Original Article

American Journal of Rhinology & Allergy

0(0) 1–6
Lingual Tonsil Hypertrophy in Patients ! The Author(s) 2019
Article reuse guidelines:
With Allergic Rhinitis sagepub.com/journals-permissions
DOI: 10.1177/1945892419875086
journals.sagepub.com/home/ajr

Kübra Çoban, MD1 , Alper K€

oycü, MD1, and Erdinc Aydın, MD1

Abstract
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, smok-
ing, 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 endo-
scopic 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 ¼.001).
Similarly, the incidence of grade 3 LTH was significantly higher in the study group compared to the controls (P ¼.002).
Conclusion: According to our results, LTH is more frequently observed in patients with allergic rhinitis. Grade 3 repre-
senting larger LTH is more commonly seen in patients with allergic rhinitis.

Keywords
allergic rhinitis, lingual tonsil, lingual tonsil hypertrophy, sleep apnea, airway obstruction, dysphagia

Introduction
base in some patients which can obscure the valleculae.6
Lingual tonsils, part of the Waldeyer’s ring, consist of It is suggested that the assessment of the lingual tonsils
nonencapsulated lymphoid tissue in the base of the should be done in multiple views of the airway that the
tongue, posterior to the circumvallate papillae.1–3 Due tongue should be in various positions, not only in
to the increased immunological activity, they are protrusion.6
commonly seen in childhood and regress in adulthood.3 There are few reports that considered the relation
When persistent during adulthood, lingual tonsils may between history of allergy and the use of allergy medi-
obscure the view of vallecula and epiglottis. Obesity, cations and LTH1,8 and no correlation was found.
laryngopharyngeal reflux (LPR), younger age, and To our knowledge, there are no studies that investigated
smoking are commonly associated with lingual tonsil the incidence of LTH in patients diagnosed with allergic
hypertrophy (LTH), while though contradictory, there rhinitis. We aimed to understand the role of allergic
are reports that support the compensatory hyperplasia
of lingual tonsils following childhood adenotonsillec-
tomy. The etiology still remains uncertain.1,3–5 1
Otorhinolaryngology Department, Medical Faculty, Başkent University,
Although there are few endoscopic grading systems Ankara, Turkey
defining LTH in the literature, a standardized classifica-
Corresponding Author:
tion is still not available.3,4,6,7 However some reports Kübra Çoban, Otorhinolaryngology Department, Medical Faculty, Alanya
support that the classifications considering the valleculae Research and Application Center, Baskent University, Ankara, Turkey.
may not be sufficient due to hypertrophy of the tongue Email: [email protected]
2 American Journal of Rhinology & Allergy 0(0)

