemic B-symptoms (fever, night sweats, weight loss) suggest malignancy rather than benign hyperplasia 4
Evaluate obstruction: Determine if the hyperplastic tissue causes dysphagia, airway compromise, or significant voice changes requiring intervention 5
When Biopsy is Indicated
Biopsy should be performed when clinical features cannot reliably exclude lymphoma or when tissue persists despite addressing inflammatory triggers 4:
- Atypical presentation (unilateral, rapidly growing, firm mass)
- Persistence beyond 4-6 weeks after treating underlying inflammation
- Patient age >40 years with new-onset throat mass
- Any concern for malignancy based on examination
Multiple deep biopsies are essential if sampling is performed, as superficial biopsies may miss diagnostic features 5. The histologic hallmark of benign hyperplasia includes well-polarized germinal centers with tingible-body macrophages, polyclonal B and T cells, and absence of light chain restriction 6, 4.
Management Strategy
Conservative Management (First-Line)
Most cases resolve spontaneously once the inflammatory stimulus is removed 5:
- Address underlying triggers: Treat gastroesophageal reflux with proton pump inhibitors, manage chronic rhinosinusitis, recommend smoking cessation 1
- Observation period: Allow 4-6 weeks for spontaneous resolution after addressing inflammatory causes 5
- Symptomatic relief: Voice rest, hydration, and analgesics for associated discomfort 1
Surgical Excision (Selective Indications)
Surgical removal is indicated only when 5, 4:
- Obstructive symptoms: Significant dysphagia, airway compromise, or persistent voice changes affecting quality of life
- Diagnostic uncertainty: When biopsy cannot definitively exclude lymphoma despite immunohistochemistry and molecular studies
- Recurrent symptoms: Persistent or recurrent hyperplasia despite addressing inflammatory triggers for >3 months
Important caveat: Laryngeal lymphoid hyperplasia may recur after surgical excision, but this does not indicate malignant transformation 5. Recurrence should prompt repeat biopsy only if clinical features change or suggest progression.
Critical Pitfalls to Avoid
Do not assume all throat masses require antibiotics: Lymphoid hyperplasia is not an infectious process requiring antimicrobial therapy unless secondary bacterial infection is documented 1
Do not confuse with lymphoma based on histology alone: Follicular lymphoid hyperplasia may show indistinct germinal centers and ill-defined mantles that mimic follicular lymphoma; immunohistochemistry for light chain restriction and bcl-2 protein is essential to avoid misdiagnosis 4
Do not overlook HIV testing: HIV-associated lymphoid hyperplasia with multinucleated giant cells occurs in 67% of HIV-positive patients with tonsillar/adenoid hyperplasia and requires different management considerations 3
Do not perform aggressive treatment without tissue diagnosis: Extensive lymphoid hyperplasia can clinically and radiographically mimic lymphoma, but aggressive chemotherapy or radiation is inappropriate without histologic confirmation of malignancy 6, 4
Follow-Up Protocol
Persistent symptoms beyond 2-3 weeks: Perform laryngoscopy to visualize the extent of hyperplasia and rule out other pathology 1
Post-excision monitoring: Follow patients for at least 2 years, as recurrence can occur but does not indicate malignant transformation 5
HIV-positive patients: Coordinate with infectious disease specialists, as lymphoid hyperplasia may harbor significant HIV viral load and reflect immune activation 2, 3