Wheeling Hospital Family Medicine Residency Program, Wheeling, WV 26003
Learning Objectives
- Identify chronic lymphocytic lymphoma as a rare but important cause of hoarseness/tonsillitis in adults.
- Review the diagnostic approach of hoarseness and chronic cough
A 59-year-old Caucasian man complained of worsening hoarseness and a dry, hacking cough, off and on, over the past 8-10 weeks. He had had no previous care for this problem. The patient denied shortness of breath, chest pain, fatigue, fever, weight loss, dysphagia, otalgia, nausea, and vomiting. His past medical history included only hypertension, for which he was on lisinopril. He denied alcohol, tobacco, or voice abuse.
Physical examination revealed moderately enlarged tonsils with exudates. He had poor dental hygiene. Examination of the respiratory system showed scattered wheezes.
We replaced the patient's lisinopril with losartan (Cozaar). A chest X-ray and an ENT consult were obtained. The X-ray report cited mediastinal/hilar abnormalities and recommended a follow-up CT scan. The CT scan of the chest revealed an 8 mm right lower lobe nodule with mediastinal and bilateral hilar lymphadenopathy. A PET scan to evaluate the nodule revealed a “fairly intense hypermetabolic focus in the left side of the neck along the lateral margin of the left tonsillar pillar.”
The ENT physician performed an examination including flexible laryngoscopy. This showed only enlarged tonsils, left more than right. He ordered a focused CT scan of the neck that showed “soft tissue prominence in the left side of the oropharynx involving the left tonsillar fossa. This contains a calcification and corresponds to the hypermetabolic activity seen on the recent nuclear medicine PET scan.”
Pathology of the removed specimens revealed involvement of the tonsils by a B-cell small lymphocytic lymphoma/chronic lymphocytic lymphoma. This neoplasm tends to be a slowly growing disease process wherein no immediate treatment is indicated. As directed by an oncologist, the patient is being followed at our clinic with serial CBC and differential counts, which have remained within normal limits for the three months since the diagnosis was made.