rhinitis, which affects the entire airway, on LTH. This is tomato, banana, Betula betulaceae (Allergopharma
the first prospective study searching the incidence of D-21462 Reinbek, Germany), with the technique stan-
LTH in patients diagnosed with allergy confirmed both dardized by the European Academy of Allergy and
with laboratory and skin prick tests. Clinical Immunology.10 Histamine was used for positive
control, while physiologic saline was used for negative
control. Following the puncture of the inner surface of
Materials and Methods
the forearm, the skin reaction was recorded after
The study was performed in Otorhinolaryngology 15 minutes and the wheal diameters were measured.
Department, Medical Faculty, Başkent University in Results greater than 3 mm when compared to the nega-
between October 2018 and March 2019. All the patients tive control were marked positive. Patients with positive
involved in the study were informed and asked to sign skin test to at least one of the allergens were consid-
the clinical research informed consent form. This study ered atopic.
was approved by Başkent University Institutional Lingual tonsil evaluation was done with live assess-
Review Board and Ethics Committee (Project no: ment by another senior otolaryngologist who was
KA18/351) and supported by Başkent University blinded to the study. The tongue was in both neutral
Research Fund. position and protruded. A combination of the 2 grading
Following the sample size calculations for both systems of Sung et al.4 and Friedman et al.6 was used:
groups, the study group consisted of 77 adult patients grade 0: no tonsil tissue; grade 1: scattered tonsil tissue,
attended to our clinic with allergy complaints who have visible tongue base vasculature; grade 2: diffuse tonsils
positive skin prick tests. The control group included age- with limited vertical thickness, invisible tongue base vas-
and sex-match healthy volunteers who have no history culature; grade 3: lingual tonsils covering the entire
of allergy with negative skin prick tests. Complete tongue base with 5 to 10 mm vertical thickness, and/or
otorhinolaryngology examination including fiberoptic invisible valleculae; and grade 4: significant tonsil tissue
endoscopic evaluation was performed on both groups. with 1 cm vertical thickness, and/or epiglottis invisible.
Blood samples were obtained for total immunoglobulin Statistical analyses were performed using SPSS 25.0
E (IgE) levels, and skin prick tests were performed to (IBM Corporation, Armonk, NY, USA). The relevance
both groups. Exclusion criteria for both groups were of the parameters to the normal distribution was ana-
as follows: lyzed with the Shapiro–Wilk test. The comparison of the
groups for age was performed with Mann–Whitney U
1. Patients <18 years. test with Monte Carlo results. The comparison of the
2. Obesity. groups for categorical variables “sex” and LTH was
3. Smoking habits. achieved with Pearson v2 test, using Exact and Monte
4. Patients who have reflux symptoms and/or diagnosed Carlo simulation techniques, and P values were obtained
with LPR. with Benjamini–Hochberg corrections. The odds ratio
5. Comorbid systemic diseases (including asthma), the for the incidence of LTH between groups was given
use of systemic drugs (ie, phenytoin). with 95% confidence interval. Quantitative variables
6. Gestation. were shown as median (Minimum–Maximum), while
7. Patients under medical therapy for allergy. categorical variables were noted as n (%). P < .05 was
8. Patients and volunteers with previous tonsillectomy. considered as statistically significant.
9. For the control group, healthy volunteers with posi-
tive skin prick tests, for the study group, patients with
negative skin prick tests.
Results
A total of 119 patients were included. There were 77
The medical history, physical examination data, patients in the study group and 42 healthy volunteers
grade of LTH, and skin prick test results of both in the control group. Age and sex distribution was
groups were noted. The diagnosis of AR was made clin- noted in Table 1. In our study, 2 patients had nasal
ically according to Allergic Rhinitis and its Impact on polyposis. These 2 patients were newly diagnosed
Asthma guidelines.9 during the study and had never received any local or
The skin prick test was performed using standardized systemic allergy or polyposis treatment. LTH grade
allergen extracts Dermaatophagoides pteronyssinus, was 0 in one patient and grade 2 in the other patient
Dermatophadoides farinea, grass-mix pollens, grain-mix with nasal polyp and AR. The presence of LTH is
pollens, weed-mix pollens, Blatella germanica (cock- 4.6 times more frequent in the study group (P ¼ .001).
roaches), cat dander, dog dander, latex, Platain plantago, The incidence of grade 0 lingual tonsils was significantly
Parieteria officinalis, Cladosporium, Alternaria alternata, higher in the control group, compared to the study
Artemisia vulgaris, Penicilium mix, Olea Europea, patients (P ¼ .002). The incidence of grade 3 LTH was
Çoban et al. 3

significantly higher in the study group compared to the and the incidence of LTH (P ¼ .916). When the incidence
controls (P ¼ .002). The incidences of grades 1 and 2 of LTH and its grade was compared between seasonal
LTH were not significantly different in both groups and perennial AR, no statistically significant difference
(P > 0.05). The incidences of all grades of LTH were was achieved (Table 4). In addition, there was no signif-
not statistically different between genders in both icant correlation between total IgE levels and the inci-
groups (Table 2). Grade 4 LTH was not observed in dence of LTH in the study group (P ¼ .524).
both groups. The frequency of seasonal and perennial
AR with the number of positive allergens of the patients
was given in Table 3. However, there was no statistically Table 3. Number of Patients With Seasonal and Perennial AR and
significant correlation between the number of allergens the Number of Positive Allergens.

