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Lymphangioma of the Palatine Tonsil.

A lymphangioma is mostly a congenital lesion consisting of a benign proliferation of lymphatic channels. Approximately 50% of these lesions are apparent at birth, with 80% to 90% detected within the first 2 decades of life. (1) In contrast to congenital hemangiomas, lymphangiomas do not involute over time. (2) Although these lesions tend to surround and sometimes invade nearby anatomic structures, they have no malignant potential. (1) There is also considerable debate over the etiology of lymphangiomas, which may represent true neoplasms, malformations, or hamartomas.

Three morphologic types of lymphangiomas are distinguished. Capillary, or simple, lymphangiomas are usually found in the superficial skin and composed of capillary-sized, thin-walled lymphatic vessels. Cavernous lymphangiomas are subcutaneous lesions composed of mildly dilated, large spaces that are larger than those seen in capillary lymphangiomas. Cystic hygromas, the third type, are most common in the neck and composed of large, dilated, cystic lymphatic spaces. (3) Thus, these 3 types of lymphangiomas can be differentiated from one another based purely on the characteristics of the component lymphatic spaces. In addition, combinations of the 3 types can sometimes be found in a single lesion. Therefore, the 3 types of lymphangiomas represent the same pathologic process along a spectrum and should be considered as a unified concept. (1) Moreover, differentiating lymphangiomas on the basis of histologic type appears without clinical implications.

Lymphangiomas tend to occur in places where lymphatics are abundant, with more than 90% of all lymphangiomas arising in the head and neck region. Most are found in the skin and subcutaneous tissues, but they have also been described in the larynx, parotid gland, mouth, and tongue. (4) The palatine tonsil is a far less common site for the development of lymphangioma and has rarely been reported in the literature. A recent case of tonsillar lymphangioma at our institution inspired our review of this unusual entity. Our search of the English literature found 31 other reported cases of this lesion, dating back to the 1930s, as shown in the Table. Although the various authors assign different terminology to describe these lesions, upon review of the reported microscopic features, all of the listed cases are histologically consistent with lymphangioma.

CLINICAL FEATURES

The Table lists the 32 cases of lymphangioma of the palatine tonsil (31 previously reported cases and our case) reported in the English literature, including patient age and sex, presenting symptoms, lesion laterality, and size (greatest dimension). The 18 males and 14 females range in age from 3 to 80 years, with a mean age at presentation of 25.9 years (median, 22.5 years).

A tonsillar lymphangioma may be asymptomatic, especially when small in size, and may, therefore, be discovered incidentally on physical examination or posttonsillectomy. When symptomatic, common presenting symptoms include dysphagia, recurrent sore throat, and foreign body sensation in the throat, which may cause a nonproductive cough. (5) A change in the quality of the patient's voice has also been reported as a result of this lesion. (6) A remarkably large mass may compress surrounding structures to produce respiratory difficulty, stridor, or nausea. Difficulty with swallowing may progress, causing excessive saliva in the oral cavity. (5)

On examination of the oral cavity, a lymphangioma is typically found to be an oval, pediculate mass protruding from the surface of the palatine tonsil. There is 1 report of a patient with a lymphangioma arising from the adenoids, presenting as a mass in the nasopharynx. (7) Lymphangiomas are almost always unilateral, with no apparent side predilection. Of the cases in our review that reported lesion laterality, 12 were on the right, 13 were on the left, and there was 1 case of bilateral lymphangiomas of the palatine tonsils. (8) On palpation, a lymphangioma is smooth and firm with intact mucosa, and a crepitant sound may be produced as lymphatic fluid is pushed from one area to another. (2) Cervical lymphadenopathy is not typically present. (7) However, Evans and Odom (9) reported a case of a 13-year-old girl with lymphangioma of the right palatine tonsil who had palpable lymph nodes in the right cervical region.

