Is oropharyngeal cancer being misdiagnosed as acute tonsillitis?

DISCUSSION

Head and neck cancers are an uncommon group of malignancies. OPC accounts for 28% of all head and neck cancers in England and Wales, including cancers in the tonsils, the tongue base, and the posterior pharyngeal wall.¹ The annual rate of OPC in the UK in 2006 was 11 per 100 000.² This has increased from the 7 per 100 000 in 1989. The rise is believed to be due to a greater incidence of human papilloma virus (HPV)-related cases.³ The 5-year survival rate is 52%.³

Smoking and alcohol consumption are independent risk factors for OPC. They should be considered when assessing older patients presenting with chronic sore throat and swallowing issues, particularly with neck masses and when patients notice a lesion or mass in the back of the throat. A mass from OPC will be ulcerated rather than erythematous and overwhelmingly unilateral (Figures 1 and 2).

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Figure 1.

Oropharyngeal carcinoma of the left tonsil.

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Figure 2.

Acute tonsillitis.

The reason a diagnosis of tonsillitis was made in these 18 patients was because they presented with a sore throat with or without enlargement of the tonsils. However, the history of the symptoms of OPC contrast with those of acute tonsillitis (Table 2). Acute tonsillitis symptoms include fever, malaise, severe throat pain, and nausea. Clinical examination reveals bilaterally enlarged, erythematous tonsils covered with white exudate and tender cervical lymphadenopathy.⁴ Episodes have a duration of 5–14 days and are successfully treated with antibiotics to which Gram-positive cocci are sensitive, such as penicillin V. Acute tonsillitis principally affects children and young adults and is very rare in adults aged >45 years, whereas OPC affects older adults. Older patients presenting with peritonsillar abscesses may require further assessment to detect OPC.⁵–⁷

It is impossible to say if patients’ prognoses were affected by delayed diagnosis. However, earlier-stage OPC has a better prognosis than advanced stage and the non-resolving nature of the symptoms in these patients were suggestive of malignancy.³

The findings in this study are significant as the incidence of OPC is rising due to HPV-related OPC and patients could present to primary care more often with a range of symptoms.⁸,⁹ In this series, patients’ age and smoking history were reliable indicators of OPC when symptoms were taken into account. These should be considered by primary care practitioners, as should the age of the patient. Physical examination in primary care for oropharyngeal masses with non-tender cervical lymphadenopathy in this group is important too.

Based on the incidence of OPC, a GP will see a case every 5–7 years. Separating a common disease such as tonsillitis from a rare tumour such as OPC when the presenting symptom is the same is a challenge in primary care. The vast majority of patients with any sore throat symptom will not have OPC, and chronic sore throat is not the only symptom of head and neck cancer. Patients’ age, smoking history, and the duration of symptoms should be considered when judging the likelihood of OPC against tonsillitis.