Percentage

Table 1. LTH Grades and Their Distribution in Both Groups. Seasonal

Absent 75.3
Total Control Study Present 24.7
Median Median Median Perennial
(Min/Max) (Min/Max) (Min/Max) Absent 24.7
n (%) n (%) n (%) P Present 75.3
Number of positive allergens
Age 38 (18/80) 42 (20/80) 37 (18/77) .766a
1 22.1
Sex
2 13.0
Female 71 (59.7) 22 (52.4) 49 (63.6)
3 15.6
Male 48 (40.3) 20 (47.6) 28 (36.4)
4 14.3
LTH Grade
5 11.7
0 27 (22.7) 17 (40.5)b 10 (13.0) .002c
6 3.9
1 37 (31.1) 13 (31.0) 24 (31.2)
7 3.9
2 31 (26.1) 9 (21.4) 22 (28.6)
8 2.6
3 24 (20.2) 3 (7.1) 21 (27.3)d
9 3.9
LTH
10 2.6
Absent 27 (22.7) 17 (40.5) 10 (13.0) .001e
11 1.3
Present 92 (77.3) 25 (59.5) 67 (87.0) 4.6 (1.8–11.3)f
12 1.3
Abbreviations: LTH, lingual tonsil hypertrophy; Max: maximum; Min, mini- 15 1.3
mum. Boldface values represent statistically significant P values. 16 1.3
a
Mann–Whitney U test (Monte Carlo). 17 1.3
b
Significant compared to the study group. Median (Min/Max)
c
Pearson v2 test (Monte Carlo).
d
Significant compared to the control group. Number of allergens 3 (1/17)
e
Pearson v2 test (Exact).
f
Odds ratio (95% confidence interval).

Table 2. Incidence of LTH Between Genders.

Control Study Total

F M F M F M

n (%) n (%) P n (%) n (%) P n (%) n (%) P

LTH
0 8 (36.4) 9 (45.0) .731a 8 (16.3) 2 (7.1) .741a 16 (22.5) 11 (22.9) .976b
1 6 (27.3) 7 (35.0) 15 (30.6) 9 (32.1) 21 (29.6) 16 (33.3)
2 6 (27.3) 3 (15.0) 13 (26.5) 9 (32.1) 19 (26.8) 12 (25.0)
3 2 (9.1) 1 (5.0) 13 (26.5) 8 (28.6) 15 (21.1) 9 (18.8)
LTH
Absent 8 (36.4) 9 (45.0) .754c 8 (16.3) 2 (7.1) .312d 16 (22.5) 11 (22.9) .999c
Present 14 (63.6) 11 (55.0) 41 (83.7) 26 (92.9) 55 (77.5) 37 (77.1)
Abbreviation: LTH, lingual tonsil hypertrophy.
a
Fisher Freeman Halton test (Monte Carlo).
b
Pearson v2 test ( Monte Carlo).
c
Pearson v2 test (Exact).
d
Fisher exact test (Exact).
4 American Journal of Rhinology & Allergy 0(0)

Table 4. Incidence and Grades of LTH in Patients With Seasonal and Perennial AR.

Seasonal Perennial

Absent Present Absent Present

Median Median Median Median

(Min/Max) (Min/Max) P (Min/Max) (Min/Max) P
a
LTH grade 2 (0/3) 2 (1/3) .056 2 (1/3) 2 (0/3) .055a
n (%) n (%) n (%) n (%)
LTH
Absent 10 (17.2) 0 (0.0) .060b 0 (0.0) 10 (17.2) .060b
Resent 48 (82.8) 19 (100.0) 19 (100.0) 48 (82.8)
Abbreviations: LTH, lingual tonsil hypertrophy; Max, maximum; Min, minimum.
a
Mann–Whitney U test (Monte Carlo).
b
Fisher exact test (Exact).

Discussion initially be eliminated by palatine and lingual tonsils.

