by Nancy W. Burkhart, RDH, EdD
Your patient today is a 55-year-old female. Rita has been diagnosed with squamous cell carcinoma of the tonsil. The dentist has been treating Rita recently for some restorative work prior to her radiation treatment and has suggested a scaling and prophylaxis before the treatment.
Rita has a history of alcohol use and smoking. She uses no prescription medications, but does use antacids on a regular basis for problems related to gastric reflux.
The tonsillar cancer was diagnosed when she was evaluated by an otolaryngologist. Rita had become alarmed when she noticed difficulty in swallowing and a small extraoral nodule inferior to the mandible on the left side.
She reports no family history of cancer and has considered herself in good health (see Figure 1).
Etiology: Although no one factor alone is thought to cause cancer of the tonsil, several possible promoting factors have been cited. Along with the usual risk factors of smoking, alcohol, environmental factors, and genetic predisposition for cancers in general, GER gastroesophageal reflux (GER) or gastroesophageal reflux disease (GERD) is associated with several tumors such as cancer of the esophagus, larynx, and pharynx. The stomach gastric acid involved in GER is a risk factor in both malignant and nonmalignant nodules. The acidic properties are also thought to be a co-promoter in the development of other neoplasms in the oral cavity and pharynx.
Controlled studies by Mercante et al. (2003) of 274 patients examined by esophago-gastro-duodenoscopy revealed a significant difference between two groups of individuals. A high percentage of nonsmoking, nondrinking patients were affected by GER and squamous cell carcinoma of the upper parts of the airways and the gastrointestinal system when compared to the control group of healthy patients. The authors concluded GER is a possible co-promoting factor of cancer in some patients.
Other studies by Ukpo et al. (2009) found that patients with human papilloma virus (HPV-positive) oropharyngeal squamous cell carcinomas had a higher prevalence of neck nodal metastases and high-grade lesions. Of 102 treated patients, 48 (47.1%) had HPV-positive carcinomas. The Epstein-Barr virus (EBV) has been implicated in tonsillar cancer as well.
Epidemiology: Cancer of the tonsil is often included in statistics of those related to the oropharyngeal regions in head and neck reports. Cancers often involve the base of the tongue, esophagus, and the laryngopharyngeal areas as well. Laryngeal and pharyngeal cancers often overlap by the time of diagnosis, and the statistics for these may be varied with the overlap of head and neck areas. Statistics vary with regard to the prevalence of oral cancer.
According to the American Cancer Society, deaths from oral cancer in general have declined since 1975 for males and since 1980 for females. In 2007, 34,360 new cases of all types of oral cancer were expected with 7,550 deaths. Oral cancer is the eighth leading cause of death in males and accounts for 3% of all cancer deaths. With that said, oral cancer is increasing in the under 40 age population, many of whom have no known risk factors, and increases are also noted in black males. SEER data from 1975 to 2005 shows an 82% five-year survival rate for patients with localized lesions, a 53% five-year survival rate for regional metastasis, and a 28% 5-year survival rate for patients with distant metastasis from oral lesions. According to data from SEER, an estimated 35,720 men and women (25,240 men and 10,480 women) will be diagnosed with and 7,600 men and women will die of cancer of the oral cavity and pharynx in 2009. Obviously, the earlier the lesion is diagnosed and treated, less surgery may be necessary, and the odds of a successful recovery will be higher.
Extraoral characteristics: Swollen lymph nodes inferior to the mandible may be noted when there is lymph node involvement. The nodes are usually firm and nodules; they may or may not be fixed. Patients may complain of difficulty in swallowing and continuous clearing of the throat.
Perioral and intraoral characteristics: The normal tonsil may be cryptic (having many folds and crevices) with widely varying textures that change from time to time. Often when the tonsils are highly cryptic, the presence of stones (food particles and bacteria) may be noted, and the tonsil may appear more bulbous with these white to yellow stones. The distorted appearance may mask other more serious issues.
Intraoral photographs may be taken and used for future comparison. Careful evaluation must be performed and intraoral documentation is a valuable diagnostic tool. Some patients may have large tonsils that appear very bulbous most of the time. Again, the clinician must evaluate whether this is normal for each particular patient. Examining the patient's tonsils and the oropharynx area at each visit aids in establishing normal patterns for each individual patient.
Differential diagnosis: Tonsil enlargement may present as asymmetry as well as bilateral enlargement. Asymmetrical enlargement of the tonsil should be viewed with high suspicion. Asymmetrical tonsil enlargement may cause sleep problems and airway obstruction just as bilateral enlargement depending upon the extent of the tissue.
A publication by Ramar (2008) reported findings of a 61-year-old obese male with a history of hypertension and alcohol abuse. The patient was evaluated because he complained of snoring, apnea, frequent sore throat, gasping, and choking episodes. During examination, a mass was discovered in the left tonsil with metastatic lymph nodes. Biopsy confirmed squamous cell carcinoma in the tonsil.
Disease states such as lymphoma may cause distortion and bulbous tonsils as well. Reported cases of peritonsillar abscess, pleomorphic adenomas affecting the tonsil, and internal carotid aneurysm have also been noted as swellings and considerations. Colds, flu, strep throat, and other disease states affect the tonsils and are routinely observed in dental offices.
