Tonsillar swelling: always a simple diagnosis?

A 45-year-old man presented with marked, progressive bulging of the right tonsil (Figure, A) and slight swelling of the right submandibular region. Gadoliniumenhanced magnetic resonance imaging of the head and neck showed a large (5 4 3 cm) neoplasm, occupying the right parapharyngeal space, extending from the deep parotid lobe to the ipsilateral tonsillar region (Figure, B). The neoplasm was removed via an incision in the neck and identified, by histological examination, as a pleomorphic adenoma. In many cases, the first clinical sign of a deep-lobe parotid neoplasm is enlargement of the tonsillar region. Other differential diagnoses of tonsillar swelling include peritonsillar abscess, tonsillar neoplasm and internal carotid aneurysm.