ENT: Neck lumps and cancer

🩺 Neck lumps and head and neck cancer -most neck lumps in children and young adults are enlarged lymph nodes from infection. In adults over 40, a persistent neck lump is cancer until proven otherwise, often a lymph node spread from a mouth, throat or larynx cancer. Head and neck cancer is linked to smoking and alcohol, and increasingly to HPV in younger non-smokers. Early referral makes a big difference to survival and to how much treatment is needed.
Your four questions for every patient: How old are they, and how long has the lump been there? Where exactly is it -midline or lateral, and does it move with swallowing or tongue protrusion? Are there red flags (hard, fixed, growing, hoarseness, dysphagia, ear pain, weight loss, smoking)? Does this need a suspected cancer referral?

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Assessing a Neck Lump

• History:
  • Duration -days (infection) versus weeks to months (cancer, congenital).
  • Size change; pain; recent infection (sore throat, dental).
  • Red flag symptoms -hoarseness, dysphagia, painful swallowing, referred ear pain, one-sided nasal blockage or bleeding, mouth ulcer, weight loss, night sweats, fevers.
  • Risk factors -smoking, alcohol, HPV exposure, betel or paan chewing, previous radiotherapy, immunosuppression, TB contact, HIV risk.
• Examination -from behind, chin slightly down:
  • Site -midline or lateral; anterior or posterior triangle; level (I–VI).
  • Size, consistency (soft, rubbery, hard), tenderness, fixity, skin changes.
  • Moves with swallowing -thyroid (or thyroglossal cyst).
  • Moves with tongue protrusion -thyroglossal cyst.
  • Pulsatile -carotid body tumour or aneurysm.
  • Examine the mouth, throat, ears, scalp and skin (primary sites) and other node areas, liver and spleen.
• Age guide:
  • Children -mostly reactive lymph nodes and congenital lesions; cancer is rare (but lymphoma, leukaemia, neuroblastoma).
  • Young adults -reactive nodes, glandular fever, congenital cysts, lymphoma, thyroid; HPV-related cancer is rising.
  • Over 40 -a persistent lump is malignant in a large proportion (metastatic squamous cell carcinoma, lymphoma, thyroid).

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Enlarged Lymph Nodes

• Reactive (the commonest) -after throat, dental, scalp or skin infections; tender, soft, under 2 cm; settle within 2–6 weeks.
• Infections:
  • Glandular fever (EBV) -posterior nodes, sore throat; CMV; toxoplasmosis.
  • TB ("scrofula") -matted, painless nodes, may discharge; people from high-TB countries, HIV.
  • Atypical mycobacteria -young children; violet skin over a painless node.
  • Cat-scratch disease (Bartonella).
  • HIV -generalised lymphadenopathy.
  • Bacterial lymphadenitis (abscess).
• Malignant:
  • Metastatic squamous cell carcinoma -hard, painless, often fixed; from the mouth, throat, larynx or skin.
  • Lymphoma -rubbery, painless, often several nodes; B symptoms (fever, night sweats, weight loss); alcohol-induced pain (Hodgkin).
  • Thyroid cancer (papillary spreads to nodes, often in young people).
  • Leukaemia (CLL in older people).
  • Metastases from below the neck -Virchow's node (left supraclavicular) from stomach or other abdominal cancers (Troisier's sign).
• Other -sarcoidosis, Kikuchi disease, Kawasaki disease (children), drugs (phenytoin).
• Red flags:
  • Persisting over 3–6 weeks, or growing.
  • Over 2 cm; hard; fixed; supraclavicular.
  • B symptoms; hepatosplenomegaly; generalised lymphadenopathy.
  • Smoker or drinker; head and neck symptoms.
• NICE NG12: Adults aged 45 or over with an unexplained persistent neck lump -suspected cancer pathway referral. Children and young people with unexplained lymphadenopathy or splenomegaly -very urgent FBC (leukaemia) and specialist assessment.