All types of immunoglobulin are synthesized in tonsils,
Most of the reports of LTH in adults are from incidental
including IgE, one of the essential types in allergic reac-
findings during difficult airway cases, and the actual inci-
tions.21,22 In a study by Ganzer and Bachert, it was
dence still remains uncertain.11
shown that IgE in AR was not only synthesized in the
Although it has been associated with various symp-
nasal mucosa but also within the lymphatic tissue of the
toms related to the upper airway, lingual tonsils have
been a neglected anatomical structure. When they Waldeyer’s ring.23 However, we did not find any signif-
enlarge, they are observed as 2 lateral masses symmetri- icant correlation between serum total IgE levels and
cally located on either side of the glossoepiglottic fold.12 LTH in our patient group. In a study, serum IgE levels
Clinically, patients complain about globus sensation, were measured, but they reported that they did not find
voice changes, chronic cough, dyspnea, and/or sleep the prevalence of allergy different from the controls.24
apnea. These symptoms may also be seen in patients Accordingly, serum IgE levels alone may not be a reli-
with allergic rhinitis, as oropharyngolaryngeal hypersen- able marker to test AR.
sitivity may associate the nasal symptoms.13 Allergy may precipitate recurrent upper respiratory
Although still controversial, there are studies sug- system infections (URSIs).14,25 Recurrent URSIs
gesting that atopy may induce adenotonsillar hypertro- increase the functions of tonsils and that could induce
phy in children.14–16 Waldeyer’s ring is the first barrier tonsil hypertrophy.14 Alternatively, viral URSIs may
against the antigens. As in AR, the antigenic stimula- cause allergic rhinitis. There are strong evidences sup-
tion seems to cause hyperstimulation of the immuno- porting that rhinovirus infections contribute to acute
logic activities in the tonsillar tissues, due to the asthma attacks.25 A chicken or egg? Does LTH develop
anatomical proximity and their mutual lymphatic following AR, or does recurrent/chronic URSIs, con-
drainage.16 It is reported that the allergic reactions in tributes to the exacerbations of AR attacks, leading
the nasal mucousa are also found in the pharyngeal to LTH?
tonsils.17,18 Similarly, Ameli et al.14 reported that ton- LTH is commonly associated with obesity, smoking,
sillar hypertrophy is associated with nasal pale mucosa younger age, and LPR.1,8 There were no data in the
and edema; however, they did not find any correlation English literature showing an association between
between tonsil size and AR. Modrzynski on the other URSIs and LTH. Accordingly, it seems that allergic
hand reported that pharyngeal tissue transiently reactions may directly contribute to the development of
enlarges in spring season.19 LTH. However, there are very limited data in the litera-
The mucosal-associated lymphoid tissue (MALT) ture investigating the role of allergy on LTH. Harris
gives various immunological responses to foreign anti- et al.8 studied the factors associated with LTH, and
gens, and via toll-like receptors, they have important found no relation between history of allergy and LTH.
roles in the clearance of pathogens. Waldeyer’s ring rep- However, they evaluated the allergy status of their
resents the first-line MALT in the respiratory and diges- patients with a questionnaire. Hwang et al. studied the
tive systems.20 Lingual tonsils are part of the Waldeyer’s related factors with LTH in their retrospective research
ring, and in mouth breathers due to allergic rhinitis, and found no significant relation between the use of aller-
most of the noxious pathogens and allergens may gy medication and LTH.1
Çoban et al. 5

