Lingual tonsil hypertrophy: causes and treatment

The lingual tonsil is a collection of lymphoid tissue at the base of the tongue, part of Waldeyer's ring. Hypertrophy of the lingual tonsil refers to an increase in the volume of this tissue, which can be asymptomatic or cause a sensation of a "globus globus," dysphagia, snoring, a change in the pitch of the voice, chronic cough, and even episodes of upper airway obstruction during sleep. The condition is less common in adults than in children, but has been described as a cause of obstructive sleep apnea and difficult intubation. [1]

The clinical significance of hypertrophy is determined by a combination of tonsil size, base of tongue anatomy, and associated factors such as excess body weight, laryngopharyngeal reflux, and prior tonsillectomy. In some patients, enlargement is detected only during targeted examination with a flexible endoscope or during drug-induced sleep endoscopy. [2]

Modern diagnostics rely on endoscopic verification and, if necessary, high-definition imaging. Treatment includes eliminating reversible causes, sleep rehabilitation, and, in cases of persistent anatomical obstruction, minimally invasive surgery, including radiofrequency and robotic techniques. [3]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, 10th revision, hypertrophy of the lingual tonsil is coded in the group of chronic diseases of the tonsils and adenoids. In practice, J35.1 "Hypertrophy of tonsils" or J35.3 "Hypertrophy of tonsils with hypertrophy of adenoids" are used. A number of reference books explicitly note that J35.1 includes "hypertrophy of the lingual tonsil." Additional attributes are used to clarify the classification by foreign combinations and stages. [4]

The International Classification of Diseases, 11th revision, includes a section on "Chronic diseases of the tonsils and adenoids." CA0F.0 is used for tonsil hypertrophy, and CA0F.3 is used for combined tonsil and adenoid hypertrophy. The post-coordination system allows for the anatomical localization to be specified as "lingual tonsil." [5]

Table 1. Coding of lingual tonsil hypertrophy

Classification	Code	Name	Application Note
ICD-10	J35.1	Hypertrophy of the tonsils	Includes hypertrophy of the lingual tonsil.[6]
ICD-10	J35.3	Hypertrophy of the tonsils with hypertrophy of the adenoids	With simultaneous enlargement of adenoids. [7]
ICD-11	CA0F.0	Hypertrophy of the tonsils	Basic code, localization is being clarified. [8]
ICD-11	CA0F.3	Hypertrophy of the tonsils with hypertrophy of the adenoids	Includes the variant "lingual tonsil with adenoids".[9]

Epidemiology

The exact prevalence of lingual tonsil hypertrophy in the general population is unknown due to its frequent incidental discovery and variability in assessment criteria. In studies of adults with suspected sleep-disordered breathing, hypertrophy is not universally detected and is considered relatively rare, even among patients with obstructive sleep apnea. [10]

Retrospective series show that marked hypertrophy in adults is more often associated with laryngopharyngeal reflux and increased neck circumference than with the presence of sleep apnea itself, emphasizing the role of phenotype and associated factors. [11]

In children, hypertrophy of the lingual tonsil is less common than hypertrophy of the palatine tonsils and adenoids, but can be the cause of persistent symptoms after classical adenotonsillectomy, being detected by drug-induced sleep endoscopy. [12]

Cases of clinically significant lingual tonsil obstruction have been described in both adult and pediatric cohorts, but remain relatively rare relative to other causes of base of tongue obstruction.[13]

Reasons

Lingual tonsil hypertrophy results from chronic antigenic stimulation and inflammation. Associations with laryngopharyngeal reflux are most frequently discussed, where proximal episodes of gastric and duodenal reflux support lymphoid hyperplasia. [14]

Chronic infections and allergic inflammation of the upper respiratory tract play a role, contributing to an increase in lymphoid tissue at the base of the tongue. In some patients, hypertrophy is considered compensatory after tonsillectomy. [15]

Constitutional factors, including excess body weight, can increase the soft tissue volume of the tongue base and exacerbate the clinical significance of even moderate hypertrophy. This is particularly noticeable in sleep-disordered breathing. [16]

Rarely, specific granulomatous and immune processes become the cause, however, in case of isolated hypertrophy of the lingual tonsil, this is rather an exception and requires an individual assessment. [17]

Table 2. Common causes and supporting factors

Group	Examples	Clinical significance
Reflux	Laryngopharyngeal reflux, proximal reflux	Supports lymphoid tissue hyperplasia. [18]
Inflammation	Recurrent infections, allergic rhinitis	Chronic stimulation of the amygdala.[19]
Anatomy and body weight	Overweight, large neck	Increased obstruction with the same degree of magnification. [20]
After operations	After tonsil removal	Compensatory hypertrophy of the lingual tonsil is possible. [21]