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Midline Neck Lumps

• Thyroid swelling -moves up with swallowing:
  • Diffuse goitre, multinodular goitre, single nodule, cyst.
  • Tests -TFTs, ultrasound (U1–U5 grading), fine needle aspiration (FNA) if suspicious.
  • See the Thyroid Disease chapter.
• Thyroglossal duct cyst:
  • A remnant of the thyroid's path of descent from the tongue base.
  • Children and young adults; smooth, round, midline (usually just below the hyoid).
  • Moves up when the tongue is stuck out (and on swallowing).
  • Can become infected.
  • Treatment -Sistrunk operation (removes the cyst, the track, and the middle of the hyoid bone); check that normal thyroid tissue is present first.
• Dermoid cyst -midline, doesn't move with tongue protrusion; children.
• Lymph nodes -submental (under the chin) from lip, chin or front of mouth.
• Laryngeal or tracheal tumours; thymus (children).

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Lateral Neck Lumps

• Lymph nodes -the commonest (see above).
• Branchial cyst:
  • A congenital cyst at the front edge of the sternocleidomastoid, junction of its upper and middle thirds.
  • Young adults (20s–30s); smooth, soft, may swell with infections.
  • Aspirate contains cholesterol crystals.
  • Surgical removal.
• Cystic lymph node in an adult -a "branchial cyst" appearing after age 35–40 is a metastatic HPV-positive oropharyngeal cancer (or papillary thyroid cancer) until proven otherwise.
• Carotid body tumour (paraganglioma):
  • At the carotid bifurcation (angle of the jaw); may be pulsatile, with a bruit.
  • Moves side to side, but not up and down (Fontaine's sign).
  • Splays the internal and external carotids on imaging ("lyre sign").
  • Don't biopsy (bleeding) -imaging and genetic testing (SDH mutations); surgery or watch.
• Salivary glands -parotid (in front of the ear, at the jaw angle) and submandibular (under the jaw).
• Cystic hygroma (lymphatic malformation) -babies and young children; soft, transilluminates; posterior triangle; sclerotherapy or surgery.
• Laryngocele -air-filled sac that swells on blowing (trumpet players); can hide laryngeal cancer.
• Cervical rib -hard lump above the clavicle; may cause thoracic outlet symptoms.
• Sternocleidomastoid "tumour" -firm swelling in a baby's neck muscle; torticollis; physiotherapy.
• Lipoma; sebaceous cyst; neurofibroma; schwannoma.

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Investigating a Neck Lump

• ENT examination -including flexible nasendoscopy to look at the nasopharynx, tongue base, larynx and hypopharynx.
• Ultrasound -first-line imaging; shows whether the lump is solid or cystic, its nature, and guides biopsy.
• Ultrasound-guided FNA or core biopsy -diagnosis with HPV (p16) testing, or lymphoma typing (core biopsy is better for lymphoma).
• Avoid open excision biopsy of a suspected squamous cell carcinoma node -it spreads tumour and makes later treatment harder. Excision biopsy is reserved for suspected lymphoma when a core isn't enough.
• CT or MRI neck -staging; CT chest (lung metastases and second primary).
• PET-CT -finds the primary site in "unknown primary" cancer; staging; checking response after treatment.
• Examination under anaesthetic -with biopsies (tonsillectomy, tongue base) if the primary site isn't found.
• Bloods -FBC and film, ESR, LFTs, TFTs, EBV and HIV serology as appropriate.
• Most hospitals have one-stop neck lump clinics (ENT consultation, ultrasound and FNA in one visit).

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Salivary Stones

• Sialolithiasis -about 80% in the submandibular gland (its saliva is thicker and its duct runs uphill).
• Features:
  • Pain and swelling under the jaw with eating (or even the thought of food), settling over an hour or two.
  • A stone may be felt in the floor of the mouth.
  • Infection -persistent swelling, redness, pus from the duct (sialadenitis).
• Tests: Ultrasound; X-ray (most submandibular stones are radio-opaque); sialography or CT.
• Treatment:
  • Hydration, massage, warm compresses, sialogogues (sour sweets, lemon) to flush small stones.
  • Antibiotics if infected (e.g. co-amoxiclav or flucloxacillin).
  • Removal -through the mouth, sialendoscopy (tiny camera), lithotripsy, or gland removal for recurrent problems.

