Proximal pharyngeal reflux correlates with increasing severity of lingual tonsil hypertrophy

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

Influence of Lingual Tonsillar Volume in Patients with Obstructive Sleep Apnea

This study aimed to evaluate the influence of lingual tonsil (LT) volume measured using a three-dimensional (3D) reconstruction volume rendering program on clinical parameters and polysomnography (PSG) results. A total of 100 patients who underwent PSG, computed tomography (CT), and allergy test from April 2016 to April 2020 were randomly selected. LT volume was measured using an imaging software program that enables 3D reconstruction of CT images. PSG parameters were analyzed by dividing the subjects into two groups according to LT volume (each 50 people). Based on the medial volume of 0.863 cm³, the upper half LT volume group and the lower half LT volume group were analyzed. Clinical factors such as body weight, neck circumference, body mass index (BMI), and age showed no difference between the two groups. Among PSG parameters, supine arousal index and non-rapid eye movement (NREM) arousal index were significantly higher in the upper half LT volume group (p = 0.012, 0.037). However, there was no significant difference in apnea-hypopnea index (AHI) between the upper and lower half LT volume groups (p = 0.749). Arousal snoring index and REM arousal index also showed no difference between the two groups. The prevalence of allergic rhinitis was not different in the two groups. High LT volume is associated with NREM arousal and arousal in the supine position, but it is not related to AHI.

Impact of subspecialty training on management of laryngopharyngeal reflux: results of a worldwide survey

OBJECTIVE

To study the management of laryngopharyngeal reflux (LPR) among the subspecialties of practicing otolaryngology-head and neck surgeons and their trainees.

METHODS

A survey was sent to over 8000 otolaryngologists (OTOHNS) over 65 countries, utilizing membership lists of participating otolaryngological societies. The outcomes were answers to questions regarding LPR knowledge and practice patterns, and included queries about its definition, prevalence, clinical presentation, diagnosis, and treatment.

RESULTS

Of the 824 respondents, 658 practiced in one specific otolaryngologic subspecialty. The symptoms and findings thought to be the most related to LPR varied significantly between subspecialists. Extra-laryngeal findings were considered less by laryngologists while more experienced OTOHNS did not often consider digestive complaints. Compared with colleagues, otologists, rhinologists and laryngologists were less aware of the involvement of LPR in otological, rhinological and laryngological disorders, respectively. Irrespective of subspecialty, OTOHNS consider symptoms and signs and a positive response to empirical therapeutic trial to establish a LPR diagnosis. Awareness regarding the usefulness of impedance pH-studies is low in all groups. The therapeutic approach significantly varies between groups, although all were in agreement for the treatment duration. The management of non-responder patients demonstrated significant differences among laryngologists who performed additional examinations. The majority of participants (37.1%) admitted to being less than knowledgeable about LPR management.

CONCLUSIONS

LPR knowledge and management vary significantly across otolaryngology subspecialties. International guidelines on LPR management appear necessary to improve knowledge and management of LPR across all subspecialties of otolaryngology.

The efficacy of a personalised treatment depending on the characteristics of reflux at multichannel intraluminal impedance-pH monitoring in patients with acid, non-acid and mixed laryngopharyngeal reflux

OBJECTIVE

To assess the evolution of symptoms and findings of laryngopharyngeal reflux (LPR) patients according to the type of reflux (acid, non-acid, mixed and gastro-oesophageal (GERD)).

DESIGN

Prospective uncontrolled multicentre study.

METHODS

One hundred and six patients with LPR have been recruited from 3 European Hospitals. According to the reflux characteristics at the impedance-pH monitoring (acid, non-acid, mixed, GERD), patients received a personalised treatment based on the association of diet, pantoprazole, alginate or magaldrate for 3 months. Reflux Symptom Score (RSS) was assessed at baseline, 6 and 12 weeks post-treatment. Reflux Sign Assessment (RSA) has been used to rate laryngeal and extra-laryngeal findings at baseline and 12 weeks post-treatment. Overall success rate and the evolution of symptoms and findings were evaluated according to the LPR types.

