Head and Neck 2 week wait
referral
Richard Gracie
Lee Cooper
Aims
1. List the 2WW referral criteria for suspected
head and neck cancer
2. Develop a differential diagnosis for cases of
suspected head and neck cancer
3. Apply the criteria to clinical cases
4. Take into account patient risk factors
5. Know when to refer
6. Make a referral using the referral form
Introduction
• 15% GP consultations involve upper
respiratory tract or head and neck
• Wide range of symptoms and conditions
– Minor to life threatening
• Minimal exposure to ENT as students/juniors
• How do you know what is serious?
Could it be Cancer?
•
•
•
•
•
•
•
•
Hoarseness
FB sensation in throat
Epistaxis
Otalgia
Rhinorrhoea
Hearing Loss
Neck Lump
Dysphagia
•
•
•
•
•
•
Laryngitis
Globus
Anti-coagulants
Otitis Media
Allergy
Age Related
How common is Head and Neck
Cancer?
Type
Incidence (cases/year)
Laryngeal
2360
Oral
6767
Tyroid
2727
Lung
44,488
Colorectal
41,581
http://www.cancerresearchuk.org/health-professional/cancer-statistics
GROUP WORK
1. What else would you like to know from the
history and examination
2. What is your list of differential diagnoses
3. What would make you worry, and what
would re-assure you?
4. Would you refer as a 2WW?
Case 1
• 45 year old female
• 6 weeks of hoarseness
History
•
•
•
•
•
•
Onset, duration, progression
Phonotrauma
Reflux symptoms
Recent/recurrent URTI
Previous surgery
Drugs
– Steroid inhalers, ACEi
• Smoking
• Alcohol
Differential Diagnosis
• Muscle tension
dysphonia
• Laryngitis
– Acute laryngitis
– Chronic laryngitis
– Reflux laryngitis
• Vocal fold
nodule/cyst/polyp
• Vocal fold paralysis
• Leukoplakia
• Laryngeal Cancer
Polyp
Reflux Laryngitis
Cancer
Laryngeal Cancer
• 25% of head and neck cancers
• M:F 4:1
• Risk Factors
– Smoking
– Alcohol
– Radiotherapy
– FH
– GORD (weak)
What does NICE say?
• Consider a suspected cancer pathway referral
for laryngeal cancer in people aged 45 and
over with
– persistent unexplained hoarseness
– or an unexplained lump in the neck
• Local referral criteria
– Hoarseness >3 weeks
ENT assessment
•
•
•
•
FNE
CT neck
CT chest
Biopsy
Case 2
42 year old lady presents with a swelling low down
in the front of her neck .
Case 2
History
• The lump - Where, how long, how big, getting
bigger, painful, one lump?
• Compressive symptoms - Swallowing or
breathing difficulties
• Thyroid symptoms- most will be euthyroid
• Nerve palsy - hoarseness
• Smoker, drinker and family history of thyroid
problems
Case 2
Differential
•
•
•
•
•
•
Reactive lymph node
Autoimmune and inflammatory/infective
Sebaceous cyst
Benign disease, adenomas, multi-nodular, cysts.
Thyroid cancer
Lymphoma
Case 2
What would make you worry?
•
•
•
•
•
Rapidly increasing size
Recurrent laryngeal nerve palsy
Previous neck irradiation
Extreme of age
Compressive symptoms - Breathing/swallowing
difficulties
• Smoker, drinker, positive family history for thyroid
cancer/disease.
Case 2
Gloucestershire
A thyroid swelling associated with any of,
1) Solitary nodule increasing in size
2) History of neck irradiation
3) Family history of endocrine tumour
4) Unexplained hoarseness or voice change
5) Pre-pubertal patient
6) Age 65 or over
NICE
Consider a suspected cancer pathway referral (for an appointment within
2 weeks) for thyroid cancer in people with an unexplained thyroid lump
Case 2
Investigation and management
• Generally thyroid nodules >1cm should be
investigated.
• USS +/- FNAC
Ty score
Management
Ty 1
Insufficient. Repeat FNAC
Ty 2
Likely benign. 6 weekly follow up, unless
compressive symptoms or rapidly progressive.
