Lingual Tonsil Hypertrophy Producing
Obstructive Sleep Apnea
Ahmet Dundar, MD; Adnan Ozunlu, MD; Murat Sahan, MD; Fuat Ozgen, MD
The hypertrophy of the lingual tonsil is a rare oc-
currence in adults. This disorder may cause obstruc-
tive sleep apnea (OSA) and also may lead to a life-
threatening obstruction of the upper airway.
Diagnosis of lingual tonsil hypertrophy in patients
with OSA requires a careful examination by ad-
vanced technologic methods. The sleep apnea is suc-
cessfully treated by lingual tonsillectomy, with or
without tracheotomy.
In this study the case of an adult with OSA
caused by lingual tonsil hypertrophy which was
treated with lingual tonsillectomy is presented, and
the diagnosis and the treatment procedure of such
cases are discussed.
LARYNGOSCOPE,
1061167-1169,1996
INTRODUCTION
Obstructive sleep apnea (OSA)is a clinical entity
occurring as a consequence of many anatomic and
physiologic diseases of the upper airway. One of the
causes is lingual tonsil abnormality such as hyper-
tropy, hyperplasia, or lingual tonsillitis. Hypertrophy
of the lingual tonsil was first described by Vesalius in
1543.The true incidence of lingual tonsillitis has been
underestimated for the last hundred years. This fact
may be explained by the position of the lingual tonsils,
since they are difficult to visualize on routine physical
examination.1 Improved visualization and physiologic
evaluation of the upper respiratory tract made possi-
ble by developing technology permitted detection of
disease in this region.2.3
The upper airway of patients with OSA has been
evaluated anatomically and physiologically for the
last two decades, using advanced techniques such as
direct and fiberoptic visualization, cephalometric
roentgenograms, fluoroscopy, computerized tomogra-
phy, magnetic resonance imaging, and polysomnogra-
phy.2 Polysomnography is especially important in the
From the Departments of Otorhinolaryngology-Head and Neck Sur-
gery (A.D., A.o., M.s.) and Psychiatry (F.o.), Gulhane Military Medical Acade-
my, Etlik-Ankara, Turkey.
Editor’s Note: This Manuscript was accepted for publication April 9,
1996.
Send Reprint Requests to Adnan Oziinlii, MD, Giilhane Military Med-
ical Academy, Department of Otolaryngology & Head and Neck Surgery, Et-
lik-Ankara, 06018, Turkey.
Laryngoscope 106:September 1996
identification of the nature of apnea and the determi-
nation of physiopathologic changes due to apnea.
Surgical removal of the lingual tonsils is a thera-
peutic option in patients with recurrent infection.
However, when chronic adenotonsillitis, adenotonsil-
lar hypertrophy, and especially lingual tonsil hyper-
trophy are associated with OSA, surgery is absolutely
indicated. Lingual tonsillectomy is performed with the
patient under general anesthesia, using various tech-
niques including sharp dissection, snare, cryosurgery,
or the CO, laser in children or adults. The tracheoto-
my is carried out if necessary.
In this study a report concerning an adult patient
with OSA caused by lingual tonsil hypertrophy is pre-
sented, and the diagnosis and the treatment of such
cases are discussed by reviewing the literature.
CASE REPORT
A 58-year-old man presented with a 3-year history of
sleep disturbance and a 2-month history of pain in the
suprahyoid region. At night, he awoke because of apneic
episode three or four times, and he snored intermittently
and loudly. Symptoms were worse when he was supine. He
had dysphagia that was eased by protruding his chin and ex-
tending his neck. Swallowing provoked pain in the suprahy-
oid region. He had been treated with palatine tonsillectomy
in another hospital in 1961. He had not smoked in 10 years
and denied drinking alcoholic beverages.
On physical examination, about 5 x 4 cm of pale, soft,
extremely hypertrophic lingual tonsil tissue was noted on
the base of the tongue (Fig. 1).This was more evident when
traction was applied to the tongue. Scar tissue from the for-
mer palatine tonsillectomy was observed between front and
back plicas. Indirect laryngoscopy revealed the hypertrophic
lingual tonsil tissue extending into the aryepiglottic plicas
and vallecula, displacing the epiglottis posteriorly and pro-
ducing a nearly total obstruction of the glottis. Because of
lingual tonsil hypertrophy and overhanging epiglottis, the
larynx could not be evaluated. After topical anesthesia
with 2% pantocaine, fiberoptic laryngoscopic examination
showed that the larynx was normal. During Muller’s ma-
neuver the hypopharynx was almost completely obstructed
because of hypertrophy of the lingual tonsil. Allergy was not
found. Cephalometry was normal. The patient underwent
polysomnographic studies in the preoperative and postoper-
ative periods.
