A 64-year-old smoker and heavy drinker with no other history of interest. The picture he explains is odynodysphagia of 3 months of evolution and left otalgia. He provides a dentist's report that rules out a dental cause. He also refers to having been visited by different specialists and provides a head and neck CAT scan (without iodine contrast) which is reported as normal. On examination there was a decrease in the propulsive capacity of the tongue; palpation of the base of the left tongue showed an induration of stony consistency of approximately 3cm and with indirect laryngoscopy no ulceration of the mucosa was observed. Cervical palpation is negative for lymphadenopathy. What is your presumptive diagnosis and course of action?
We are presented with a patient with risk factors for oropharyngeal cancer, but in whom the examination and tests are normal. What is going on here? This question is reverse psychology: what did the questioner want me to know? This question was asked by an otolaryngologist. He already tells you that the dentist "didn't see anything", so he rules out 1. It is not an abscess of the base of the tongue either, because in three months it would have killed him: neither is 2. So we are left with ankyloglossia, tongue base cancer and non-specific inflammation. When there is doubt that it could be cancer, we should not fool around and order a new CT scan and biopsy. Tongue base cancers are very treacherous and it is one of the fears of any otolaryngologist when he suspects a neoplasm. It is not uncommon for them to arise without exophytic masses or ulcerations of the tongue mucosa and they are difficult to detect on CT when contrast is not used. The correct answer is 4 and I do not think it can be challenged.
Dental cause / reevaluation by the dentist.
Abscess of the base of the tongue / debridement.
Ankyloglossia / surgical release of the same.
Malignant process of oropharynx / repeat CT scan and biopsy.
Nonspecific inflammation / corticosteroid treatment.
the dentist "didn't see anything", so he rules out 1.
It is not an abscess of the base of the tongue either, because in three months it would have killed him: neither is 2.
When there is doubt that it could be cancer, we should not fool around and order a new CT scan and biopsy.