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 one fifth 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 exam may reveal no obvious primary, as the tumor may be submucosal and not visible on physical exam. 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 tumor is very small (<1 cm) or has already regressed secondary to an immunologic response to the tumor. 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 HPV-associated shows squamous cell carcinoma. If these studies are negative, a careful flexible nasolaryngoscopy exam and exam under general anesthesia should follow, combined with directed biopsies and/or diagnostic tonsillectomy and/or base of tongue mucosectomy.
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