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Why did this man have a sore throat and inflamed tonsil?


The patient

‘I can't get rid of this sore throat, doctor.' Not an unusual presentation in the middle of winter. But a slightly strange context in that the patient was a 60-year-old infrequent attender. Also, his symptom had apparently persisted for about three weeks and was predominantly affecting just the left side. Odder still, he had no other symptoms suggesting an upper respiratory tract infection.

His past medical history revealed a lifelong smoking habit and excess alcohol intake. Unsurprisingly, he suffered COPD, for which he took bronchodilators and inhaled steroids. Otherwise, the only other entries on his summary referred to an appendicectomy and tonsillectomy many years ago.

First instinct

Examination revealed a nasty, inflamed-looking tonsillar fossa on the left side. He otherwise seemed well. Despite the atypical presentation – and given the number of throat infections I'd seen recently – my gut reaction was to assume this was some sort of persistent throat infection.

Differential diagnosis

• Pharyngitis

• Glandular fever

• Candidiasis

• Blood dyscrasia

• Malignancy

A throat that looked like this in a young adult – especially if bilateral – would automatically be viewed as a streptococcal tonsillitis or glandular fever. And less impressive symptoms and a less dramatic appearance would point towards a simple viral infection, especially if a cough was present, too. Yet this patient wasn't young, he'd had his tonsils removed, and the symptoms and signs were categorically unilateral.

Candidiasis was a more likely explanation. That can certainly produce an unpleasantly sore throat with a similar appearance – and the inhaled steroids would support this hypothesis. But I was still bothered by the marked localisation of the pathology – most cases of pharyngeal candida are more diffuse.

This made me consider the more obscure and serious pathologies such as a pharyngeal malignancy and a blood dyscrasia – the only other time I saw anything like this presentation, the elderly lady with the horrendous sore throat turned out to have leukaemia.

The hidden clue

I decided to stop pontificating and complete the examination. This revealed, almost immediately, an enlarged, very hard, non-tender and obviously pathological lymph node on the left side of his neck. This could, of course, have been the result of infection. But, with the gland being painless and hard, the prospect of benign disease was diminishing: a pharyngeal cancer was clearly, now, top of the list.

Getting on the right track

I referred the patient to the local ENT department under the two-week cancer rule. When I received the clinic letter, a few weeks later, I wasn't surprised to hear that malignancy had been confirmed. I was amazed to hear that the primary was tonsillar, though – apparently carcinoma can arise from a post-tonsillectomy remnant. My patient is now undergoing staging with a view to surgery and possible radiotherapy.

Dr Keith Hopcroft is a GP in Laindon, Essex

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