Ashdin Publishing Journal of Case Reports in Medicine Vol. 5 (2016), Article ID 235978, 3 pages doi:10.4303/jcrm/235978 ASHDIN publishing Case Report A Suspected Palatine Tonsil Tumor Hides an Unrecognized Vagal Schwannoma in a 75-Year-Old Patient: A Case Report Arianna Di Stadio Department of Otolaryngology, “La Sapienza” University of Rome, Rome, Italy Address correspondence to Arianna Di Stadio, ariannadistadio@hotmail.com Received 8 March 2016; Accepted 15 March 2016 Copyright © 2016 Arianna Di Stadio. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background. We discuss a particular case of apparent pala- tine tonsil cancer that was then shown to be vagal schwannoma. Only a few cases of palatine schwannoma have been discussed in the inter- national literature. This case is the first in which a vagal schwannoma manifested itself as a palatine tonsil cancer. Case report. A 75-year-old man reported persistent dysphonia associated with dyspnea in a hori- zontal position with lateral left decubitus that had started four months prior in the absence of any apparent causes. After conducting clinical examinations and a biopsy, we initiated MRI and CT investigations prior to surgery. We identified the correct diagnosis of vagal schwan- noma. After surgery, the patient was resolved completely of his symp- tomatology, and he retained his nerve function. Conclusion. In some cases, the history and the age of patients can render diagnoses incor- rect. We emphasize that rare diseases can mimic other pathologies. Keywords oral cancer; dysphonia; schwannoma; palatine tonsil 1. Introduction Tonsil cancer, a cancer that occurs in one of three types, represents 2% of all cancer cases [1]. It most commonly occurs in the palatine tonsils, and it is more common in males approximately 55–60 years old [2]. The most com- mon malignant tumor of the palatine tonsils is lymphoma, followed by squamous cell carcinoma (SCC) [1, 2]. The inci- dence of palatine tonsil cancer has grown in the last 20 years in the United States and England [3]. Smoking with a per- centage of 93% is the most common risk factor for SSCs of the tonsils [3]. Alcohol is also a risk factor; the combination of smoking and alcohol use presents an even greater risk of developing palatine tonsil cancer than using either substance alone [3]. The clinical symptoms and signs of tonsil cancer include pain (especially in the ears), difficulties in swallow- ing, tonsil asymmetry, palpable firmness or visible lesions in the tonsils, neck mass, and unexplained weight loss. In the early stages of the disease, there are no symptoms. Schwan- nomas, as opposed to SSC, are benign, slow-growing neo- plasms that can arise from any peripheral spinal or cranial nerve that includes Schwann cells. Schwannomas are less common than neurofibromas and make up approximately 5% of all benign soft-tissue tumors [4, 5]. Schwannomas are typically asymptomatic and become symptomatic when the mass involves adjacent structures that may cause the pres- ence of pain or paresthesia [6]. Symptoms are nonspecific and are related to the structure involved in the growth of the tumor. We can accordingly define schwannoma symptoms as indirect. Approximately 25% of extracranial schwanno- mas are located in the head and neck [5]. We present here a case of a suspected palatine tonsil tumor hiding a parapha- ryngeal schwannoma. 2. Case report A 75-year-old man came to our attention for persistent dys- phonia associated with dyspnea in a horizontal position with lateral left decubitus that had started four months prior in the absence of any apparent causes. The patient did not present dysphagia or coughing. He was a former smoker who had smoked more than 20 cigarettes for day for 30 years. He occasionally drank alcohol, but not more than one glass of it at a time. He had no history or Herpes Zoster virus infection or Varicella Zoster virus. Upon otolaryngological examination, an ulcerative lesion 1.5–2 cm was found that covered the patient’s right tonsil in its oral portion (Figure 1); this lesion was limited to the tonsil without involving the surrounding structure. No cough was present during neck palpation, and we found a bilateral lymphadenopathy unfixed on the surrounding planes of the neck; it was not painful upon palpation, and the lymph node was larger than 3 cm in the right neck and less than 3cm in size in the left one. We suspected a T2N2Mx tonsil cancer, and we performed a tonsil biopsy under local anesthesia without touching the lymph node. A histopathological examination revealed only diffuse inflammation with the rich presence of neutrophils and lymphocytes in the active phase. We treated the patient with systemic antibiotic therapy for 15 days. However, when he came back for a followup with the same symptoms, we decided to conduct an additional investigation. We