Small B cell lymphocytic lymphoma presenting as obstructive sleep apnea

Abstract

Background: Most lymphomas that involve the tonsil are large B cell lymphomas. Large B-cell lymphoma is a high grade malignancy which progresses rapidly. Tonsillar lymphoma usually presents as either a unilaterally enlarged palatine tonsil or as an ulcerative and fungating lesion over the tonsillar area. Small lymphocytic lymphomas (SLL) of the Waldeyer's ring are uncommon.

Case presentation: We report a 41-year-old male who presented with a ten-year history of snoring. Physical examination revealed smooth bilateral symmetrically enlarged tonsils without abnormal surface change or cervical lymphadenopathy. Palatal redundancy and a narrowed oropharyngeal airway were also noted. The respiratory disturbance index (RDI) was 66 per hour, and severe obstruction sleep apnea (OSA) was suspected. No B symptoms, sore throat, odynophagia or dysphagia was found. We performed uvulopalatopharyngoplasty (UPPP) and pathological examination revealed incidental small B-cell lymphocytic lymphoma (SLL).

Conclusion: It is uncommon for lymphoma to initially present as OSA. SLL is an indolent malignancy and is not easy to detect in the early stage. We conclude that SLL may be a contributing factor of OSA in the present case.

Figure 1

a) surgical specimen of palatine tonsils; b) picture of oropharynx post UPPP 3 months later

Figure 2

Photomicrograph a) effacement of normal architecture and infiltration of monotonous small lymphoid cells is visible (Hematoxylin and Eosin 100X); b) Bone marrow showing monotonous small lymphoid cells infiltration (Hematoxylin and Eosin 100X).

Figure 3

a):Mild lymphadenopathy over bilateral posterior neck area; b:Gallium scan: gallium-avid lymphoma in bilateral submandibular regions and suspected lesions in the mid-abdomen