RESULTS

One hundred and two LPR patients (42 acid, 33 non-acid, 27 mixed, including 49 with LPR and GERD) completed the study. RSS and RSA total scores significantly improved from baseline to post-treatment time in acid, mixed and non-acid groups. The presence of GERD in addition to LPR did not impact the clinical improvement. The 3-month success rates of treatment ranged from 62% to 64%, and there were no significant differences between groups. The success rate of patients with non-acid LPR was similar to those of patients with mixed and acid LPR.

CONCLUSION

MII-pH is useful to specify the type of LPR and the related most adequate therapeutic regimen. Non-acid or mixed LPR similarly respond to treatment than acid LPR but require a treatment based on alginate or magaldrate covering the non-acid proximal reflux events.

Evaluation of the Reflux Symptom Index and the Endolaryngeal Findings Scale after Treatment in Individuals with Laryngopharyngeal Reflux

Introduction  Laryngopharyngeal reflux (LPR) is a prevalent condition in outpatients visiting the otorhinolaryngological clinic, with many controversies regarding its diagnosis and follow-up. Therefore, there is a need for clinical instruments that can diagnose individuals and monitor the results of their treatment. Objective  To evaluate the applicability of the scores translated and adapted to Brazilian Portuguese: Reflux Symptom Index (RSI) and Endolaryngeal Reflux Findings Scale (ERFS), as instruments for post-treatment follow-up of LPR. Method  A total of 35 individuals with atypical symptoms of gastroesophageal reflux disease and with an objective diagnosis of LPR, confirmed by high digestive endoscopy and 24-hour esophageal pH-metry dual probe test were submitted to the RSI and ERFS questionnaires, used in the pre- and post-treatment of 90 days with a Proton Pump Inhibitor. Result  The evaluation of RSI and ERFS in the pre- and post-treatment showed a reduction in the results of the two scores, with a higher drop in the RSI ( p  < 0.001) than in the ERFS ( p  = 0.014). Although there was an improvement in the values in 23.9% of the individuals in the ERFS, there was no change in the category ( p  = 0.057), different from the RSI ( p  < 0.001), where there was a 67.4% improvement in values, as well as change in category (score went from positive to negative). There was a correlation between RSI and ERFS, moderate in the pretreatment and strong in the post-treatment. Conclusion  The RSI and ERFS scores, when translated and adapted for Brazilian Portuguese and applied simultaneously, can be considered a good tool for post-treatment LPR follow-up.

Laryngopharyngeal Reflux Disease: Outcome of Patients After Treatment in Otolaryngology Clinics

Introduction Laryngopharyngeal reflux (LPR) is a different entity from gastroesophageal reflux disease (GERD). Patients with LPR usually present with a variety of symptoms such as hoarseness, voice fatigue, burning sensation in the throat, persistent cough, sore throat, dysphagia, a sensation of a lump in the throat, and chronic throat clearing. The management of LPR is based on medications (proton pump inhibitors) along with lifestyle and dietary modifications. It has been suggested that the Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) are useful parameters to assess patients with LPR. The aim of this study is to assess the subjective and objective benefits of RFS and RSI for diagnosing and management of LPR in the tertiary care center and to find the difference in RSI and RSI scoring with respect to gender. Methods A prospective study was performed and 102 patients were included according to inclusion criteria. RFS and RSI questionnaires were filled on the first visit of patients and then treatment with proton pump inhibitors was started along with lifestyle modification instructions. Questionnaires were filled after four weeks and then 12weeks post-treatment. Repeated measure analysis of variance (ANOVA) was performed to compare the mean RFS and RSI from baseline to the end of treatment. The post hoc analysis was done using the Bonferroni test of multiple comparisons. An independent sample t-test was also used to compare the mean RFS and RSI between genders. P-values less than 0.05 were considered statistically significant Results RFS and RSI were found to be significantly decreased post-treatment after four weeks and 12 weeks post-treatment (p-value- <0.01). Eight point eight percent (8.8%) side effects were observed in the study, the change in quality of life after a three-month treatment was significantly improved among 62.7% patients, and 75.5% did lifestyle modifications. In the mean comparison of RFS and RSI with respect to gender, it was observed that the mean RFS of females samples after one month and three months of treatment were significantly less as compared to male samples, p<0.01. There was no significant mean difference observed for RSI after one month and three months of treatment with respect to gender (p>0.05). Conclusion RFS and RSI are convenient and helpful for diagnosing LPR, and they can be easily implemented in ear, nose, throat (ENT) clinics for the subjective and objective assessment of LPR. Females showed greater improvement on laryngoscopy findings (RFS scores) post-treatment as compared to males.