GROSS PATHOLOGY

Grossly, a tonsillar lymphangioma appears as an exophytic polypoid nodule arising from the palatine tonsil. The lesion is generally pedunculated, but it may instead be sessile. (7) The lesions in our review range in size from 0.5 to 5 cm (mean, 2.49 cm) in largest diameter. The outer surface of the lesion is typically smooth, but 1 reported case is remarkable for a villous appearance of the external surface, with multiple fronds of varying sizes. (10) The consistency of the lesions varies from spongy to firm, and the cut surface is uniformly smooth, appearing white, tan, or yellow in color. (7)

HISTOPATHOLOGY

The microscopic findings associated with tonsillar lymphangiomas are well described. Of note, the Figure referenced below is from our recent case.

Microscopically, the surface of the lymphangioma is remarkable for stratified squamous epithelium (Figure 1A).

Variable hyperplasia and dyskeratosis may be present, but dysplasia is not seen. Rarely, tonsillar lymphangiomas may have papillary architecture; this feature has been reported exclusively in tonsillar lymphangiomas affecting children. (7)

Diffusely distributed within the submucosa are numerous dilated lymphatic spaces lined by endothelial cells, with the walls of larger spaces sometimes containing a few disorganized smooth muscle bundles. This lymphatic proliferation is characteristically present underneath the overlying epithelium, with little or no intervening connective tissue. Valves can often be appreciated within the lymphatic spaces (Figure 1B). The lymphatic spaces can also contain proteinaceous material, as well as occasional lymphocytes and erythrocytes (Figure 1C). (2)

The stroma of the lymphangioma is comprised of adipose tissue, fibrous tissue, and lymphocytes (Figure 1D). Adipose tissue is present in varying amounts; some reports note absence of this component entirely, and in our case only a small amount was present. The collagenous component is much more abundant. Collections of lymphocytes are found not only in the submucosa but also within the squamous epithelium of the lesion. (4) Some cases display a nested epitheliotropism of lymphocytes, which refers to small lymphocytes clustered into rounded intramucosal spaces. (7) In the submucosa, foci of well-organized lymphoid tissue may sometimes be found as well (Figure 1E). (5) Regardless of the location of these lymphocytes, they display the morphology of normal mature lymphocytes, with small round nuclei and a small rim of cytoplasm. Cytologic atypia is notably absent from tonsillar lymphangiomas, as is infiltration of the underlying stroma of the normal tonsil. (7)

Routine hematoxylin-eosin sections are sufficient for making the diagnosis of tonsillar lymphangioma, but Kardon et al (7) used immunohistochemical staining to determine the immunoprofile of these lesions. In the 15 cases examined, the endothelium and subendothelium of the lymphatic channels stained positive for factor VIII-related antigen, and the majority of channels stained positive for either anti-CD31 or anti-CD34. Additionally, the walls of the dilated lymphatic vessels expressed smooth muscle actin. As far as the lymphoid population of cells, the leukocyte markers CD3, CD20, and CD45 (leukocyte common antigen) revealed a distribution of lymphocyte expression consistent with tonsillar tissue. Intraluminal and intraepithelial lymphocytes were predominantly CD3 immunoreactive. Thus, Kardon et al (7) confirmed the endothelial origin of the vascular proliferation and a mixed lymphoid population.

Our recent case was stained with D2-40 (podoplanin), a sialoglycoprotein found on lymphatic endothelial cells, which highlighted the lymphatic spaces within the lesion (Figure 1F). The small, endothelium-lined vessels that were negative for D2-40 were presumably capillaries. Positive staining with MECA-79 has also been documented in tonsillar lymphangiomas. This antibody recognizes a carbohydrate epitope expressed in high endothelial venules, specialized structures involved in lymphocyte homing into lymphoid tissues. (11) Lastly, immunohistochemical staining for fibronectin and collagens I and III revealed a decreased and disorganized distribution of these extracellular matrix proteins in lymphangiomas compared with normal tonsils. (11)

DIFFERENTIAL DIAGNOSIS

Unilateral tonsillar enlargement may be caused by a malignant neoplasm, benign lesion, or acute or chronic inflammation. Alternatively, a parapharyngeal mass may result in apparent tonsillar enlargement because of medial displacement of the tonsil. (7) In a study of approximately 2000 tonsillar neoplasms during a 30-year period from the Otolaryngic Pathology Registry of the Armed Forces Institute of Pathology, the most common malignant neoplasms of the palatine tonsils included squamous cell carcinoma and lymphoma. Benign neoplasms represented 25% of total cases, with tonsillar lymphangiomas representing 8% of the benign entities. (12) Because these statistics are likely influenced by referral bias, the lesion may be encountered even more infrequently, especially in the community hospital setting.