Dundar et al.:Obstructive Sleep Apnea
1167

Fig. 1. Lingual tonsil tissue on the base of the tongue: pale, soft, and
about 5 x 4 cm. Extremely hypertrophic. (T = tongue; It = lingual
tonsil.)
Surgical treatment was elected. The severity of the air-
way compromise and the potential for postoperative airway
distress led us to tracheotomy with local anesthesia. The pa-
tient subsequently underwent a lingual tonsillectomy with
general anesthesia, using sharp dissection and a Boyle
Davis mouth gag for exposure. Hemostasis was achieved
with bipolar cautery, and the surgery was concluded by plac-
ing a nasogastric tube. There were no bleeding or airway
complications in the immediate postoperative period. On
macroscopic examination the right lingual tonsil was brown
and its dimensions were 6.5 x 4.5 x 1.5cm, whereas the left
lingual tonsil was gray-brown and its dimensions were 6 X
4.5 X 1.2 cm (Fig. 2). Lymphoid hyperplasia was evident on
microscopic study. Postoperatively the patient’s alimenta-
tion was managed by the nasogastric tube for 5 days. The pa-
tient was decannulated on the sixth postoperative day, and
the tracheotomy was surgically closed. Clinically, his com-
plaint was dysphagia that persisted for a few days after the
surgery. His sleep returned to normal.
The polysomnographic studies were conducted in the
preoperative period and at the end of the first postoperative
month for 2 consecutive nights. The second nights of these
studies were evaluated. The preoperative study showed a
91% sleep efficiency index, 20-minute initial sleep latency,
87-minute rapid eye movement (REM)latency, and 0%third
and fourth sleep stage rate. Postoperative values were 94%
sleep efficiency index, absence of initial sleep latency, 37-
minute REM latency, and 12%third and fourth sleep stage
rate. Increasing third and fourth sleep stage rate and de-
creasing initial sleep latency after the surgery were consid-
ered as signs of improving sleep structure of the patient. Be-
fore the surgery the patient could not sleep deeply by night
because of apnea and felt tired in the day. After the surgery
these symptoms resolved. All the determined apneas were of
obstructive type. There were 22 apneic episodes of 40 sec-
onds and longer, all during REM sleep. Preoperatively the
apnea index was 45.5, and the longest apnea was 92 seconds.
Postoperativelythe apnea index was 2.5, and the longest ap-
nea was 33 seconds. The incidence of apnea was 212 before
Laryngoscope 106: September 1996
1168
Fig. 2. On macroscopic study the right lingual tonsil is brown and 6.5
x 4.5x 1.5cm, and the left lingual tonsil is gray-brownand 6 x 4.5 x
1.2 cm after the surgery.
the surgery but decreased to 12 within an 8-hour sleep after
the surgery. Preoperative and postoperative apnea condi-
tions are shown in Figure 3.
At 2 months after surgery the patient was completely
relieved of his symptoms of sleep disturbance, snoring, and
dysphagia. Scar tissue was noted on the tongue base.