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Parotitis and Mumps

• Acute bacterial parotitis:
  • Older, frail, dehydrated patients; after surgery; poor oral hygiene; anticholinergic drugs.
  • Painful, red, swollen parotid, fever, pus from the parotid duct (opposite the upper second molar) on massage.
  • Usually Staphylococcus aureus.
  • Treatment -rehydration, oral hygiene, sialogogues, antibiotics (flucloxacillin, or per local policy); drain an abscess.
• Mumps (paramyxovirus):
  • Bilateral (sometimes one-sided) painful parotid swelling with fever, malaise; ear lobes pushed out.
  • Outbreaks in young adults (students) who missed MMR doses.
  • Complications -orchitis (painful testes, after puberty; rarely infertility), oophoritis, pancreatitis, viral meningitis, encephalitis, sensorineural deafness.
  • Diagnosis -saliva swab (PCR) or oral fluid test.
  • Notifiable; supportive care; exclude from school or work for 5 days after swelling starts.
  • Prevention -2 doses of MMR.
• Recurrent parotitis of childhood -repeated swelling; usually settles by puberty.

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Other Salivary Swellings

• Sjögren's syndrome -dry eyes and mouth with salivary gland swelling; anti-Ro and anti-La; raised risk of lymphoma (MALT) -new firm gland swelling needs investigation.
• Sarcoidosis -bilateral parotid swelling; Heerfordt syndrome (with uveitis, fever and facial palsy).
• HIV -bilateral cystic parotid swelling (lymphoepithelial cysts).
• IgG4-related disease -firm, bilateral submandibular gland swelling (Küttner tumour) or lacrimal and salivary swelling (Mikulicz disease); raised IgG4; responds to steroids.
• Sialosis -painless, bilateral, soft parotid enlargement: alcohol, diabetes, bulimia, malnutrition, cirrhosis, drugs.
• Ranula -a bluish mucus cyst in the floor of the mouth (sublingual gland).
• Mucocele -small cyst on the inner lower lip after biting.
• Drooling (sialorrhoea) -in Parkinson's disease, MND, cerebral palsy -hyoscine patches, glycopyrronium, botulinum toxin.

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Salivary Gland Tumours

• Rule of 80s (roughly): about 80% occur in the parotid, and about 80% of parotid tumours are benign. The smaller the gland, the more likely a tumour is malignant (sublingual and minor salivary gland tumours are mostly malignant).
• Benign:
  • Pleomorphic adenoma -the commonest; middle-aged women; slow-growing, painless, firm lump. Can recur if not removed fully and can rarely turn malignant after many years.
  • Warthin tumour -older male smokers; soft, sometimes bilateral or multiple; lower pole of the parotid.
• Malignant:
  • Mucoepidermoid carcinoma -the commonest malignant type.
  • Adenoid cystic carcinoma -spreads along nerves (perineural) -pain and facial palsy; late recurrence.
  • Acinic cell carcinoma, salivary duct carcinoma, lymphoma, metastases (skin cancers of the scalp and face spread to parotid nodes).
• Signs of malignancy:
  • Facial nerve weakness.
  • Pain.
  • Rapid growth.
  • Fixed to skin or deep tissues; skin ulceration.
  • Neck nodes.
• Investigation: Ultrasound with FNA or core biopsy; MRI.
• Treatment:
  • Superficial or total parotidectomy, preserving the facial nerve if possible; radiotherapy for malignant tumours.
  • Complications of parotidectomy -facial nerve weakness (usually temporary), numb earlobe (great auricular nerve), Frey syndrome (sweating and flushing of the cheek when eating -"gustatory sweating"), salivary fistula.