The differential diagnosis of a benign polypoid tonsillar lesion includes squamous papilloma, lymphangioma, epidermal inclusion cyst, juvenile angiofibroma, hemangioma, fibroepithelial polyp, fibroma, fibroxanthoma, lipoma, adenoma, and chondroma. (12) Of these benign entities, the most common is squamous papilloma, which is a proliferation of the surface epithelium without involvement of the underlying stroma and with absence of lymphatic and lymphocytic components. (7) An epidermal inclusion cyst appears as a small, tense, yellow mass just beneath the mucosa, and it represents a true cyst with a squamous lining. A fibroepithelial polyp arises from the mesodermal tissue and is composed of varying amounts of stroma covered by squamous epithelium. Hemangioma, fibroma, lipoma, adenoma, and chondroma refer to benign proliferations of blood vessels, fibrous tissue, mature fat cells, glandular elements, and hyaline cartilage, respectively. (12)

Differentiating a lymphangioma from a juvenile angiofibroma is especially important because the latter diagnosis warrants a more aggressive surgical resection and carries an increased risk of recurrence. (13) Histologically, the stroma of an angiofibroma is more cellular, consisting of cells with plump nuclei arranged radially around staghornlike thin walled vascular channels; lymphocytes are not a prominent cell type. (7) Therefore, the characteristic histologic features of a tonsillar lymphangioma allow pathologists to differentiate it from tonsillar lesions that may appear similar clinically.

CURRENT TREATMENT AND PROGNOSIS

The prognosis of a tonsillar lymphangioma is excellent. Tonsillar lymphangiomas are treated by wide surgical excision, with tonsillectomy as the preferred procedure to ensure complete removal. Because of their lack of encapsulation, recurrences of lymphangiomas, in general, are common if they are not completely removed. (1) Recurrence of tonsillar lymphangiomas after complete removal has not been reported in the literature. However, the length of patient follow-up is not always reported, and the longest reported follow-up period is 5 years. Thus, total absence of recurrence cannot be proven. These lesions are radio-resistant, so radiotherapy is ineffective and increases the risk for maldevelopment and malignancies of the head and neck. (14)

PATHOGENESIS

The pathogenesis of tonsillar lymphangioma is controversial. Chronic inflammation and associated obstruction of lymphatic channels have previously been suggested as a possible mechanism, with congestion eventually leading to mucosal prolapse and the appearance of a polypoidal swelling. (15) However, evidence against this explanation is that chronic tonsillitis occurs much more commonly than tonsillar lymphangiomas, and many patients presenting with tonsillar lymphangioma lack a history of tonsillitis. The recurrent sore throats some patients experience could be a consequence, rather than a cause, of a tonsillar lymphangioma. (16) Furthermore, a study of 14 cases of tonsillar lymphangioma found no gross evidence of lymphatic obstruction in the lesions or associated resected normal tonsils, even after serial sectioning of the tissue specimens. (11) This suggests that another mechanism is likely responsible for the pathogenesis of these tumors.

Wiegand et al (17) proposed several theories for the pathogenesis of tonsillar lymphangioma. One hypothesis is that the failure of primordial lymphatic sacs to drain into veins produces dilation of the isolated lymphatic channels. Alternatively, abnormal sequestration of lymphatic tissue early in embryogenesis with subsequent failure to join the normal, more central, lymphatic channels may explain the morphology of the more peripheral lesions, such as capillary and cavernous lymphangiomas. Another theory involves abnormal budding of the lymphatic structures, with the aberrant buds losing their connections with the primordial lymphatics and eventually canalizing to form lymph-filled cysts. These cysts maintain their ability to branch and grow, and do so in an uncontrolled, disorderly manner, with a tendency to penetrate and destroy normal anatomic structures.

