Background and Clinical Significance: Cervical lymphadenopathy with an occult primary tumor represents a common yet diagnostically challenging clinical scenario in head and neck oncology. While endoscopic evaluation is typically relied upon for tumor localization, submucosal lesions may remain undetected. Case Presentation: We report a 41-year-old woman presenting with an isolated right level II neck mass without constitutional symptoms. Initial fiberscopic examination revealed no mucosal abnormalities; however, contrast-enhanced computed tomography demonstrated asymmetric enlargement of the right palatine tonsil with effacement of the adjacent parapharyngeal fat plane, alongside multiple enlarged cervical lymph nodes. Subsequent positron emission tomography supported focal metabolic activity in the tonsillar region. Histopathological examination confirmed a low-grade mucoepidermoid carcinoma arising from the minor salivary glands of the palatine tonsil. Immunohistochemistry showed strong p16 positivity (70%), while MAML2 rearrangement was not detected. Conclusions: This case highlights a critical pitfall where imaging-endoscopy discordance signals a submucosal malignancy. Furthermore, strong p16 expression should be interpreted in conjunction with tumor morphology and clinical context, as p16 positivity is not entirely specific for HPV-related squamous cell carcinoma. Through integration of the current case with a focused literature review, we propose a structured diagnostic framework emphasizing imaging prioritization and morphology-based interpretation to improve recognition of occult submucosal tonsillar malignancies.

A 2-year-old male presented to ophthalmology following a short admission for dacryoadenitis, with a background of 6 months of bilateral fluctuating upper lid swelling, obstructive airway disease, and enlarged tonsils. He had been treated for an allergy-related disease with little effect and, post-hospital discharge, continued in a similar fashion as prior. Given the poor response to escalating allergy medication, a biopsy was taken from the right lacrimal gland. This demonstrated an eosinophil-rich small vessel vasculitis with extravascular eosinophilic granulomas, consistent with a diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome. The patient was placed on a tapering course of steroids and started on long-term mycophenolate immunosuppression. To our knowledge, this patient is the youngest case of EGPA with orbital involvement. The case and its heterogeneous presentation add to the growing knowledge of this rare condition.

Background and Clinical Significance: Cancer-associated retinopathy (CAR) is a rare paraneoplastic autoimmune retinopathy caused by antibodies targeting tumor antigens with cross-reactivity to retinal proteins. Paraneoplastic cerebellar degeneration (PCD) results from autoimmune injury to cerebellar tissue triggered by onconeural antigens. We report a rare case of CAR occurring concurrently with seronegative PCD in a patient with poorly differentiated tonsillar squamous cell carcinoma, and we describe the long-term sequelae of CAR-related macular atrophy; Case Presentation: A 66-year-old male presented with progressive painless bilateral peripheral and night vision loss, truncal ataxia, dysmetria, and dysarthria. Optical coherence tomography demonstrated diffuse outer retinal loss, and multifocal electroretinography showed markedly reduced responses bilaterally. Evaluation revealed poorly differentiated squamous cell carcinoma of the right tonsil. CAR antibody testing was positive for recoverin, enolase, and carbonic anhydrase II antibodies. Brain MRI demonstrated cerebellar atrophy. After exclusion of other autoimmune etiologies, he was diagnosed with seronegative PCD. Treatment included robotic tonsillectomy with neck dissection, intravenous immunoglobulin, high-dose corticosteroids, and maintenance rituximab. At 6 months, visual acuity, color vision, and electro-retinography improved. Seven years later, he remains independent in activities of daily living despite the progression of retinal atrophy and cerebellar dysfunction; Conclusions: This case highlights the rare coexistence of CAR and seronegative PCD associated with tonsillar squamous cell carcinoma. Multimodal oncologic and immunosuppressive therapy produced meaningful neurologic and visual improvement, despite progressive long-term retinal degeneration.

IntroductionAlthough adult tonsillectomy is common, it has a relatively high risk of perioperative airway adverse events. To identify and validate preoperative predictors of major airway adverse events in tonsillectomy and evaluate a predictive model.MethodsThis single-center retrospective study included 218 adults undergoing tonsillectomy (Jan 2023 to Sep 2025). Patients were grouped by the occurrence of a composite airway event, which included difficult intubation, severe hypoxemia, postoperative airway intervention, or unplanned ICU admission.Univariate and multivariate logistic regression identified independent predictors. A nomogram-based model was developed. Data were split into training and validation sets. Performance was assessed using ROC curves, calibration plots, bootstrap resampling, and decision curve analysis (DCA).ResultsMultivariate analysis identified body weight (OR=1.11), modified Mallampati classification (OR=2.55), and tonsil size grade (OR=3.74) as independent predictors. The model showed excellent discrimination with AUCs of 0.904 (training) and 0.924 (validation). At a cutoff of 0.244, the model showed 83.8% sensitivity and 84.8% specificity in the training set, and 88.9% sensitivity and 91.7% specificity in the validation set, with negative predictive values of 94.1% and 98.2%, respectively. High-risk patients had a 7.09-fold increased risk (95% CI: 2.35-27.04, P<0.001). The model was well-calibrated, and DCA indicated a net clinical benefit for threshold probabilities between 0.05 and 0.50.ConclusionsAA model incorporating body weight, modified Mallampati classification, and tonsil size demonstrated good discriminative performance and may serve as a useful preoperative screening tool for perioperative airway risk stratification in adults undergoing tonsillectomy. Its high negative predictive value may be particularly useful for identifying patients at relatively low risk, while high-risk predictions should be interpreted in conjunction with clinical assessment.

