|Year : 2015 | Volume
| Issue : 2 | Page : 134-136
Ectopic tonsillar tissue presenting with bilateral arytenoid swelling: A case report
Anie Melootu Thomas, Nevil Varghese, Arjun Gopinatha Menon
Department of ENT, Amala Institute of Medical Sciences, Thrissur, Kerala, India
|Date of Web Publication||31-Dec-2015|
Anie Melootu Thomas
Department of ENT, Amala Institute of Medical Sciences, Thrissur, Kerala
Source of Support: None, Conflict of Interest: None
Arytenoid swelling, especially in a male patient presenting with complaints of change in voice needs to be evaluated to rule out malignancy. We present the case of a 60 year old male with a change in voice, bilateral arytenoid swelling, which on further evaluation diagnosed as laryngeal tonsil. Lymphoid hyperplasia presenting with bilateral arytenoid swelling is very rare and should be considered in atypical presentations of larynx.
Keywords: Ectopic tonsil, gastroesophageal reflux disease, laryngitis, lymphoid hyperplasia, tonsil
|How to cite this article:|
Thomas AM, Varghese N, Menon AG. Ectopic tonsillar tissue presenting with bilateral arytenoid swelling: A case report
. Int J Adv Med Health Res 2015;2:134-6
| Introduction|| |
Arytenoid swelling or edema is caused by various inflammatory and noninflammatory conditions such as gastroesophageal reflux disease (GERD), exposure to irritants, allergies, following radiotherapy, laryngitis, and hidden malignancy. ,, Lymphoid tissue hyperplasia in the pharynx commonly involves all the tissues of Waldeyer's ring including adenoidal, tubal, palatine, and lingual tonsils. Ectopic tonsil is tonsillar tissue that was established at areas outside the Waldeyer's ring, a complete circle of lymphoid tissue surrounding the entrance to the gastrointestinal and respiratory tracts. Ectopic lymphoid tissues in arytenoids are rarely reported. Here, we report a case of bilateral arytenoid swelling simulating hidden malignancy which on further evaluation turned out to be benign lymphoid hyperplasia. The aim of this report is to point out the atypical presentation of an ectopic tonsillar tissue in larynx (arytenoids).
| Case Report|| |
A 60-year-old male presented with complaints of change in voice, insidious in onset, and nonprogressive. He denied having pain, dyspnea, dysphagia, or foreign body sensation. No history of smoking, use of alcohol, or any other medical illness including GERD. On examination, he had muffled voice. Bilateral smooth, globular arytenoid swellings were present, obscuring the view of true and false vocal cords, with minimal pooling of saliva. Visible parts of anterior two-third of true vocal cords were normal [Figure 1] and no evidence of lymphadenopathy. From these findings, differential diagnoses of arytenoid edema due to hidden malignancy, possibly postcricoid or pyriform fossa origin, and amyloidosis larynx were made. Blood investigations such as hemogram, liver, and renal functions tests were normal. Preoperative investigations such as chest X-ray was also normal. The patient was initially treated medically with proton pump inhibitors (pantoprazole, 40 mg) and prokinetics (domperidone, 30 mg) but with no improvement. Surgery was done to rule out malignancy as it was the only concern of the patient. Under general anesthesia, microlaryngoscopy was done. The extent of lesion was assessed. Smooth arytenoid swellings without any involvement of adjacent sites were seen. The lesion was superficially excised, preserving the arytenoids and specimen sent for histopathology. The risk of airway compromise like going to stridor postoperatively, due to laryngeal spasm was there. Hence, emergency tracheostomy was also arranged if necessity arises. However, in this case, surgery was uneventful without any complications. The postoperative course was uneventful. Histopathology of the specimen showed hypertrophied laryngeal lymphoid nodule with no evidence of amyloidosis or malignancy [Figure 2]. In view of inadequate sample, typical features of tonsil-like crypts were not found. During the follow-up of 6 months, there was no sign of recurrence of the swelling or complications.