Risk factors

Risk factors include signs of laryngopharyngeal reflux on endoscopic scales, excess body weight, and a large neck circumference. These predictors are associated with more pronounced hypertrophy in adults. [22]

In some patients, tonsillectomy is accompanied by a subsequent relative increase in the proportion of lymphoid tissue at the base of the tongue in Waldeyer's ring, which may be of clinical significance in the case of a tendency to snoring and sleep-disordered breathing. [23]

Children with persistent sleep apnea after removal of adenoids and tonsils are associated with the likelihood of detecting hypertrophy of the lingual tonsil, which requires targeted diagnostics. [24]

Difficult intubation and difficult visualization of the larynx are more common in cases of severe hypertrophy of the lingual tonsil and may be an important perianesthesiological finding and risk sign. [25]

Table 3. Risk factors for clinically significant hypertrophy

Factor	Confirmation	Practical significance
Laryngopharyngeal reflux	Associations for the reflux symptom scale	Indications for antireflux therapy. [26]
Overweight	Associations in observational studies	Recommendations for weight loss. [27]
Post-tonsillectomy	Observational data	Careful endoscopic examination of the base of the tongue. [28]
Persistent sleep apnea in children	Sleep endoscopy data	Search for obstruction at the level of the base of the tongue. [29]

Pathogenesis

The lymphoid tissue of the lingual tonsil physiologically responds to antigenic stimulation with proliferation and hyperplasia. Chronic exposure to inflammatory agents results in persistent tissue enlargement. In the setting of laryngopharyngeal reflux, contact of the mucosa with pepsin and acid plays a key role. [30]

Anatomical factors such as limited space in the oropharynx and the large soft tissue mass of the tongue base increase the functional impact of even moderate hypertrophy on the lumen of the airway and esophageal inlet.[31]

During sleep, decreased muscle tone of the tongue and pharynx increases the relative narrowing of the lumen in the presence of an enlarged lingual tonsil, which contributes to episodes of obstructive sleep apnea and micro-awakenings. [32]

With a long-term course, chronicity of the inflammatory response and tissue remodeling is possible, which maintains a stable increased volume of the tonsil even with moderate exposure to causative factors. [33]

Symptoms

Common complaints include a foreign body sensation, painful swallowing, choking, changes in voice quality, snoring, and unrefreshing sleep. Some patients remain asymptomatic, and the finding is discovered incidentally during endoscopy. [34]

With significant hypertrophy, episodes of difficulty breathing during sleep, periodic pauses in breathing, loud snoring, daytime sleepiness, and decreased concentration are possible. In children, manifestations are often masked by behavioral problems and learning difficulties. [35]

Less commonly, chronic unproductive cough is observed due to mechanical irritation of the posterior pharyngeal wall and the base of the tongue by an enlarged tonsil. [36]

In anesthesiological practice, hypertrophy of the lingual tonsil may present with difficult mask ventilation and intubation, which requires preliminary examination and readiness for alternative methods of airway management. [37]

Classification, forms and stages

Descriptive degrees of lingual tonsil enlargement are used for clinical assessment, based on the endoscopic image and the volumetric tissue deposited into the lumen of the oropharynx and at the level of the epiglottis. In pediatric practice, a gradation by degree is proposed, with surgical treatment being considered at the maximum degree. [38]

Based on clinical impact, a distinction is made between asymptomatic hypertrophy, symptomatic hypertrophy without sleep-disturbed breathing, and hypertrophy with clinically significant impact on the airway during sleep. This division helps develop a step-by-step approach. [39]

Based on etiology, a distinction is made between laryngopharyngeal reflux-associated, post-infectious, allergic-associated, and post-tonsillectomy forms. This guides prevention and treatment choices. [40]

In case of combined pathology, the involvement of other levels of obstruction is indicated, including the palatine tonsils, lingual base, epiglottis and pharyngeal walls, which is important for planning multi-level treatment of sleep-disordered breathing. [41]

Table 4. Practical classification

Criterion	Options	What is it for?
Magnification factor	From mild to severe by endoscopy	Determines the need for observation or intervention. [42]
Clinical impact	Asymptomatic, symptomatic, with effects on the respiratory tract during sleep	Helps to choose conservative therapy or surgery. [43]
Etiology	Reflux, infection, allergy, post-tonsillectomy	Determines prevention and concomitant treatment. [44]
Comorbidity	Multilevel obstruction	Multilevel surgery plan or alternatives.[45]

