A 40-year-old woman comes to the office for evaluation of a sore throat. It began 2 months ago, worsens with swallowing, and is making it difficult for her to swallow solid foods. She has also noticed worsening bad breath. Medical history is unremarkable. She has never smoked and uses alcohol rarely. The patient is currently in a long-term monogamous relationship and has had multiple sexual partners over her lifetime. Temperature is 37 C (98.6 F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Ear examination reveals a clear external ear canal with an intact tympanic membrane with no middle ear fluid. The nasal mucosa is pink with no nasal drainage. Oral cavity examination shows mild dental disease but no mucosal lesions. Oropharyngeal examination reveals an enlarged, firm right tonsil with a 2-cm ulceration. There are also 2 enlarged, firm, fixed, nontender lymph nodes in the right side of her neck. Which of the following is most likely responsible for this patient's condition?
This patient's persistent, enlarged, firm neck mass and ulcerated tonsillar lesion are consistent with head and neck squamous cell carcinoma (HNSCC), which can also lead to pharyngitis, dysphagia, and halitosis (bad breath). Traditional risk factors for HNSCC include older age, tobacco and alcohol exposure, and poor dentition. With the decrease in smoking rates, there has been a decline in many types of HNSCC; however, the incidence of oropharyngeal (eg, tonsil, base of tongue) HNSCC has dramatically increased.
This increase is due to human papillomavirus (HPV)–positive HNSCC, often seen in younger patients with no tobacco exposure and multiple sexual partners (as in this patient). HPV-positive HNSCC primarily affects the oropharynx (possibly due to the higher concentration of lymphatic tissue facilitating viral processing) and often presents with neck lymphadenopathy. However, it is more responsive to therapy than HPV-negative HNSCC. The most common causative subtype is HPV-16, which is covered by the HPV vaccine.
This patient should undergo biopsy of the tonsil lesion with evaluation of HPV status, neck imaging (eg, CT scan) to characterize the lesion and associated nodal metastasis, and endoscopic evaluation of the upper aerodigestive tract.
(Choice A) Cervicofacial actinomycosis is a rare infection presenting as a slowly progressive, nontender mass that can form abscesses and draining sinus tracts with characteristic yellow "sulfur granules." Regional adenopathy is unlikely because the infection spreads by direct extension, ignoring normal tissue planes.
(Choice B) Infectious mononucleosis due to Epstein-Barr virus (EBV) may cause enlarged tonsils and lymphadenopathy. However, oropharyngeal HNSCC is much more likely given the absence of fever and the unilaterally enlarged, ulcerated tonsil with ipsilateral firm lymphadenopathy. EBV is also associated with certain lymphomas (eg, Burkitt) and with nasopharyngeal (rather than oropharyngeal) cancer, all of which are unlikely to cause unilateral tonsillar ulceration.
(Choice C) Fusobacterium necrophorum causes Lemierre syndrome, a life-threatening, deep neck space infection that progresses to suppurative thrombophlebitis of the internal jugular vein. Although it presents with painful pharyngitis and odynophagia, it also has a more acute (<1 week) and toxic presentation with high fevers (>39 C [102 F]), rigors, and respiratory distress from associated septic pulmonary emboli.
(Choice E) Although Streptococcus pyogenes causes painful pharyngitis, it presents acutely with fever and would not be expected to cause persistent, unilateral, firm tonsillar enlargement with ulceration and unilateral enlarged, nontender adenopathy.
(Choice F) Primary syphilis (caused by Treponema pallidum) can present with a typically painless oral ulcer (chancre). Chancres on the tonsil are extremely rare and would not present with adenopathy. In addition, primary syphilis typically occurs within weeks after the initial exposure (eg, unprotected sexual encounter).
Educational objective:
An enlarged, ulcerated tonsil with ipsilateral cervical adenopathy is likely oropharyngeal (head and neck) squamous cell carcinoma. Human papillomavirus is the likely etiology in the absence of traditional risk factors (smoking, alcohol).