DISCUSSION
The lingual tonsil is lymphoid tissue located on
the base of the tongue. It has no capsule. Recurrent in-
fection and hyperplasia of this tissue may be the caus-
es of respiratory problems and, rarely, OSA. The
pathologic condition of lingual tonsil hypertrophy is
usually hyperplasia, but papillary hyperplasia is
rarely ~een.4~5 Although the lymphoid tissue in
Waldeyer’sring tends to decrease with advancing age,
the lingual tonsil may increase in size. Research has
shown that the most important cause of lingual tonsil
hypertrophy is the occurrence of compensatoryhyper-
plasia following adenotonsillectomy. It was first de-
scribed by Brown (in 1899),175Elia6 reported in 1959
that 70% of 43 patients had lingual tonsil hypertrophy
after adenotonsillectomy. On the other hand, allergy,
alcohol, smoke, and chronic infections are cited as oth-
er possible etiologic factors.5 The most common symp-
toms of lingual tonsil enlargement are pain, dyspha-
gia, otalgia, and sensation of a lump in the throat.7
Five cases of OSA due to lingual hyperplasia have
been recorded in the prior literature. These include a
case of lingual tonsil hypertrophy and a case of large
lingual cyst reported by Olsen et a1.8 A 12-year-oldgirl
with Down’s syndrome was reported by Phillips and
Rogers.1A 5-year-oldboy with lingual tonsil hypertro-
phy and a 9-year-old boy with Down’s syndrome were
reported by Guarisco et al.7 Elia6 in a study of 43 pa-
tients with lingual tonsil hypertrophy and Joseph et
al.5 in a study of 11patients with lingual tonsillitis did
not report any patients with OSA due to lingual tonsil-
Dundar et al.: Obstructive Sleep Apnea
 100
90
80
IC 70
60
c
0 formed tracheotomy in one case because of respiratory
50
8 distress. Other authors preferred nasotracheal intu-
5 40
.-
‘0
-e
0 30
20
10
0 the surgery in our patient because of partial obstruc-
0-20 21-30 31-40 41-50
Apnea duration (sec)
Fig. 3. Preoperativeand postoperative apnea conditions.
litis or lingual tonsil hypertrophy. Among these cases
only one patient is a 13-year-oldyouths; the others are
children. We could not find any case of lingual tonsil
disease causing OSA in adults in the review of litera-
ture except the above-mentionedpatient described by
Olsen et a1.8 Consequently, one can state that the oc-
currence of OSA due to lingual hyperplasia in adults is
extremely rare.
Preoperative and postoperative evaluation of pa-
tients with OSA is very important. Polysomnography
is important to document and characterize the ap-
neas.2.9.10 In OSA apneic episodes of 40 seconds and
longer and apneic episodes in REM sleep are frequent.
We found that apneic episodes of 40 seconds and
longer appeared 22 times in our patient, all recorded
during REM sleep. Besides apnea, the most important
problems in the patients with OSA are sleep distur-
bance, tiredness, and snoring. After surgery, these pa-
tients feel better because of tranquil sleep. We ob-
served that our patient’s apnea index decreased, the
longest apnea shortened, and the apnea number di-
minished after the surgery. The patient was comfort-
able and active, and his sleep was regular.
The differential diagnosis of lingual tonsil hyper-
trophy includes lingual thyroid tissue, thyroglossal
duct cysts, dermoid cysts, lymphagiomas, angiomas,
adenomas, fibromas, papillomas, lymphomas, squa-
mous cell carcinomas, and minor salivary gland tu-
mors on the base of the tongue.5
The treatment of OSA due to lingual tonsil hyper-
trophy consists of lingual tonsillectomy performed
with the patient under general anesthesia. The surgi-
cal technique should be chosen according to equip-
ment, the patient’s clinical features, and the prefer-
ence of the surgeon. Lingual tonsillectomy can be
Latyngoscope 106: September 1996
accomplished by adopting various techniques includ-
ing sharp dissection, snare, cryosurgery, or the CO,
laser. Olsen et a1.8 reported the use of tracheotomy be-
fore tonsillectomy in their cases. Joseph et al.5 noted
that they preferred nasotracheal intubation but per-
bation during the surgery because OSA was not pres-
ent in their cases.1,7*8In other words, most of their
parents were not faced with serious respiratory dis-
tress. We preferred to establish tracheotomy before
51+ tion. It was obvious that the tissue edema occurring in
the postoperative period would cause respiratory dis-
tress in the patient.
In all reported cases treated with surgery, namely,
in patients with OSA, surgery resulted in a consider-
able improvement in regard to respiratory distress
and recurrent infections. Examination and laboratory
findings confirmed an adequate upper airway interval
in the postoperative period.1,5,7,8Jo
CONCLUSION
Lingual tonsil hypertrophy is a rare cause of OSA.
Nonetheless, lingual tonsil abnormalities may pro-
duce severe airway compromise or OSA in adults. The
patient with OSA should be examined carefully to rule
out anatomic abnormalities such as lingual tonsil hy-
pertrophy. A tracheotomy may be required before sur-
gery when a serious respiratory problem is present.
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the upper airway in patients with obstructive sleep apnea.
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