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Head and Neck Cancer -Overview

• How common: About 12,000 new cases a year in the UK; incidence is rising, mainly because of HPV-related oropharyngeal cancer.
• Type: About 90% are squamous cell carcinomas.
• Sites:
  • Oral cavity (lips, tongue, floor of mouth, gums, cheek).
  • Oropharynx (tonsils, tongue base, soft palate).
  • Larynx.
  • Hypopharynx.
  • Nasopharynx.
  • Nose and sinuses; salivary glands.
• Risk factors:
  • Smoking -the biggest.
  • Alcohol -and smoking with alcohol multiplies the risk.
  • HPV (especially HPV-16) -oropharyngeal cancer; oral sex and number of partners.
  • Betel quid, paan and gutka chewing (South Asian communities) -mouth cancer.
  • EBV and diet (salted fish) -nasopharyngeal cancer in Southern Chinese, South-East Asian and North African populations.
  • Sun exposure -lip cancer.
  • Wood dust (sinonasal); previous radiotherapy; immunosuppression; Fanconi anaemia; poor diet; deprivation.
• Prevention:
  • Stop smoking; reduce alcohol.
  • HPV vaccination -offered to all children aged 12–13 (girls and, since 2019, boys); a single dose since 2023; also to men who have sex with men up to age 45.
  • Regular dental checks (dentists spot many mouth cancers).
• Field cancerisation -the whole lining of the mouth and throat is exposed to carcinogens, so second primary cancers (head and neck, lung, oesophagus) are common.

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Symptoms and Referral

Symptoms that should raise suspicion (especially if over 3 weeks, in smokers and drinkers):

• Persistent hoarseness.
• Neck lump.
• Mouth ulcer that doesn't heal; red or white patch; lump in the mouth.
• Difficulty or pain swallowing.
• One-sided sore throat; referred ear pain with a normal ear.
• One-sided nasal blockage, bloody discharge or nosebleeds; one-sided glue ear in an adult.
• Stridor (late); haemoptysis.
• Loose teeth or poorly fitting dentures; numbness of the tongue or lip.
• Weight loss.

NICE NG12 -suspected cancer pathway referrals:

• Laryngeal cancer -consider for people aged 45 or over with persistent unexplained hoarseness or an unexplained neck lump.
• Oral cancer -consider for unexplained mouth ulceration for more than 3 weeks or a persistent unexplained neck lump; GPs refer red or red-and-white patches or mouth lumps (or arrange an urgent dental review).
• Thyroid cancer -unexplained thyroid lump.

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Mouth Cancer

• Sites: Side of the tongue (the commonest), floor of the mouth, gums, cheek lining, hard palate, lip.
• Features:
  • Non-healing ulcer with raised, hard edges; often painless at first.
  • Red or white patch (erythroplakia, leukoplakia).
  • Lump; bleeding; loose teeth; ill-fitting dentures.
  • Pain, ear pain, numbness (later).
  • Neck nodes.
• Precancerous conditions: Leukoplakia, erythroplakia (highest risk), erosive lichen planus, oral submucous fibrosis (betel nut chewers -stiff mouth, trismus).
• Lip cancer -usually the lower lip; sun exposure; good prognosis.
• Treatment: Surgery (often with neck dissection and reconstruction with a free tissue flap); radiotherapy or chemoradiotherapy after surgery for high-risk features.

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Oropharyngeal Cancer and HPV

• Sites: Tonsils, tongue base, soft palate.
• Two types:
  • HPV-positive (now most UK cases):
    • Younger (40s–50s), often non-smokers or light drinkers.
    • Often presents with a neck lump (cystic node) with a small or hidden primary.
    • Much better prognosis and response to treatment.
    • Shown by p16 staining on biopsy.
  • HPV-negative -smokers and drinkers; older; worse outcomes.
• Features:
  • Neck lump.
  • Persistent one-sided sore throat; ear pain.
  • Painful or difficult swallowing.
  • One-sided enlarged tonsil.
  • "Hot potato" voice (tongue base); weight loss.
• Treatment: Chemoradiotherapy (radiotherapy with cisplatin) or transoral surgery (robotic or laser) with neck dissection for smaller tumours; trials of reducing treatment intensity in HPV-positive disease.

