December 13, 2024

76-year-old woman with pain and difficulty swallowing

By Med-Challenger · 1 minute read

A 76-year-old woman who appears well presents to you with complaints of low-grade fever, runny nose, and cough that have lasted for 1 day. These symptoms were preceded by pain on swallowing (odynophagia) and difficulty swallowing (dysphagia) for the last 3 weeks.

Figures 1 and 2 show her pharynx.

image (31)

Figure 1.

Figure 2.

The swelling in the soft palate is firm and nontender. Her lungs are clear.

What would be your next step in the process of evaluation and treatment?

Admit her to the hospital for intravenous antibiotics.
Inquire about her immunization status and ask about her exposure to farm animals.
Order computed tomography (CT).
Consult an otolaryngologist for possible incision and drainage in the operating room.

The correct answer is:

Order computed tomography (CT).

Educational Objective:

Discuss the differential diagnosis for pharyngeal swelling.

Key Point:

A nontender mass in the pharyngeal area should raise suspicion of a tumor.

Explanation:

A well-appearing patient who presents with a substantially firm, nontender mass points toward a tumor rather than an infectious process. Thus, CT should be ordered. If the mass can be directly inspected, then induration and ulceration will often be noted, which, in the context of a minor illness, such as this patient's upper respiratory infection, can mislead the clinician into treating the tumor as an infectious problem. If the pharyngeal swelling were due to a pharyngeal or tonsillar abscess, then the patient would have appeared to be more ill.

Indeed, CT in this patient revealed a large parotid tumor that had eroded into the soft-palate area. Excision revealed benign pleomorphic adenoma.

References:

Pfaff JA. Otolaryngology (chapter 62). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:820-831.

Stadler ME. Molecular biology of head and neck cancer: risks and pathways. Hematol Oncol Clin North Am. 2008;22(6):1099-1124.

This question appears in Med-Challenger Internal Medicine Exam Review with CME

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