TEST YOUR KNOWLEDGE

Pdf version

A MAN WITH HOT POTATO VOICE AND NECK SWELLING

M Irfan, A Puvan Arul
Department of Otorhinolaryngology - Head & Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia. (Irfan Mohamad, Puvan Arul Arumugam)

Address for correspondence: Dr Irfan Mohamad, Department of Otorhinolaryngology - Head & Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kota Bharu, Kelantan. Tel: 09-7676 420, Fax: 06-7676 424, Email: irfan@kb.usm.my

CASE HISTORY

A 47-years-old Malay gentleman presented with painless left neck swelling for one month (Figure 1). One week prior to the symptom, he experienced change of voice (hot potato voice) associated with sore throat and odynophagia. There was no fever, dysphagia, loss of weight, or loss of appetite. There was no trismus or any past history of foreign body in throat. Ear and nasal symptoms were negative.

Figure 1		Figure 2

QUESTION

1. Describe the abnormalities in the oral cavity examination (Figure 2).
2. What additional symptoms you should be looking for?
3. What is the most likely diagnosis?

ANSWER:

1. An enlarged left tonsil occupying more than 50% of the oropharyngeal space, crossing midline leaving small residual airway.

2. Besides muffled voice (also known as hot potato voice) and cervical lymphadenopthy (which can be unilateral or bilateral, single or multiple), the patient may complain of foreign body sensation in the throat and dysphagia. Snoring would become prominent if the condition is complicated by obstructive sleep apnoea (OSA).^1,2 Oropharyngeal haemorrhage can also occur, which sometimes can be massive, and mimic the presentation of an advanced tonsillar squamous cell carcinoma.³

3. The most likely diagnosis for asymmetry tonsillar enlargement in the presence of cervical lymphadenopathy is lymphoma. The most common histological type is large β cell lymphoma.¹ Beaty et al. had defined six risk factors of tonsillar malignancy, they were: history of cancer, tonsillar asymmetry, tonsillar lesion, neck mass, weight loss and constitutional symptoms. Of these, tonsillar asymmetry was the commonest presentation or findings of tonsillar malignancy, which accounted for 84% of the patients.⁴ The diagnosis must be established by histological examination from punch biopsy specimen. In this patient, his punch biopsy confirmed the diagnosis of diffuse large β cell lymphoma. Computed tomography scan must be obtained to stage the disease. Referral to Haematology-Oncology Unit is done for definitive treatment of chemotherapy for lymphoma. During the course of treatment, airway must be evaluated. A prophylactic tracheostomy must be considered especially for the mass that already occupies a significant portion of the oropharyngeal space.

REFERENCES

1. Tsou YA, Cheng YK, Lin CD, et al. Small B cell lymphocytic lymphoma presenting as obstructive sleep apnea. World J Surg Oncol. 2004;2:26. [PubMed] [Full text]
2. Feldman BS, Quan SF. Tonsillar lymphoma as a cause of obstructive sleep apnea. Sleep Med. 2002;3(5):441-2. [PubMed]
3. Othrub KA, Mohamad I. Intraoral lymphoma mimicking tonsillar carcinoma. International Medical Journal. 2011;18(3):252-3.
4. Beaty MM, Funk GF, Karnell LH, et al. Risk factors for malignancy in adult tonsils. Head Neck. 1998;20(5):399-403. [PubMed]