Cases in Tonsil Disease: From the Routine to the Serious

Gordon H. Sun, MD, MS


May 23, 2017

A Chronic Unilateral Sore Throat and Swelling

Dr Jensen, a 48-year-old scientist, presented to his primary care provider with a 3-month history of mild right-sided sore throat and discomfort while swallowing. Three weeks ago, while shaving, he noticed a swelling along the right side of his face and neck. He denied fevers or other constitutional symptoms, shortness of breath, changes in his voice, dental problems, or otalgia. He denied any history of head and neck surgery, medication use, or allergies. He reports having 10 lifetime sexual partners but is currently monogamous. He is a nonsmoker and nondrinker. He stated that he had gone to an urgent care center 2 weeks ago and was given a 5-day course of azithromycin, which did not have any noticeable impact on the symptoms.

Physical examination demonstrated a well-nourished, well-appearing man in no apparent distress, with normal vital signs. His voice was clear without stridor. Ocular, nasal, and otoscopic exams were unremarkable. Oral exam revealed an erythematous, ulcerated mass within the right tonsillar fossa measuring roughly 2x2 cm. The tongue was fully mobile but somewhat tender with palpation. No masses were palpable in the base of the tongue. A rounded 2-cm mass was palpable just below the right angle of the mandible. Dentition was grossly intact. Mirror laryngoscopy revealed no lesions in the endolarynx.

The patient was referred to a pathologist at his medical center, who performed ultrasound-guided fine needle aspiration (FNA) of the right neck mass. At the patient's follow-up appointment a week later, the pathology report of the FNA read "specimen consistent with nonkeratinizing squamous cell carcinoma." The pathologist further noted that the biopsy was positive for human papillomavirus (HPV) subtype 16. The primary care provider placed an urgent referral to an otolaryngologist for further imaging, workup, and definitive management. The patient was incredulous at the diagnosis and asked how he could have cancer: "I thought throat cancer only came from cigarettes and alcohol."


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