Tonsillectomy is a common procedure associated with significant postoperative morbidity. Intracapsular tonsil surgery (ICTS), which preserves the tonsillar capsule, may reduce complications compared to traditional extracapsular tonsil surgery (ECTS). This systematic review and meta-analysis evaluates comparative outcomes of ICTS and ECTS, focusing on adult and mixed-age populations. We conducted a systematic review following PRISMA guidelines, searching multiple databases for randomized controlled trials (RCTs) comparing ICTS and ECTS in adult and mixed-age populations (mean age ≥18 years). Primary outcomes were postoperative pain and hemorrhage; secondary outcomes included analgesia use and recovery. Data were pooled using meta-analysis where appropriate. Four RCTs (n=231) were included. ICTS was associated with significantly lower postoperative pain scores and reduced analgesia requirements. The pooled risk of postoperative hemorrhage was significantly lower with ICTS (Risk Ratio 0.34, 95% CI 0.15-0.78, p=0.01). Recovery to normal diet and activity was faster following ICTS. The primary trade-off was a higher incidence of tonsillar remnants, though long-term symptom control remained effective. ICTS may reduce postoperative pain, analgesic use, and hemorrhage risk compared with ECTS, though evidence is limited by small sample sizes, mixed-age populations, and heterogeneous techniques, warranting further adult-specific RCTs.

Infectious mononucleosis is clinically difficult to distinguish from bacterial causes of tonsillitis/pharyngitis. First-line investigations include monospot testing, despite 63% sensitivity in certain cohorts. Therefore, national recommendations include repeating an initial negative monospot within five to seven days. A point-of-care clinical scoring tool could improve clinical outcomes, increase diagnostic accuracy and reduce unnecessary testing. We conducted a retrospective cohort study at Luton and Dunstable University Hospital including patients aged 15-24 presenting with sore throat, lymphadenopathy or fever between 01/01/2021 and 31/01/2024 who underwent monospot testing. Extracted data included demographics, observations, and laboratory results. Patients were randomly split into training (80%) and testing (20%) cohorts. Eleven parameters were used to develop four predictive models; classical multivariate logistic regression, machine-learning logistic regression with LIBLINEAR approximation, machine-learning decision tree classifier, and a simplified clinical risk-stratification model from machine-learning methods. Total of 278 presentations from 264 patients were included. The machine-learning decision tree classifier demonstrated superior performance, achieving 100% sensitivity, 98.0% specificity, and 98.2% diagnostic accuracy using only three parameters: lymphocyte count, neutrophil count, and alanine aminotransferase. The simplified clinical risk-stratification model demonstrated 83.3% sensitivity, 98.0% specificity, and overall 96.4% accuracy. All four models represent potential methods for developing clinical tools to predict monospot positivity. Our risk-stratification model showed significant promise as an easily memorisable, point-of-care clinical scoring tool. Using this, we propose an alternative diagnostic pathway with early counselling and de-escalation of antibiotics in high-risk cases, and reduced testing in low-risk cases; reducing population-level morbidity and epidemiological spread, whilst improving diagnostic accuracy and conserving resources.

We describe two patients with Tangier disease (TD) and provide a narrative review of its clinical features, genetics, diagnosis, and management. A literature search of PubMed and Google Scholar was performed to identify English-language publications on TD, and relevant articles were reviewed narratively.

During antibody responses, germinal centers (GCs) act as a key site for somatic hypermutation (SHM) and affinity maturation of B cells. However, their lymphoid tissue localization has made experimental manipulation of human germinal center B (GCB) cells difficult. Here, we describe a simple in vitro method, modeling T cell-derived signaling, that converts human naive B cells into BCL6[+] induced GCB-like (iGCB) cells. Through side-by-side proteomic and transcriptional single-cell analysis of iGCB and human tonsil GCB cells, we show that iGCB cells recapitulate the surface marker, transcription factor, DNA repair, and glycosylation signatures that define human GCB cells and display ongoing activation-induced cytidine deaminase (AID)-dependent SHM. iGCB cells can be generated from naive B cells and from unswitched memory/circulating marginal zone cells but not class-switched memory B cells. Using this system, we define signals critical for human GCB formation and identify interventions that block their induction, providing a simple and manipulable model of human GCB cell biology.