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Tonsillar Hypertrophy in a Patient With Obstructive Sleep Apnea

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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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B. Acromegaly

The diagnosis of acromegaly was suspected from the patient’s clinical features, including tonsillar hypertrophy with macroglossia, enlargement of the hands and feet, and prognathism, and was confirmed with elevated serum insulinlike growth factor 1 (IGF-1) and growth hormone (GH) levels: 720 ng/mL (age-specific reference range, 76-230 ng/mL) and 11.1 ng/mL (age-specific reference range, 0.06-5.0 ng/mL), respectively. (To convert IGF-1 levels to nanomoles per liter, multiply by 0.131; conversion of GH levels to micrograms per liter is 1:1.) Magnetic resonance imaging of the pituitary gland showed a hypoenhancing mass in the left aspect of the sella measuring up to 1.2 cm, consistent with a pituitary adenoma. The patient was referred to the departments of Endocrinology and Neurosurgery for further evaluation.

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Article Information

Corresponding Author: Kara Silberthau, BA, Jordan Medical Education Center, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19146 (kara.silberthau@pennmedicine.upenn.edu).

Published Online: January 9, 2020. doi:10.1001/jamaoto.2019.4164

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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