Changes of Laryngeal and Extralaryngeal Symptoms and Findings in Laryngopharyngeal Reflux Patients

OBJECTIVES/HYPOTHESIS

To assess the evolution of laryngeal and extralaryngeal symptoms and findings of laryngopharyngeal reflux (LPR) throughout a 3-month to 9-month treatment.

STUDY DESIGN

Prospective Controlled Study.

METHODS

One hundred twenty-seven LPR patients and 123 healthy individuals were enrolled from four European hospitals. Patients were managed with a 3-month personalized treatment considering the LPR characteristics at the impedance-pH monitoring. Regarding the clinical therapeutic response, treatment was adapted for 3 to 6 additional months. Symptoms and findings were assessed throughout the therapeutic course with the Reflux Symptom Score (RSS) and the short version of the Reflux Sign Assessment (sRSA). The relationship between patient and reflux characteristics, symptoms, and findings was assessed.

RESULTS

One hundred twenty-one LPR patients completed the study. LPR patients exhibited more laryngeal and extralaryngeal symptoms and findings than healthy individuals. RSS significantly improved from baseline to 6 weeks posttreatment and continued to improve from 3 months to 6 months posttreatment. sRSA significantly improved from baseline to 3 months posttreatment. No further improvement was noted at 6 months posttreatment for pharyngeal and oral findings. Laryngeal findings continued to improve from 3 months to 6 months posttreatment. There was a significant association between patient stress level and RSS (P = .045). At 3 months posttreatment, 28.1% of patients had high or complete response, whereas 47.1% required 6 months or 9 months of treatment. Overall, 24.8% of patients had an LPR chronic course.

CONCLUSIONS

Laryngeal and extralaryngeal symptoms and findings significantly improved throughout treatment in LPR patients. The improvement of laryngeal findings was slower. Regarding the low prevalence of some digestive or otolaryngological symptoms, a short version of the RSS could be developed.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1332-1342, 2021.

Use of the transoral robotic surgery to treat patients with recurrent lingual tonsillitis

BACKGROUND

This study evaluates the efficacy of lingual tonsil resection by transoral robotic surgery (TORS) in a large group of patients with recurrent lingual tonsillitis (RLT).

METHODS

Eighty-four patients with RLT treated with a lingual tonsil surgical resection using TORS were analyzed in terms of their postoperative results, disease recurrence, postoperative dysphagia, and quality of life.

RESULTS

A reduction of the mean number/year of acute lingual tonsillitis (LT) episodes emerged after surgery (5.17 vs 0.54 events), comparing the mean number of preoperative and postoperative LT episodes, a statistical significance emerged (P = .0001). The postoperative endoscopic evaluation showed 94.1% of patients with absent or poor lymphatic tissue on the tongue base. Evaluation of postoperative dysphagia showed good results with an average score of 85.9 ± 7.5.

CONCLUSION

This article explains how in patients with chronic LT with medical therapy failure and impaired quality of life, TORS could represent a valid therapeutic option.