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Laryngeal Cancer

• Who: Older men; smoking and alcohol.
• Sites and features:
  • Glottic (vocal cords) -the commonest. Hoarseness early, and the cords have little lymphatic drainage, so it is often found early with a good prognosis.
  • Supraglottic (above the cords) -swallowing problems, throat pain, ear pain, neck nodes; hoarseness later; spreads to nodes early.
  • Subglottic (below the cords) -rare; stridor; late presentation.
• Late features: Stridor, haemoptysis, weight loss, neck nodes.
• Diagnosis: Nasendoscopy; biopsy under general anaesthetic (microlaryngoscopy); CT neck and chest.
• Treatment:
  • Early -radiotherapy or transoral laser surgery (both aim to preserve the voice).
  • Advanced -chemoradiotherapy, or total laryngectomy (permanent neck stoma -see the ENT Emergencies chapter).
  • Voice after laryngectomy -voice prosthesis (tracheo-oesophageal valve), electrolarynx, oesophageal speech.

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Hypopharyngeal Cancer

• Sites: Pyriform fossa (the commonest), post-cricoid region, posterior pharyngeal wall.
• Features: Painful or difficult swallowing, referred ear pain, voice change, a neck lump (often the first sign), weight loss. Usually presents late, so prognosis is poor.
• Post-cricoid cancer -linked to Plummer–Vinson (Paterson–Brown-Kelly) syndrome: iron deficiency anaemia, dysphagia from an oesophageal web, glossitis -mostly in women.
• Treatment: Chemoradiotherapy or surgery (pharyngolaryngectomy with reconstruction).

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Nasopharyngeal Cancer

• Who: Much more common in people of Southern Chinese, South-East Asian and North African origin; EBV is involved; salted fish diet.
• Features -often subtle:
  • Neck lump (upper neck, posterior triangle) -the commonest presentation.
  • One-sided glue ear and hearing loss in an adult (blocked Eustachian tube).
  • Nasal blockage; blood-stained nasal discharge or nosebleeds.
  • Cranial nerve palsies -especially VI (double vision) and V (facial numbness) from skull base spread.
  • Headache.
• Diagnosis: Nasendoscopy and biopsy; MRI; EBV DNA in blood (also used to monitor).
• Treatment: Radiotherapy (very radiosensitive) with chemotherapy; surgery is rarely used.

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Treatment

• Multidisciplinary team (MDT) -ENT and maxillofacial surgeons, oncologists, radiologists, pathologists, specialist nurses, speech and language therapists, dietitians, restorative dentists, psychologists.
• Before treatment:
  • Dental assessment -remove unhealthy teeth before radiotherapy (to prevent osteoradionecrosis).
  • Nutrition -feeding tube (gastrostomy) may be placed if swallowing is expected to be badly affected.
  • Stop smoking (improves treatment response and survival); alcohol support.
• Treatment options:
  • Surgery -removal of the tumour (often transoral for smaller tumours), neck dissection, and reconstruction (free flaps).
  • Radiotherapy -intensity-modulated radiotherapy (IMRT) to spare salivary glands; daily over about 6 weeks.
  • Chemoradiotherapy -radiotherapy with cisplatin (or cetuximab if cisplatin isn't suitable).
  • Recurrent or metastatic disease -immunotherapy (pembrolizumab, alone or with chemotherapy, for tumours expressing PD-L1; nivolumab after platinum chemotherapy), chemotherapy, cetuximab, palliative care.
• Early-stage disease -often single treatment (surgery or radiotherapy) with good cure rates.
• Advanced disease -combined treatment; 5-year survival varies widely by site and HPV status.

