Sir, I am writing with regards to my recent experience as a DCT1 in a district general OMFS department during a consultation with a patient. In this encounter, saying 'AAHHH' revealed a previously unseen sinister lesion of the right pharyngeal tonsil. Following biopsy, tonsillar squamous cell carcinoma (SCC) was diagnosed, measuring 3.0 x 2.5 cm. The lesion was unrelated to the initial reason for referral, with surprisingly few symptoms.

Many 'self-checklists' for oral cancer screening exist and I had completed these but saw nothing of concern. Since working in OMFS and shadowing colleagues, the importance of asking the patient to say 'AAAHH' has been reiterated, acting to depress the tongue and raise the soft palate. It also reminds the clinician to pay attention to the oropharynx as part of their habitual examination. In some patients, just sticking the tongue forward will give a good view of the oropharynx and tonsillar area. However, as an anaesthetic Mallampati score shows1(Fig. 1), this is not the case for everyone. Individual factors, along with lying in the supine position (often the case at the dentist), can make this area difficult to properly assess with protrusion of the tongue alone, possibly leading to lesions in the area being missed.

Fig. 1
figure 1

Anaesthetic Mallampati score. Illustrating patient variation in visualising the soft palate and oropharynx with protrusion of the tongue.1 Illustration by Joseph Ash

Full size image

Tonsillar carcinoma is the most common site of SCC of the oropharynx and the incidence of oropharyngeal cancer is increasing, mainly due to the increased prevalence of human papillomavirus (HPV).2 The simple practice of depressing the tongue with a dental mirror and having the patient loudly say 'AAAHH' allows a thorough examination of this area, revealing anatomy which may otherwise remain hidden.