Validity and Reliability of the Reflux Sign Assessment

OBJECTIVE

To develop and validate the Reflux Sign Assessment (RSA), a clinical instrument evaluating the physical findings of laryngopharyngeal reflux (LPR).

METHODS

A total of 106 patients completed a 3-month treatment based on the association of diet, pantoprazole, alginate, or magaldrate with the LPR characteristics (acid, nonacid, mixed). Forty-two asymptomatic individuals completed the study (control group). The RSA results and reflux finding score (RFS) were documented for the LPR patients at baseline and after treatment. Intrarater reliability was assessed through a test-retest blinded evaluation of signs (7-day intervals). Interrater reliability was assessed by comparing the RSA evaluations of three blinded otolaryngologists through Kendall's W. Responsiveness to change was evaluated through a comparison of the baseline and 3-month posttreatment findings. The RSA cutoffs for determining the presence and absence of LPR were examined by receiver operating characteristic (ROC) analysis.

RESULTS

A total of 102 LPR patients completed the study (68 females). The mean age was 53 years. The mean RSA at baseline was 25.95 ± 9.58; it significantly improved to 18.96 ± 7.58 after 3 months of therapy (P < .001). RSA exhibited good intra- (r = 0.813) and interrater (Kendall's W = 0.663) reliabilities (N = 56). There was no significant association between the RSA, gastrointestinal endoscopy findings, and the types of reflux (acid, nonacid, or mixed) according to impedance-pH monitoring. An RSA >14 may be suggestive of LPR.

CONCLUSION

The RSA is a complete clinical instrument evaluating both laryngeal and extralaryngeal findings associated with LPR. The RSA demonstrated high intra- and interrater reliabilities and responsiveness to change.

Lingual Tonsil Hypertrophy in Patients With Allergic Rhinitis

Background

Lingual tonsils, part of the Waldeyers’ Ring, are located in base of the tongue. They are commonly observed in childhood, due to increased immunological activity. Several factors such as laryngopharyngeal reflux, younger age, smoking, and obesity are associated with hypertrophy of lingual tonsils (LTH) in adulthood. However, the relation between allergic rhinitis and LTH is not clearly highlightened in the literature so far.

Objective

To investigate the role of allergic rhinitis in the development of LTH.

Methods

Adult patients who were diagnosed with allergic rhinitis were included in the study group. The control group consisted of age- and sex-match healthy volunteers. Complete otorhinolaryngology examination including fiberoptic endoscopic evaluation was performed to both groups. Blood samples were obtained for total immunglobulin E levels, and skin prick tests were performed to both groups. Patients with allergy complaints and positive skin prick tests were included in the study group, while healthy volunteers with negative skin prick tests were enrolled in the control group. The grading for LTH was achieved by a physician who was blind to the study.

Results

The incidence of LTH was significantly higher in the study group when compared to the control group ( P = .001). Similarly, the incidence of grade 3 LTH was significantly higher in the study group compared to the controls ( P = .002).

Conclusion

According to our results, LTH is more frequently observed in patients with allergic rhinitis. Grade 3 representing larger LTH is more commonly seen in patients with allergic rhinitis.

Relationship between extralaryngeal endoscopic findings, proton pump inhibitor (PPI) response, and pH measures in suspected laryngopharyngeal reflux