Many argue that lymphangiomas represent hamartomatous lesions. Reported tonsillar lymphangiomas contain an admixture of fibrous and adipose elements, lymphatic spaces, and lymphocytes. These components are normal constituents of the tonsil, but are arranged in a disordered manner, consistent with the haphazard arrangement of elements in a hamartoma. (16) Reinforcing this notion is the finding of a disorganized pattern of distribution of fibronectin and collagens I and III within the stroma of lymphangiomas, revealed using immunohistochemical staining. (11)

Another possibility is that the pathogenesis of tonsillar lymphangiomas may be multifactorial, due to a combination of the proposed factors, occurring sequentially or synchronously. First, aberrations during development may produce a hamartomatous focus with its own growth potential. Second, chronic inflammation, secondary to stimuli such as trauma or infections, may trigger a growth phase responsible for the eventual polypoid mass. (18) A delay in this second event would help explain the occurrence of lymphangiomas in older patients.

More recent studies have proposed that lymphangiomas develop as a result of a neoplastic proliferation of lymphatic vessels, leading to a network of lymphatics that never achieve sufficient anastomosis with larger lymphatic vessels. The uncontrolled proliferation of lymphatic vessels is thought to be caused by a dysregulation of growth factors involved in lymphangiogenesis, such as Prox-1 and vascular endothelial growth factor C (VEGF-C). The transcription factor Prox-1 is expressed in lymphatic endothelial cells and lymphangioblasts, and its expression has been detected in the endothelium of lymphangiomas. Additionally, the growth factor VEGF-C and its receptor VEGFR-3 have been shown to have increased expression in the lymphatic endothelium of lymphangiomas versus normal lymphatic vessels. Lastly, 2 inhibitors of angiogenesis, pigment epithelium-derived factor and thrombospondin-1, have been found to have reduced expression in lymphangiomas. (17) Therefore, the development of lymphangiomas may depend on active lymphangiogenesis as well as increased angiogenesis.

CONCLUSIONS

Regardless of the uncertain pathogenesis of tonsillar lymphangiomas, these lesions have histologic features that differ from their counterparts in other anatomic locations. Although the lymphatic spaces of tonsillar lymphangiomas are frequently dilated, they are generally not as large or as prominent as in the lymphangiomas found elsewhere. Furthermore, the lymphoid and fibrous stromal components in tonsillar lymphangiomas are frequently more abundant than the lymphatic vessels. (19) Although some lymphangiomas involute over time, the involution of tonsillar lymphangiomas has not been described in the literature to date. (7) Thus, tonsillar lymphangiomas may represent a somewhat unique lesion.

In part because of the controversy over its pathogenesis, the classification of tonsillar lymphangiomas has been inconsistent, adding to the difficulty in assessing the lesion's true incidence. Reports in the literature use different nomenclature when referring to these lesions, such as tonsillar lymphangiomatous polyp, angioma, angiofibroma, fibrolipoma, polypoid tumor containing fibroadipose tissue, hamartomatous tonsillar polyp, and lymphangiectatic fibrous polyp. (4) The more recent reports have addressed this issue, and hopefully, with increased awareness of this lesion, a more uniform classification system will emerge. The reported incidence will likely increase as more clinicians and pathologists recognize this lesion.

In summary, lymphangioma of the palatine tonsil presents as a mass lesion constituting a benign proliferation of dilated lymphatic spaces amid stroma with fibrous, lymphoid, and adipose components, covered by stratified squamous epithelium. The histologic features, which suggest that the lesion represents a hamartomatous proliferation, allow differentiation from other possible entities included in the differential diagnosis of a tonsillar mass. The true incidence of tonsillar lymphangiomas may be higher than reported, because of historical underrecognition in the literature and inconsistencies in the terminology used to classify the lesion.

References

(1.) Zadvinskis DP, Benson MT, Kerr HH, et al. Congenital malformations of the cervicothoracic lymphatic system: embryology and pathogenesis. Radiographics. 1992; 12(6):1175-1189.

(2.) Regezi JA, Sciubba JJ, Jordan RC. Connective tissue lesions. In: Oral Pathology: Clinical Pathologic Correlations. 4th ed. St. Louis, MO: Saunders; 2002:169-170.

