Hypertrophy of the Tonsil 
of the Tongue 
WITH HISTORY OF CASTS 
BY 
J. W. GLEITSMANN, M.D. 
PROFESSOR OF LARYNGOLOGY AND EH INOLOGY, NEW YORK POLYCLINIC 
Reprinted from The Medical Record, December 17, 1887 
NEW YORK 
TROW’S PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1887 Hypertrophy of the Tonsil of the 
Tongue, 
WITH HISTORY OF CASES.' 
By J. W. GLEITSMANN," M.D., 
PROFESSOR OF LARYNGOLOGY AND RHINOLOGY, NEW YORK POLYCLINIC. 
The affection which forms the subject of my paper does 
not receive the attention it well deserves. It is often an 
unrecognized source of a variety of complaints, which 
are only successfully relieved by treatment of the glan- 
dular hypertrophy in question. Although numerous re- 
searches have revealed the true pathological character 
and the microscopic constituents of the diseased tissue, 
very few writers have given a description of its clinical 
features, and the majority of publications confine them- 
selves to an enumeration of one or the other prominent 
symptom of the individual case. As I had occasion to 
treat a number of cases during this year, I beg to submit 
the result of my observations to the meeting. 
The tonsil of the tongue consists of a group of follic- 
ular glands, similar to those of the faucial and pharyn- 
geal tonsil, and forms the connecting link of the great 
lymphatic ring of the pharynx. Commencing at the 
pharyngeal tonsil, this ring extends to the orifice of the 
Eustachian tube, then turning downward along the pos- 
terior surface of the soft palate to the faucial tonsil, it 
reaches the base of the tongue, and returns in the same 
1 Read before the Section on Laryngology and Rhinology of the New York 
Academy of Medicine, November 22, 1887. 2 
order. The ring has an almost vertical position, and is 
characterized by an accumulation of follicular glands in 
several places. The glands are found in two different 
forms ; in some localities they appear in aggregated, in 
others in disseminated form. When they are aggregated 
they represent a circumscribed mass, which is commonly 
called a tonsil. Other attributes of a tonsil are a dense, 
diffuse infiltration of the connective tissue with lymph- 
cells, and the prevalence of follicular, or, as Cohen better 
calls them, saccular glands. While these three condi- 
tions exist in the faucial and pharyngeal tonsil, the tonsil 
of the Eustachian tube and of the tongue have not the 
circumscribed form, and contain the follicular glands in 
the disseminated state. But cases are not rare in which 
the accumulation of these glands assumes a formidable, 
well-defined shape, and the Eustachian tonsil has been 
known as such for some time. The name, tonsil of the 
tongue, has, as I think, been used with perfect propriety 
by some writers for a similar condition at the base of 
this organ. Without further entering into the histology 
of these formations, it is well to remember that they are 
not glands in the common sense. They have no excre- 
tory duct nor outlet, are closed bodies, and by their 
function belong to the lymphatic system. They are of 
the size of a lentil, are loosely embedded in the submu- 
cous tissue, and their hilus is covered by a thin mucous 
membrane. Their sac contains a varying number of fol- 
licles, closely resembling those of Peyer’s glands of the 
intestines. 
According to the researches of Swain, who has given 
so far the best description of our subject, the existence 
of these glands at the base of the tongue is a normal 
condition. They are located between the papillae cir- 
cumvallatae and the epiglottis, often encroaching on both, 
and they generally appear at the period of puberty. In 
the hypertrophic state their growth is uniform, and all 
the parts of the gland take part in it. The whole gland 
is enlarged twice its size, and more; the follicles them- 3 
selves become considerably larger. This hyperplasia re- 
sembles closely the condition observed in chronic hyper- 
trophy of the faucial tonsil, and is another instance of 
similarity of these two organs. 
