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Ectopic Tonsillar Tissue in the Nasal Septum
Auris·Nasus·Larynx (Tokyo) 10, 37-41, 1983
ECTOPIC TONSILLAR TISSUE IN THE NASAL SEPTUM Mitsuru
FURUKAWA,
M. D., Satoshi
and Ryozo
UMEDA,
TAKEUCHI,
M. D.,
M. D.
Department of Otorhinolaryngology, School of Medicine, Kanazawa University, Kanazawa, Japan
A rare case of hypertrophied lymphoid tissue in the nasal septum considered to be an ectopic tonsil was reported. The patient was a 53-yearold male, and a polypoid mass attached to the septal wall by a stalk was removed. Histological examination showed that the tumour was an ectopic hyperplastic tonsil presenting in the nasal septum. The pathogenesis of this tumour was not clear, but it was considered as hyperplasia or a new formation of primary or secondary lymphoid follicles. This is the first case report of such a rare condition. In general, tumours of the nasal septum are rare compared with the lateral wall of the nose and accessory sinuses (EGGSTON and WOLFF, 1947a; GOLDSTEIN and SISSON, 1980). Recently, we experienced a hypertrophied lymphoid mass of the nasal septum which histologically resembled the palatine tonsil. The lesion was considered to be hyperplasia of ectopic tonsillar tissue. This is the first case report of this rare condition. CASE REPORT
The patient was a 53-year-old male, who has had several episodes of bleeding from the nasal cavity and progressive nasal obstruction for one month. Examination with a nasal speculum showed a polypoid mass attached to the septal wall of right side by a stalk. The mass was firm and greyish-white in appearance (Fig. 1). The patient was in good health and had no history of recurrent tonsillitis. The palatine tonsils were located normally in the postero-Iateral oropharynx and no regional lymph node involvement was observed. X-rays of the nose and paranasal sinuses were normal and no bone destruction was shown in tomographical examinations. The family and past histories showed no particular abnormalities. Routine chest X-ray, haemogram and urine studies were basically normal. Received for publication April 27, 1982 37
38
M. FURUKAWA, S. TAKEUCHI, and R. UMEDA
Fig. 1. Examination of the right nasal cavity showing polypoid tissue on septum.
Fig. 2. The tumour excised with a stalk.
During an operation on 28 November 1980, a well-defined tumour with a size of 2.8 X 2.2 X 1.4 cm was removed together with 0.3 cm diameter stalk attached to the antro-superior part of the septum (Fig. 2). Histological examination showed a tumour composed of connective tissue and lymphoid tissue in varied stages of development. The surface epithelium of the tumour was fibrous tissue covered with squamous cells which invaginated into the lymphoid tissue producing crypts. The crypts were irregular in shape and extended throughout the depth of parenchyma and were surrounded by lymphoid follicles. Hyper- and para-keratosis in the epithelium of the crypts was observed and the
ECTOPIC TONSILLAR TJSSUE
39
(b)
Fig. 3. Histology showing a tumour composed of lymphoid tissue without cellular anaplasia (a). x 400 Lymphoid follicles with large and numerous germinal centers are present (b). x 100
presence of cilliary epithelium was noted. Large and numerous germinal centers were present but there was less cellular activity than in tonsillar hyperplasia found in a child and no evidence of cellular anaplasia was exhibited (Fig. 3, a and b). These histological findings suggested that the tumour was an ectopic hyperplasic tonsil presenting in the septum.