(3.) Gnepp DR. Cysts of the neck, unknown primary tumor, and neck dissection. In: Gnepp DR, ed. Diagnostic Surgical Pathology of the Head and Neck. 2nd ed. Philadelphia, PA: Saunders; 2009:665-666.

(4.) Cardesa A, Slootweg PJ. Lymphangiomatous tonsillar polyp. In: Pathology of the Head and Neck. New York, NY: Springer; 2006:187.

(5.) Balatsouras DG, Fassolis A, Koukoutsis G, Ganelis P, Kaberos A. Primary lymphangioma of the tonsil: a case report [published online ahead of print May 31, 2011]. Case Rep Med. 2011; 2011:183182.

(6.) Purghit GN, Chhangani DL. Lymphangioma of the tonsil. Indian J Otolaryngol. 1980; 32(1):24.

(7.) Kardon DE, Wenig BM, Heffner DK, Thompson LD. Tonsillar lymphangiomatous polyps: a clinicopathologic series of 26 cases. Mod Pathol. 2000; 13(10): 1128-1133.

(8.) Chen HH, Lovell MA, Chan KH. Bilateral lymphangiomatous polyps of the palatine tonsils. Int J Pediatr Otorhinolaryngol. 2010; 74(1):87-88.

(9.) Evans WH, Odom RE. Polyp of the tonsil: report of a case. Ann Otol Rhinol Laryngol. 1939; 48:495-498.

(10.) Pyun KS, Friedman SI. Papillary lymphoid polyp of the palatine tonsil. Ear Nose Throat J. 1985; 64(5):243-245.

(11.) Barreto I, Costa AF, Martins MT, Furuse C, de Araujo VC, Altemani A. Immunohistochemical study of stromal and vascular components of tonsillar polyps: high endothelial venules as participants of the polyp's lymphoid tissue. Virchows Arch. 2011; 459(1):65-71.

(12.) Hyams VJ. Differential diagnosis of neoplasia of the palatine tonsil. Clin Otolaryngol Allied Sci. 1978; 3(2):117-126.

(13.) Park E, Pransky SM, Malicki DM, Hong P. Unilateral lymphangiomatous polyp of the palatine tonsil in a very young child: a clinicopathologic case report [published online ahead of print January 4, 2012]. Case Rep Pediatr. 2011; 2011: 451-542.

(14.) Hazra TK, Dutta SK, Mondal SK. Lymphangioma of the tonsil. Indian J Otolaryngol Head Neck Surg. 1996; 48(3)225-227.

(15.) Visvanathan PG. A pedunculated tonsillar lymphangioma. J Laryngol Otol. 1971; 85(1):93-96.

(16.) Al Samarrae SM, Amr SS, Hyams VJ. Polypoid lymphangioma of the tonsil: report of two cases and review of the literature. J Laryngol Otol. 1985; 99(8):819-823.

(17.) Wiegand S, Eivazi B, Barth PJ, et al. Pathogenesis of lymphangiomas. Virchows Arch. 2008; 453(1):1-8.

(18.) Kasznica J, Kasznica A. Tonsillar polypoid lymphangioma in a small child. N J Med. 1991; 88(10):729-731.

(19.) Roth M. Lymphangiomatous polyp of the palatine tonsil. Otolaryngol Head Neck Surg. 1996; 115(1):172-173.

(20.) Harrison GI, Johnson LA. Lymphangioma of the tonsil: report of a case with a critical review of the literature. Ann Otol Rhinol Laryngol. 1960; 69:961-968.

(21.) Lake CF, Zimmerman AL, Parkhill EM. An unusual polypoid tumor of the tonsil. Ann Otol Rhinol Laryngol. 1962; 71:1005-1008.

(22.) Hiraide F, Inouye T, Tanaka E. Lymphangiectatic fibrous polyp of the palatine tonsil: a report of three cases. J Laryngol Otol. 1985; 99(4):403-409.

(23.) Lupovitch A, Salama D, Batmanghelichi O. Benign hamartomatous polyp of the palatine tonsil. J Laryngol Otol. 1993; 107(11):1073-1075.

