Background Combined small cell lung cancer (c-SCLC) is a subtype of small cell lung cancer that contains both small cell and non small cell carcinoma components. While it is an aggressive tumour with early distant metastasis commonly to the liver, bone and brain, spread to the oropharynx is exceptionally rare. Metastatic lesions in the glossotonsillar sulcus are particularly uncommon and pose a diagnostic challenge in patients presenting with head and neck symptoms. Case Report A 72-year-old male presented with a several week history of left neck lumps with no other upper aerodigestive tract symptoms. On examination there was a firm exophytic lesion to the left inferior tonsil and multiple palpable left level II-III lymph nodes to the neck. Initial US FNA of the left sided lymph nodes was consistent with a neuroendocrine carcinoma with no specific type differentiated. He underwent a PET scan which showed FDG avidity to the left glossotonsillar sulcus, left cervical and mediastinal lymph nodes and to a nodule in the left lower lung lobe. Subsequent biopsies of the left glossotonsillar sulcus and lung nodule were both consistent with combined small cell lung carcinoma on immunohistochemistry, suggesting a primary lung cancer with metastatic spread to the left glossotonsillar sulcus rather than a primary tonsillar lesion. The patient is undergoing palliative chemo-immunotherapy with good symptomatic response. Discussion/ Conclusion Metastatic involvement of the glossotonsillar sulcus by c-SCLC is extremely rare. This case highlights how the mixed histopathological features of c-SCLC contribute to this diagnostic challenge. Even in patients presenting with symptoms that mimic a primary head and neck malignancy, recognition of this atypical metastatic pattern must be emphasised to ensure it is considered as a differential to allow for timely diagnosis and commencement of treatment to improve quality of life for affected patients.