Hwang et al.1 reported that male gender was signifi- (without tongue base hypertrophy or any other risk fac-
cantly associated with LTH; however, in our study, there tors for LTH) may solve their swallowing problems too.
was no statistically significant difference between genders. Further studies related to this issue are necessary.
DelGaudio et al.3 considered the severity of LTH Another clinical importance of LTH in patients with
when the tongue was at rest and protruded as mild, mod- AR is difficulty in intubation. Clinicians should be aware
erate, and severe. Costello et al.7 reported their clinical of the fact that AR patients may have enlarged lingual
LTH classification which they called “Swansea lingual tonsils that may cause intubation problems during sur-
tonsil classification.” They evaluated the lingual tonsils gical interventions.
when the mouth is closed and the tongue is in neutral There are few limitations of the study. Primarily,
position. Sung et al.4 classified when the tongue was although the most common method to identify LTH is
protruded. According to Friedman et al.,6 LTH should awake endoscopy,11 it is a subjective method to deter-
be evaluated both in neutral position and when the mine the grade of the lingual tonsils. We hope to inves-
tongue is protruded. tigate the LTH grades via computerized tomography
When grading the LTH, we combined the 2 classifi-
(CT) or magnetic resonance imaging (MRI) in further
cation systems of Sung et al.4 and Friedman et al.,6 in
studies with wider patient series.
order to avoid study bias. The evaluation was performed
This is the first study related to this topic, thus further
with the tongue in multiple positions. We simultaneously
studies with larger patient series are necessary.
evaluated the vascular appearance of the tongue base,
We evaluated LTH in the adult population; however,
the vallecula, epiglottis, glossoepiglottic fold, and the
vertical thickness of the lingual tonsils. In some patients, the affects of AR on the lingual tonsils of children are
the tongue base was notably hypertrophic that hides the uncertain. Further studies are substantial.
view of the vallecula; thus, in those patients, the classi- In addition, LTH evaluations with at least 2 more
fications regarding the vallecula or epiglottis only may physicians who are blinded to the study would be nec-
not be sufficient. According to the classification of essary to establish an interrater reliability.
Friedman et al.,6 the vertical thickness of the lingual
tonsils was first voiced which corresponds to grade 3
and grade 4, with grade 3 the first stage in which the Conclusion
tonsils have apparent vertical height. In our study, Our study results showed that not only the incidence of
grade 3 LTH was significantly more frequent in the LTH is significantly higher in the study group but also
study group. Increased vertical height may be associated the incidence of greater LTH was significantly higher in
with dysphagia and sleep apnea and compromises the the allergy group when compared to healthy controls.
airway when intubating. We did not observe grade 4 in Allergy seems influential in the enlargement of the
neither of our groups.
upper respiratory system lymphoid tissues. To our
We found a positive correlation between AR and
knowledge up to date, our study is the first prospective
LTH in this study. It is worthy of note that AR patients
controlled study that investigated the relationship
suffering from dyspnea and sleep apnea should be inves-
between allergic rhinitis and LTH, and the results are
tigated for LTH.
If observed, anti-allergic therapies may also be includ- promising. However, in order to clarify the exact mech-
ed as an adjuvant therapy to regress LTH. Therefore, to anisms of LTH in AR patients and the effect of anti-
determine the optimal therapies, further research is nec- allergic therapies on LTH, further prospective controlled
essary in patients with AR, who have complaints regard- studies with wide patient series are required.
ing dyspnea and sleep apnea, and who have enlarged
lingual tonsils. Declaration of Conflicting Interests
Although asthma is a systemic disease that can be
associated with allergic rhinitis, asthma patients were The author(s) declared no potential conflicts of interest with
excluded in our study. The reason for this is that the respect to the research, authorship, and/or publication of
inhaler therapies used in this patient group can predict this article.
reactive hyperplasia in the lingual tonsillar tissue. In our
opinion, the relationship between asthma and lingual
Funding
tonsil should be questioned separately.
In addition to breathing problems, these patients may The author(s) received no financial support for the research,
also have swallowing problems. Otorhinolaryngologists authorship, and/or publication of this article.
should keep in mind that dysphagia may be the first or
one of the primary complaints of patients with AR. ORCID iD
Anti-allergic treatments for those patients with LTH Kübra Çoban https://orcid.org/0000-0002-4633-0983
6 American Journal of Rhinology & Allergy 0(0)