Ty 3
Possibly malignant. Hemi-thyroidectomy,
histology and if malignant, completion
thyroidectomy and radio-iodine treatment.
Ty 4
Likely malignant. Total thyroidectomy
Ty 5
Malignant. Total thyroidectomy plus radioiodine
Case 2
5% chance of malignancy in a solitary nodule.
Types
• Epithelial - Papillary and follicular
• Poorly differentiated - Anaplastic
• Medullary - Calcitonin producing C-cells
• Others – SCC, sarcoma, lymphoma
Case 3
• 76 year old lady presents with swelling over the
left cheek, and left facial droop
Case 3
History
• The lump - Where, when, how long, rapidly
increasing, single lump, any others
• Infective symptoms - erythema, fevers, discharge
in the mouth, punctum, is it painful
• Sialadenitis, sialolithiasis
• Nerve Palsy - Facial nerve
• Smoker, drinker family history
Case 3
Differential
• Sialolithiasis
• Parotiditis
• Tumour Benign - Pleomorphic adenoma and
Warthins
• Malignant – Many different types based on
histology and grade.
Case 3
What would make you worry?
• Rapidly progressing mass in an elderly smoker
with evidence of facial nerve palsy.
Case 3
Gloucestershire
• Swelling in the parotid or submandibular
gland
NICE
?
Case 3
Investigation and management
• USS and FNAC – 85% accurate
• CT scan to elucidate extent
• Benign 80% - Surgical excision
• Malignant – Surgical excision plus
Chemo/radiotherapy
Case 4
• 62 year old man presenting with persistent right
sided neck pain.
Case 4
History
•
•
•
•
•
•
•
•
•
Level of the pain - low middle or high.
Associated mass
Odynophagia and dysphagia.
Pain all the time
Stridor or SOB
Concurrent infective symptoms
Recurrent tonsillitis.
Smoker/drinker positive family history.
Trauma, previous surgery, head and neck irradiation
Case 4
Differential
•
•
•
•
•
Tumour
Tonsillitis/quinsy/pharyngitis
Neck space abscess
Reactive lymph node
Globus
• Foreign body
Case 4
What would make you worry
•
•
•
•
Unilateral persistent tonsillar swelling
Persistent pain
Associated mass
Cranial nerve involvement i.e. glossopharyngeal
leading to referred otalgia.
• Smoker drinker, family history, elderly.
Case 4
Gloucestershire
• Unilateral unexplained pain in the head and
neck > 4weeks associated with otalgia and
normal otoscopy.
NICE
?
Case 4
Investigation and management
•
•
•
•
FNE
CT, MRI
Examination under anaesthetic +/- biopsy,
PET
SCC most common pharyngeal malignancy
• Surgery depending on site a multitude of surgical approaches.
• Around the pharynx generally pharyngectomy and neck dissection.
• Post nasal space and sinuses including FESS depending on stage, maxillafacial surgery
• Radiotherapy.
NICE guidelines (NG12)
Laryngeal cancer
• People aged 45 and over with:
– persistent unexplained hoarseness or
– an unexplained lump in the neck.
Oral cancer
• Unexplained ulceration in the oral cavity lasting for more than 3 weeks or
• Persistent and unexplained lump in the neck.
• Dental referral for
– a lump on the lip or in the oral cavity or
– a red or red and white patch in the oral cavity consistent with erythroplakia or
erythroleukoplakia.
– a lump on the lip or in the oral cavity consistent with oral cancer or
Thyroid cancer
• Unexplained thyroid lump
Local policy
•
Hoarseness >3 weeks
•
Stridor
•
Swelling in parotid/submandibular gland
•
Persistent red and white patches of the oral
mucosa
•
Unexplained tooth mobility >3 weeks
•
Unexplained persitant sore throat
•
Progressive mouth, throat ulceration
•
Persistent oral swelling/ulcer > 3 weeks
•
Unilateral, unexplained pain in head >4 weeks,
with otaligia and normal otoscopy
•
Thyroid swelling with any of:
–
–
–
–
–
–
Solitary nodule increasing in size
History of neck irradiation
FH of endocrine tumour
Unexplained hoarseness/voice change
Very young (pre-pubertal)
> 65 years old
Conclusion
• Will see lots of ENT problems
• Head and neck cancer is rare but serious