Laryngopharyngeal reflux (LPR) is a clinical entity diagnosed by history laryngoscopic findings that has a variable response to empiric proton-pump inhibitor (PPI) therapy. While the reflux finding score (RFS), an endoscopic scoring scheme, has been advanced as a measure of LPR, it has not been externally validated against symptom severity in practice. Extralaryngeal pharyngeal endoscopic findings may have diagnostic utility but remain underexplored. This study assesses the correlation between extralaryngeal findings and (1) 24-hour oropharyngeal pH & (2) PPI response in patients with suspected LPR. Subjects presented to a tertiary care center with laryngeal symptoms ≥1 month and reflux symptom index (RSI) ≥13. Following baseline questionnaires, laryngoscopy, and a 24-hour oropharyngeal pH probe study, subjects were prescribed 8-12 week omeprazole trials. Baseline endoscopic findings were scored in a blinded fashion using the RFS and extralaryngeal score criteria, summatively the 'ELS.' PPI response was defined as ≥50% improvement in RSI. Thirty-three subjects with flexible endoscopic recordings completed baseline and follow-up questionnaires. The cohort's baseline mean RSI was 23.0 ± 7.2 with a ΔRSI = 9.8 after PPI therapy. The baseline RFS score averaged 5.3 ± 2.7. 45% of our subjects was found to be PPI responsive. The Cohen's kappa for the ELS but not the RFS was significant. There were no significant differences between the RFS (P = 0.10) or ELS (P = 0.07) for PPI responders & nonresponders. Oropharyngeal pH measures did not correlate with the RFS or ELS. In conclusion, endoscopic scores of laryngeal and extralaryngeal findings did not predict PPI response or oropharyngeal acid exposure in suspected LPR.

Lingual tonsil lymphatic tissue regrowth in patients undergoing transoral robotic surgery

OBJECTIVES/HYPOTHESIS

To evaluate a possible regrowth of lingual tonsil lymphatic tissue in patients submitted to lingual tonsil resection with transoral robotic surgery (TORS).

STUDY DESIGN

Retrospective Study.

METHODS

Medical records of patients surgically treated by means of TORS to remove excessive lymphatic tissue of the lingual tonsil were retrospectively reviewed. Postoperative endoscopic data after long-term follow-up were analyzed to investigate possible lymphatic tissue regrowth. Preoperative and postoperative lingual tonsil lymphatic tissue were classified according to the standardized Friedman's grading scale ranging from 0 to 4.

RESULTS

Sixty-eight patients (41 male and 27 female; mean age = 51.3 years) were considered suitable for the study analysis. Clinical regrowth was observed in six (8.8%) patients: four (5.9%) and two (2.9%) patients with grade 2 and 3 lymphatic hypertrophy, respectively. No correlation between the grade of regrowth, the time interval from surgery, and the volume of lymphatic tissue removed was found.

CONCLUSIONS

The lymphatic tissue regrowth after TORS resection appears to be very low.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2652-2657, 2019.

Surgical ablation of lingual tonsils in the treatment of obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

The retrolingual space is one of the potential sites of obstruction identified in patients with obstructive sleep apnea syndrome (OSAS). Hypertrophied lingual tonsils (LT) can obstruct the airway at this level. The goal of this study was to measure the tolerance and efficacy of lingual tonsillectomy in patients with OSAS.

STUDY DESIGN

A retrospective chart review was conducted recruiting all patients with OSAS confirmed on sleep recording, who either had failed or refused medical treatment and who underwent lingual tonsillectomy.

MATERIALS AND METHODS

Diagnosis of LT hypertrophy was made by full ENT clinical examination using a flexible endoscopy, completed by MRI and followed by drug-induced sleep endoscopy. The surgical intervention was carried out endoscopically by diode laser or coblation. The primary endpoint to measure efficacy was drop in apnea-hypopnea index (AHI) on sleep recording at 6 months. Secondary endpoints comprised reduced snoring and Epworth Sleepiness Scale (ESS) and postoperative symptom tolerance.

RESULTS

Eleven patients aged 44.3±12.6 years were included. AHI dropped from 29.5±21.7/h to 11.6±9.6/h: i.e., by 60% (P=0.005). Five patients had AHI<10/h: i.e., cure rate of 45%. ESS dropped from 13±3.4 to 8.1±4.9 (P=0.012). No complications were observed.

CONCLUSIONS

LT ablation seemed effective in OSAS with retrolingual obstruction in failure of medical treatment.

LEVEL OF EVIDENCE

4.

