John Rothchild HPV is the leading cause of oropharyngeal squamous cell carcinoma. The CDC states that HPV is the most common sexually transmitted infection in the United States. Of the more than 100 types of HPV, about 40 types can spread through direct sexual contact to genital areas, as well as the mouth and throat. Oral HPV can be transmitted to the mouth by oral sex or in other ways.
Many people are exposed to oral HPV in their life. About 10% of men and 3.6% of women have oral HPV, and oral HPV infection is more common with older age. The age of diagnosis of HPV squamous cell carcinoma starts in males and females at about 30 years old and peaks between 60-69 and then starts decreasing after that. Most people clear HPV within 1 to 2 years, but HPV infection persists in some people.
HPV can infect the mouth and throat. It usually takes years after being infected with HPV for cancers to develop in the oropharynx. This includes the back of the throat, including the base of the tongue and tonsils. HPV oropharyngeal cancer is thought to cause 60% to 70% of oropharyngeal cancers in the United States. HPV is not known to cause other head and neck cancers including those of the larynx, lip, nose or salivary glands. HPV related oropharyngeal cancer is the eighth most common cancer in men.
There is a difference between HPV positive oropharyngeal cancer and HPV negative cancer. HPV negative cancer is usually caused by tobacco and alcohol factors. HPV positive oropharyngeal cancers tend to be more responsive to treatment.
Symptoms include a long-lasting sore throat, earaches, hoarseness, swollen lymph nodes, pain on swallowing and unexplained weight loss. Some patients have no symptoms.
The overall 5-year survival rate in patients with oropharyngeal cancer is about 52%. However, prognosis for HPV positive survival rate is >80% whereas HPV negative patients have a survival rate of <50%. With more than 13,000 new diagnoses of throat cancer each year in the US, the disease has surpassed cervical cancer as the most common cancer with HPV.
A 46-year-old male patient of mine presented to the clinic with chronic sore throat. He had been having issues with it for about 2 years and had been seen by an ENT physician. He had fallen and down some stairs recently and a lump was noted by a massage therapist. He was examined and was dismissed as having a hematoma due to the trauma. He had been a patient of mine for many years coming regularly for routine dental restorative issues and hygiene appointments. He presented to the clinic with left posterior base of the tongue swelling, left tonsillar swelling, chronic throat pain, submandibular swelling and weight loss. He hadn’t felt well for a while. He had recently been to his primary care physician who also dismissed it as viral. The PCP tested for strep throat twice but both times results were negative. Palpation of the left neck region revealed a swollen submandibular lymph gland about the size of a quarter with mobility. Intraoral examination revealed a left sided red and swollen tonsillar pillar area and unusual swelling at the base of the tongue. It was difficult to visualize due to the swelling and his gag reflex. Low level laser therapy was applied to the area using a Lightwalker Twin Light erbium/yag and ND/yag Laser utilizing both mediums on a twice weekly basis.
He returned two weeks later with continued discomfort. The patient noticed more swelling in the cervical lymph node area. We continued Nd/yag low level laser therapy twice weekly for about 3 weeks as the patient stated that things were getting better but was still feeling some pain on his neck and jaw. A recent CBCT revealed asymmetry of the left side of the lower oropharynx near the epiglottis.
He was immediately referred to the ENT office for further evaluation. I sent the ENT office a snap shot of a recent CBCT and an intraoral photo. The physician’s assistant saw the patient and dismissed my snapshot of the CBCT and photo but took a biopsy of the left tonsillar fossa.
The biopsy came back positive stage IV HVP squamous cell carcinoma. Due to the extent of the carcinoma, surgical intervention was ruled out and a combination of chemotherapy and radiation was instituted to try to shrink the carcinoma.
Image 1 - Intraoral photo of the lesion at the base of the tongue
Image 2 and 3 - Cross sectional and axial view from CBCT 8 years ago
Image 4 and 5 - Cross sectional and axial view from 1 year ago showing pathology
Image 6 and 7- Cross Sectional and axial view several months after chemo and radiation therapy
The patient seems to be doing well after treatment. A biopsy was recently performed which nicked the carotid artery and required ligation of the artery to stop the bleeding. The biopsy was clear of any carcinoma.
In retrospect, continued sore throat and swelling should have been a red flag followed up by his PCP. However, I am glad we were able to discover this lesion and refer quickly to save this gentleman's eating and swallowing functions and his life.
John Rothchild, DDS.
