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Sinha P, Kallogjeri D, Gay H, Thorstad WL, Lewis JS Jr, Chernock R, et al. High metastatic node number, not extracapsular spread or N-classification is a node-related prognosticator in transorally-resected, neck-dissected p16-positive oropharynx cancer. . 2015 Mar 11. .

Bishop JA, Lewis JS Jr, Rocco JW, Faquin WC. HPV-related squamous cell carcinoma of the head and neck: An update on testing in routine pathology practice. . 2015 Feb 4. .

Luginbuhl A, Sanders M, Spiro JD. Prevalence, morphology, and prognosis of human papillomavirus in tonsillar cancer. . 2009 Oct. 118(10):742-9. .

Nasman A, Attner P, Hammarstedt L, Du J, Eriksson M, Giraud G. Incidence of human papillomavirus (HPV) positive tonsillar carcinoma in Stockholm, Sweden: an epidemic of viral-induced carcinoma?. . 2009 Jul 15. 125(2):362-6. .

Harley EH. Asymmetric tonsil size in children. . 2002 Jul. 128(7):767-9. .

Syms MJ, Birkmire-Peters DP, Holtel MR. Incidence of carcinoma in incidental tonsil asymmetry. . 2000 Nov. 110(11):1807-10. .

Puttasiddaiah P, Kumar M, Gopalan P, Browning ST. Tonsillectomy and biopsy for asymptomatic asymmetric tonsillar enlargement: are we right?. . 2007 Jun. 36(3):161-3. .

Sunkaraneni VS, Jones SE, Prasai A, Fish BM. Is unilateral tonsillar enlargement alone an indication for tonsillectomy?. . 2006 Jul. 120(7):E21. .

McQuone SJ, Eisele DW, Lee DJ, Westra WH, Koch WM. Occult tonsillar carcinoma in the unknown primary. . 1998 Nov. 108(11 Pt 1):1605-10. .

Koch WM, Bhatti N, Williams MF, Eisele DW. Oncologic rationale for bilateral tonsillectomy in head and neck squamous cell carcinoma of unknown primary source. . 2001 Mar. 124(3):331-3. .

Goldenberg D, Sciubba J, Koch WM. Cystic metastasis from head and neck squamous cell cancer: a distinct disease variant?. . 2006 Jul. 28(7):633-8. .

Randall DA, Johnstone PA, Foss RD, Martin PJ. Tonsillectomy in diagnosis of the unknown primary tumor of the head and neck. . 2000 Jan. 122(1):52-5. .

Ash-Bernal R, Wise R, Wright SM. Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals. . 2004 Sep. 83(5):265-73. .

Villarroya Gonzalez A, Longas Valien J, Vicente Armijo JJ, Cuartero Lobera J. [Orotracheal tube ignited by an electrocautery device during tracheostomy]. . 2009 Jan. 56(1):47-9. .

El-Mofty SK. Human papillomavirus-related head and neck squamous cell carcinoma variants. . 2015 Jan. 32(1):23-31. .

Media Gallery
Sweetheart retractor.
Endoscopic biopsy forceps.
Anatomy of the pharynx.
Retropharyngeal carotid artery, right.
Patient is placed in Crowe Davis suspension prior to biopsy to ensure appropriate exposure. Image courtesy of Brian Reilly, MD.
The tumor is noted to arise from the right tonsil and extend beyond the tonsillar pillars to the posterior oropharynx. Image courtesy of Brian Reilly, MD.
Close up of the same submucosal tumor arising from the oropharynx. Image courtesy of Brian Reilly, MD.
Injection with 1% lidocaine with 1:100,000 epinephrine prior to biopsy. Image courtesy of Brian Reilly, MD.
Defect from the biopsy with cupped forceps. Pathology was consistent with poorly differentiated squamous cell carcinoma. Image courtesy of Brian Reilly, MD.
Oropharyngeal biopsy video. Video courtesy of Brian Reilly, MD.
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Contributor Information and Disclosures

Johnathan D McGinn, MD, FACS Associate Professor, Residency Program Director, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine Johnathan D McGinn, MD, FACS is a member of the following medical societies: DRESSES Kneelength dresses Maria Coca rYtsuQyuMR
, American College of Surgeons , American Rhinologic Society , TROUSERS Casual trousers PiccionePiccione QU3gTl1y6V
, Society of University Otolaryngologists-Head and Neck Surgeons Disclosure: Nothing to disclose.

Thanks for your article. 51 y.o. husband just had B12 done and it was at the low end of normal. Now he is going for more testing. We are not vegan . He is not anemic. We follow a good diet with meats, fish, poultry, fruits veggies, eggs, low on grains and sugar. Not much in the way of processed food. Doesn’t drink or smoke. Would not have found this if a work health screen would not have indicated a high bilirubin level. Thankfully we have a doc who listened when I asked to check B12. Finally feel like we might be getting somewhere with the fatigue and other issues.


Can you have normal RBC count but still be B12 deficient even though serum tests say otherwise?


I just recently got out of the hospital after what one doc called a TIA and another said could possibly be a migraine. I fell, couldn’t talk, swallow, my tongue felt incredibly thick– I had numbness and tingling in my right arm, dizziness and queasiness. MRI and CT were okay. Homocysteine levels were high.