I am unable to give a satisfactory explanation of the 
causes productive of this disease. My patients, as well 
as those of others, had attained the age of puberty, the 
majority of them being between twenty and forty years 
of age. Aside from the knowledge of an ailment which 
made them seek medical aid, they were unaware of the 
condition existing in their throat, and greatly surprised 
when informed of the nature of the trouble. In my 
opinion the same agencies are most likely at work 
which bring on hypertrophy of the faucial tonsil, with 
the difference of their appearance at a later age of the 
patient. 
The symptoms we observe in patients are manifold, 
but mainly due to the mechanical irritation brought on 
by the hypertrophic glands. Some of these symptoms 
have already been described, and we are indebted to two 
members of our Section for having pointed out two of 
the most important ones. Dr. Rice has given a very 
graphic illustration how a severe spasmodic cough can 
be completely relieved by proper reduction of these 
glands, and Dr. H. Curtis related his experience of their 
influence on the singing voice. Dr. Curtis was, as far 
as I know, the first to have drawn attention to these 
growths from a clinical stand-point. But besides these 
two symptoms we notice an array of others, and we shall 
now investigate them more fully. We hear the patients 
complain—i, of the sensation of a foreign body or of 
pressure in their throat ; 2, of interference with their 
speaking or singing; 3, of pain when there is subacute 
inflammation of the glands; 4, of radiating pain; 5, of 
cough; 6, of asthmatic attacks. 
The first symptom I found to be the most constant 
one. The existence of a mass of hypertrophic tissue at 
the base of the tongue creates the feeling of the presence 4 
of a foreign body, and the patient endeavors to remove 
it by swallowing. This is the cause of the so-called 
empty-swallowing, which is often incessantly repeated 
with but temporary relief. This sensation is experienced 
less during eating, and generally only when no food is 
taken. It is next to impossible to enumerate all the 
foreign substances which the patients believe to be 
present. All imaginable things, from a leaden ball to a 
hair, are given as the source of the evil. In this connec- 
tion it will not be amiss to state that quite a number of 
cases of globus hystericus can be satisfactorily explained 
by the hypertrophy of these glands, and cured by their 
destruction. The sensation of pressure in the throat is 
in the same manner due to the enlarged glands, and ag- 
gravated when there is actual contact between the 
epiglottis and the tongue. Nervous patients become 
more and more irritated by the foreign body and the 
pressure they feel in their throat, and very often experi- 
ence great suffering. 
The interference with speech and song is probably the 
most interesting symptom of our disease. In some cases 
the patients only tire out very soon when using their 
voice, in others the voice is entirely lost. There are in- 
stances known where the voice is good one day, bad the 
next, and where it breaks suddenly during singing. 
Professionals also say that they are no longer able to 
find the right key, or that the voice has lost a great 
deal of clearness and metal. 
The only complaint of other patients is that they have 
pain while talking, without being hoarse. I refer now 
only to patients who have no concomitant disease, as, 
for instance, catarrhal laryngitis, granular pharyngitis, or 
to such whose ailment continued unabated after hyper- 
trophic faucial tonsils, or granulations of the pharynx, or 
the like had been effectively treated. If the hypertrophy 
of the glands is so great as to overlap the free border of 
the epiglottis, the explanation of their influence on the 
voice is easy. In this case the free movement of the 5 
epiglottis is seriously interfered with, and the constant 
exertion necessary to produce a sound creates a feeling 
of fatigue. If there is no impingement of the epiglottis 
and simple contact with the tongue, we have to remem- 
ber that the position of the tongue and larynx change 
with each articulation. When the follicular glands are 
swollen the epiglottis is exposed to friction with each 
movement, its nerves become irritated, and this irrita- 
tion is transmitted to the muscles and nerves of the 
larynx. In some cases the fatigue of voice can be traced 
to deficient innervation. 