(24.) Sah SP, Bahadur KT, Rani S. Lymphangiectatic fibrolipomatous polyp of the palatine tonsil. Indian J Pathol Microbiol. 2000; 43(4):449-451.

(25.) Shetty SC, Balasubramanya AM, Chary G, Amirtham U, Garg I. Tonsillar lymphangiomatous polyp--a case report. Indian J Otolaryngol Head Neck Surg. 2000; 52(3):283-284.

(26.) Raha O, Singh V, Purkayastha P. Lymphangioma tonsil--rare case study. Indian J Otolaryngol Head Neck Surg. 2005; 57(4):332-334.

(27.) Ohtsuki Y, Kurita N, Iguchi M, et al. Case report: a pedunculated hamartomatous polyp of the palatine tonsil. Biomed Res. 2006; 17(3):155-158.

(28.) Barreto I, Juliano P, Chagas C, Altemani A. Lymphoid polyps of the palatine tonsil. Int J Surg Pathol. 2007; 15(2):155-159.

(29.) Duggal P, Chakravorty S, Sharma S, Ahluwalia RK. Pedunculated hamartomatous polyp of palatine tonsil in a child: a new presentation. Int J Pediatr Otorhinolaryngol. 2008; 3:120-123.

(30.) Lyngdoh RH, Devaraju S, Leena JB. A pedunculated hamartomatous polyp of the palatine tonsil. Iran J Pathol. 2013; 8(1):45-47.

Stacey Mardekian, MD; Julie Katz Karp, MD

Accepted for publication February 07, 2013.

From the Department of Pathology, Thomas Jefferson University Hospital, Methodist Division, Philadelphia, Pennsylvania.

The authors have no relevant financial interest in the products or companies described in this article.

Reprints: Julie Katz Karp, MD, Department of Pathology, Thomas Jefferson University Hospital, Methodist Division, 2301 S Broad St, Philadelphia, PA 19148 (e-mail: julie.karp@jefferson.edu).

Caption: Lymphangioma of the palatine tonsil. A, Polypoid structure with a pedicle seen at the upper left. Abundant dilated lymphatic spaces with overlying stratified squamous epithelium. B, Lymphatic space with valve leaflets visible beneath the nonkeratinized stratified squamous epithelium. C, Lymphatic spaces with clusters of lymphocytes and red blood cells. D, Stroma composed of adipose tissue, fibrous tissue, and lymphocytes. E, Focus of well-organized lymphoid tissue and lymphocytic epitheliotropism. F, D2-40 immunohistochemical stain highlights the lymphatic endothelium (hematoxylin-eosin, original magnifications X10 [A], X100 [B,C], X40 [D], X100 [E]; original magnification X100 [F]).

Caption: Please Note Illustration(s) are not available due to copyright restrictions.
Reported Cases of Lymphangioma of the Palatine Tonsil in
the English Literature

Case   Source, y            Presenting Symptoms   Age,
No.                         (Duration)            y/Sex

1      Evans and Odom,      Mass (2 wk)           13/F
       (9) 1939

2      Harrison and         Sore throat,          27/F
       Johnson, (20) 1960   "spitting up blood"
                            (2 wk)

3      Lake et al, (21)     Mass (1 y)            30/F
       1962

4      Visvanathan, (15)    Dysphagia for         31/M
       1971                 solids, sore throat
                            (5-6 mo)

5      Purghit and          Mass (5 mo)           18/F
       Chhangani, (6)
       1980

6      Purghit and          Mass (6 mo), change   22/M
       Chhangani, (6)       in voice, sore
       1980                 throat

7      Al Samarrae et al,   Mass (6 y),           32/M
       (16 1985             recurrent sore
                            throat

8      Al Samarrae et al,   Slowing               35/F
       (16) 1985            deglutition,
                            bilateral tinnitus

9      Hiraide et al,       Mass (10 y),          13/F
       (22) 1985            recurrent
                            tonsillitis

10     Hiraide et al,       Asymptomatic,         44/M
       (22) 1985            incidental finding

11     Hiraide et al,       Mass (20 y), FBS,     60/M
       (22) 1985            recurrent
                            tonsillitis

