Here rises a tale of mystery dealing with the occult.

An 80 something year old gentleman, came into my office a few months ago with a new lump on his neck. It didn’t hurt; he had no sores in his mouth; and he noted nothing else unusual, except that he had been recently widowed and he missed his wife terribly.

On exam there was a hard lump behind his ear and jaw measuring about the shape and size of an olive. My initial exam of ear canals, hearing, nasal passages, mouth, tongue, and throat found him to be normal. His voice was clear and there were no palpable irregularities of the trachea, which was positioned midline in his neck.

I sent him to the Ears-Nose-and-Throat (ENT) specialist to take a direct look with a scope at the back of the nose, throat, vocal cords, and to remove or biopsy the lump. The scope exam was clear but after the biopsy of the lump, the microscopic exam brought the diagnosis of metastatic squamous cell carcinoma of the head and neck, with occult primary.

In other words his cancer started from skin-like thin sheets of cells that commonly line the upper airways, and the term “occult” is medical lingo for a cancer that has spread from another site but the original “primary” site remains a mystery. I remember another case of a metastatic cancer first discovered in the brain, but on autopsy the occult primary was from the lung. The medical meaning of occult is nothing mystical or magical, just unknown, and sometimes devastating.

Looking for the source of such a head and neck cancer I did some research and learned of the following risk factors for squamous cancer of the head and neck: exposure to excessive amounts of alcohol; tobacco smoke or chew; wood dust; fine nickel and metal particles; formaldehyde; preserved or salted foods; paan (an addictive leaf or nut chewed in Southeast Asia;) and bitter mate (a tea-like beverage sipped in South America.)

Our patient is a typical retired college professor originally from a farm on the Dakota prairie, with little tobacco, wood, industrial, or travel history; only having lived a dedicated life helping students and savoring time with his wife.

For now, after removing the nodule, we’ve provided no other treatment; our patient is doing fine; and still the origin for the cancer remains occult.

Dr. Rick Holm wrote this Prairie Doc Perspective for “On Call®,” a weekly program where medical professionals discuss health concerns for the general public. “On Call®” is produced by the Healing Words Foundation in association with the South Dakota State University Journalism Department. “On Call®” airs Thursdays on South Dakota Public Broadcasting-Television at 7 p.m. Central, 6 p.m. Mountain. Visit us at


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