2016, Volume 32, Number 2, Page(s) 119-121
Lymphangiomatous Polyp of Tonsil: A Case Report
Hamide SAYAR1, Çağdaş SAYAR2, Fulya ADAMHASAN3, Aysun UĞUZ4
1Department of Pathology, Kahramanmaraş Sütçü İmam University, Faculty of Medicine, KAHRAMANMARAŞ, TURKEY
2Department of Otolaryngology, Kahramanmaraş State Hospital, KAHRAMANMARAŞ, TURKEY
3Adana Numune Education and Research Hospital, ADANA, TURKEY
4Çukurova University, Faculty of Medicine, ADANA, TURKEY
Keywords: Tonsillar neoplasm, Polyps, Hamartoma
Lymphangiomatous polyps of the palatine tonsils are uncommon
hamartomatous proliferations that could be clinically misdiagnosed
as malignant neoplasms. These polyps consist of dilated lymphatic
vessels located inside fibrous and/or adipose tissue. In this paper,
a 27-year-old man who presented to the outpatient clinic with a
complaint of dysphagia is presented. On physical examination, the
patient had a smooth, polypoid mass extending from the posterior
section of the right palatine tonsil into the oropharynx. The patient
underwent right tonsillectomy. Histopathological examination of
the specimen showed typical features of a lymphangiomatous polyp
of the tonsil. The case is reported with the accompanying literature
to avoid the possibility of misdiagnosing it as a malignant lesion
Lymphangiomatous polyps are uncommon, benign
hamartomatous proliferations that generally arise from the
surface of the palatine tonsils1
. The polyp is covered by
squamous epithelium and its stroma consists of different
components that vary from loose to dense collageneous and
adipose tissue, dilated lymphatic channels and lymphoid
. In this paper, we report an extremely rare case
of a lymphangiomatous polyp on the right tonsil.
A 27-year-old man presented with dysphagia. Physical
examination of the patient showed a smooth, polypoid mass
extending from the posterior section of the right palatine
tonsil into the oropharynx. The rest of the oral cavity,
nasopharynx and laryngopharynx proved to be otherwise
normal on inspection. He underwent right tonsillectomy
under general anesthesia. On gross examination of the right
tonsil, it was measured as 30x20x15 mm in size and there
was an exophytic polypoid nodule measuring 40x20x15 mm that was attached without a stalk (Figure 1
). The cut
surface was smooth and white-to-tan in color.
Histologically, the polyp was covered by squamous
epithelium and its stroma consisted of a variety of loose
fibrous connective tissues, lymphoid aggregates and dilated
lymphatic vascular channels (Figure 2A,B). The tonsil was
slightly hypertrophic and inflamed. Immunohistochemical
tests showed that the lymphatic vessels of the endothelium
were reactive with anti-CD31 (Figure 3A) and anti-CD34
(Figure 3B). LCA was expressed in the lymphoid cells within
the vascular channels and stroma. In these lymphoid cells,
a polymorphous pattern with CD3 and CD20 were present.
There was no sign of recurrence of the lesion in this case
during the follow-up period of three years.
Click Here to Zoom
|Figure 2: Lymphangiectatic channels and small aggregates of lymphoid tissue are seen irregularly dispersed in the fibrous stroma and the
polyp is covered by stratified squamous epithelium. A) H&E; x40, B) H&E; x100.
Click Here to Zoom
|Figure 3: Lymphangiomatous polyps of the palatine tonsils were positive for A; (CD31; x200) and B; (CD34; x100).
Lymphangiomatous lesions mostly arise from the head
and neck region and they constitute more than 90% of all
lymphangiomas. They originate from the palatine tonsils
. Tonsillar lymphangiomatous polyps are uncommon benign lesions, but it is possible that they are
clinically misdiagnosed as malignant neoplasms1,2
In previous reports, lymphangiomatous polyps were
described under different names such as lymphangiectatic
fibrous polyp, polypoid lymphangioma of the tonsil, and
hamartomatous tonsillar polyp2,4,5
. Kardon et al.
presented the series with the largest number including
26 patients in 2000 and detected 10 cases that were welldocumented
in the literatüre2
. Most of the published
cases were adults6,7
and a few were children1,5
to different terminologies, finding out the true incidence is
In the mentioned series, it was shown that the median age
of the patients was 25 (range 363) years without a gender difference2. The clinical signs of the lymphangiomatous polyps were dysphagia, dyspnea, a sensation of a foreign
body in the throat, sore throat, tonsillitis, and tonsillar
mass1,5. The most important and only symptom was
dysphagia in our case.
The underlying pathophysiological mechanism of polyp
formation is not clearly known, but two hypotheses
have been proposed. In the first theory, Visvanathan
postulated that chronic inflammation results in irreversible
obstruction of the lymphatic channels with congestion,
eventually leading to the formation of the polyp8,9.
Similarly, our case had recurrent tonsillitis attacks. In the
second theory, Heffner has proposed that these lesions
should be regarded as hamartomas in tonsillar tissue rather
than as a neoplasm as these elements are normally found
in the tonsillar fossa but arranged in a different pattern1,10. Tonsillar hamartomas may be found in different
histologic spectra that polyps with lymphoid, fibrous, and/
or lymphangiomatous features2,11.
A lymphangiomatous polyp is covered by squamous
epithelium3,10. The polyp's stroma consists of different
components that are interchangeable between loose
to dense collagenous tissue, adipose tissue, prominent
dilated lymphatic channels and lymphoid tissue1,2.
Transformation to malignancy has never been reported
in the literature. In our case, the lymphangiomatous polyp
contained loose fibrous connective tissue, rich lymphocyte
infiltration, and dilated lymphatic channels. Kardon et al
found fatty tissue in 9 of 26 cases2. We did not observe
any fat tissue.
Factor VIII-related antigens including CD31 and CD34
staining are uniformly positive in the dilated lymphatic
vessel5. CD34 is less frequently reactive than CD31 for
lymphatic vessels2. CD31 and CD34 positive endothelial
cells were detected both in blood and lymph vessels in
our case. The hematologic markers including CD3 and
CD20 showed polymorphous infiltrate of the lymphoid
cells within the vascular channels and stroma. However,
immunohistochemistry is not needed for definitive
The differential diagnosis includes juvenile angiofibroma,
squamous papilloma, and lymphangioma2,3. Juvenile
angiofibromas that typically present with recurrent epistaxis
mainly arise in male adolescents. These tumors are
benign, locally aggressive, and extremely vascular. Juvenile
angiofibromas have variably dense fibrovascular connective
tissue containing staghorn-like, thin walled vessels2.
Furthermore, tonsillar lymphangiomatous polyps mostly have a loose fibrous stroma and lymphocytic aggregates.
Squamous papilloma is composed of exophytic fronds
of thickened, squamous epithelial proliferation that are
arranged in multiple layers and lack lymphatics and lymphocytic
components2,10. Generally, lymphangiomas
contain prominent dilated lymphovascular channels with
proteinaceous fluid and less stroma than lymphangiomatous
polyp2,12. Complete surgical excision of the mass
and the tonsil is the curative treatment and recurrence was
not reported after surgery2.
In this paper, an unusual case of lymphangiomatous polyp
arising from the tonsil is presented. It is important to diagnose
a lymphangiomatous polyp as it clinically resembles a
malignant neoplasm. Histopathological evaluation must be
performed to establish its benign nature.
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