40
M. FURUKAWA, S. TAKEUCHI, and R. UMEDA
The wound healed well and the septal mucosa remained intact with no signs of recurrence of the tumour after one year. DISCUSSION
We presented a brief case report of an ectopic tonsil in the nasal septum. The lesion was considered to be hyperplasia of lymphoid tissue with the characteristic findings of numerous germinal centers and cellular components (KORNBLUT, 1980). AFIP (Armed Forces Institute of Pathology) fascicles can serve as a reference for an encyclopedic review of the nasal tumours prior to 1964, and do not refer to such a lesion (ASH and RAuM, 1964), and no new reports of tonsillar tissue in the nasal septum have been presented (BATSAKIS, 1974; GOLDSTEIN and SISSON, 1980). As lymphoid tissue does not normally exist in the septum, an ectopic tonsil is a rare presentation. The pathogenesis of this tumour is not clear, but we sometimes experience accessory tonsils and lymphoid tissues in the tonsillar fossa and nasopharynx. Usually they have been considered as hyperplasia or a new formation of primary or secondary lymph follicles and frequently the result of a persistent infection in a person of lymphoid diathesis (EGGSTON and WOLFF, 1947b). The ectopic appearance of lymphoid follicles and their hyperplasia in our case are considered to be in the same aetiological category as accessory tonsils. Recently, PELLETTIERE et al. (1980) reported lymphoid hyperplasia of the larynx simulating neoplasia which conformed to hyperplastic laryngeal tonsillar tissue. They reviewed seven additional cases and emphasized the histological criteria for diagnosis in lymphoid hyperplasia, benign lymphoma and pseudolymphoma. In our case, the cellular components indicated that the lesion was apparently hyperplasic lymphoid tissue. SUMMARY
A rare case of hypertrophied lymphoid tissue in the nasal septum considered to be an ectopic tonsil was presented. Hyperplasia of ectopic tonsillar tissue in the right nasal septum producing a tumour mass with subsequent bleeding has not been previously reported. REFERENCES ASH, J. E., and RAuM, M.: An Atlas of Otolaryngologic Pathology, Washington, D.C., American Registory of Pathology, Armed Forces Institute of Pathology, 1964. BATSAKIS, J.: Tumors of the Head and Neck, Baltimore, Williams and Wilkins Co., 1974. EGGSTON, A. A., and WOLFF, D.: Cysts and tumors of the nose and accessory sinuses, Histology of the Ear, Nose and Throat, Baltimore, Williams and Wilkins Co., 1947a. EGGSTON, A. A., and WOLFF, D.: Histology and physiology of the pharynx and larynx, Histology of the Ear, Nose and Throat, Baltimore, Williams and Wilkins Co., 1947b. GOLDSTEIN, J. C., and SISSON, G. A.: Tumors of the nose, paranasal sinuses, and nasopharynx,
ECTOPIC TONSILLAR TISSUE
41
Paparella and Shurnrick, Otolaryngology, pp. 2078-2114, Philadelphia, Saunders W.B.Co., 1980. KORNBLUT, A. D.: Non-neoplastic diseases of the tonsils and adenoids, Paparella and Shurnrick, Otololaryngology, 2263-2282, Philadelphia, Saunders W.B.Co., 1980. PELLETTIERE, E. Y., HOLINGER, L. D., and SCHILD, J. A.: Lymphoid hyperplasia of larynx simulating neoplasia. Ann. 0101. Rhinal. Laryngol. 89: 65-68, 1980.
Request reprints from:
Dr. M. Furukawa, Department of Otorhinolaryngology, School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa 920, Japan
ECTOPIC TONSILLAR TISSUE IN THE NASAL SEPTUM Mitsuru
FURUKAWA,
M. D., Satoshi
and Ryozo
UMEDA,
TAKEUCHI,
M. D.,
M. D.
Department of Otorhinolaryngology, School of Medicine, Kanazawa University, Kanazawa, Japan
A rare case of hypertrophied lymphoid tissue in the nasal septum considered to be an ectopic tonsil was reported. The patient was a 53-yearold male, and a polypoid mass attached to the septal wall by a stalk was removed. Histological examination showed that the tumour was an ectopic hyperplastic tonsil presenting in the nasal septum. The pathogenesis of this tumour was not clear, but it was considered as hyperplasia or a new formation of primary or secondary lymphoid follicles. This is the first case report of such a rare condition. In general, tumours of the nasal septum are rare compared with the lateral wall of the nose and accessory sinuses (EGGSTON and WOLFF, 1947a; GOLDSTEIN and SISSON, 1980). Recently, we experienced a hypertrophied lymphoid mass of the nasal septum which histologically resembled the palatine tonsil. The lesion was considered to be hyperplasia of ectopic tonsillar tissue. This is the first case report of this rare condition. CASE REPORT
The patient was a 53-year-old male, who has had several episodes of bleeding from the nasal cavity and progressive nasal obstruction for one month. Examination with a nasal speculum showed a polypoid mass attached to the septal wall of right side by a stalk. The mass was firm and greyish-white in appearance (Fig. 1). The patient was in good health and had no history of recurrent tonsillitis. The palatine tonsils were located normally in the postero-Iateral oropharynx and no regional lymph node involvement was observed. X-rays of the nose and paranasal sinuses were normal and no bone destruction was shown in tomographical examinations. The family and past histories showed no particular abnormalities. Routine chest X-ray, haemogram and urine studies were basically normal. Received for publication April 27, 1982 37
38
M. FURUKAWA, S. TAKEUCHI, and R. UMEDA
Fig. 1. Examination of the right nasal cavity showing polypoid tissue on septum.
Fig. 2. The tumour excised with a stalk.
