Ectopic (Oral) Tonsil |
||
|
||
Tonsillar tissue of the oral floor is blister-like and semitransparent. |
||
Quick Review for Patients
Note: click on underlined words for more detail or photos.
Nodules of tonsillar tissue, usually called benign lymphoid aggregates, lingual tonsils (posterior lateral tongue), oral tonsils, or oral tonsil tags, are found in several oral and pharyngeal regions besides the tonsillar beds of the lateral pharynx. This tissue, which corresponds to the adenoidal tissue of the nasopharynx, responds to infection and antigenic challenges, undergoing proliferation and appearing to become more numerous as very small, clinically invisible aggregates enlarge to a visible size. Lymphoid hyperplasia is the state in which many of these variants of normal anatomy are biopsied and the prevalence of hyperplastic oral tonsils is 1-2/1,000 adults (Table 1).
It should be mentioned that one in ten individuals have a small buccinator
lymph node of the anterior buccal region below the occlusal plane. Some of
these are located immediately beneath the mucosal epithelium and may enlarge
to a size of 1-2 cm. as a result of local trauma, dental infection or upper
respiratory infection. Histopathological inflammatory changes are consistent
with those found in cervical and other lymph nodes.
Clinical Features
Intraoral and pharyngeal lymphoid aggregates are more prominent in younger individuals, reaching their peak size during the adolescent and teenage years. While they may become especially large in young people, the hyperplastic state may be seen in persons of any age.
Sites of occurrence, in decreasing order of frequency, are the posterior
pharyngeal wall, the lateral posterior tongue, the soft palate and the oral
floor. During and for several days after an upper respiratory
or other acute infection, benign lymphoid aggregates become enlarged,
erythematous and perhaps somewhat tender, but they do not reach a size greater
than 0.8 cm. except on the posterior lateral tongue, where reported cases
have been 1.5 cm. or greater in diameter. Without hyperplasia the aggregates
are 0.1-0.4 cm. in size and have a pale yellow, semitransparent appearance
(Figures 1-3).
Pathology and Differential Diagnosis
The benign lymphoid aggregate is comprised predominantly of well differentiated lymphocytes collected into a single aggregation, usually with one or more germinal centers containing reactive lymphoblasts, predominantly B-cell types (Figures 4 & 5). Mitotic figures are seen in the germinal centers, as are macrophages containing phagocytized "tingible bodies" of nuclear debris from the surrounding proliferating lymphocytes. Linear streaking, or "Indian filing" of lymphocytes may be seen at the periphery of the aggregate and scattered lymphocytes are occasionally present in the surrounding fibrovascular stroma. There is no nodal encapsulation and vascular channels are minimally present, perhaps invisible without special staining.
The surface epithelium is often atrophic but occasional nodules of lymphoid aggregation show deep "tonsillar" clefts from the surface, perhaps filled with sloughed keratin. These clefts may crimp off at the surface, resulting in a keratin-filled lymphoepithelial cyst, or they may be considerably widened by the keratin build-up. In the latter case, the keratin may mushroom above the surface and become clinically visible as a tonsillar keratin plug.
The lymphoid cells of a lymphoid aggregate must be carefully evaluated to differentiate it from extranodal lymphoma and to determine whether or not the aggregate is hyperplastic. Microscopic criteria for hyperplasia and lymphoma are the same as those used for other lymphoid tissues of the body. Differentiation from a simple chronic inflammatory cell infiltrate is usually not difficult because the inflammatory infiltrate is much less abruptly demarcated from surrounding stroma, has many more lymphocytes in the surrounding stroma, has a greater admixture of inflammatory cell types, and lacks germinal centers.
It should be mentioned that certain very chronic inflammatory or immune-related
conditions, such as lichen planus or lupus erythematosus,
may demonstrate small lymphoid aggregates deep in the submucosal tissues.
These never produce surface nodules.
Treatment and Prognosis
The benign lymphoid aggregate requires no treatment, but may have to be excisionally biopsied in order to provide an appropriate diagnosis and to rule out lymphoid or other malignancy.