Complications and consequences

Without treatment, clinically significant hypertrophy may perpetuate sleep disturbances with daytime sleepiness, cognitive decline, and cardiovascular risks associated with obstructive sleep apnea. [46]

During anesthesia, hypertrophy increases the risk of difficult ventilation and intubation, requiring the preparation of an alternative strategy and examination of the base of the tongue before elective interventions.[47]

Following surgical treatment, bleeding, pain, transient swallowing and taste disturbances, and swelling of the base of the tongue may occur, requiring observation. The incidence of serious complications in specialized centers is low. [48]

In children, persistent obstruction after standard adenoid and tonsil surgery worsens sleep quality and may require targeted correction at the level of the lingual tonsil. [49]

When to see a doctor

You should consult a doctor if you experience a persistent sensation of a lump in your throat, dysphagia, snoring, episodes of sleep apnea, daytime sleepiness, or a recurring chronic cough without a clear cause. Endoscopic evaluation is helpful in such cases. [50]

Children with persistent symptoms of sleep-disordered breathing after removal of adenoids and tonsils are advised to consult an otolaryngologist with consideration of sleep endoscopy to determine the level of obstruction. [51]

In patients undergoing elective procedures under general anesthesia who complain of difficulty breathing during sleep or severe snoring, a preliminary examination of the base of the tongue is recommended due to the risk of difficult intubation. [52]

If shortness of breath, stridor, or difficulty swallowing saliva increases, an urgent assessment of the airway patency is required. [53]

Diagnostics

The initial visit includes a collection of complaints, an assessment of risk factors, and an examination of the oropharynx. The key method is flexible endoscopy of the nasopharynx and laryngopharynx with visualization of the base of the tongue and assessment of the extent of tissue insertion into the lumen. [54]

If hypertrophy is suspected of being involved in sleep-disordered breathing, drug-induced sleep endoscopy is considered, which allows identifying the level and mechanism of obstruction and planning targeted treatment. [55]

Polysomnography is used for objective verification of sleep-disordered breathing and assessment of treatment effectiveness, especially in children and adults with multicomponent obstruction. [56]

High-definition imaging is used when indicated for differential diagnosis and preoperative planning. If associated anomalies or tumor processes are suspected, computed tomography or magnetic resonance imaging are used. [57]

Table 5. Step-by-step diagnostic algorithm

Step	What are we doing?	For what
1	Complaints, examination, risk factor assessment	Preliminary risk stratification and indications. [58]
2	Flexible endoscopy of the nasopharynx and laryngopharynx	Confirm hypertrophy and its degree. [59]
3	Drug-induced sleep endoscopy when indicated	Specify the level of obstruction during sleep. [60]
4	Polysomnography	To assess the severity of sleep-disordered breathing and the effect of treatment. [61]
5	High definition visualization when needed	Exclude combined pathology, plan surgery. [62]

Differential diagnosis

Lingual tonsil hypertrophy is distinguished from acute inflammatory conditions such as lingual tonsillitis, which is accompanied by systemic signs of infection and is often treated conservatively. [63]

It is necessary to exclude volumetric processes of the tongue base, including benign and malignant neoplasms, as well as cysts and granulomas, which require visualization and, if necessary, biopsy. [64]

The contribution of other levels of obstruction, including the palatine tonsils, soft palate, and epiglottis, should be assessed, as lingual tonsil hypertrophy is often part of a multilevel sleep-disordered breathing phenotype.[65]

In patients with difficult intubation, it is important to differentiate lingual tonsil hypertrophy from edema and anomalies of the epiglottis, which affects the planning of anesthetic tactics. [66]

Treatment

The first step is correcting reversible factors and monitoring mild to moderate symptoms. Weight loss if overweight, sleep hygiene, positional therapy, treatment of laryngopharyngeal reflux with proton pump inhibitors and lifestyle measures, and antiallergic therapy if allergies are identified are recommended. This approach can reduce tonsil volume and clinical manifestations. [67]

For sleep-disordered breathing in adults, positive airway pressure (PAP) remains the standard treatment. In some cases, even with persistent hypertrophy, adequate device settings provide symptom control, thereby avoiding surgery. The decision is based on polysomnography data and patient preference. [68]

If conservative measures are insufficient and lingual tonsil hypertrophy is confirmed as a clinically significant factor in obstruction, minimally invasive interventions are considered. Radiofrequency reduction and cold plasma ablation are aimed at reducing tissue volume with limited surgical trauma and moderate postoperative pain. [69]

Endoscopic lingual tonsillectomy with cold instruments or a microdebrider is used for severe hypertrophy and accessible anatomy. Publications note acceptable safety with proper selection, with controlled risks of bleeding and edema. [70]

