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Year : 2005  |  Volume : 7  |  Issue : 1  |  Page : 60-63

Unilateral tonsillar enlargement;Normal or neoplastic: A case report

1 King Faisal Specialist Hospital, Jeddah, Saudi Arabia
2 Dr. Erfan-Bagedo General Hospital, Jeddah, Saudi Arabia

Date of Web Publication21-Jul-2020

Correspondence Address:
Razan K Daghislani
P.O. Box 11217, Jeddah 21453
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.290332

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Unilateral tonsillar masses are common in children and are usually due to simple infection. However, underlying malignancy cannot be roled out specially when there are associated risk factors. We report a 10 years old boy with a large pedunculated tonsillar mass that turned out to be a benign hyperplasia. The literature will be reviewed.

Keywords: tonsillar enlargement, UTE, tonsillar asymmetry, tonsillar fossa

How to cite this article:
Daghislani RK, Daghistani KJ, Linjawi SS. Unilateral tonsillar enlargement;Normal or neoplastic: A case report. Saudi J Otorhinolaryngol Head Neck Surg 2005;7:60-3

How to cite this URL:
Daghislani RK, Daghistani KJ, Linjawi SS. Unilateral tonsillar enlargement;Normal or neoplastic: A case report. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2005 [cited 2023 Mar 27];7:60-3. Available from: https://www.sjohns.org/text.asp?2005/7/1/60/290332

  Introduction: Top

Unilateral tonsillar enlargement (UTE)or asymmetry in the size or appearance of the tonsils is a relatively common finding in children and is often discovered incidentally. It may result from infection, chronic inflammatory response or neoplasm. Neoplasms that commonly produce a UTE include lymphomas, and squamous cell carcinoma. Rarer tumours include extramedullar)' plasmacytoma, Hodgkin’s disease, leukaemia and metastatic neoplasms [1]. Sarcoidosis was reported as a case of isolated tonsillar asymmetry [2].

The finding of a UTE often raises the concern of neoplasm of the tonsil or the tonsillar fossa. In most cases the, larger-appearing tonsil is situated more medially within the tonsillar fossa. In some cases the enlargement is caused by unilateral infection [3]. Only rarely is the enlargement caused by malignancy. Here, not only is the tonsil enlarged, but its surface may also appears abnormal with areas of ulceration or necrosis. On the other hand the surface may appear smooth and intact. Squamous cell carcinoma of the tonsils often presents with ulceration of the mucosa of the tonsil. Nonepidermoid malignancy of the tonsil often presents with normal mucosa and asymmetry [4]

We report a case of a child with a very big pedunculated mass arising from the middle of the right tonsil. This proved to be a normal tonsil. The literature is reviewed.

  Case Report: Top

A 10 years old Saudi boy was referred to the ORL clinic from the paediatrician who noticed a large unilateral tonsillar enlargement. Neither the child nor the parents gave any history of sore throat, or difficulty in swallowing and the mass was discovered incidentally. The child was otherwise healthy with no past medical history beside the usual common childhood ailments. He was taken to the paediatrician for meningitis vaccination.

Examination of the oral cavity and pharynx revealed a very large pedunculated mass arising from the middle of the right tonsil [Figure 1]A , [Figure 1]B. The mass was about 3x2 cm large with a normal mucosal covering. It was slightly firm on palpation with no tenderness or bleeding surface. The left tonsil was normal. Rest of the ORL examination was negative.

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The right jugulodiagstric lymph node was palpable. It was soft, mobile, non-tender and without fluctuation or redness. There were no other palpable cervical lymph nodes.

General systemic examination was also normal. Full blood count and ESR and CT scan of the neck were requested.

Laboratory tests were normal. CT scan showed a pedunculated mass (1.5x2.5 cm) in the oropharynx. The mass appeared to be arising from the right tonsil with downward protrusion of the mass into the lower oropharynx. The lower most border of the mass ended above the level of the hyoid bone. The mass was solid with homogenous pattern of enhancement with no evidence of necrosis. There were bilaterally enlarged jugulodiagstric lymph nodes [Figure 2]A, [Figure 2]B.

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Routine tonsillectomy was performed. The right tonsil with the mass was sent for hsitpathological examination [Figure 3]. The histopathoiogy report indicated the weight of the tonsil to be 9 gms. And measuring 3.5\2\1 cm. Sections of the tonsil showed lymphoid tissue covered by squamous epithelium infiltrated with polymorphic inflammatory cells. The underlying lymphoid tissue showed preserved architecture and prominent follicular hyperplasia. The overlying crypts showed many large fungal colonies [Figure 4].
Figure 3: Operative specimen with mass of the right of figure and tonsil on the left.