Although the enlarged condition of the follicular glands 
is decidedly a chronic process, subacute inflammation does 
sometimes occur. Patients who formerly complained only 
of discomfort in swallowing, or of pressure in their throat, 
suffer actual pain when an inflammatory exudation of 
fibrinous material into the follicles takes place. In a lady 
under observation, who only had the sensation of a for- 
eign body in her throat, the glands were moderately en- 
larged without touching the epiglottis. After most of 
them had been reduced by the galvano-cautery she ap- 
peared one day suffering severe pain in her throat, which 
she considered due to a cold. On inspection numerous 
white spots, of the size of a pin’s head, could be seen, cov- 
ering the entire base of the tongue, and resembling closely 
the aspect we are wont to see in follicular tonsillitis. It 
took very persistent scraping with the sharp spoon, and 
repeated insertions of a fine galvano-cautery point into 
the diseased follicles to make the inflammatory symp- 
toms disappear. 
Radiating pains toward other parts of the body I no- 
ticed only in one patient. She complained of shooting 
pains toward each side of the throat, extending upward to 
the ears. Destruction of the hypertrophic glands gave 
prompt and complete relief. Cases are described in 
which patients felt pain between the shoulder-blades, in 
the larynx, trachea, also in the stomach. 
Quite a number of patients suffer from cough, which is 6 
observed in two different forms. It is either a violent, 
spasmodic, almost incessant, or a hacking cough, appear- 
ing at shorter or longer intervals. The spasmodic form, 
as a rule, occurs when the hypertrophic glands encroach 
upon the epiglottis, and is less frequent than the hacking 
cough. The latter often gives rise to great anxiety on 
the part of the patient and his relatives, as they fear it to 
be a symptom of developing phthisis of the lungs. In 
the cases under my observation this form of cough was 
present when there was merely contact between the 
glands and the epiglottis, and it is most probably due to 
the friction of the tongue and epiglottis against each 
other during their movements. 
Finally, the last symptom to be mentioned are asth- 
matic attacks. Although I have not seen any case my- 
self, Heyman and Seifert describe attacks of dyspnoea, 
resembling asthma, in patients with enlarged follicular 
glands. So far the observations are very few in number, 
but it will be advisable, in the future, to examine closely 
the base of the tongue before we consider a case of 
asthma as one of purely nervous origin. 
To illustrate more fully the symptoms alluded to, and 
their great variety, I append the histories of a few pa- 
tients : 
Case I.—Mrs. R , married, aged twenty-nine, pro- 
fessional singer. She had been performing in concerts 
and opera on the Continent and in this country. Her 
voice had never failed her, and although subjecting it 
sometimes to an unusual strain, she never felt any dis- 
comfort afterward. About one year ago she began to 
feel easily fatigued when singing any length of time, and 
when continuing she could only do so by great exertion. 
Of late she noticed, on several occasions, that in making 
such an exertion she would lose control over her voice, 
and it broke completely. She also complained of a slight 
sensation of pressure in her throat. The patient was 
otherwise perfectly healthy, but very downcast on ac- 
count of the fear of never regaining her full vocal power. 7 
At the examination the whole upper air-tract was found 
to be normal, except a few patches of granular tissue in 
the pharynx, and moderately enlarged follicular glands, 
which, however, did not interfere with the movements of 
the epiglottis. Not fully appreciating the importance of 
this condition at the time, I was greatly surprised when, 
after destruction of the granulations, but slight improve- 
ment was obtained. Permanent benefit only resulted 
from a methodic, and, in this case, especially persistent, 
treatment of the follicular hypertrophy. The means 
adopted in this and other instances I shall summarize 
when speaking of the treatment. 
Case II.—Mrs. G , married, aged thirty-seven, 
complained of a dryness and burning in her throat for 
the past four weeks, obliging her to drink very often. She 
also has the sensation of a string lying on the back of her 
tongue, which she in vain tries to get rid of by frequent 
attempts at deglutition. When she takes food this feel- 
ing is less, but after she has swallowed a mouthful some 
particles of food seem to remain on the tongue, and the 
fruitless efforts at swallowing commence again. During 
the last week she was also greatly annoyed by pain in 
both ears, which, although of short duration and coming 
at long intervals, was nevertheless very acute and pain- 
ful. 
