A Lump in the Throat (UPDATED)
A middle-aged gentleman presented to the ED complaining of a "lump in his throat" for 4 days. It was slightly painful, and the "lump" made it somewhat difficult to swallow. When he would lie flat, he felt like he was choking. When he would clear his throat, he noticed some streaks of blood in his saliva. He had eaten some fish a couple of days prior to the onset, and he experienced some mild pharyngeal irritation at that time but he never looked in his throat. He was afebrile, in no distress, and his respirations were unlabored. His speech was slightly muffled, there was no stridor, and he was able to swallow his saliva.
His throat looked like this (click to enlarge):
A 2 cm purplish pedunculated structure emanated from the right tonsil. It was fairly mobile about its attachment point. A CT scan of the neck was obtained, and ENT consultation was requested.
In the midst of a very busy night with a lot of workups, I was hoping for a quickie. When you hear a story like that, 98 times out of 100 it will be some sort of pharyngitis, and the other two times it might be a fish bone. I'd never seen anything like this. I actually took a step back and said "What the heck is THAT??!!"
That probably isn't what a patient wants to hear, but I couldn't help myself. It was weird. It flopped toward me like some sort of alien. What was worse, I knew that I couldn't make a disposition because I had no clue what this thing was. Was it some sort of tonsillar tumor or granuloma? A hematoma? An AVM? Was it going to rupture and drown him in his own blood? A specialist was going to have to see it. At 3 am.
Someday we'll have little endoscopes that can transmit images over the internet to on-call docs at home to view in real-time. But in 2007, the ENT doc has to get out of bed and drive to the hospital. He wasn't sure what it was either, so I don't feel so bad. I'll post updates as the diagnosis develops.
UPDATE: Final pathology
Necrotic polypoid tissue, no evidence of carcinoma.
Most likely this was a benign polypoid lesion or tonsilar tissue which underwent torsion and resulting ischemia
His throat looked like this (click to enlarge):
A 2 cm purplish pedunculated structure emanated from the right tonsil. It was fairly mobile about its attachment point. A CT scan of the neck was obtained, and ENT consultation was requested.
In the midst of a very busy night with a lot of workups, I was hoping for a quickie. When you hear a story like that, 98 times out of 100 it will be some sort of pharyngitis, and the other two times it might be a fish bone. I'd never seen anything like this. I actually took a step back and said "What the heck is THAT??!!"
That probably isn't what a patient wants to hear, but I couldn't help myself. It was weird. It flopped toward me like some sort of alien. What was worse, I knew that I couldn't make a disposition because I had no clue what this thing was. Was it some sort of tonsillar tumor or granuloma? A hematoma? An AVM? Was it going to rupture and drown him in his own blood? A specialist was going to have to see it. At 3 am.
Someday we'll have little endoscopes that can transmit images over the internet to on-call docs at home to view in real-time. But in 2007, the ENT doc has to get out of bed and drive to the hospital. He wasn't sure what it was either, so I don't feel so bad. I'll post updates as the diagnosis develops.
UPDATE: Final pathology
Necrotic polypoid tissue, no evidence of carcinoma.
Most likely this was a benign polypoid lesion or tonsilar tissue which underwent torsion and resulting ischemia
posted by scalpel at 8:43 AM
8 Comments:
That ain't no fish bone! His palate/upper left gum area doesn't look too healthy, either. I'd say that said gentleman should make plans for a pretty big chunk of time off work .....
~RWS
Oh man, what is that? Poor guy.
Melanoma? Hemangioma?
Any adenopathy?
CardioNP
I wonder if INterventional radiology could embolize it? Looks vascular. Whatever you do, don't poke it!
GruntDoc
It doesn't look good, that's for sure...
thats disgusting, if I was the patient I think I'd be scream "cut it out cut it out!"
KS risk factors?
No adenopathy, no KS risk factors.
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