In cases of multilevel obstruction and unfavorable anatomy, transoral robotic techniques are used. Robot-assisted lingual tonsillectomy allows for gentle removal of pathologically enlarged tissue with good visual control, significant improvement in quality of life, and a low rate of serious complications in experienced hands. [71]

In pediatric practice, lingual tonsillectomy is used for persistent sleep-disordered breathing with proven obstruction at the base of the tongue. Systematic reviews and case series report a reduction in the apnea-hypopnea index and satisfactory tolerance, although some patients require multilevel correction. [72]

The key to surgical success is correct selection: medically induced sleep endoscopy is mandatory to map the levels of obstruction and plan single-level or multi-level intervention, sometimes in combination with tongue base reduction. [73]

Postoperative management includes analgesia, anti-edema support, nutritional monitoring with gradual texture expansion, and monitoring for signs of bleeding and respiratory difficulties. In most series, serious complications are rare, but episodes of late bleeding and transient swallowing difficulties may occur. [74]

Efficacy is assessed based on symptom dynamics, repeat polysomnography for initial sleep-disordered breathing, and endoscopy if recurrence is suspected. If multilevel obstruction persists, staged interventions or combined strategies are discussed. [75]

In patients with hypertrophy of the lingual tonsil combined with severe laryngopharyngeal reflux and excess body weight, long-term correction of these factors is necessary for a lasting effect even after successful surgery. [76]

Table 6. Treatment approaches and expected effects

Approach	Who is it indicated for?	Expected effect	Main risks
Modification of factors and observation	Mild symptoms	Reduction of complaints, sometimes a decrease in volume	The risk of underestimating multi-level obstruction. [77]
Positive pressure during sleep	Adults with sleep-disordered breathing	Control apnea and symptoms without surgery	It takes commitment and alignment. [78]
Radiofrequency reduction, cold plasma ablation	Moderate hypertrophy	Decreased volume, moderate pain	Bleeding, swelling of the base of the tongue. [79]
Endoscopic tonsillectomy	Severe hypertrophy	Quick removal of mechanical component	Pain, bleeding, swelling. [80]
Robot-assisted tonsillectomy	Unfavorable anatomy, multilevel surgery	Precise control, good access, improved quality of life	Cost, need for team experience. [81]

Prevention

Control of laryngopharyngeal reflux through lifestyle modification and drug therapy reduces chronic tonsil stimulation and may decrease the severity of hypertrophy.[82]

Weight loss in overweight adults reduces soft tissue pressure on the upper airway and improves symptom severity.[83]

After the ineffectiveness of standard surgery on adenoids and tonsils in children, targeted diagnostics of the base of the tongue is advisable, which prevents the prolonged adverse effects of sleep disorders on development. [84]

When planning general anesthesia in patients with severe snoring and daytime sleepiness, it is important to inform the anesthesiologist in advance and consider endoscopic assessment to reduce the risks of difficult intubation.[85]

Forecast

In mild forms and with effective correction of factors, the prognosis is favorable, many patients do without surgery and maintain symptom control. [86]

In clinically significant sleep apnea, the prognosis is determined by the completeness of correction of the multilevel obstruction. Modern minimally invasive and robotic techniques provide improved quality of life in appropriately selected patients. [87]

In children, lingual tonsillectomy with proven obstruction improves sleep outcomes but may require staged interventions or combined surgery depending on the phenotype.[88]

The risk of symptom recurrence is associated with the return of factors that maintain hypertrophy, primarily laryngopharyngeal reflux and weight gain.[89]

FAQ

Is lingual tonsil hypertrophy dangerous?
The danger is determined by the degree of impact on the airway and sleep, as well as the risk of difficult intubation; in cases of severe hypertrophy, targeted diagnostics and a treatment plan are required. [90]

Is surgery possible?
Yes, in mild cases, correction of factors, reflux treatment, and sleep management techniques can help. Surgery is considered when a clinically significant effect on the airway is proven. [91]

What surgery is considered modern and gentle?
Endoscopic and robotic-assisted techniques are used, allowing for precise removal of enlarged tissue with good visual control and an acceptable complication rate in experienced centers. [92]

Is hypertrophy always associated with obstructive sleep apnea?
No, it can be an incidental finding. Endoscopy, polysomnography results, and sleep endoscopy are crucial to confirm the causal role. [93]

Will reflux treatment help?
In some patients, a reduction in reflux is accompanied by a reduction in the severity of hypertrophy and symptoms, so reflux correction is a mandatory component of the plan. [94]