References (Chronologic Order)
Note: General references can be found by clicking on that topic to the left.
Simpson HE. Lymphocyte hyperplasia in foliate papillitis. J Oral Surg 1964; 22:209-214.
Joseph M, Ricardon E, Goodman H. Lingual tonsillectomy: a treatment for inflammatory lesions of the lingual tonsil. Laryngoscope 1984; 94:179-183.
Bouquot JE, Gundlach KKH. Odd tongues: the prevalence of common tongue lesions in 23,616 white Americans over 35 years of age. Quint Internat 1986; 17:719-730.
Napier SS, Newlands C. Benign lymphoid hyperplasia of the palate: report of two cases and immunohistochemical profile. J Oral Pathol Med 1990; 19:221-225.
Bhargava D, Raman R, Alabri RK, Bushnurmath B. Heterotopia of the tonsil. J Laryngol Otol 1996; 110:611-612.
Endo LH, Altemani A, Chone C, et al.
Histopathological comparison between tonsil and adenoid responses to allergy.
Acta Oto-Laryngol 1996; S523:17-19.
Table 1: Gender-specific
prevalence rates per 1,000 population for selected oral masses and surface
alterations in U.S. adults, ranked by total frequency. Modified from Bouquot JE.
Common oral lesions found during a mass screening examination. J Am Dent
Assoc 1986; 112:50-57, and Bouquot JE, Gundlach KKH. Oral exophytic lesions
in 23,616 white Americans over 35 years of age. Oral Surg Oral Med Oral
Pathol 1986; 62:284-291. Diagnosis Number of lesions per 1,000
population* Males Females Total Leukoplakia 43.2 20.9 28.9 Torus palatinus 13.2 21.7 18.7 Irritation fibroma 13.0 11.4 12.0 Fordyce granules 17.7 5.2 9.7 Hemangioma 8.4 4.1 5.5 Papilloma 5.3 4.2 4.6 Epulis fissuratum 3.5 4.4 4.1 Varicosities, lingual 3.5 3.4 3.5 Papillary hyperplasia 1.7 3.8 3.0 Mucocele 1.9 2.6 2.5 Enlarged lingual tonsil 2.4 1.2 1.6 Lichen planus 1.2 1.1 1.1 Buccal exostosis 0.9 0.9 0.9 Median rhomboid glossitis 0.8 0.5 0.6 Epidermoid cyst 0.7 0.4 0.5 Oral melanotic macule 0.5 0.3 0.4 Oral tonsils (except lingual) 0.5 0.3 0.4 Lipoma 0.2 0.1 0.2 Ranula 0.2 0.1 0.2 Buccinator node, hyperplastic 0.1 0.1 0.1 Pyogenic granuloma 0.0 0.07 0.04 Nasoalveolar cyst 0.0 0.07 0.04 Neurofibroma 0.0 0.07 0.04 * total examined population = 23,616 adults over 35 years of
age
Torus
mandibularis
9.6
7.9
8.5
Erythema,
inflammatory
4.5
4.8
4.7
Fissured
tongue
3.5
3.1
3.2
Benign
migratory glossitis
3.4
3.0
3.1
Aphthous
ulcer
3.3
3.0
3.1
Herpes
labialis (herpes simplex)
2.4
2.6
2.5
Traumatic
ulcer
2.1
2.1
2.1
Angular
cheilitis
1.8
1.9
1.9
Smokeless
tobacco keratosis
4.3
0.2
1.7
Hematoma or
ecchymosis
2.0
1.4
1.6
Chronic
cheek bite
0.7
1.4
1.2
Squamous
cell carcinoma
2.5
0.1
0.9
Amalgam
tattoo
0.6
1.0
0.9
Leaf-shaped
fibroma
0.4
1.2
0.9
Hairy
tongue
1.2
0.3
0.6
Nicotine
palatinus
1.2
0.2
0.6
Atrophic
glossitis (smooth tongue)
0.6
0.5
0.6
Leukoedema
0.4
0.3
0.3
Gingival
hyperplasia
0.1
0.1
0.1
