ENT aims to treat all patients who have a cancer ‘within 62 days of that suspicion being raised’, in line with government targets. To achieve this, most ‘urgent suspected cancer’ (USC) patients need to be seen within 2 weeks, as many will need further investigation. ENT also aims to see all ‘urgent’ referrals quickly, but there are longer waits for routine appointments.
The head and neck section of the Scottish Cancer Referral Guidelines outlines that the risk factors include:
- Socio-economic deprivation
- Smoking and tobacco chewing habits (including betel, gutkha, snus and pan)
- Human Papilloma Virus (HPV) (increasing incidence of oropharyngeal cancer in a younger population)
- Excessive alcohol use
- Recreational drug use (especially opioids and cannabis)
- Poor diet
- Older age.
HPV may be the only risk factor in younger groups (30-40 years), who may not present with typical risk factors (e.g. have never smoked or used drugs recreationally).
GP referrers were previously advised to use the Head and Neck Cancer Risk Assessment tool, but its use has now only been validated for specialist care, and it will no longer be routinely used in Lothian. However, its fields reflect the known high-risk symptoms, and that information will still be requested on SCI Gateway.
Assessing Symptoms.
Please see ‘who to refer’ below for red flag symptoms. But also of note:
- Symptom clusters can help identify higher risk of head and cancer, e.g. combination of hoarseness, dysphagia, and pain on swallowing especially if radiating to the ear is very suspicious of cancer in the upper airway.
- A feeling of something stuck in the throat (FOSSIT) or globus sensation, is unlikely to be head and neck cancer. In the absence of any other concerning features this symptom can be managed in primary care or via non-USC referral.
- The ENT neck lump (rather than throat) pathway on SCI Gateway ensures that the patient is seen at a multi-disciplinary clinic, with scanning facilities. This does not apply to non-suspicious lumps such as sebaceous cysts, lipomas and longstanding non-progressive lesions: these are intradermal lumps, which are superficial and can be differentiated from deeper lumps by palpation. They are often found on the scalp and do not require referral on a head and neck pathway. Examination of the neck to ascertain the position, mobility and consistency of any neck lump is key. Lymph nodes felt behind the sternomastoid muscle are more likely to be reactive and less concerning than those found in front of it or below the angle of the jaw Referral is not needed for nodes felt clinically likely to be reactive.
- Dysphagia: PLEASE NOTE THAT UNLESS THERE ARE VERY SPECIFIC PHARYNGEAL SYMPTOMS, TRUE DYSPHAGIA AT ANY LEVEL SHOULD BE REFERRED TO GI DYSPHAGIA SERVICES. This is particularly important where there is also significant, unintentional weight loss. This is because ENT can only endoscope to the top of the oesophagus and therefore cannot visualise the most at-risk sites.
- Pharyngeal symptoms can include difficulty with the initiation of the swallowing mechanism. But if there are any symptoms relating to food ‘sticking’, the referral should be to gastroenterology.
C.M & A.H. 10-02-26
Who to refer:
Refer a person with any of the following unexplained clinical features lasting three weeks or more as a USC to:
ENT:
- Constant hoarseness (voice is never normal) in those aged 35 years or over
- Constant unilateral throat pain (not simply a feeling of something stuck in the throat – FOSSIT)
- Pain on swallowing (odynophagia)
- Tonsillar ulcers or masses – whenever they present.
NECK LUMP CLINIC:
- Neck or parotid lump
ORAL AND MAXILLOFACIAL SURGERY:
- Red or mixed red and white patches of the oral mucosa (not oral thrush)
- Ulceration or swelling/induration of the oral mucosa
Please note that:
- Anyone presenting with upper airway compromise (e.g. stridor) should be referred as a same day emergency (ENT)
- Persistent or progressive dysphagia (not ‘feeling of something stuck in the throat’ – FOSSIT) should be referred to gastroenterology
- Thyroid lumps should be referred to the endocrine clinic (with no prior scanning).
How to refer:
Please refer via Sci Gateway to Lauriston / St John’s-ENT-Throat.
Stridor – refer on call ENT at St John’s (same day phone call).
If you think a patient has a true concern of malignant disease rather than just wishing to exclude cancer, please explain to the patient that you are concerned that they may have cancer and that they will be seen quickly, usually within 2 weeks. We hope this will encourage patients to attend their appointment with the multidisciplinary team to use this resource efficiently and ensure they are seen promptly.
