Case history
Case history
A 62-year-old man presents with a sore throat and 6 kg unintentional weight loss. He has smoked 1 pack of cigarettes daily for the past 45 years and drank 1 bottle of whiskey daily for the past 5 years. On examination, there is a large left tonsillar mass extending to the soft palate, with no cervical adenopathy.
Other presentations
Oropharyngeal carcinoma can present with a neck mass, without any other symptoms. Head and neck examination may reveal no obvious primary, as the tumour may be submucosal and not visible on physical examination. A small percentage of human papillomavirus (HPV)-associated oropharyngeal cancer also presents as an 'unknown primary'. In this case, it is possible that the primary tumour is very small (<1 cm) or has already regressed secondary to an immunological response to the tumour. Additional diagnostic studies such as positron emission tomography scan alone, or combined with computed tomography scan, can orient the surgeon to biopsy the primary site (base of tongue, tonsil) if the neck mass biopsy shows HPV-associated squamous cell carcinoma. If these studies are negative, a careful flexible nasolaryngoscopy examination and examination under general anaesthesia should follow, combined with directed biopsies and/or diagnostic tonsillectomy and/or base of tongue mucosectomy.
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