|Figure 1: Rigid laryngoscopy: Bilateral arytenoid swelling and visible anterior third of true vocal cords. A — Arytenoid, B — Base of tongue, C — Vallecula, D — Posterior pharyngeal wall and E — Epiglottis|
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|Figure 2: Photomicrograph showing lymphoid tissue with intervening blood vessels (H and E, ×40)|
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| Discussion|| |
A collection of subepithelial lymphoid tissue around the entrance to pharynx is called the Waldeyer's ring. The lymphatic tissue is arranged in a circular manner. The inner ring consists of adenoids, tubal tonsils, palatine tonsils, and lingual tonsils. These lymphoid tissues have no afferents, and they have only efferent channels. The main function of Waldeyer's ring is defense. It produces local antibodies, IgA, and lymphocytes. The so-called outer ring of Waldeyer is composed of groups of lymphnodes immediately draining the inner ring that is, submental, submandibular, facial, upper deep cervical, and retropharyngeal nodes. Ectopic tonsil is tonsillar tissue that was established at areas outside the Waldeyer's ring. Previous reports showed the presence of ectopic tonsillar tissues in various regions such as nasal septum, hypopharynx, floor of the mouth, orbit, ventral surface of the tongue, soft palate, and also in the larynx. ,,,,,,, Pellettiere et al. reported the lymphoid hyperplasia of the adult larynx which recurred following the surgical excision without any additional therapy.  Ectopic tonsillar tissue simulating a benign tumor of the hypopharynx (pyriform sinus) is described in a case report by Baba et al.  In this report, smooth mucosal swelling in the right pyriform recess was found but no vocal cord fixation. Computed tomography revealed no space-occupying lesion in the right pyriform recess. Hence, a preoperative diagnosis of a benign tumor was made. The swelling was restricted to the surface of the hypopharyngeal mucosa, and they resected the tissue laryngoscopically under general anesthesia. 
Laryngeal tonsil is an irregular collection of lymphoid tissue on the posterior aspect of the epiglottis and in the ventricle of the larynx. Synonyms include folliculi lymphatici laryngei and lymphatic follicles of larynx. Smooth, symmetric nature of the arytenoid swelling without any involvement of adjacent sites may be attributed to the benign pathology. Histological criteria for diagnosis are emphasized. However, one of the main drawbacks remains in the inadequate sampling for biopsy.
Laryngeal tonsil presenting with bilateral arytenoid swelling is unique in the site of occurrence of lymphoid tissue. Despite the large swelling obscuring vocal cords, our patient did not have dyspnea or dysphagia. Deteriorated voice quality and restricted phonation capabilities were reported in patients with reflux laryngitis.  Despite a few cases reported so far in literature, in order to define the pathogenesis and ultimate biologic potential of this lesion, more cases with a long follow-up is required.
| Conclusions|| |
Although ectopic tonsillar tissue in various sites has been reported, lymphoid hyperplasia presenting with bilateral arytenoid swelling is very rare and hitherto unexplained entity, which should be considered in out of ordinary clinical presentations of larynx.
We acknowledge Dr. Vinayakumar AR, Professor and Head of the Department of ENT, for the valuable advice and intellectual support; Dr. Ajith TA, Professor, Department of Biochemistry, for his help during the preparation of this manuscript; and the team of the Pathology Department of Amala Institute of Medical Sciences, who contributed to the final diagnosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ichimura K, Sugasawa M, Nibu K, Takasago E, Hasezawa K. The significance of arytenoid edema following radiotherapy of laryngeal carcinoma with respect to residual and recurrent tumour. Auris Nasus Larynx 1997;24:391-7.
Cobzeanu MD, Voineag M, Drug VL, Ciubotaru A, Cobzeanu BM, Palade OD. Laryngeal morphological changes due to gastroesophageal reflux disease. Rev Med Chir Soc Med Nat Iasi 2012;116:1011-5.
Reiter R, Brosch S. Chronic laryngitis - Associated factors and voice assessment. Laryngorhinootologie 2009;88:181-5.
Furukawa M, Takeuchi S, Umeda R. Ectopic tonsillar tissue in the nasal septum. Auris Nasus Larynx 1983;10:37-41.
Baba Y, Kato Y, Ogawa K. Hyperplasia of lymphoid structures in the hypopharynx: A case report. J Med Case Rep 2010;4:388.
Knapp MJ, Colonel L. Pathology of oral tonsils. Oral Surg Oral Med Oral Pathol 1970;29:295-304.
Knapp MJ. Oral tonsils: Location, distribution, and histology. Oral Surg Oral Med Oral Pathol 1970;29:155-61.
Mogi K. Ectopic tonsillar tissue in the mucosa of the floor of the mouth simulating a benign tumour. Case report. Aust Dent J 1991;36:456-8.
Patel K, Ariyaratnam S, Sloan P, Pemberton MN. Oral tonsils (ectopic oraltonsillar tissue). Dent Update 2004;31:291-2.
Wolter JR, Roosenberg RJ. Ectopic lymph node of the orbit simulating alacrimal gland tumor. Am J Ophthalmol 1977;83:908-14.
Pellettiere EV, Holinger LD, Schild JA. Lymphoid hyperplasia of larynx simulating neoplasia. Ann Otol Rhinol Laryngol 1980;89:65-8.
Pribuisiene R, Uloza V, Kupcinskas L, Jonaitis L. Perceptual and acoustic characteristics of voice changes in reflux laryngitis patients. J Voice 2006;20:128-36.
[Figure 1], [Figure 2]