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Unilateral tonsillar hypertrophy with accompanying cervical lymphadenopathy gives immediate suspicion of lymphoma or squamous cell carcinoma as the most probable diagnosis.    Aim  We aim to highlight the role of diagnostic tonsillectomy for intact looking tonsil as opposed to incisional biopsy for obvious fungating mass or ulcerative lesion. We also emphasise not to overlook abnormal preliminary blood work up. If leukocytosis is present, a peripheral blood film must be done to rule out ongoing infection or a more cynical haematological disease.    Case study  We report a case of a young female presenting with progressive dysphagia as well as bilateral neck swelling. Examination showed a unilateral tonsillar hypertrophy  with bilateral cervical lymph nodes highly suggestive of tonsil lymphoma.    Results and discussion  She was opted for tonsillectomy for both diagnostic as well as therapeutic purposes. Histopathological examination (HPE) of the left tonsil removed paired with an elaborated blood workup finally diagnosed her with a rare case of mixed phenotype acute leukemia.    Conclusions  A multidisciplinary team approach and early intervention are crucial to arrive at the correct diagnosis allowing prompt treatment and better prognosis and symptomatic relief.

A sinister mixed phenotype acute leukemia mimicking tonsil lymphoma