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Figure 4: Lymphoid tissue with hyperplasia

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Post-operatively the child made a full recovery. He was seen six month later with no problems.

  Discussion Top

“ unilateral tonsil hypertrophy presumed to be neoplastic” is one of the indications for tonsillectomy listed in the American Otolaryngology-Head and Neck Surgery Clinical Indicator Compendium.[5] The limited evidence available suggests that the incidence of malignancy in children with unilateral tonsillar enlargement is very low, and that in many cases, the apparent enlargement is due to asymmetry of the mucosa of the tonsillar pillars [6]. In patients without cervical adenopathy . determining the presence of a malignancy in a tonsil with normal mucosa is almost impossible. It is important when examining a patient with apparent unilateral enlargement of the tonsil to exclude any parapharyngeal mass displacing the tonsil medially [7].

Cinjar, 2004 [8], reports that the presence of tonsil asymmetry without factors such as suspicious appearance, concomitant neck adenopathy, or progressive tonsil enlargement may not be enough to indicate malignancy. Berkowitz and Mahadevan, 1999 [9] recommend that tonsillectomy should be performed for biopsy purposes in UTE where there is a history of progressive enlargement, significant upper aerodiagestive symptoms, systemic sy mptoms, suspicious appearance of the tonsil, cervical adenopathy or hepatosplenomegally. The diagnosis of tonsillar lymphoma should be considered when UTE is present in an immunocompromised child or when acute tonsillitis is asy mmetric and unresponsive to medical treatment.

Our patient had a very large pedunculated mass from his right tonsil with a slight enlargement of the right jugulodiagstric lymph node. He was otherwise completely asymptomatic. Based on the size of the mass and smooth appearance of its surface in addition to the CT scan findings lymphoma was suspected. This we considered an indication for tonsillectomy.

Syms et al. 2000, [4] conclude that a relatively high number of tonsillectomies will be performed to yield an approximately 5% positive rate of malignancy within removed tonsils that are asymmetrical with normal mucosa and no cervical adenopathy. They also state that many unnecessary tonsillectomies are performed when UTE is taken as an indication for surgery in the absence of any other suspicious features.

In conclusion we report a case where the size and appearance of a mass arising from the right tonsil in addition to the CT scan findings lead us to perform tonsillectomy. Although the histopathology proved the mass to be simple hyperplasia, we believe that tonsillectomy should be performed in such cases in order to reach a definitive diagnosis.

  References Top

Cortez EA. Mattox DE,Holt GR.Gatcs GA. Unilateral tonsillar enlargement. Otolary ngol Heda Neck Surg 1979;S7(6):707-16.  Back to cited text no. 1
Campadretii GC.Nannini R. Tasca I. Isolated tonsillar sarcoidosis manifested as asymmctric palatine tonsils. Am J Otolaryngol 2003;24(3):187-90.  Back to cited text no. 2
Tom LWC. .Jacobs IN. Diseases of the oral cavity, orophary nx, and nasophary nx. In Ballenger’s Otorhinolaryngology Mead and Ncck Surgery. John B. Snow and John Jacob Ballcnger eds. 6th ed. BC Decker In. Spain. pp.1020-I047.2003.  Back to cited text no. 3
Syms MJ. Birkmirc-Peters DP.I Ioitel MR. Incidcnce of carcinoma in incidental tosil asy mmetry . Lary ngoscope 2000:110(11): 1807-1810.  Back to cited text no. 4
Clinical Indicator Compendium. Washington,DC:American Academy of Otolaryngology-Head and Neck Surgery. 1999:17.  Back to cited text no. 5
Spinou E. Kubba H,Konstantinidis I,Johnston A. Tosnillectomy for biopsy in children with unilateral tonsillar enlargement. Int J Pcdiatr Otorhinolaryngol 2002;63:15-7  Back to cited text no. 6
Cowan DL, Hibbert J. Acute and chronic infection of the oropharynx and tonsils. In: Scott-Brown’s Otolarynolgoy, Vol 5.Alan G.Kerr, Genral cd. 6th cd. Butterworth-Heinemann, Oxford.pp 5/4/1-5/4/24.1997.  Back to cited text no. 7
Cinar F. Significance of asymptomatic tonsil hypertrophy. Otolaryngol Head Neck Surg 2004:131 (1): 101 -3.  Back to cited text no. 8
Berkowitz RG, Mahadevan M. Unilteral tonsillar enlargement and tonsillar lymphoma in children. Ann Otol Rhinol Laryngol 1999;I08(9):876-9.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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