Oral cavity & oropharynx
General
Lingual tonsil

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Molly Housley Smith, D.M.D.

Minor changes: 4 June 2021

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Molly Housley Smith, D.M.D.
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Cite this page: Smith MH. Lingual tonsil. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/oralcavitylingualtonsil.html. Accessed June 20th, 2021.
Definition / general
  • Collection of reactive submucosal lymphoid nodules situated on the dorsal or lateral aspects of the tongue base, which presents clinically as red papules or nodules
  • One of the three sets of tonsils present within Waldeyer ring, along with the pharyngeal and palatine tonsils
Essential features
  • Clinically presents as red papules or nodules posterior to the circumvallate papillae
  • Often clinically diagnostic, although asymmetric, hyperplastic nodules may warrant biopsy to rule out lymphoma or other pathology
  • Hyperplastic lingual tonsil is associated with obesity, obstructive sleep apnea, acid reflux disease, younger age, allergic rhinitis and smoking (Am J Rhinol Allergy 2020;34:87)
Terminology
  • Hyperplastic lingual tonsil
  • Hyperplastic lymphoid aggregates
  • Lingual tonsillar hypertrophy
ICD coding
  • ICD-10: J35.1 - hyperplastic lingual tonsil
Epidemiology
Sites
  • Base of tongue, dorsal or lateral aspects, posterior to the circumvallate papillae
  • Anterior to the epiglottis
Diagrams / tables

Images hosted on other servers:
Lingual tonsil anatomy Lingual tonsil

Lingual tonsil anatomy

Clinical features
Diagnosis
  • Diagnosis is made upon clinical features or awake endoscopy (Otolaryngol Head Neck Surg 2018;158:391)
  • Biopsy rarely is indicated to rule out other pathological causes of submusocal masses (e.g. lymphoma)
  • Head and neck computed tomography (CT), magnetic resonance imaging (MRI), skull lateral radiographs may prove useful in diagnosis and staging of lingual tonsil hypertrophy (Otolaryngol Head Neck Surg 2017;157:898)
Radiology description
  • Head and neck computed tomography (CT), magnetic resonance imaging (MRI) and skull lateral radiographs demonstrate lingual tonsils at the level of the epiglottis on the tongue base (Otolaryngol Head Neck Surg 2017;157:898)
Radiology images

Contributed by Molly Housley Smith, D.M.D.
Sagittal T1 weighted MRI

Sagittal T1 weighted MRI

Case reports
  • 17 year old girl and 26 and 30 year old women present with eosinophilic lingual tonsillitis following sublingual immunotherapy for allergic rhinitis (Clin Case Rep 2020;8:2211)
  • 48 year old woman with lingual tonsil abscess contributing to rapidly progressing sore throat (BMJ Case Rep 2019;12:e229555)
  • 70 year old woman with hyperplastic lingual tonsil leading to partial airway obstruction (Cureus 2020;12:e8309)
Treatment
  • Nonsurgical medical management or surgical debulking / removal may be indicated in cases of hyperplastic lingual tonsil contributing to sleep apnea (Clin Otolaryngol 2017;42:144)
Clinical images

Contributed by Molly Housley Smith, D.M.D.
Posterior dorsal tongue

Posterior dorsal tongue

Posterior lateral tongue

Posterior lateral tongue

Numerous enlarged papules

Numerous enlarged papules

Gross images

Images hosted on other servers:

Inferior view

Superior view

Microscopic (histologic) description
  • Aggregates of benign lymphoid tissue, often with germinal center formation; germinal centers lack capsules and sinusoidal spaces
  • May contain crypts lined by specialized keratinized stratified squamous epithelium (termed reticular epithelium) that invaginate from the surface; crypts are often filled with desquamated epithelial cells and bacteria, which may calcify
  • Often surrounded by other normal structures of the tongue, including striated muscle, mucinous glands and serous glands
  • Reference: Anat Histol Embryol 2005;34:27
Microscopic (histologic) images

Contributed by Molly Housley Smith, D.M.D.
Germinal center formation

Germinal center formation

Epithelial crypt formation

Epithelial crypt formation

Diffuse lymphocytic tissue

Diffuse lymphocytic tissue

Reticular epithelium

Reticular epithelium

Videos

Histology of the lingual tonsil

Lingual tonsillectomy for obstructive sleep apnea

Sample pathology report
  • Tongue base, incisional biopsy:
    • Hyperplastic lingual tonsil (see comment)
    • Comment: Microscopic examination reveals surface stratified squamous epithelium and supporting connective tissue. The surface epithelium contains scattered taste buds and focally invaginates into the mesenchymal tissue forming deep crypts containing keratin flakes. Within the supporting connective tissue is a well defined area of lymphoid tissue. Germinal center formation is noted. Lobules of minor salivary glands and associated ductal structures are noted in the surrounding stroma.
Differential diagnosis
  • Lymphoepithelial cyst:
    • Often clinically presents as an opaque yellow-white nodule that easily ruptures upon manipulation
    • Microscopically similar to lingual tonsil, although an enlarged cystic space is seen rather than an crypt-like invagination of surface epithelium (J Clin Exp Dent 2017;9:e1035)
Board review style question #1

Oral examination of a patient reveals an asymmetric 4 mm red nodule of the dorsal tongue base. The patient is asymptomatic and was unaware of the finding. Biopsy of the lesion is shown. Which of the following is true regarding the diagnosis?

  1. Diagnosis of this entity relies heavily on immunohistochemical findings
  2. Diagnosis represents a reactive hyperplasia of a normal structure
  3. Significant clinical follow up is recommended, as malignant transformation occurs in the majority of patients with this finding
  4. This entity is more commonly found in older adults
Board review style answer #1
B. Diagnosis represents a reactive hyperplasia of a normal structure

Comment Here

Reference: Lingual tonsil
Board review style question #2

A patient presents with a focal collection of red papules on the posterior lateral tongue. Biopsy demonstrates a well defined aggregate of lymphocytes showing germinal center formation. An epithelial lined crypt containing keratin is seen in the central aspects of the lymphocytic nodule. What is the most likely diagnosis?

  1. Fibroma
  2. HPV related squamous cell carcinoma
  3. Lingual tonsil
  4. Lymphoma
Board review style answer #2
C. Lingual tonsil

Comment Here

Reference: Lingual tonsil
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