I got a second opinion from another neurologist and it turned out that my B12 level was something like 190 (may have been 160… can’t remember). Since my “episode” I have felt terrible. My body aches, my arm still tingles from time to time, I’m exhausted, and I feel as if I am living in a fog. I want to get back to my normal, busy life.

My 2nd opinion doc prescribed oral B12 pills, but they have been making my stomach cramp and I’ve felt sick while taking them. This morning, he switched it over to injections. Although I am scared at the thought of taking shots, I am ready to do whatever I can to get everything back on track!

What made my levels drop so suddenly? I have a small spot on my stomach that both previous docs said was most likely melanoma. I am seeing a surgeon tomorrow about that. Can melanoma make B12 drop? How soon will the injections start to make a difference in how I feel?

Thanks for reading, and I’d appreciate any advice. This is a whole new ballgame for me!


Hi Lucy,

If the form of b12 was EFFECTIVE for you, methylb12 and adenosylb12 are the most effective for the most people. If it was effective it almost immediately induces any of several other deficiencies. The two almost 100% that get set off are potassium decrease which can make you horridly sick and which can be quickly relieved with 500mg of potassium or so. The other most common will be an induced folate deficiency relieved by Metafolin. These can occur by the second or third day after start an effective b12 as the cell formation apparatus starts up. Both of these could leave you feeling sick. An injection of hycbl or cyanocbl is unlikely to have that same effect as a sublingual mb12 or adb12 tablets. A typical balance of nutrients for those who experience this startup for people with normal folate handling is 50-5000mcg of mb12/adb12, 2000-3000mg of potassium titrated by effect, 2400-4000 Metafolin titrated by effect. If a person has folic acid or folinic acid assimilation problems then they may need 6000-8000mcg or 12,000-30,000mcg of Metafolin for sufficiency and healing of specific symptoms such as IBS, angular cheilitis and other folate deficiency characteristics.

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Need a way to block obviously bogus sign ups

All Star
‎04-04-2018 01:54 PM
‎04-04-2018 01:54 PM
Need a way to block obviously bogus sign ups
99.99% of the sign ups we get for our web site are obviously fake. Most of them have the same few nonesense words in them and the word "HOLLAND" in call caps. Surely there is a way to block bogus sign ups from fake domains?
Tags (3)
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CTCT Employee
‎04-05-2018 05:30 PM
‎04-05-2018 05:30 PM
Re: Need a way to block obviously bogus sign ups

Hello @SusanS1485 ,

Thank you for reaching out to the community!

We apologize for any trouble you are having with invalid sign-ups. I will explain what is happening here; the sign-ups that you are receiving are (in most cases) done by what is called a "bot." A bot is a program or computer that is filling out sign-up forms all over the internet at one time to try and collect information. When this happens the program is inputting an email address along with other required information following a standard format such as xyz@xyz.com. When this information is placed into the email portion of the form it is considered to be in the correct format, therefore, it will be added to your list. The Constant Contact system has no way to determine that a domain is valid or not.

Even though there is no way to prevent this from happening, we have a safety in place. When a sign-up form reaches 50 consecutive sign-ups in 24 hours it will place a CAPTCHA check on the form. This check will be able to prevent any additional sign-ups from being added by a bot. Only a human can fill out this CAPTCHA check due to its complexity. At this time the only way to have the CAPTCHA show on a sign-up form is by the process mentioned above.

Civil engineers specialize in road, bridge, buildings and water supply system design and construction. They supervise and direct construction teams and work with other engineers. These professionals ensure that every structure built is environmentally compliant and can withstand earthquakes and hurricanes. This is especially true in places where these natural calamities often strike. Read More...

Computer Engineers develop and improve the software programs and hardware that make computers run. Computer Engineers may specialize in either software or hardware. From operating system software, such as Windows and Linux, to individual computer programs, such as Photoshop and Microsoft Office, Software Engineers turn piles of hardware into fully functional computers. Hardware Engineers develop the hardware of computers, including the motherboards, graphics and audio cards and drives that are later programmed by Software Engineers. Read More...

Drafting and Design Engineering is an exciting career that allows the engineer to be involved in all stages of the design process, from conception to presentation of the finished plans. This career requires a working knowledge of drafting and design principles, material types and properties, and manufacturing processes. Read More...

Electrical engineers specialize in power supply and generation. They design, develop, test and supervise electrical equipment manufacturing. They have also been trained to handle responsibilities like wiring and lighting installations in buildings, automobiles and aircraft. What is great about being an electrical engineer is that the training is so extensive that graduates may land a job in many different industries such as construction, manufacturing and design. Read More...

Environmental engineers use science and engineering principles to protect and improve the environment. The quality of air, water, and soil is their primary focus. They seek solutions to water-borne diseases, wastewater management, and air pollution. They work to improve recycling, waste disposal, and industrial hygiene. They analyze soil and water samples. They understand the law as it applies to protecting the environment. Read more...

Geological engineering involves geology,civil engineering, and fields such as mining, forestry and geography. These engineers apply earth sciences to human problems. Specialty areas include geotechnical site studies of rock and soil slope stability for projects; environmental studies and planning for construction sites; groundwater studies; hazard investigations; and finding fossil fuel and mineral deposits. Read more...

Marine Engineers are responsible for the design and construction of seagoing vessels and structures, focusing primarily on their internal systems. Simply put, they design the onboard electrical, environmental and propulsion systems aboard everything from oil platforms to cruise ships. Read more...

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