12     Pyun and Friedman,   Difficulty speaking   13/F
       (10) 1985            (9 mo), recurrent
                            tonsillitis

13     Kasznica and         Recurrent bilateral    3/M
       Kasznica, (18)       serous otitis media
       1991

14     Lupovitch et al,     Asymptomatic,         80/F
       (23) 1993            incidental finding

15     Hazra et al, (14)    FBS (8 mo), sore      38/F
       1996                 throat

16     Roth, (19) 1996      Mass, FBS             14/M

17     Sah et al, (24)      Mass (6 mo),          23/M
       2000                 excessive
                            salivation, FBS (1
                            mo)

18     Shetty et al, (25)   Mass, FBS             36/M
       2000

19     Raha et al, (26)     Mass (3 y),            8/M
       2005                 tonsillitis, sleep
                            apnea

20     Ohtsuki et al,       Tonsillar swelling    41/F
       (27) 2006            (6 y), sneezing,
                            sleep apnea

21     Barreto et al,       Recurrent             14/F
       (28) 2007            tonsillitis

22     Barreto et al,       Recurrent             17/M
       (28) 2007            tonsillitis

23     Barreto et al,       Dysphagia, sore       20/F
       (28) 2007            throat (40 d)

24     Barreto et al,       Dysphagia, mass (7    27/M
       (28) 2007            mo)

25     Barreto et al,       Mass                  28/M
       (28) 2007

26     Barreto et al,       Dysphagia, mass (4    56/M
       (28) 2007            mo)

27     Duggal et al, (29)   Nonproductive cough   13/M
       2008                 (2 y), recurrent
                            vomiting (15 d)

28     Chen et al, (8)      Obstructive            4/F
       2010                 breathing

29     Balatsouras et al,   FBS, cough (2-3       17/M
       (5) 2011             wk), dysphagia (3
                            d) (3 d)

30     Park et al, (13)     Dysphagia for          3/F
       2011                 solids

31     Lyngdoh et al,       Tonsillar swelling    32/M
       (30) 2013            (3 y), sneezing,
                            dysphagia

32     This study,  2013    Mass (8-10 wk), FBS   17/M

Case   Laterality   Size,   Diagnosis
No.                  cm

1          R          4     Polyp

2          R         1.4    Lymphangioma

3          R          5     Polypoid tumor
                            containing
                            fibroadipose tissue

4          L         2.5    Lymphangioma

5          R          2     Lymphangioma

6          R         NR     Lymphangioma

7          L         2.5    Polypoid lymphangioma

8          L         2.8    Polypoid lymphangioma

9          R         2.1    Lymphangiectatic fibrous
                            polyp

10         L         2.1    Lymphangiectatic fibrous
                            polyp

11         L         1.8    Lymphangiectatic fibrous
                            polyp

12         R         3.5    Papillary lymphoid polyp

13         R         1.2    Polypoid lymphangioma

14         L         1.1    Benign hamartomatous
                            polyp

15         L         4.5    Lymphangioma

16         L         NR     Lymphangiomatous
                            polyp

17         R          2     Lymphangiectatic
                            fibrolipomatous polyp

18         L          3     Lymphangiomatous
                            polyp

19         L          5     Lymphangioma

20         R         3.8    Pedunculated
                            hamartomatous polyp

21         NR         1     Lymphoid polyp

22         NR        1.2    Lymphoid polyp

23         NR         2     Lymphoid polyp

24         NR        1.5    Lymphoid polyp

25         NR        0.8    Lymphoid polyp

26         NR         4     Lymphoid polyp

27         L         3.5    Pedunculated
                            hamartomatous polyp

28         B         0.5    Lymphangiomatous
                            polyp

29         R         2.6    Lymphangioma

30         R         NR     Lymphangiomatous
                            polyp

31         L         1.5    Pedunculated
                            hamartomatous polyp

32         L         3.2    Lymphangioma

Abbreviations: B, bilateral; FBS, foreign body sensation;
NR, not reported.
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Date:Dec 1, 2013
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