Targeted Treatment With Radio Frequency Ablation for Lingual Tonsil

Objectives

Benign enlargement of the lingual tonsils due to various causes may cause symptoms that warrant treatment. Conventional lingual tonsillectomy remains a challenging procedure, and there is no established standard procedure. We aimed to review the patients receiving different methods of lingual tonsil surgery for various indications at our institute.

Methods

Retrospective clinical data on all patients with an ablative operation of the tongue base during the 8-year period between 2007 and 2014 at the Helsinki University Hospital, Helsinki, Finland, were reviewed. The larger cohort comprised 35 patients, of whom 26 were men (74%). Ten patients had undergone solely lingual tonsil radio frequency ablation (LTRFA). The minimum follow-up time for all patients was 2 years.

Results

Of the 10 patients, 5 patients with LTRFA had been operated on because of symptomatic lingual tonsil hypertrophy and 5 because of periodic fever associated with possible lingual tonsil involvement. In 2 of the 5 patients with periodic fever, the fever cycles ended after the operation. Of the 5 patients, 3 patients with symptomatic lingual tonsil hypertrophy have been non-symptomatic after 1 to 3 treatment sessions. The last 2 patients continue to have persistent symptoms. There were no major complications.

Conclusions

Development of new approaches for the management of various lingual tonsil conditions is warranted. Lingual tonsil volume reduction by LTRFA seems to be a treatment alternative with low morbidity but with limited curative effect only.

Lingual Tonsillectomy for Treatment of Pediatric Obstructive Sleep Apnea: A Meta-analysis

Importance

Evidence indicates correlations between lingual tonsil hypertrophy and pediatric obstructive sleep apnea (OSA). However, to our knowledge, a meta-analysis of surgical outcomes for lingual tonsillectomy in children with OSA has not been conducted.

Objective

To evaluate the therapeutic outcomes of lingual tonsillectomy for treatment of pediatric OSA.

Data Sources

The study protocol was registered on PROSPERO (CRD42015027053). PubMed, MEDLINE, EMBASE, and the Cochrane Reviews databases were searched independently by 2 authors for relevant articles published by September 2016.

Study Selection

The literature search identified English-language studies that used polysomnography to evaluate children with lingual tonsil hypertrophy and OSA after lingual tonsillectomy alone. The search keywords were lingual tonsil, lingual tonsillectomy, sleep endoscopy, sleep apnea, and child.

Data Extraction and Synthesis

Polysomnographic data from each study were extracted. A random-effects model pooled postoperative sleep variable changes and success rates for lingual tonsillectomy in treating pediatric OSA.

Main Outcomes and Measures

Four outcomes for lingual tonsillectomy were analyzed. These included net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum oxygen saturation, the overall success rate for a postoperative AHI less than 1, and the overall success rate for a postoperative AHI less than 5.

Results

This meta-analysis consisted of 4 studies (mean sample size, 18.25 patients), with a total of 73 unique patients (mean [SD] age, 8.3 [1.1] years). Fifty-nine percent (27 of 46) of the patients were male, and 1 of the 4 studies did not specify number of males. Lingual tonsillectomy was indicated for persistent OSA after adenotonsillectomy in all cases. Lingual tonsil hypertrophy was evaluated using computed tomography or magnetic resonance imaging in 1 study, sleep endoscopy in 2 studies, and cine magnetic resonance imaging in 1 study. The mean change in the AHI after lingual tonsillectomy was a reduction of 8.9 (95% CI, -12.6 to -5.2) events per hour. The mean change in the minimum oxygen saturation after lingual tonsillectomy was an increase of 6.0% (95% CI, 2.7%-9.2%). The overall success rate was 17% (95% CI, 7%-35%) for a postoperative AHI less than 1 and 51% (95% CI, 25%-76%) for a postoperative AHI less than 5. Postoperative complications that developed included airway obstruction, bleeding, and pneumonia.

