Abstract | April 9, 2023

A Rare Case of Acute Lingual Tonsillitis with COVID-19 Infection

Salon Shrike MD

Austin Ciccati, DO, Family Medicine, PGY1, Mercy Hospital, Fort Smith, AR; Melissa Kuehl, DO, Internal Medicine, Core Faculty, Mercy Hospital, Fort Smith, AR

Learning Objectives

  1. - Identify the symptoms of lingual tonsilitis
  2. - Implement an appropriate strategy to evaluate patients with pharyngitis and differentiate the diagnosis from fatal diseases such as epiglottitis
  3. - Utilize appropriate tests to diagnose lingual tonsilitis

Introduction:

Lingual tonsillitis is a rare cause of acute pharyngitis and is commonly seen in patients with a history of adenoidectomy and palatine tonsillectomy. The lingual tonsils are lymphoid tissue located at the base of the tongue and anterior to the epiglottis, forming the inferior aspect of the Waldeyer’s ring. Similar to palatine tonsils, they are prone to infections, malignancy, abscesses, ulcers, and varices. While 50% of adult cases are attributed to rhinoviruses and coronaviruses, this is the first known case reporting COVID-19 as an underlying etiology of lingual tonsillitis. Patients with acute, infectious lingual tonsillitis present with fever and a wide range of aerodigestive symptoms (shown in Table1). Clinical manifestations can mimic fatal illnesses. Peritonsillar abscess, epiglottitis, foreign body ingestion, and malignancy should be excluded. Radiographic findings demonstrate associated inflammatory changes of the epiglottis and supraglottis, mistakenly ruling in a diagnosis of epiglottitis. In suspected epiglottitis direct laryngoscopy should be avoided; instead, indirect laryngoscopy can be diagnostic. Although extremely rare lingual tonsillitis can lead to abscess formation, extension into the epiglottis, and airway obstruction. However analgesics, antipyretics, corticosteroids, and/or antibiotics provide rapid symptomatic resolution.

Case Presentation: A 19-year-old female with a history of adenotonsillectomy presented with fever, sore throat, neck pain, dysphagia, and drooling. Two days prior she tested positive for COVID-19. Oral examination showed cobblestoning of the hypopharynx with posterior oropharyngeal erythema and exudate. A contrast-enhanced neck CT demonstrated inflammation of the lingual tonsils and the base of the epiglottis, thickening of the aryepiglottic folds, edematous pre-epiglottic space, and enlarged jugulodigastric lymph nodes. The patient was suspected of having early epiglottitis. Flexible nasopharyngolaryngoscopy showed normal epiglottis but inflammation and hypertrophy of the lingual tonsils with pustules extending into the aryepiglottic folds.

Final Diagnosis: The patient was diagnosed with lingual tonsilitis and admitted for observation.

Management & Outcome: The patient was treated with intravenous (IV) ampicillin-sulbactam and dexamethasone. On follow-up examination 24 hours later, she reported decreased throat discomfort and was able to tolerate a regular diet. She was discharged home with oral amoxicillin-clavulanate and a 4-day course of prednisone 40 mg daily.

 

References

Awai S, Miller BJ, Dimitrov L, et alLingual tonsil abscess: a rare, life-threatening cause of acute sore throatBMJ Case Reports CP 2019;12:e229555.

De Alwis, A. C., & Kwon, S. (2021). LINGUAL TONSILLITIS: AN UNDER-RECOGNISED MANIFESTATION OF INFECTIOUS MONONUCLEOSIS. Journal of paediatrics and child health, 57(3), 459. https://doi.org/10.1111/jpc.15367

 

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