The Longstanding Sore Throat

CLINICAL

The longstanding sore throat

Chrysostomos Tornari, Krishan Ramdoo, Tse Choong Charn, Taran Tatla

Case Question 2 to the right and the tonsil itself is not A Caucasian man, 64 years of age, who is How should a patient with these findings noticeably prominent. an ex-smoker (50 cigarettes/day, stopped be investigated and referred? Fortunately, malignancy rates in adults 14 years ago) and social drinker, saw his remain low in the context of asymmetrical general practitioner (GP) over a three- Question 3 tonsils that are not associated with month period with persistent symptoms What lifestyle factors are associated risk factors, associated symptoms of odynophagia and sore throat. No with an increased risk of head and neck or mucosal abnormalities.1–7 Benign other symptoms were reported and a squamous cell carcinoma? tonsillar asymmetry can be explained by repeated diagnosis of bacterial tonsillitis hypertrophy, anatomical factors2,3 and was made. Despite multiple courses Question 4 extrinsic compression.8,9 There is a diverse of oral antibiotics, his symptoms failed How is this patient likely to be managed in range of causes for extrinsic compression, to improve. His past medical history secondary care? such as aneurysm, neoplasms of the deep included osteoarthritis and gout. lobe of the parotid and parapharyngeal While on holiday, the patient experienced Answer 1 neoplasms.8,9 increasing difficulties with eating The key feature of a true tonsillar solids because of food ‘sticking,’ as asymmetry on examination is the position Answer 2 well as difficulty swallowing liquids. of swelling. In cases of peritonsillar Blood tests with particular attention to This prompted assessment by a duty abscess (ie quinsy), the swelling arises the full blood count can help to identify doctor. On examination, the tonsils were from the peritonsillar space. The tonsil haematological malignancies. Depending enlarged and asymmetrical. Along with itself is not asymmetrical but pushed on local protocols, throat swabs or the above symptoms, this prompted into a medial position by the lateral serological tests can be sent with liver immediate repatriation. oropharyngeal swelling. In both panels of function tests to identify Epstein–Barr Figure 1, the soft palate and tonsillar pillars virus or group A streptococcal infection. Question 1 are symmetrical but the tonsil on one side How can true tonsillar asymmetry, as is clearly larger than the other. In Figure 2, seen in Figure 1, be differentiated from a the left tonsillar pillar is expanded by a peritonsillar abscess? peritonsillar abscess, the uvula is deviated

A B

Figure 2. Clinical photograph of the oral cavity and oropharynx This shows an example of left peritonsillar abscess. Figure 1. Clinical photographs of the oral cavity and oropharynx showing examples of tonsillar asymmetry The asymmetry can be seen to arise from within A. Intraoperative photograph of right tonsillar asymmetry due to squamous cell carcinoma the anterior tonsillar pillar rather than from the (in a different patient to the one presented in the text); B. Clinical photograph of a left tonsillar lymphoma tonsil itself.

Depending on the social and sexual lying flat, night sweats and lethargy. is suspected, the patient is likely to be history, human immunodeficiency virus Depending on the results of the history discussed in a multidisciplinary team (HIV) serology may also be warranted. and examination, which would also include meeting prior to tonsillectomy or biopsy A diagnostic algorithm for patients abdominal examination for splenomegaly, to obtain a histological diagnosis. with an unexplained symptom of sore head and neck or haematology referral can throat can be seen in Figure 3. Sore be made as appropriate.10 Case continued throat with tonsillar asymmetry of the An MRI of the patient’s neck and CT duration seen in this case should prompt Answer 3 of his chest showed a locally advanced expedited referral to ear, nose and throat Smoking, alcohol consumption and right tonsillar tumour, which had (ENT) – head and neck services. Despite betel quid chewing are all risk factors metastasised regionally to the draining a low (approximately 2%) incidence for tonsil carcinoma.11 Human papilloma lymph nodes, but not to the chest. He of malignancy,5 the significance of virus (HPV) is also a risk factor, which was listed for urgent panendoscopy missing tonsillar malignancy means that should be sensitively explored by taking a and incisional biopsy of the right tonsil. asymptomatic patients should still be sexual history, as HPV is associated with Histology revealed a small squamous referred on the basis of their signs. 40–90% of oropharyngeal squamous cell cell carcinoma of the tonsil with the Persistent tonsillar asymmetry alone is carcinomas.12 presence of HPV, and he was referred an indication for referral and tonsillectomy for radical radiotherapy with curative (if there is progressive enlargement of the Answer 4 intent following a multidisciplinary tonsil, associated neck lymphadenopathy Following clinical examination, fibre optic team meeting discussion. or family history of malignancy).2 The nasendoscopy would be performed presence of any mucosal abnormality, to identify any nasal, postnasal space, Key points such as red, white or bleeding patches, oropharyngeal, hypopharyngeal and • Smoking, alcohol and betel quid is concerning and should also prompt laryngeal abnormalities. This would chewing are risk factors for squamous expedited referral.4,10 allow airway assessment to determine cell carcinoma of the upper Regardless of symmetry, progressive the likelihood of airway compromise. aerodigestive tract. tonsillar hypertrophy in adults can be In addition, computed tomography • HPV is associated with 40–90% due to lymphoma. Therefore, direct (CT) or magnetic resonance imaging of oropharyngeal squamous cell questioning should screen for symptoms (MRI) of the neck and appropriate chest carcinomas. such as shortness of breath when imaging would be arranged. If cancer • Duration of symptoms with no obvious benign cause for six weeks or longer should prompt expedited referral to ENT – head and neck services. • If tonsillitis fails to respond to repeated Sore throat with no benign explanation courses of antibiotics, this should prompt specialist referral for the exclusion of a malignant cause. No airway compromise Airway compromise • Tonsillar asymmetry can be differentiated from peritonsillar abscess by determining whether the Emergency ENT review Unexplained additional symptoms swelling is intrinsic or extrinsic to the or signs: tonsil. • Mucosal abnormality No additional symptoms • The standard of care is still for • Referred otalgia persistently asymmetrical tonsils to be • Dysphagia removed for histological examination. • Neck Lump or tonsillar asymmetry • Hoarseness Arrange expedited ENT review Authors to coincide with six-week Chrysostomos Tornari MB, PhD, MRCS, DOHNS, Arrange expedited ENT review duration of symptoms ENT Registrar, St George’s Hospital, London, UK. [email protected] (cancel if symptoms resolve) (cancel if symptoms resolve) Krishan Ramdoo MBChB, MRCS (ENT), Research Registrar, Northwick Park Hospital, London, UK Tse Choong Charn MBBS, MRCS (Edin), MMed Figure 3. A diagnostic algorithm for patients with sore throat (ORL), DOHNS, EBEORL, Associate Consultant in ENT, Sengkang Health, Singhealth, Singapore

