Each month, this department features a discussion of an unusual diagnosis. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome via email at pedann@Healio.com.
A healthy 5-year-old male presented with a nodule on his right palatine tonsil that had been present for the past 2 weeks. During a short episode of fever (which lasted only a few hours, did not recur, and had no other symptoms), the mother looked into her son’s throat and discovered a “white projection” located at the pole of his right tonsil. During the 2 weeks prior to presentation, repeated inspections of his throat by his mother showed that the lesion persisted and had increased slightly in size, prompting the mother to take the boy for a medical consultation. The child was asymptomatic without any discomfort in the oral cavity (such as pain or a sensation of a foreign body), the lesion did not interfere with eating or swallowing, and it did not cause breathing difficulties or snoring. The child’s medical history was remarkable for upper respiratory tract infections (most of them with negative throat cultures for beta-hemolytic group A streptococcus) and infectious mononucleosis (positive immunoglobulin M for cytomegalovirus, and positive Epstein-Barr nuclear antigen [EBNA] immunoglobulin G for Epstein-Barr virus). Physical examination was normal, and the oropharyngeal examination revealed a mass arising from the right palatine tonsil (Figure 1). The tonsil itself was not inflamed. No palpable lymph nodes or swelling were detected on either side of the neck. Routine laboratory tests (complete blood cell count, blood chemistry panel, and urinalysis) were normal. The lesion was surgically excised. Following excision, the tissue specimen was sent for pathological examination. No complications were noted in the short-term or long-term postoperative period. A microscopic examination of the lesion revealed the diagnosis.
A mass arising from the right palatine tonsil of a 5-year-old male.
Fibroepithelial Polyp of Tonsil
Microscopic examination showed a polypoidal lesion lined by squamous epithelium with parakeratosis. The stalk presents fibro-fatty tissue mildly rich in capillaries in the subepithelial area associated with mild chronic infiltrate. The features are compatible with a fibroepithelial polyp (FEP). Adjacent to the FEP was a deep crypt in the lymphoepithelial tissue (Figure 2).
Microscopic examination shows a polypoidal lesion lined by squamous epithelium with parakeratosis. Note the deep crypt in the lymphoepithelial tissue.
FEPs are also called “acrochordons” or, if large, are called “soft fibromas” or “pedunculated lipofibromas.”1,2 FEPs in the pharynx of children and adults are uncommon benign lesions with a very low incidence of malignancy. The prevalence of FEPs is 12 per 1,000 people, with a male predominance.1,2 Farboud et al.1 were the first to report an FEP arising from the tonsil of an adult (a 33-year-old male), and to our knowledge this case report presented here is the first description in children. Mangar et al.2 reported an acute presentation of a pharyngeal FEP compromising the airway in a 60-year-old male, and Seshul et al.3 described a 5-year-old female with an asymptomatic fibrovascular polyp extending from the posterior tonsillar pillar to the oropharynx and esophagus without airway obstruction.
The clinical presentation of FEPs may be asymptomatic, or may manifest as a sensation of foreign body, pain during eating and swallowing, snoring, breathing difficulties, or even airway compromise.2
Histologically, FEPs are lined by squamous epithelium with various degrees of lymphocytic infiltrates, dyskeratosis, and some epithelial hyperplasia. The stroma is composed of collagen, smooth muscle, and adipose tissue.2
The differential diagnosis of FEP includes other rare but benign lesions of the tonsils, such as lymphoid polyps that are hamartomas with overgrowth of lymphoid tissue that contain follicles with microscopic germinated centers, crypts lined by epithelium, and fibrous tissue in small numbers in the center of the lesion.4 The differential diagnosis also includes lymphangiomatous polyps representing benign lymph-vascular proliferations with components of fibrous, adipose, and lymphoid tissues in varying degrees.5 Other benign tonsillar lesions, many of which represent hamartomas of tonsils such as fibrovascular polyp, lipoma, fibroma, neurofibroma, schwannoma, plasma cell granuloma, hemangiomatous hamartoma, hairy polyp (dermoid), and lymphangiectatic fibrolipomatous polyp have also been diagnosed.1 Sahni et al.6 described a large, unilateral tonsillar mass causing dysphagia in a 5-year-old child with Proteus syndrome, which is a hamartomatous syndrome characterized by hyperostosis, hyperplasia of connective tissue, epidermal nevi, and vascular malformations.
Although FEPs are rare and benign lesions, excision biopsy is the treatment of choice, and emergently securing the airway is indicated in those cases presenting with oropharyngeal obstruction.
An FEP is one of the rare, benign lesions affecting the tonsils. It can be asymptomatic or can cause upper airway obstruction, requiring emergency treatment to secure the airway. The differential diagnosis of FEPs is with other lesions representing hamartomas of the tonsils. Excision biopsy is the treatment of choice, even though malignancy is rare.
- Farboud A, Trinidade A, Harris M, Pfleiderer A. Fibroepithelial polyp of the tonsil: case report of a rare, benign tonsillar lesion. J Laryngol Otol. 2010;124:111–112. doi:10.1017/S0022215109991198 [CrossRef]
- Mangar W, Jiang D, Lloyd RV. Acute presentation of a fibroepithelial pharyngeal polyp. J Laryngol Otol. 2004;118:727–729. doi:10.1258/0022215042244697 [CrossRef]
- Seshul MJ, Wiatrak BJ, Galliani CA, Odrezin GT. Pharyngeal fibrovascular polyp in a child. Ann Otol Rhinol Laryngol. 1998;107:797–800. doi:10.1177/000348949810700911 [CrossRef]
- Barreto I, Juliano P, Chagas C, Altemani A. Lymphoid polyps of the palatine tonsil. Int J Surg Pathol. 2007;15:155–159. doi:10.1177/1066896906299121 [CrossRef]
- Kardon DE, Wenig BM, Heffner DK, Thompson LD. Tonsillar lymphangiomatous polyps: a clinicopathologic series of 26 cases. Mod Pathol. 2000;13:1128–1133. doi:10.1038/modpathol.3880208 [CrossRef]
- Sahni JK, Kumar S, Wadhwa V, Kathuria G. Proteus syndrome with huge tonsillar mass causing dysphagia: a rare case. J Laryngol Otol. 2006;120:408–410. doi:10.1017/S0022215106000430 [CrossRef]