Conclusions and Relevance

Lingual tonsillectomy is an effective surgical management for children with OSA caused by lingual tonsil hypertrophy, and it achieves significant improvement in the AHI and the minimum oxygen saturation. However, children frequently have residual OSA after lingual tonsillectomy, and postoperative complications must be carefully managed.

Factors associated with lingual tonsil hypertrophy in Canadian adults

Background

Hypertrophy of the lingual tonsil tissue in the adult patient is thought to contribute to the pathophysiology of obstructive sleep apnea. The underlying etiology of lingual tonsil hypertrophy (LTH) in the adult patient is unclear and likely multifactorial. Previous studies have suggested that the lingual tonsils may undergo compensatory hyperplasia post-tonsillectomy in children, although it is unknown if this occurs or persists into adulthood. The purpose of this study was to determine what factors are associated with LTH in a population of Canadian adults.

Methods

Adult patients presenting for consultation to an academic Rhinology/General Otolaryngology practice were eligible for enrollment. Demographic data including age, body mass index (BMI), Reflux Symptom Index (RSI), history of allergy, and history of tonsillectomy was collected via questionnaire. Endoscopic photographs of the base of tongue and larynx were captured. These were graded for LTH and Reflux Finding Scale (RFS) by blinded examiners. Statistical analysis was performed by comparing the mean LTH value to the variables of interest using two-tailed T-test. P < .05 was considered significant.

Results

One hundred two subjects were enrolled. Age ranged from 18 to 78. 28 patients had previous tonsillectomy. This was not associated with a significant increase in lingual tonsil tissue (r = −0.05, p = 0.61). RFS >7 or RSI >13 was considered positive for laryngopharyngeal reflux. There was no difference in LTH based on RSI positivity (p = 0.44). RFS positivity correlated with increased lingual tonsil tissue (p < 0.05). BMI >30 was associated with increased lingual tonsil hypertrophy (p < 0.05).

Conclusions

An elevated body mass index and positive Reflux Finding Score are associated with lingual tonsil hypertrophy in adults. Reflux symptom index, history of allergy and history of childhood tonsillectomy are not associated with LTH.

A Pediatric Grading Scale for Lingual Tonsil Hypertrophy

Lingual tonsil hypertrophy (LTH) is a common finding for children with residual obstructive sleep apnea (OSA) following an adenotonsillectomy. Secondary to the significant morbidity associated with OSA, identification and treatment of residual OSA are paramount. A dedicated LTH grading scale for children does not exist. The current adult LTH scale is impractical for children. Imaging is not routine for children, since it frequently requires sedation. We present a pediatric LTH grading scale with substantial interrater reliability to facilitate standardization of endoscopy findings and promote outcomes-based research for OSA surgery in children.

Factors associated with hypertrophy of the lingual tonsils

OBJECTIVE

To identify factors that may be associated with lingual tonsil hypertrophy (LTH).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic center.

SUBJECTS AND METHODS

Retrospective chart review identified 380 patients from August 2013 to April 2014 with graded lingual tonsils, documented during routine flexible laryngoscopy. Lingual tonsils were graded using a 0 to 4 scale: 0 = complete absence of lymphoid tissue, 1 = lymphoid tissue scattered over tongue base, 2 = lymphoid tissue covers entirety of tongue base with limited thickness, 3 = lymphoid tissue 5 to 10 mm in thickness, 4 = lymphoid tissue >1 cm in thickness (rising above the tip of epiglottis). Reflux symptom index (RSI collected during patient intake), presence of obstructive sleep apnea hypopnea syndrome (OSAHS; confirmed by polysomnogram), smoking habits, and basic demographics were gathered. Chi-square and linear multivariate regression analyses were used to identify significant relationships with LTH levels.

