Head and neck squamous cell carcinoma (HNSCC)

A middle aged woman with chronic sore throat, worse with swallowing especially solids, and bad breath comes to the clinic. On exam, there is an enlarged firm right tonsil with a 2 cm ulceration. Also, 2 enlarged firm, fixed, nontender lymph nodes in the right side of her neck. 

What is the most likely diagnosis, the most likely underlying etiology, and the next step in management? She most likely has head & neck squamous cell carcinoma due to HPV and the next steps involve getting a biopsy, HPV status, CT scan and endoscpy.

An elderly patient with long history of heavy smoking has chronic sore throat that doesn’t get better with antibiotics. Now has problems swallowing with solid food getting “stuck”.

  • Most likely diagnosis? Head & neck squamous cell carcinoma
  • Most likely underlying etiology? smoking

  •  Etiology
    • Risk factors
      • older age, tobacco, alcohol exposure, poor dentition
      • younger age with HPV and multiple sexual partners
        • with the decrease in smoking rates, there has been a decline in many types of HNSCC; however, the incidence of oropharyngeal (eg, tonsil, base of tongue) HNSCC has dramatically increased. This increase is due to human papillomavirus (HPV) positive HNSCC, often seen in younger patients with no tobacco exposure and multiple sex partners.
  • Mechanism
    • HPV-positive HNSCC primarily affects the oropharynx (possibly due to the higher concentration of lymphatic tissue facilitating viral processing) and often presents with neck lymphadenopathy. However, it is more responsive to therapy than HPV-negative HNSCC. The most common causative subtype is HPV-16, which is covered by the HPV vaccine.
  • Presentation
    • persistent, enlarged, firm neck mass and ulcerated tonsillar lesion
    • pharyngitis, dysphagia, and halitosis (bad breath)
  • Diagnosis
    • Biopsy of lesions with evaluation of HPV status, neck imaging (eg, CT scan) to characterize the lesion and associated nodal metastasis and endoscopic evaluation of the upper aerodigestive tract.