Tonsillar Asymmetry 1

Take a history from this 60 year old car salesman with left tonsillar enlargement for 5 months. He smokes and drinks alcohol heavily.

Example answer


History

  • Unilateral or bilateral

  • Onset

  • Duration

  • Rate of growth

  • Abnormal appearance – ulceration, shape

  • Associated symptoms – sore throat, lymphadenopathy, reflux, halitosis, rash

  • Red flag symptoms – odynophagia, referred otalgia, dyspnoea, dysphonia, dysphagia, haemoptysis, haematemesis

  • Constitutional symptoms – weight loss, malaise, anorexia, night sweats

  • Past Medical History – frequent URTI/tonsillitis, previous cancer, previous ENT surgery, immuno-compromise, previous quinsy

  • Drug History – immunosuppressants

  • Social History – smoking, alcohol, occupation

  • Family History – Family history of cancer

  • Systems review

  • Elicit the patient’s ideas, concerns and expectations 


Conclusion

  • Summarise consultation

  • Thank patient

  • Offer appropriate differential diagnosis

Differential diagnoses to consider*

Malignancy

  • Lymphoma

  • Squamous cell carcinoma

Benign

  • Benign tonsillar hypertrophy

Infection

  • Tonsillitis

  • Glandular fever

  • Quinsy

  • Syphilis 

  • Gonorrhoea

  • Hand foot and mouth disease

Other

  • Tonsilloliths

  • Post-nasal drip

  • Burns from hot food or drink

*Table not exhaustive


Management


You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination including nasendoscopy prior to further investigations. 

Some examples are below:-

Suspected diagnosis

The following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given

Tumour

  • Low clinical suspicion – MRI neck, PET/CT (depending on local guidelines)

  • High clinical suspicion – the above + Tonsillectomy for histology (dependent on local practice)

Reflux

Trial of PPI + gaviscon and review

Tonsilloliths

Advise on good oral hygiene

Recurrent quinsy

Tonsillectomy for histology

If lymphadenopathy observed

Ultrasound +/- FNA

You may also mention that you would ask for a senior opinion and inform the patient of the outcome if you are unsure

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