Abstract
ABSTRACT
We report submucosal tonsillar carcinoma presenting with metastatic cervical lesion without obvious tonsillar lesion. The need of careful tonsillar evaluation and role of diagnostic tonsillectomy is highlighted in this case. (Rawal Med J 2010;35 ).
Keywords
Tonsil cancer; occult primary; neoplasm metastases
INTRODUCTION
Unknown primary carcinoma presenting as cervical lymph node metastasis accounts for approximately 5% of all head and neck malignancies.1 The typical presentation involves a middle-aged man with a painless neck mass that has been present for several months. Over 90% of these malignancies are squamous cell carcinoma (SCC) originating within Waldeyer’s ring.1 The diagnosis of tonsillar carcinoma can be challenging as the lesion may be submucosal, giving tonsil a clinically normal appearance. In the setting of cervical metastasis of unknown primary, therefore, tonsils should be carefully evaluated for possible hidden malignancy. This article highlights the significance of appropriate workout, evaluation, staging and treatment of unknown primary carcinoma presenting as cervical lymph node metastasis.
CASE PRESENTATION
A 50 years old gentleman presented with painless, gradual left sided neck swelling for 8 months duration. There was no epistaxis, sorethroat, dysphagia, dyspnea or hoarseness. Systemic review was unremarkable. He has been a heavy smoker for 30 years duration and previously worked as a painter.


Fig 1. CT Scan of Neck with lymph nodes.

On examination, the cervical swelling measured 4x4cm over the anterior edge of left sternocleidomastoid muscle below the mandible, fixed, non tender and hard in consistency. Overlying skin appeared normal. Intraoral examination revealed the presence of a small superficial ulcer over the left tonsil, which was biopsied and reported as non malignant. Fine needle aspiration cytology of the cervical swelling showed presence of metastatic carcinoma, favoring adenocarcinoma. Biopsies of bilateral Fossa of Rossenmuller revealed normal findings. CXR was normal. CT scan showed left cervical lymph nodes enlargement with necrotic center (Fig 1). Serum tumor markers were all within normal range. Findings of upper and lower gastrointestinal endoscopies were unremarkable. Patient was lost to follow up.






Fig 2. CT scan at later presentation showing an obvious left tonsillar mass approaching midline.

Four months later, he came back with symptoms of sore throat and dysphagia of one month duration. The left neck swelling was bigger than before, measuring 5x5 cm now. Trismus was noted. Intraoral examination noted 2x2 cm left tonsillar mass with central irregularly-bordered ulceration, surrounding redness and swelling, approaching midline. Nonetheless, there was no airway compromise. Punch biopsy was performed and reported SCC of tonsil. Redo fine needle aspiration cytology of the same neck swelling this time reported presence of metastatic carcinoma. Redo CT s

Key words: Tonsil cancer; occult primary; neoplasm metastases