A minute inspection revealed nothing but the presence 
of a circumscribed mass of follicular glands right in the 
middle of the base of the tongue, slightly covering the 
edge of the epiglottis. Three applications with different 
agents gave complete relief. 
Case III.—W , male, aged twenty-seven, amateur 
singer; suffers since ten years from what he calls “ca- 
tarrh ; ” which, however, did not materially affect his 
singing power. About two months before presenting 
himself for treatment he found that his voice became less 
clear ; it varied very much ; was better one day, worse the 
next, but never as good as before. It was a much greater 
effort for him to sing, and he tired out when he continued, 8 
and had actual pain in the throat when he persisted. At 
the same time he had a feeling as if a hard substance was 
present in his throat which necessitated frequent swallow- 
ing. 
The patient had a considerable hypertrophy of the an- 
terior portion of both middle turbinated bodies. They 
were snared off and relieved his catarrh. The follicular 
glands covered the base of the tongue rather uniformly, 
and it required treatment extending over two months to 
reduce them to their normal condition, and thereby to 
restore his voice to its former quality. 
Case IV.—The last case I have selected from my note- 
book appears to me most interesting, and instructive at 
the same time. Miss J , aged twenty-eight, was 
brought to my office by her mother, in a state of great 
anxiety, because the young lady was believed to be a 
victim of pulmonary phthisis. The patient had not lost 
much flesh, but she looked pale, anaemic, and was very 
weak, not having had one good night’s rest for several 
weeks on account of her harassing cough. She had been 
under treatment before, and her chest had been pro- 
nounced “ weak.” Six years previously she had been 
treated for some aural disease, and later for a throat 
trouble, the exact nature of which I could not ascertain. 
On being questioned she said that for quite a long time 
she felt as though she must frequently swallow in order 
to overcome a raw, scratching feeling in her throat. 
Most careful and repeated examination of her chest 
gave no evidence of pulmonary disease. Very slight 
granulations were present in her pharynx, but their de- 
struction did not in the least relieve her cough. The 
follicular glands were, in her case, hypertrophied to such 
an extent as I have never seen since. There was a 
thick dense mass of hypertrophic tissue extending over 
the whole base of the tongue, and covering the free bor- 
der of the epiglottis completely. This mass was divided 
by longitudinal furrows, the deepest of which, centrally 
located, divided the whole tissue in two symmetrical 9 
halves. I began the treatment by snaring off each half 
with my platinum-iridium cautery-snare, and reduced the 
remaining tissue by repeated insertions of the cautery- 
knife. Improvement began immediately after the two 
parts I beg to show you here had been snared off, 
and, although the treatment extended over six weeks, 
no other means were employed, and a perfect cure was 
effected. 
From the foregoing you will see, gentlemen, that the 
disease in question presents a great variety of symptoms. 
I purposely refrained from enumerating in detail all the 
different complaints patients have to make. I only en- 
deavored to give the chief features we observe, without 
becoming tiresome. One point more, I think, is well 
worth dwelling upon. Although there are quite a num- 
ber of people with enlarged glands who have no abnor- 
mal sensation, and therefore are not objects for treatment, 
we certainly have to look upon the hypertrophy of the 
tonsil of the tongue as another source of ailment of the 
upper air-tract which merits our undivided attention. 
It is not necessary to state, in an assembly like the one 
before me, that recent experience has taught us not to 
rest contented until we have found an anatomical basis 
for any neurotic symptoms the patient may suffer from. 
It is our endeavor to localize disease, and as long as we 
do not find the true cause our line of treatment is more 
or less without proper foundation. The symptoms enu- 
merated above are not pathognostic of our disease, and 
without local examination a positive diagnosis cannot be 
made. If, therefore, in a given case, after a thorough 
examination of the usual localities, we find no definite 
cause for a certain train of symptoms, our attention 
should be directed to the base of the tongue before we 
assume a simple neurosis. The inspection of this organ 
requires no special manipulation, but it is easily seen in 
its full size when examining the larynx. As a rule, we 
are so accustomed to look at once into the larynx, and 
for the possible changes of its structure, that it will only 10 
need this suggestion to make the examination complete. 
