Painless neck lump in a non-smoker with a small tonsillar primary
51-year-old male
§Chief complaint
Lump in the neck for 3 months that does not hurt
§Medical & dental history
- 01Never smoked, minimal alcohol
- 02No comorbidities
- 03Regular dental attender, good oral health
§Clinical examination
- 01Firm, mobile 4 cm cystic-feeling right level II neck node
- 02Asymmetric right tonsil with a subtle exophytic area
- 03Mild referred otalgia; no trismus
- 04No oral cavity lesion identified
§ figuresFigures (2)
Fig. 1Oropharyngeal cancer (from right tonsil, HPV-negative), T4a N2c, 48 year old man.
“OropharyngealCancer, 2017, 6,11-25” · Jmarchn · CC BY-SA 3.0 · Wikimedia Commons
Fig. 2Oropharyngeal cancer (from right tonsil, HPV-negative), T4a N2c, 48 year old man.
“OropharyngealCancer, 2017, 4,11-30” · Jmarchn · CC BY-SA 3.0 · Wikimedia Commons
Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · HPV-associated Oropharyngeal SCC figures pending faculty review.
§Differential diagnosis
§Final diagnosis
p16-positive HPV-associated squamous cell carcinoma of the right tonsil, cT1 N1 M0 (AJCC 8 HPV-positive staging)
A cystic neck node in an adult over 40 is metastatic carcinoma until proven otherwise — never treat it as a branchial cyst. The small, subtle tonsillar primary with a large nodal mass is characteristic of HPV-driven disease.
§Investigations
- 01Ultrasound-guided core biopsy of the node — SCC, p16 positive
- 02Examination under anaesthesia with tonsillectomy for the primary
- 03MRI neck and CT thorax; PET-CT staging
- 04HPV DNA/RNA confirmation
§Treatment plan
- 01Multidisciplinary management
- 02Transoral robotic surgery with neck dissection, or definitive chemoradiotherapy
- 03De-escalation protocols only within trials
- 04Dental assessment and prevention before radiotherapy
§Surgical procedure
- 01Transoral tonsillectomy with clear margins
- 02Selective neck dissection levels II-IV
§Histopathology report
Non-keratinising squamous cell carcinoma with basaloid morphology, strong diffuse p16 positivity, HPV-16 confirmed. One node positive without extranodal extension.
§Follow-up & outcome
- 01Adjuvant radiotherapy given for nodal disease
- 02Comprehensive dental prevention with fluoride trays and 3-monthly recall
- 03Disease-free at 30 months; excellent functional outcome
§Clinical pearls / learning points
- 01p16 positivity substantially improves prognosis and changes staging, but not the need for full treatment.
- 02Any cystic neck mass in an adult over 40 needs cancer workup, not excision as a branchial cyst.
- 03Pre-radiotherapy dental assessment prevents osteoradionecrosis later.
§References
- AJCC Cancer Staging Manual, 8th ed.
- WHO Classification of Head and Neck Tumours, 5th ed. (2022).
§Similar cases
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