References 13. Jackson-Menaldi CA, Dzul AI, Holland RW. Allergies

1. Hwang MS, Salapatas AM, Yalamanchali S, Joseph NJ, and vocal fold edema: a preliminary report. J Voice.
Friedman M. Factors associated with hypertrophy of the 1999;13(1):113–122.
lingual tonsils. Otolaryngol Head Neck Surg. 14. Ameli F, Brocchetti F, Tosca MA, Schiavetti I, Ciprandi
2015;152(5):851–855. G. Tonsil volume and allergic rhinitis in children. Allergy
2. Caylakli F, Akkuzu B, Avci S. Lingual tonsillar hypertro- Rhinol (Providence). 2014;5(3):137–142.
phy: a case report. Kulak Burun Bogaz Ihtis Derg. 15. Costa EC Jr, Sabino HA, Miura CS, et al. Atopy
2004;13(1–2):28–30. and adenotonsillar hypertrophy in mouth breathers
3. DelGaudio JM, Naseri I, Wise JC. Proximal pharyngeal from a reference center. Braz J Otorhinolaryngol.
reflux correlates with increasing severity of lingual 2013;79(6):663–667.
tonsil hypertrophy. Otolaryngol Head Neck Surg. 16. Sadeghi-Shabestari M, Jabbari Moghaddam Y, Ghaharri
2008;138(4):473–478. H. Is there any correlation between allergy and adenoton-
4. Sung MW, Lee WH, Wee JH, Lee CH, Kim E, Kim JW. sillar tissue hypertrophy? Int J Pediatr Otorhinolaryngol.
Factors associated with hypertrophy of the lingual tonsils 2011;75(4):589–591.
in adults with sleep-disordered breathing. JAMA 17. Endo LH, Vassalo J, Leit~ao SR. Allergic tonsillitis. A his-
Otolaryngol Head Neck Surg. 2013;139(6):598–603. topathological study. Adv Otorhinolaryngol. 1992;47:41–45.
5. Guimaraes CV1, Kalra M, Donnelly LF, et al. The fre- 18. Bellioni P, Modica V. Histological changes in chronic aller-
quency of lingual tonsil enlargement in obese children. gic tonsillitis. Clin Otorinolaringoiatr. 1968;20(2):116–124.
AJR Am J Roentgenol. 2008;190(4):973–975. 19. Modrzy nski M, Mierzwinski J, Zawisza E, Piziewicz A.
6. Friedman M, Yalamanchali S, Gorelick G, Joseph NJ, Acoustic rhinometry in the assessment of adenoid hyper-
Hwang MS. A standardized lingual tonsil grading trophy in allergic children. Med Sci Monit.
system: interexaminer agreement. Otolaryngol Head Neck 2004;10(7):CR431–CR438.
Surg. 2015;152(4):667–672. 20. Masieri S, Trabattoni D, Incorvaia C, De Luca MC,
7. Costello R, Prabhu V, Whittet H. Lingual tonsil: clinically Dell’Albani I, Leo G, Frati F. A role for Waldeyer’s ring
applicable macroscopic anatomical classification system. in immunological response to allergens. Curr Med Res
Clin Otolaryngol. 2017;42(1):144–147. Opin. 2014;30(2):203–205.
8. Harris MS, Rotenberg BW, Roth K, Sowerby LJ. Factors 21. Ali M, Fayemi O, Nalebuff DJ. Localization of IgE in
associated with lingual tonsil hypertrophy in Canadian adenoids and tonsils: an immunoperoxidase study. Arch
adults. J Otolaryngol Head Neck Surg. 2017;46(1):32. Otolaryngol. 1979;105(12):695–697.
9. Brozek JL, Bousquet J, Baena-Cagnani CE, et al.; Global 22. Loesel LS. The role of immunoglobulins in allergic disease:
Allergy and Asthma European Network; Grading of IgE and IgG4 immunofluorescent study of adenoid tissue.
Recommendations Assessment, Development and Semin Diagn Pathol. 1987;4(2):153–156.
Evaluation Working Group. Allergic Rhinitis and its 23. Ganzer U, Bachert C. Localization of IgE synthesis in
Impact on Asthma (ARIA) guidelines: 2010 revision. immediate-type allergy of the upper respiratory tract.
J Allergy Clin Immunol. 2010;126(3):466–476. ORL J Otorhinolaryngol Relat Spec. 1988;50(4):257–264.
10. Skin tests used in type I allergy testing Position paper. Sub- 24. Griffin JL, Ramadan HH, Adham RE. Prevalence of
Committee on Skin Tests of the European Academy of IgE-mediated hypersensitivity in children with adenoton-
Allergology and Clinical Immunology. Allergy. 1989;44 sillar disease. Arch Otolaryngol Head Neck Surg.
(Suppl 10):1–59. 1994;120(2):150–153.
11. Tang JA, Friedman M. Incidence of lingual tonsil hyper- 25. Hellings PW, Fokkens WJ. Allergic rhinitis and its impact
trophy in adults with and without obstructive sleep apnea. on otorhinolaryngology. Allergy. 2006;61(6):656–664.
Otolaryngol Head Neck Surg. 2018;158(2):391–394.
12. Golding-Wood DG, Whittet HB. The lingual tonsil.
A neglected symptomatic structure? J Laryngol Otol.
1989;103(10):922–925.