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Life After Treatment

• Dry mouth (xerostomia) -from radiotherapy to the salivary glands; often permanent. Saliva substitutes, frequent sips, sugar-free gum, pilocarpine tablets in some.
• Dental decay -fluoride toothpaste (high strength) and trays; regular dental review.
• Osteoradionecrosis -exposed, dead jaw bone after radiotherapy; often triggered by tooth extraction. Avoid extractions after radiotherapy where possible; specialist dental care.
• Swallowing problems -speech and language therapy (swallowing exercises before and after treatment); some need long-term tube feeding; aspiration pneumonia risk.
• Mucositis (during treatment) -painful mouth ulcers; analgesia (including opioids), mouthwashes, nutrition support.
• Trismus -stiff jaw; jaw-stretching exercises.
• Hypothyroidism -common after neck radiotherapy; check TFTs yearly.
• Carotid artery stenosis -raised stroke risk years after neck radiotherapy.
• Lymphoedema of the face and neck; neck fibrosis.
• Shoulder problems -damage to the accessory nerve (XI) during neck dissection: shoulder drop, pain, difficulty lifting the arm. Physiotherapy.
• Changes in voice, appearance, eating and taste -big psychological and social impact; depression; support groups.
• Follow-up -typically for 5 years: recurrence and second primaries (head and neck, lung, oesophagus); keep off tobacco.

⚠️ Safety Pearl: Before a tooth extraction in someone who has had head and neck radiotherapy, involve a specialist dentist -extractions in irradiated bone can cause osteoradionecrosis of the jaw.

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Drug Reference Table

Drug	Key points
Cisplatin	Given with radiotherapy (chemoradiotherapy); kidney damage, hearing loss, nausea, neuropathy -hydration and audiology.
Cetuximab	Anti-EGFR antibody with radiotherapy if cisplatin unsuitable, or in recurrent disease; acne-like rash, infusion reactions, low magnesium.
Pembrolizumab	Immunotherapy for recurrent or metastatic disease (PD-L1 positive); immune side effects -thyroid, colitis, pneumonitis, hepatitis.
Nivolumab	Immunotherapy after platinum chemotherapy.
Pilocarpine tablets	Dry mouth after radiotherapy (if some gland function remains); sweating.
High-fluoride toothpaste (e.g. 5,000 ppm)	Prevents decay after head and neck radiotherapy.
Levothyroxine	Hypothyroidism after neck radiotherapy -check TFTs yearly.
Flucloxacillin / co-amoxiclav	Acute bacterial parotitis and infected salivary stones (per local policy).
HPV vaccine	Single dose at age 12–13 (girls and boys); MSM up to 45.
MMR vaccine	Two doses prevent mumps; catch-up for young adults.

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Spot the Diagnosis

Clue	Diagnosis
Midline lump that rises when the tongue is stuck out	Thyroglossal duct cyst
Midline lump that rises on swallowing only	Thyroid nodule or goitre
Soft lump at the front edge of sternocleidomastoid in a 22-year-old	Branchial cyst
Cystic neck node in a 48-year-old non-smoker	HPV-positive oropharyngeal cancer
Pulsatile lump at the jaw angle that moves side to side, not up and down	Carotid body tumour
Soft, transilluminating neck swelling in a baby	Cystic hygroma
Hard left supraclavicular node with weight loss and dyspepsia	Virchow's node (gastric cancer)
Rubbery nodes, night sweats, pain after alcohol	Hodgkin lymphoma
Matted painless nodes in a man from a high-TB country	TB lymphadenitis
Swelling under the jaw when eating	Submandibular stone
Dehydrated older patient after surgery with a hot swollen parotid and pus from the duct	Acute bacterial parotitis
Student with bilateral parotid swelling and a painful testis	Mumps with orchitis
Slow-growing painless parotid lump in a 45-year-old woman	Pleomorphic adenoma
Bilateral soft parotid lumps in an older male smoker	Warthin tumour
Parotid lump with facial weakness	Malignant parotid tumour
Sweating on the cheek when eating after parotid surgery	Frey syndrome
Hoarseness in a 68-year-old smoker for 2 months	Glottic laryngeal cancer
Iron deficiency, dysphagia and glossitis in an older woman	Plummer–Vinson syndrome (post-cricoid cancer risk)
Adult of Southern Chinese origin with one-sided glue ear and a neck lump	Nasopharyngeal carcinoma
Exposed jaw bone after a tooth extraction, past neck radiotherapy	Osteoradionecrosis
Shoulder drop and pain after neck dissection	Accessory nerve injury

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Exam-style Scenarios

1. A 52-year-old non-smoker has had a painless lump in the right upper neck for 6 weeks. It is 3 cm and partly cystic on ultrasound. Examination of the mouth looks normal.
Answer: Suspected metastatic HPV-positive oropharyngeal cancer.

