INTRODUCTION: Obstructive sleep apnea (OSA) is a common, yet serious, medical condition that may result from an anatomically narrowed upper airway lumen. Lymphoma is a rare cause of tonsillar hypertrophy most often effecting the pediatric population. We report, for the first time in the literature to our knowledge, the case of an adult with undiagnosed large B-cell lymphoma and bilateral tonsillar hypertrophy who presented because of signs and symptoms of obstructive sleep apnea.
CASE PRESENTATION: A thin 39-year-old man presented to his primary care physician (PCP) for evaluation of disruptive snoring. Several months earlier he had experienced tender, swollen cervical lymph nodes on the right which had resolved spontaneously. Aside from a globus sensation when he swallowed, he had no other complaints. The patient was referred to the ear, nose and throat (ENT) clinic where asymmetric bilateral tonsillar hypertrophy without associated cervical lymphadenopathy was detected. Although he denied excessive daytime sleepiness (Epworth Sleepiness Scale = 2), he complained of severe snoring (Snoring Severity Scale = 8) and had a history of hypertension. He was subsequently referred for polysomnography which showed repeated airway obstruction (apnea/hypopnea index = 57.4) associated with severe oxygen desaturations (low SpO2 = 71%). Given the apparent anatomic cause for his symptoms, the patient elected to undergo surgical modification of the upper airway which included uvulopalatopharyngoplasty (UPPP) with tonsillectomy and coblation-assisted turbinate reduction. The excised tonsils were asymmetrically enlarged (right, 4.5 x 4.5 x 2.5 cm; left, 4.5 x 2.5 x 1 cm) and pathology demonstrated large B-cell lymphoma effecting both tonsils. He was subsequently treated with CHOP chemotherapy.
DISCUSSIONS: OSA is a common disorder effecting overweight/obese adults. Non-obese adults with obstructive sleep apnea should be carefully assessed for evidence of an anatomic limitation of the upper airway lumen that might result from various craniofacial anomalies, macroglossia and adenoid tonsillar hypertrophy. Tonsillar hypertrophy is a common remedial risk factor for OSA in the pediatric population, but may also play a role in the pathophysiology of sleep-related upper airway obstruction in adults1. The most common causes of asymmetric tonsils are unequal scarring from prior infection and benign lymphoid hyperplasia. An asymmetric appearance of the tonsils may also result from unequal depth of the surrounding tonsillar fossa. Despite the uncertainties, routine tonsillectomy with pathologic evaluation is the standard of care2 and recommendation of the American Academy of Otolaryngology for children with asymmetric tonsillar hypertrophy. No such recommendations exist for adults and individuals with asymmetric tonsils should be carefully questioned for symptoms or signs of malignancy including pain, ulceration, cervical adenopathy, and constitutional symptoms.
CONCLUSION: Patient’s with signs and symptoms of obstructive sleep apnea should be carefully examined for evidence of anatomic abnormalities/obstruction of the upper airway including pharyngeal tonsil enlargement. Asymmetric tonsillar hypertrophy is most often benign; however underlying malignancy should always be considered.
DISCLOSURE: Jose Gomez, No Financial Disclosure Information; No Product/Research Disclosure Information