Excessive Reactive Lymphoid Hyperplasia in a Child With Persistent Obstructive Sleep Apnea Despite Previous Tonsillectomy and Adenoidectomy

Abstract

Both lingual tonsil and adenoid are the lymphoid tissue members of Waldeyer ring. Enlargement of the lingual tonsil and adenoid occurs in children with persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy relatively frequently.In this article, we present a case with upper airway obstruction and infection findings because of excessive lingual tonsil and adenoid tissue hyperplasia and, additionally, bilateral multiple cervical lymphadenopathies. The patient had had tonsillectomy and adenoidectomy 8 years ago. Etiopathogenetic mechanisms, clinical, radiologic, histopathologic aspects, and surgical therapeutic options for obstructive sleep apnea related to excessive reactive lymphoid hyperplasia in children are discussed reviewing the literature.

Factors associated with lingual tonsil hypertrophy in Canadian adults

“…There appears to be a complex interplay with laryngopharyngeal reflux (LPR) emerging as a strong potential contributor to LTH and, subsequently, OSA. Previous authors have also demonstrated an association between LTH and OSA, BMI, age and smoking, but there has not been general agreement [1, 7]. This study adds further support to an association between a positive reflux finding score and BMI with lingual tonsil hypertrophy, but does not support a history of childhood tonsillectomy or age being associated with lingual tonsil size in adults.…”

“…Sung et al demonstrated a correlation between BMI, reflux finding score and lingual tonsil hypertrophy in OSA patients [1]. A trend was also seen for a negative correlation with age, but was not statistically significant.…”

“…In this study, the LTH scoring scale described by Sung et al was used because Friedman’s scale was not yet published at the time of study [8]. Previous methods of measurement using both CT and MRI have also been described, but given the expense are not justified for routine evaluation in a universal-payer system such as in Canada [1]. Both Sung and Friedman’s scales have demonstrated similarly good inter-rater agreement.…”

“…An advantage of Friedman’s scale is the use of video and various positions of the tongue, which appears to allow for greater inter-rater agreement and consistency and may be a source of some of our inter-rater disagreement. Sung’s group did, however, demonstrate good correlation with measurements on MRI suggesting validity of their scale and the use of standardized photography for grading [1]. Lastly, although lingual tonsil hypertrophy has been observed in pediatric patients with prior adenotonsillectomy, a post-mortem study examining 497 corpses found only 16 (3.2%) had LTH.…”

“…Lingual tonsil hypertrophy (LTH) can also contribute to obstructive sleep apnea (OSA) at the level of the oropharynx. In children, compensatory LTH has been observed after routine tonsillectomy [1]. Recently, Sung et al examined factors that were associated with lingual tonsil hypertrophy in Korean patients with OSA.…”