What are the clinical manifestations of tonsil cancer?

Clinical Appearance of Tonsil Cancer

Tonsil cancer typically presents as a visible mass, ulceration, or mucosal abnormality of the tonsil, often with induration on palpation and frequently accompanied by unilateral tonsillar enlargement. 1

Visual and Palpable Characteristics

Primary Tonsillar Lesion Features

• Ulceration or mucosal abnormality of the enlarged tonsil is highly suspicious for malignancy and represents the most critical visual finding 1
• Visible mass protruding from the tonsillar fossa, which may appear irregular or exophytic 1
• Induration on palpation suggests neoplastic infiltration into deeper tissues 1
• Unilateral tonsillar enlargement is the most common presentation, though asymmetry alone without other concerning features has low malignancy risk (approximately 5% in asymptomatic patients) 2, 3

Surface Characteristics

• The tonsillar surface may show red or white patches (erythroplakia or leukoplakia) indicating dysplasia or carcinoma 4
• Non-healing ulcers that persist despite conservative management are concerning for malignancy 4
• The normal cryptic architecture of the tonsil may be replaced by irregular, friable tissue 4

Associated Regional Findings

Cervical Lymphadenopathy

• Firm, fixed, nontender cervical lymph nodes >1.5 cm strongly suggest metastatic disease 1
• Tonsillar cancers commonly metastasize to levels II-IV cervical lymph nodes 4
• Bilateral cervical metastases can occur with tonsillar primaries due to midline lymphatic drainage 4
• Ulceration overlying a neck mass may indicate metastatic cancer breaking through the lymph node capsule 1

Tongue Base and Oropharyngeal Extension

• Decreased tongue mobility indicates muscle or nerve invasion from tumor extension 1
• Manual palpation of the tongue base and tonsil fossae may reveal induration or mass effect not visible on inspection 4
• Extension to the soft palate, anterior pillars, or pharyngeal wall may be visible on examination 4

High-Risk Patient Demographics

The appearance of tonsil cancer must be interpreted in clinical context:

• Age >40 years is the single most important demographic risk factor for malignancy in tonsillar enlargement 1
• Tobacco and alcohol use are synergistic risk factors that increase suspicion for squamous cell carcinoma 1
• HPV-positive oropharyngeal cancers (approximately 30-35% of cases) may present with smaller primary tumors but larger cystic neck nodes 4

Critical Diagnostic Pitfall

The American Academy of Otolaryngology-Head and Neck Surgery warns against prescribing multiple courses of antibiotics without definitive diagnosis, as this delays cancer diagnosis and worsens outcomes. 1 Only a single course of broad-spectrum antibiotics with mandatory reassessment within 2 weeks should be considered if infection is suspected 1. Any persistent abnormality requires tissue diagnosis through biopsy 4.

Examination Requirements

Complete evaluation must include:

• Flexible fiberoptic endoscopy to visualize the nasopharynx, base of tongue, hypopharynx, and larynx, as these are common sites for occult primary tumors 4
• Bimanual palpation of the tonsils and floor of mouth to assess for deep infiltration 4
• Manual palpation of the tongue base and tonsil fossae to detect submucosal masses 4
• Contrast-enhanced CT or MRI is mandatory to assess tumor extent and regional lymph nodes, though imaging does not substitute for physical examination 4