Severe benign lymphoid hyperplasia (LH) is unusual in the head and neck region, but the diagnosis of LH is of clinical importance as it may be confused with malignant lymphoma, both on clinical examination and pathologically. While the etiology is poorly understood, a number of previous theories exist, which are included here in the context of a literature review. In this paper we present a case of severe pharyngeal lymphoid hyperplasia causing airway obstruction and requiring tracheotomy and subsequent surgical debulking.
A 64-year-old African Canadian female with a history of urinary incontinence was admitted for an elective bladder suspension procedure by the gynaecology service in our institution. At the time of induction, our service was called emergently due to failed intubation related to a “pharyngeal mass.”
Upon examination with direct laryngoscopy a large, multiloculated, exophytic mass was identified, emanating from the oropharynx and extending distally to the level of the supraglottis, occupying >90% of the upper aerodigestive tract. The obstructive lesion was biopsied, and specimens were sent fresh for lymphoma histopathology protocol. The airway was subsequently secured, and the procedure was undertaken. Review of the preoperative anaesthesia records revealed no features of airway obstruction nor B symptoms on clinical history.
Postoperatively the patient was deemed unsafe for extubation and transferred to the intensive care unit while placed on high-dose intravenous dexamethasone.
CT scan revealed the epicenter at the base of tongue and an appearance suspicious for malignancy (Figure
CT scan in the axial plane revealing near-complete airway obstruction at the level of the oropharynx.
Open tracheotomy was performed on POD 3 due to the absence of a leak, and biopsies were again performed, which ultimately revealed the equivalent benign pathologic findings.
The patient was kept on a three-week course of tapering prednisone and proton-pump inhibitors. Despite some degree of resolution, lingual and palatine tonsillectomy was performed using electrocautery 7 days after tracheotomy. This procedure was carried out under general anesthetic in the form of a modified adenotonsillectomy, using a Boyle Davis gag for exposure and a combination of monopolar cautery for the palatine tonsils and suction cautery for subtotal ablation of the lingual tonsils. The patient was decannulated and discharged home 14 days after tracheotomy. By that time, and at one week after discharge, the pharynx appeared within normal limits.
Follicular lymphoid hyperplasia (FLH) is an uncommon benign entity related to a rapid increase in the abundance of lymphocytes contained within or outside of lymph nodes. It has been historically referred to as reactive lymphoid hyperplasia or pseudolymphoma [
The diagnosis of FLH is of clinical importance as it may be confused with malignant lymphoma, both on clinical examination and histopathology. The etiology is poorly understood, although some authors have postulated a relationship with chronic irritation (i.e., reflux, poorly fitting dentures, etc.) or a reactive lymphoid proliferation to an unknown antigenic stimulation [
LH most commonly affects older patients, with a mean age of 61 and female-to-male ratio of nearly 3 : 1. It tends to present as a unilateral, painless, slow-growing, nonulcerated mass. The mean size is 2.5 cm in the literature (range 1–5 cm). Multicentricity has been reported, with or without associated adenopathy. Clinical and laboratory investigations are routinely negative [
The differential diagnosis includes lymphoma, mesenchymal tumors, salivary gland neoplasms, and adenomatoid hyperplasia [
Surgical debulking/excision is the treatment of choice. External beam radiation has been successful in a single case [
Severe benign LH is unusual in the head and neck region, but the diagnosis should be entertained on the part of the clinician both clinically and histologically when lymphoma is suspected—particularly in the oral cavity.