During an operation on 28 November 1980, a well-defined tumour with a size of 2.8 X 2.2 X 1.4 cm was removed together with 0.3 cm diameter stalk attached to the antro-superior part of the septum (Fig. 2). Histological examination showed a tumour composed of connective tissue and lymphoid tissue in varied stages of development. The surface epithelium of the tumour was fibrous tissue covered with squamous cells which invaginated into the lymphoid tissue producing crypts. The crypts were irregular in shape and extended throughout the depth of parenchyma and were surrounded by lymphoid follicles. Hyper- and para-keratosis in the epithelium of the crypts was observed and the
ECTOPIC TONSILLAR TJSSUE
39
(b)
Fig. 3. Histology showing a tumour composed of lymphoid tissue without cellular anaplasia (a). x 400 Lymphoid follicles with large and numerous germinal centers are present (b). x 100
presence of cilliary epithelium was noted. Large and numerous germinal centers were present but there was less cellular activity than in tonsillar hyperplasia found in a child and no evidence of cellular anaplasia was exhibited (Fig. 3, a and b). These histological findings suggested that the tumour was an ectopic hyperplasic tonsil presenting in the septum.
40
M. FURUKAWA, S. TAKEUCHI, and R. UMEDA
The wound healed well and the septal mucosa remained intact with no signs of recurrence of the tumour after one year. DISCUSSION
We presented a brief case report of an ectopic tonsil in the nasal septum. The lesion was considered to be hyperplasia of lymphoid tissue with the characteristic findings of numerous germinal centers and cellular components (KORNBLUT, 1980). AFIP (Armed Forces Institute of Pathology) fascicles can serve as a reference for an encyclopedic review of the nasal tumours prior to 1964, and do not refer to such a lesion (ASH and RAuM, 1964), and no new reports of tonsillar tissue in the nasal septum have been presented (BATSAKIS, 1974; GOLDSTEIN and SISSON, 1980). As lymphoid tissue does not normally exist in the septum, an ectopic tonsil is a rare presentation. The pathogenesis of this tumour is not clear, but we sometimes experience accessory tonsils and lymphoid tissues in the tonsillar fossa and nasopharynx. Usually they have been considered as hyperplasia or a new formation of primary or secondary lymph follicles and frequently the result of a persistent infection in a person of lymphoid diathesis (EGGSTON and WOLFF, 1947b). The ectopic appearance of lymphoid follicles and their hyperplasia in our case are considered to be in the same aetiological category as accessory tonsils. Recently, PELLETTIERE et al. (1980) reported lymphoid hyperplasia of the larynx simulating neoplasia which conformed to hyperplastic laryngeal tonsillar tissue. They reviewed seven additional cases and emphasized the histological criteria for diagnosis in lymphoid hyperplasia, benign lymphoma and pseudolymphoma. In our case, the cellular components indicated that the lesion was apparently hyperplasic lymphoid tissue. SUMMARY
A rare case of hypertrophied lymphoid tissue in the nasal septum considered to be an ectopic tonsil was presented. Hyperplasia of ectopic tonsillar tissue in the right nasal septum producing a tumour mass with subsequent bleeding has not been previously reported. REFERENCES ASH, J. E., and RAuM, M.: An Atlas of Otolaryngologic Pathology, Washington, D.C., American Registory of Pathology, Armed Forces Institute of Pathology, 1964. BATSAKIS, J.: Tumors of the Head and Neck, Baltimore, Williams and Wilkins Co., 1974. EGGSTON, A. A., and WOLFF, D.: Cysts and tumors of the nose and accessory sinuses, Histology of the Ear, Nose and Throat, Baltimore, Williams and Wilkins Co., 1947a. EGGSTON, A. A., and WOLFF, D.: Histology and physiology of the pharynx and larynx, Histology of the Ear, Nose and Throat, Baltimore, Williams and Wilkins Co., 1947b. GOLDSTEIN, J. C., and SISSON, G. A.: Tumors of the nose, paranasal sinuses, and nasopharynx,
ECTOPIC TONSILLAR TISSUE
41
Paparella and Shurnrick, Otolaryngology, pp. 2078-2114, Philadelphia, Saunders W.B.Co., 1980. KORNBLUT, A. D.: Non-neoplastic diseases of the tonsils and adenoids, Paparella and Shurnrick, Otololaryngology, 2263-2282, Philadelphia, Saunders W.B.Co., 1980. PELLETTIERE, E. Y., HOLINGER, L. D., and SCHILD, J. A.: Lymphoid hyperplasia of larynx simulating neoplasia. Ann. 0101. Rhinal. Laryngol. 89: 65-68, 1980.
Request reprints from:
Dr. M. Furukawa, Department of Otorhinolaryngology, School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa 920, Japan