280 AFP VOL.45, NO.5, MAY 2016 © The Royal Australian College of General Practitioners 2016 THE LONGSTANDING SORE THROAT CLINICAL

Taran Tatla MBBS, BSc (Hons), DLO, FRCS(Eng), 6. Puttasiddaiah P, Kumar M, Gopalan P, Browning ST. 12. Boscolo-Rizzo P, Del Mistro A, Bussu F, et al. ENT – Head and Neck Consultant, Northwick Park Tonsillectomy and biopsy for asymptomatic New insights into human papillomavirus- Hospital, London, UK asymmetric tonsillar enlargement: Are we right? associated head and neck squamous cell Competing interests: None. J Otolaryngol 2007;36(3):161–63. carcinoma. Acta Otorhinolaryngol Ital 2013;33(2):77–87. Provenance and peer review: Not commissioned, 7. Papouliakos S, Karkos PD, Korres G, Karatzias G, externally peer reviewed. Sastry A, Riga M. Comparison of clinical and histopathological evaluation of tonsils in pediatric References and adult patients. Eur Arch Otorhinolaryngol 2009;266(8):1309–13. 1. Syms MJ, Birkmire-Peters DP, Holtel MR. 8. Altin G, Sanli A, Erdogan BA, Paksoy M, Aydin S, Incidence of carcinoma in incidental tonsil asymmetry. Laryngoscope 2000;110(11):1807–10. Altintoprak N. Huge internal carotid artery aneurysm presenting as tonsillar asymmetry. 2. Cinar F. Significance of asymptomatic tonsil J Craniofac Surg 2012;23(5):1565–67. asymmetry. Otolaryngol Head Neck Surg 2004;131(1):101–03. 9. Vourexakis Z. Images in clinical medicine. 3. Spinou C, Kubba H, Konstantinidis I, Johnston A. Tonsillar asymmetry from a parotid tumor. N Engl Role of tonsillectomy in histology for adults J Med 2014;370(13):e20. with unilateral tonsillar enlargement. Br J Oral 10. National Institute for Health and Care Excellence. Maxillofac Surg 2005;43(2):144–47. Suspected cancer: Recognition and referral. 4. Sunkaraneni VS, Jones SEM, Prasai A, Fish BM. London: NICE, 2015. Available at www.nice. Is unilateral tonsillar enlargement alone an org.uk/guidance/ng12/resources/suspected- indication for tonsillectomy? J Laryngol Otol cancer-recognition-and-referral-1837268071621 2006;120(7):E21. [Accessed 9 November 2015]. 5. Oluwasanmi AF, Wood SJ, Baldwin DL, Sipaul F. 11. Llewellyn CD, Johnson NW, Warnakulasuriya KA. Malignancy in asymmetrical but otherwise Risk factors for squamous cell carcinoma of the normal palatine tonsils. Ear Nose Throat J oral cavity in young people – A comprehensive 2006;85(10):661–63. literature review. Oral Oncol 2001;37(5):401–18.