A 66-year-old man comes to the office due to a sore throat over the last 3 months. The pain in the throat is worsening and is particularly noticeable when the patient swallows. He thought the pain was related to tonsil stones and tried picking them out with toothpicks and gargling with salt water after meals, but this did not relieve the pain. The patient has noticed an ulcer on the right tonsil that bleeds when he touches it. Medical history is significant for chronic obstructive pulmonary disease, for which he uses multiple inhalers. The patient has smoked 2 packs of cigarettes daily for the past 50 years. Vital signs are within normal limits. Ear examination is normal. The nasal mucosa is dry, and examination of the oral cavity shows poor dentition with no lesions. Oropharyngeal examination shows an enlarged, firm right tonsil with a 1-cm ulceration with surrounding fibrinous debris. The left tonsil has several small tonsil stones without surrounding inflammation. There is no cervical adenopathy. Biopsy of this lesion would most likely reveal which of the following?

Question

A 66-year-old man comes to the office due to a sore throat over the last 3 months.  The pain in the throat is worsening and is particularly noticeable when the patient swallows.  He thought the pain was related to tonsil stones and tried picking them out with toothpicks and gargling with salt water after meals, but this did not relieve the pain.  The patient has noticed an ulcer on the right tonsil that bleeds when he touches it.  Medical history is significant for chronic obstructive pulmonary disease, for which he uses multiple inhalers.  The patient has smoked 2 packs of cigarettes daily for the past 50 years.  Vital signs are within normal limits.  Ear examination is normal.  The nasal mucosa is dry, and examination of the oral cavity shows poor dentition with no lesions.  Oropharyngeal examination shows an enlarged, firm right tonsil with a 1-cm ulceration with surrounding fibrinous debris.  The left tonsil has several small tonsil stones without surrounding inflammation.  There is no cervical adenopathy.  Biopsy of this lesion would most likely reveal which of the following?

Quizplus · Accepted Answer

An ulcerated tonsillar lesion in a patient with a long smoking history is highly suspicious for oropharyngeal squamous cell carcinoma (SCC). Oropharyngeal SCC may present with sore throat and odynophagia due to tumor invasion or local irritation. Lesions often ulcerate and can be friable (eg, bleeding to light touch). Other manifestations include referred otalgia or an isolated neck mass (representing regional nodal spread of disease). referred otalgia Traditional risk factors for oropharyngeal SCC include age >40, tobacco use, alcohol use, and immunocompromised status. There has also been a dramatic increase in oropharyngeal cancer due to human papillomavirus (HPV), which may be seen in younger, nonsmoking patients. This patient should undergo biopsy of the tonsil lesion with evaluation of HPV status as well as neck imaging (eg, CT scan) to characterize the lesion and any associated nodal metastasis. Tonsil stones (tonsilloliths)-commonly occurring concretions of food, cellular, and bacterial debris-are not known to be risk factors for oropharyngeal SCC and can be managed with gentle removal (eg, gargling with salt water). However, frequent patient manipulation (eg, with toothpicks) can cause mucosal trauma, which may be mistaken as an ulcerated neoplasm. (Choice A) A tonsil malignancy is unlikely to be adenocarcinoma. Lung adenocarcinoma shares some risk factors (eg, smoking, age) and possible presenting symptoms (eg, cough, hemoptysis) with oropharyngeal SCC, but it does not metastasize to the tonsil. (Choice B) Aphthous ulcers are common, painful ulcers that typically present with an erythematous border and a white membrane covering the ulcer. However, they typically resolve in 1-2 weeks and are usually seen in the oral cavity (eg, tongue, buccal mucosa) rather than the oropharynx (tonsil). (Choice C) Although non-Hodgkin lymphoma rarely can present in a tonsil, it is much less common than head and neck SCC. It would also cause tonsillar enlargement rather than ulceration and is usually seen in patients with immunosuppression or autoimmune diseases. (Choice D) Pemphigus vulgaris is an autoimmune disease characterized by painful blisters of the skin and mucous membranes. Although it is seen in middle-aged and older adults and can present with mucosal ulcerations, the pain would likely be more severe, there would be multiple ulcerations, and skin blistering would be evident as well. (Choice E) Small cell carcinoma is a neuroendocrine lung tumor that occurs almost exclusively in smokers. However, it is not seen in the tonsil. Educational objective: A tonsil ulcer in a smoker is likely due to squamous cell carcinoma. References: HPV-associated head and neck cancer. (http://www.ncbi.nlm.nih.gov/pubmed/26656751) Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. (http://www.ncbi.nlm.nih.gov/pubmed/18334711) Multidetector computed tomography imaging characteristics of asymptomatic palatine tonsilloliths: a retrospective study on 3886 examinations. (http://www.ncbi.nlm.nih.gov/pubmed/29506917)

A 66-Year-Old Man Comes to the Office Due to a Sore