Hamartomatous Polyp of the Palatine Tonsil in an Adolescent: A Case Report

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J Rhinol. 2024;31(2):124-128

Publication date (electronic) : 2024 July 31

doi : https://doi.org/10.18787/jr.2024.00018

Soo Un Kwak, MD¹, Jae Hyeong Kim, MD^1,2, Jae Min Shin, PhD^1,2, Tae Hoon Kim, MD, PhD^,1,2

¹Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul, Republic of Korea

²Mucosal Immunology Institute, College of Medicine, Korea University, Seoul, Republic of Korea

Address for correspondence: Tae Hoon Kim, MD, PhD, Department of Otorhinolaryngology-Head and Neck Surgery, Korea University, College of Medicine, Korea University Anam Hospital, 73 Goryedae-ro, Seongbuk-gu, Seoul 02841, Republic of Korea Tel: +82-2-920-5486, Fax: +82-2-925-5233, E-mail: doctorthk@gmail.com

Received 2024 May 31; Revised 2024 June 24; Accepted 2024 July 4.

Abstract

INTRODUCTION

Located on both sides of the oropharyngeal wall, the palatine tonsils are among the lymphoid tissues that form Waldeyer’s ring. The palatine tonsils are flanked anteriorly by the palatoglossal arch and posteriorly by the palatopharyngeal arch. These tonsils are usually hyperplastic in the young, and become less so with age. However, asymmetric enlargement can be a sign of pathology such as tonsillitis, abscess, or benign tumors (e.g., fibromas, teratomas, and angiomas such as lymphangiomas, hemangiomas, and inclusion cysts). Benign tumors of the tonsils are relatively uncommon compared to malignant tumors, such as lymphoma, squamous cell carcinoma, or metastatic cancers [1]. We report the case of a 17-year-old male patient whose tumor on a unilateral palatine tonsil was treated surgically and diagnosed as a hamartomatous polyp of the palatine tonsil. In addition, we present a literature review on the disease.

CASE REPORT

A 17-year-old male patient presented to a local clinic with symptoms of upper respiratory infection, including cough and sore throat. A cystic mass on the left tonsil was discovered incidentally. The patient had no underlying diseases and did not exhibit symptoms of foreign body sensation, breathing difficulties, or swallowing difficulties, typical of a cystic mass of the palatine tonsil.

An endoscopic examination initially revealed an approximately 3-cm cystic mass with a smooth surface and slightly pale color, extending from a crypt in the superior part of the left palatine tonsil (Fig. 1). The mass was soft in consistency and extended downward to the left epiglottic vallecula. A contrast-enhanced computed tomography scan revealed a small, well-defined, protruding, low-density lesion that arose from the left tonsil, as well as tonsilloliths in both palatine tonsils (Fig. 2).

Fig. 1.

Approximately 3-cm pedunculated polypoid lesion extending from a crypt of the left palatine tonsil.

Fig. 2.

Contrast-enhanced computed tomography scan. A and B: Axial view. C: Sagittal view. D: Coronal view. A small well-defined protruding low-density lesion, arising from the left tonsil in each view is indicated by white arrowheads.

Surgical resection of the cystic mass of the left palatine tonsil and bilateral tonsilloliths, with bilateral palatine tonsillectomy, was performed under general anesthesia. The gross mass measured 3.7 cm×1.2 cm and extended outward from the crypt of the palatine tonsil. It was pink in color with a smooth surface (Fig. 3). Microscopic examination revealed that the tumor was covered with stratified squamous epithelium, and most of the stroma consisted of adipose and fibrous tissue. In addition, enlargement of lymphatic vessels and dense lymphocytic infiltration were observed in some regions (Fig. 4). Based on these findings, the diagnosis of hamartomatous polyp was made. The patient was discharged without any significant complications, and no recurrence or complications were observed at his follow-up outpatient visit.

Fig. 3.

Gross pathology of the tumor, which measured 3.7 cm×1.2 cm and extended outward from the crypt of the palatine tonsil. There were no abnormal findings on the resected surface of the palatine tonsil.

Fig. 4.

Microscopic examination of the tumor shows that the majority of stroma were filled with fibrous tissue and adipose tissue (black arrowheads in C) covered with stratified squamous epithelium. In some areas, dilatation of the lymphatics and lymphocytic infiltration (black arrows in B) were found (H&E staining). A: ×10 magnification. B: ×30 magnification. C: ×50 magnification.

DISCUSSION

The term “hamartoma” is derived from the Greek word “hamartia,” meaning error or defect [2]. It is a benign tumor that arises from the disorganized proliferation of tissue [3]. Hamartomatous lesions can occur anywhere but are primarily found in the lung, skin, heart, brain, and breast. Occurrences in the head and neck are rare [4,5]. Hamartomas appear infrequently and are not well known to clinicians and pathologists. In addition, the exact epidemiology is difficult to ascertain as they have been reported under various names in the literature, such as lymphangiomatous polyp [6], lymphoid polyp [7], and fibroepithelial polyp [8,9].

The pathogenesis of a hamartomatous polyp in the palatine tonsil is not yet clearly understood, but is presumed to be due to hamartomatous proliferation of lymphoid tissue. According to Chye Gan et al. [10], polyps may develop due to obstruction of lymphatic channels caused by chronic inflammation of the palatine tonsil. However, in other case reports, hamartomatous polyps accompanied by tonsillitis were less common than those without tonsillitis [11,12]. In this case, the patient had no history of chronic tonsillitis, and histopathological examination did not show signs of chronic inflammation, suggesting that the likelihood of the tumor arising due to tonsillitis was low.

In other literature, age at the onset of hamartomatous polyps in the palatine tonsil ranged from 3 to 80 years, with an average age of 27.9 years. In most cases, polypoid and pedunculated masses were found on the unilateral oropharyngeal wall, with an average size of 2.5 cm. The most common symptom was the sensation of a foreign body. Some patients complained of symptoms related to the mass effect of the tumor, such as dysphagia or dyspnea [12], while others reported sore throat in conjunction with chronic tonsillitis. There have also been reports of cases with no typical symptoms, as in this case [13].

A hamartomatous polyp is covered with squamous or respiratory-type epithelial tissue and has a rich internal composition of adipose tissue, fibrous tissue, blood vessels, and dilated lymphatics. Each tissue component of the tumor is comprised of elements that are normally present in the site of origin, but are in a disorganized arrangement [14]. Furthermore, the proportion and characteristics of tumor components have varied somewhat in reported cases, which may be why hamartomatous polyps are referred to by various names [15]. Generally, immunohistochemical analysis is deemed unnecessary for diagnosing a hamartomatous polyp [6].

In previous case reports of hamartomatous polyps, either tonsillectomy or tumor excision was performed. Although hamartoma can potentially undergo malignant transformation [16], there have been no reports of recurrence or progression to malignant tumors with either treatment approach [12]. Surgeons and pathologists should carefully review the tumor pathology and, in cases of typical hamartomatous polyps, outpatient follow-up should be scheduled 1 or 2 weeks after surgery. During the follow-up examination, if no surgical complications or signs of recurrence are found, further follow-up is unnecessary. Hamartomatous polyp of the palatine tonsil is a rare and poorly understood condition. However, given its characteristic features and favorable prognosis, it is advisable to avoid excessive examination or treatment.

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