When we are in doubt as to the locality giving rise to the 
abnormal sensations, we can avail ourselves of the action 
of cocaine, which arrests the reflex irritability, and there- 
by facilitates the diagnosis. 
The prognosis is favorable, as well in regard to the dis- 
ease itself as to the concomitant symptoms. Still I have 
found it difficult to pass judgment beforehand as to the 
time necessary for a cure, and in the beginning was more 
than once disappointed by giving a hasty opinion. They 
are not always the large hypertrophies which require 
most time for treatment; sometimes the reduction of a 
smaller but broader hypertrophic mass taxes the endurance 
of the patient and the resources of the physician a great 
deal more. 
The line of treatment to be pursued is well marked 
out, and consists in reduction or destruction of the re- 
dundant tissue. Simple pressure with a cotton-carrier, 
applications of chromic acid, or of Vienna paste, have 
been recommended. My experience is limited to four 
remedial agents: Lugol’s solution of different strength, 
nitrate of silver fused to a probe, the galvano-cautery, 
and, finally, the snare. 
Lugol’s solution is applied with the common laryngeal 
applicator, bent at a more obtuse angle and then intro- 
duced between the base of the tongue and the epiglottis. 
Although praised very highly by others, it has not proven 
so effective in my hands, and I now use it only in light 
cases or when patients object to the cautery. As one 
of its advantages I found in quite a number of cases that 
the patient feels at least temporary relief from his abnor- 
mal sensation immediately after the application. Lunar 
caustic is best adapted for cases in which the hyper- 
trophic tissue is of a soft character and not so dense and 
compact as we usually find it. My best results I have 
obtained by means of the galvano-cautery, with which I 
make repeated scarifications into the follicular glands, and 
which acts here in a similar manner as when used for hy- 11 
pertrophy of the faucial tonsil. When there is contact 
between the epiglottis and tongue, care has to be taken 
not to injure the former, and the electrode has to be em- 
bedded firmly and deeply into the diseased tissue in order 
to avoid the epiglottis. The reaction is sometimes rather 
severe, lasting for several days, and ice-pellets and cocaine- 
spray may be employed to ease the patient. When the 
hypertrophic mass is lobular in shape, or so large as to en- 
able its engagement in a snare, I consider it advisable 
always to snare it off. With the proper use of cocaine 
the elastic cautery-snare of iridium and platinum answers 
the purpose as well as the cold snare, is not more pain- 
ful, and, creating a larger slough, is more thorough in its 
action. 
Literature. 
Sachs : Du Bois-Reymond’s Archiv. fur Physiologie, 1859, p. 196. 
Boettcher: Virchow’s Archiv, vol. xviii., p. 190. 
Ostmann : Ibid., vol. xcii., p. 119. 
Biekel, G. : Ibid., vol. xcvii., p. 340. 
Stoehr : Ibid., p. 211. 
Heyman : Berliner Klinische Wochenschrift, 1887, p. 764. 
Heyman : Ibid., 1881, p. 393. 
Seifert, O. : Sitzungsberichte der Phys. Med. Gesellschaft in Wurz- 
burg, July 17, 1886. 
Seifert, O. : Berliner Klinische Wochenschrift, May 9, 1887. 
Swain, H. L. : Deutches Archiv. fur Klinische Medizin, vol. xxxix. 
Curtis, H. : New York Medical Journal, November 8, 1884. 
Rice, C. C. : The Medicai, Record, May 1, 1886. 
Lennox Browne: The Throat and its Diseases, p. 209. London, 
1887. 
Lennox Browne: Journal of the American Medical Association, 
October 29, 1887. 
Babcock, W. D. : Southern California Practitioner, 1887, p. 127.