RESULTS

Overall, 59.8% were male with a mean age of 50.2 ± 16.5 years and BMI of 30.1 ± 18.0. Chi-square analysis revealed no significant relationship between OSAHS and LTH (P = .059). When RSI was stratified to ≥ 10 or < 10, a Cochran-Armitage test supported the trend hypothesis that as RSI increases, lingual tonsil grading increases. Significant univariate correlates included younger age (r = -0.307, P < .001) and smoking (r = 0.186, P = .002). Multivariate regression revealed the combination of younger age, increasing RSI, and smoking (r = -0.297, P < .001) to be a significant correlate.

CONCLUSION

LTH does not seem to be associated with OSAHS or BMI in this group of patients. High RSI, younger age, and gender may be factors associated with increased lingual tonsil thickness.

A Standardized Lingual Tonsil Grading System

Objective

Comparisons among studies involving the tongue base are limited by lack of a universal system for grading lingual tonsils. The authors propose a new standardized clinical grading system for lingual tonsil hypertrophy (LTH). Validation was assessed via an interexaminer agreement study.

Study Design

Kappa interrater agreement study.

Setting

Tertiary academic center.

Subjects and Methods

Video assessment: The proposed grading system consists of a 0-to-4 scale: 0 = complete absence of lymphoid tissue; 1 = lymphoid tissue scattered over tongue base; 2 = lymphoid tissue covering entirety of tongue base with limited vertical thickness; 3 = significantly raised lymphoid tissue covering entirety of the tongue base, approximately 5 to 10 mm in thickness; 4 = lymphoid tissue rising above the tip of the epiglottis, ≥1 cm in thickness. The vertical height of the tonsils is a clinical approximate. A teaching video demonstrated identification of this grading system. Fourteen trained otolaryngologists graded 20 video clips of the tongue base, recorded during flexible laryngoscopy. Live assessment: A second study was performed by 2 examiners directly examining the tongue base of 23 patients using flexible laryngoscopy.

Results

Video assessment: The overall Fleiss kappa statistic was 0.775 ( P < .0001). This denotes substantial agreement. Live assessment: The overall kappa for nominal data was 0.8665 ( P < .0001). This denotes near perfect agreement.

Conclusion

The substantial interexaminer correlation demonstrated during video assessment and perfect interexaminer correlation in live assessment indicate that the proposed grading system may be a valuable and useful tool in creating a common language to describe lingual tonsils.

Measurements of adult lingual tonsil tissue in health and disease

Objectives: To report computed tomography (CT) measurements of lingual tonsil tissue (LTT) in patients with laryngopharyngeal reflux (LPR), obstructive sleep apnea-hypopnea syndrome (OSAHS), both LPR and OSAHS, or neither disease.

Study Design: Retrospective chart review.

Setting: Tertiary care center.

Subjects and Methods: Ninety-eight patients with CT scans including the tongue base and complete historical data regarding the presence or absence of symptoms, signs, and laboratory confirmation of LPR and/or OSAHS were included. LTT was measured on CT. Charts of patients meeting inclusion criteria were subsequently reviewed and patients were divided into four groups: 1) those without LPR or OSAHS, 2) those with LPR only, 3) those with OSAHS only, and 4) those with both LPR and OSAHS. Statistical analysis focused on correlating LTT thickness with the presence or absence of LPR and/or OSAHS.

Results: The mean LTT thickness for group 1 (21 patients without reflux or OSAHS) was 0.937 mm (range 0-2.67 mm). The mean for group 2 (29 patients with LPR only) was 3.35 mm (range 0-7.4 mm). The mean for group 3 (16 patients with OSAHS only) was 4.29 mm (range 0-9 mm). The mean for group 4 (32 patients with LPR and OSAHS) was 4.00 mm (range 0-19.2 mm). The mean for group 1 was lower than the other 3 groups ( P < 0.001).

Conclusion: CT images including the tongue base allow precise measurement of LTT thickness. LTT > 2.7 mm was not identified in patients without OSAHS or LPR. The mean LTT for patients with LPR and/or OSAHS was significantly greater than for patients without either disease.