• Suspected cancer pathway referral; nasendoscopy.
• Ultrasound-guided FNA or core biopsy with p16/HPV testing; avoid open excision.
• CT or MRI neck, CT chest, PET-CT if primary not found; examination under anaesthetic with tonsil and tongue base biopsies.

2. A 64-year-old smoker has had a hoarse voice for 8 weeks and left ear pain. The ear looks normal.
Answer: Suspected laryngeal (or hypopharyngeal) cancer with referred ear pain.

• Suspected cancer pathway referral to ENT for laryngoscopy.
• Urgent chest X-ray.
• Smoking cessation.

3. A 46-year-old woman has a slowly growing painless lump in front of her right ear for 2 years. Facial nerve function is normal.
Answer: Probable pleomorphic adenoma of the parotid.

• Ultrasound with FNA or core biopsy; MRI.
• Superficial parotidectomy (risk of facial nerve weakness, Frey syndrome).
• Explain the small risk of malignant change if left.

4. A 7-year-old has a smooth midline lump just below the hyoid that moves up when he sticks out his tongue.
Answer: Thyroglossal duct cyst.

• Ultrasound (confirm normal thyroid tissue elsewhere); TFTs.
• Sistrunk operation (cyst, track and middle of hyoid).

5. A man treated with chemoradiotherapy for tonsil cancer 3 years ago now has tiredness and weight gain. He also needs a lower molar removed.
Answer: Likely post-radiotherapy hypothyroidism; high risk of osteoradionecrosis.

• Check TFTs; start levothyroxine if hypothyroid; then yearly TFTs.
• Refer to a specialist (restorative or oral surgery) dentist for the extraction.
• Continue surveillance for recurrence and second primaries.

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Key Points

• A persistent neck lump in an adult over 40–45 is cancer until proven otherwise -suspected cancer referral.
• Examine the mouth, throat, ears, scalp and skin in every neck lump; ENT will do nasendoscopy.
• Ultrasound with FNA or core biopsy is first line; avoid open biopsy of a suspected squamous cell carcinoma node.
• Thyroglossal cyst moves with tongue protrusion; thyroid lumps move with swallowing.
• A "branchial cyst" in an adult over 35–40 may be a cystic HPV-positive cancer node.
• Carotid body tumours move side to side and shouldn't be biopsied.
• Submandibular stones cause swelling with meals; acute parotitis affects dehydrated frail patients.
• Most parotid tumours are benign (pleomorphic adenoma); facial weakness, pain, rapid growth or fixity suggest cancer.
• Head and neck cancer: smoking, alcohol and HPV; HPV-positive oropharyngeal cancer has a better prognosis.
• Persistent hoarseness, mouth ulcer over 3 weeks, one-sided sore throat or ear pain, and dysphagia are red flags.
• Glottic laryngeal cancer presents early with hoarseness and has a good prognosis.
• Nasopharyngeal cancer: Southern Chinese origin, one-sided glue ear, neck lump, cranial nerve palsies.
• After head and neck radiotherapy: dry mouth, dental decay, osteoradionecrosis, swallowing problems, hypothyroidism (yearly TFTs), carotid disease.
• HPV vaccination (single dose, boys and girls at 12–13) helps prevent oropharyngeal cancer.

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Guidelines and Further Reading

• NICE NG36: Cancer of the upper aerodigestive tract -assessment and management in people aged 16 and over
• NICE NG12: Suspected cancer -recognition and referral (head and neck, thyroid, lymphoma)
• ENT UK and the British Association of Head and Neck Oncologists (BAHNO): UK multidisciplinary guidelines for head and neck cancer
• UKHSA: HPV vaccination programme; mumps guidance
• NICE technology appraisals for pembrolizumab, nivolumab and cetuximab in head and neck cancer
• BNF -for current doses

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