Careful questioning of the patient is needed to determine the seriousness of the observed symptoms. The photographs presented in this article represent varied appearances, yet they all represent squamous cell carcinoma of the tonsil (see Figures 1, 2, and 3). Figure 2 has more of a white coated appearance, and Figure 3 has a more erythematous and ulcerated appearance.
Implications: Ramar (2008) cautions clinicians to be aware of the possibility of underlying malignancy or infection that may require further evaluation. Sleep disturbances have been implicated with a poor quality of health in general.
Yu (2008) presented results from a Canadian study that concluded clinicians may be less attentive in examining patients who have a low index of suspicion for cancer simply because they don't use alcohol and tobacco. He labeled several terms:
- “Patient delay” is the time from the first onset of symptoms to the initial visit to a dental or medical professional.
- “Professional delay” is the time during which the patient is under professional care until a final diagnosis is made.
- “Total delay” is the sum of the patient delay and professional delay together.
The study concludes that clinicians must be attentive to any suspicion of an abnormality regardless of the patient's personal risk factors such as tobacco and alcohol use. The longest patient delays, professional delays, and total delays occurred in nonsmokers. Clinicians may not be as attentive in examining such patients because they have a low suspicion for oral cancer. With the rise in the age group under 40 developing oral cancer who have no known risk factors, assumptions such as these are a very risky behavior on the part of the clinician. These delays in treatment greatly affect the outcome or probability of successful treatment (Gillespie et al. 2008).
Treatment and prognosis: Cancer of the tonsil is treated by performing a tonsillectomy, chemoradiation treatment (both radiation and chemotherapy together), and, depending upon the lymph node involvement, full chemotherapy in some cases. Regardless of the combination of treatment, extensive tissue is usually removed or damaged, including lymph nodes and muscle tissue. This greatly affects the quality of life for a patient. The early diagnosis of this type of cancer is very crucial. When radiation is performed, salivary gland destruction results in severe xerostomia, again affecting the quality of life.
In conclusion, keep asking good questions and listen to your patients' answers.
- American Cancer Society, http://www.cancer.org/docroot/home/index.asp
- El-Serag HB, Hepworth EJ, Lee P, Sonnenberg A. Gastroesophageal reflux disease is a risk factor for laryngeal and pharyngeal cancer. Am. J Gastroenterol 2001 96:7;213-18.
- Cohan DM, Popat S, Kaplan SE, Rigual N, Loree T, Hicks Jr, WL. Oropharyngeal cancer: current understanding and management. Current Opinion in Otolaryngology & Head and Neck Surgery. 2009, 17(2):88-94.
- Cooper MP, Smit CF, Stranojcic, LD, Devriese PP, Schouwenburg PF, Mathus-Vliegen LMH. High incidence of laryngopharyngeal reflux in patients with head and neck cancer. Laryngoscope 2000 110:1007-1011.
- Dahlstrom KR, Little JA, Zafereo ME, Lung M, Wei Q, Sturgis EM. Squamous cell carcinoma of the head and neck in never smoker-never drinkers: a descriptive epidemiologic study. Head & Neck-DOI. 1002/hed January 2008.
- Gillespie MB, Smith J, Gibbs K, McRackan T, Rubinchik S, Day TA, Sutkowski N. Human papillomavirus and head and neck cancer: a growing concern. JSC Med Assoc. 2008 Dec;104(8):247-51.
- Mercante G, Bacciu A, Ferri T, Bacciu S. Gastroesophageal reflux as a possible co-promoting factor in the development of the squamous cell carcinoma of the oral cavity, of the larynx and of the pharynx. Acta oto-rhino-laryngologica belg, 2003, 57: 113-17.
- Ramar K. Asymmetric tonsillar enlargement and obstructive sleep apnea. Sleep Medicine, 2008, 9:209-10.
- Ukpo OC, Pritchett CV, Lewis JE, Weaver AI, Smith DI, Moore EJ. Human papillomavirus-associated oropharyngeal squamous cell carcinomas: primary tumor burden and survival in surgical patients. Ann Otol Rhinol Laryngol. 2009 May;118(5):368-73.
- Yu T, Wood RE, Tenenbaum HC. Delays in diagnosis of head and neck cancers. JCDA.www.cda-adc.ca/jada74/issue-1/61.html.
- National Cancer Institute. Surveillance Epidemiology and End Results (SEER). Cancer Statistics Review, 1975 – 2005, Table XX-5a. Retrieved August 9, 2009 from: http://seer.cancer.gov/index.html
About the Author
Nancy W. Burkhart, BSDH, EdD, is an adjunct associate professor in the department of periodontics, Baylor College of Dentistry and The Texas A & M Health Science Center, Dallas. Dr. Burkhart is founder and co-host of the International Oral Lichen Planus Support Group http://www.bcd.tamhsc.edu/outreach/lichen/ and coauthor of General and Oral Pathology for the Dental Hygienist. Her web site for seminars is www.nancywburkhart.com/