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Clinical Challenge
January 9, 2020

Tonsillar Hypertrophy in a Patient With Obstructive Sleep Apnea

Author Affiliations
  • 1Jordan Medical Education Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania
  • 2Department of Otolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
JAMA Otolaryngol Head Neck Surg. 2020;146(4):373-374. doi:10.1001/jamaoto.2019.4164

A 44-year-old man was referred to the Department of Otolaryngology from the Department of Sleep Medicine for surgical evaluation of his tonsillar hypertrophy. The patient’s medical history was notable for severe obstructive sleep apnea (OSA) diagnosed in the fall of 2017, when he presented with snoring, progressive daytime fatigue, and several years of migraines. Since his diagnosis, he had been adherent to use of nightly continuous positive airway pressure (CPAP). However, he had persistent daytime fatigue and morning headaches. Several months before presentation, the patient noticed that his bite changed from an overbite to an underbite (Figure, A), which had been attributed to dental malocclusion from his CPAP machine. Examination findings of the oropharynx showed an oropharynx score of a Mallampati 4, with 3-plus tonsils and macroglossia without scalloping of the tongue (Figure, B). Nasopharyngolaryngoscopic examination findings showed that the tonsils did not approximate at midline, with a narrow anterior-to-posterior dimension of the airway owing to macroglossia and no retrognathia. On further review of systems, the patient reported growth in his tongue and feet and intermittent swelling with numbness in his hands over the past year.

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