Peter was a 59-year-old man who had seen his GP because of a sore throat on the left side. The GP noted a white patch on the left tonsil and prescribed amoxicillin 500mg tds for six days. The soreness did not go and so Peter came back and saw a different doctor at the practice. This doctor noted similar findings and equal, moderate tonsillar hypertrophy bilaterally. However, he was concerned because of Peter’s age and lack of response to treatment. Although there was no local lymphadenopathy in the neck, the patient was urgently referred to an ENT specialist, who confirmed a metastatic squamous cell carcinoma of the tonsil.
The message that comes from this case is to be careful diagnosing tonsillitis, or traumatic lesions in the mouths of older patients. Ulceration, plaques and inflammatory patches may be neoplastic. It is also important to examine under the tongue when looking in the mouth, as this is a common area for missed neoplasms.
Squamous cell cancer of the throat was most famously publicised by Michael Douglas in 2010, when he said it was caused by human papilloma virus, contracted through oral sex. He equally famously had to apologise for the obvious implication shortly after to his wife Catherine Zeta-Jones.1 Strangely, he didn’t mention his other highly significant risk factors for throat cancer, these being smoking and drinking alcohol. Epstein Barr viral infection is a more uncommon viral cause than human papilloma virus. The risk of oral cancer is also increased if the diet is deficient in fresh fruit and vegetables. Betal nut and South American mate (a beverage) consumption are other important risk factors worldwide.2 The commonest HPV types2 causing oropharyngeal cancer are 16 and 18, and the risk of the condition will hopefully reduce over subsequent decades due to the current vaccination schedule that includes these viruses.
Squamous cell cancer accounts for 70% of tonsillar neoplasms; the second most common is lymphoma.2 Overall, the tonsils are an uncommon place for oropharyngeal cancer but are important not to miss. Significant asymmetry of the tonsils is important at any age, but especially if it is previously undocumented. The other very significant point about tonsillar neoplasms is that they spread early, and it is not uncommon for them to present as a cystic neoplasm in the neck or within a jugulodigastric lymph gland (at the crossing of the posterior portion of the digastric muscle and internal jugular vein), as they are easily missed in the tonsil.2 Contrary to common belief about cancer, pain or discomfort does occur with cancers in the tonsil.2 Weight loss and fatigue may also be presenting features.2
1. Child B. Michael Douglas: I was sorry for effect of oral sex cancer comments on my wife. The Guardian. 29 June 2015
2. Kokot N. Malignant tonsil tumor surgery. Medscape. 2016 Mar.