To the Editor: We both are ear, nose and throat (ENT) specialists at a tertiary university hospital and cover 1–2 nights of emergency calls each month. Over 8 months in 2008, we witnessed four emergency patients (aged 25–39 years; three men, one woman) who had sore throat, mild fever and pain on swallowing, without any respiratory distress symptoms. One patient presented with “hot potato voice”. All had had a palatine tonsillectomy in childhood.

On examination, the oral pharynx appeared normal to mildly hyperaemic, without any suppuration. To exclude potentially fatal epiglottitis, all patients underwent transnasal flexible laryngoscopy, which revealed swollen lingual tonsils covered with fibrinous exudate typical of streptococcal infection. Distal structures, including the epiglottis and endolarynx, were normal. Acute lingual tonsillitis was diagnosed, and the patients quickly responded to penicillin therapy.

Some degree of infection of the lingual tonsils probably occurs when the pharynx is otherwise infected, but is usually left undiagnosed because it is not easily visible without laryngoscopy.1 Although none of our patients had any life-threatening symptoms, this condition could potentially cause upper airway compromise, and the course would certainly be more arduous without antibiotics.

The flexibility of our health care system in Croatia allows for some emergency patients’ to refer themselves to the relevant specialty services. If these patients had presented to general practice rather than to our department, where we performed transnasal laryngoscopy, this diagnosis would have probably gone unnoticed, and antibiotic therapy would not have been prescribed.

Thus, is acute lingual tonsillitis a neglected cause of severe sore throat? A search of the current literature and ENT textbooks did not reveal many reports of this disease.2,3 Even if our observations referred to rare cases, considering our hospital catchment population for ENT emergencies of more than 300 000, they still outnumbered all cases of epiglottitis treated at our emergency service during the same period.

Therefore, it is our opinion that acute lingual tonsillitis should be at least kept in mind as a condition that can cause severe sore throat that is oropharyngoscopically silent or mimics simple viral infection, but is effectively and readily treated with antibiotics.4 Because the base of the tongue cannot be visualised by routine intraoral examination, confirmation of the diagnosis must be made by an ENT specialist who will perform laryngoscopy.