Head and neck and thyroid cancers

Scottish referral guidelines for suspected cancer
Centre for Sustainable Delivery

Emergency (same day) referral

Head and neck or thyroid cancer:

Refer any person presenting with upper airway compromise (e.g. stridor) as an emergency (same day).

 

Urgent suspicion of cancer (USC) referral

Head and neck cancer:

Refer a person with any of the following unexplained clinical features lasting three weeks or more to the Head and Neck Service as a USC:

  • 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)
  • Red or mixed red and white patches of the oral mucosa (not oral thrush)
  • Ulceration or swelling/induration of the oral mucosa
  • Neck or parotid lump

 

Thyroid cancer:

Refer a person with a thyroid nodule, and one or more of the following features to the Head and Neck Service as a USC:

  • Nodule rapidly increasing in size
  • Associated unexplained hoarseness
  • Associated cervical lymphadenopathy
  • Previous neck irradiation
  • Family history of endocrine tumours
  • Person aged 16 years or under

 

Assessment of suspected head and neck cancers

Assessment of a person presenting with head and neck symptoms should include examination of the neck to ascertain the position, mobility and consistency of any neck lump. 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. Intradermal lumps, which are often sebaceous cysts and lipomas, 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.

It is helpful to ask about drug use as well as smoking and alcohol intake as laryngeal cancer is seen in younger patients who use recreational drugs. It is also helpful to document any pain on swallowing which radiates to the ear (in the absence of any infection) as this can be a sign of malignancy.

Good practice points

Changing pattern of disease:

For head and neck cancers (not thyroid) there is a changing pattern of disease (in particular HPV associated cancers). Younger age and absence of smoking or alcohol history should not be barriers to referral if there are concerning features as described above.

 

Neck lumps:

It is crucial that a good description of any neck lump is given in the referral to secondary care. Key features to cover are the position, size, shape, consistency, mobility and overlying skin changes. Sebaceous cysts and lipomas do not require referral to head and neck services. Small, mobile, and rubbery lumps are likely to be reactive lymph nodes and in the absence of the above concerning features can be followed up clinically or assessed by a neck USS in the first instance, where available.

Thyroid nodules that do not have the features described in the USC referral section above can be referred as non-USC for further assessment.

 

Symptom combinations:

The PPV for single symptoms in head and neck cancer are lower than the 3% threshold set as a baseline in this guide. Hoarseness is the only symptom that nears the threshold at 2.7% for laryngeal cancer.

Symptom clusters can be useful in identifying those at 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.

 

Risk calculator:

A head and neck risk calculator46 can be used to triage in secondary care but has not been validated for use in primary care.

 

Overlap with other pathways:

There is overlap between lung cancer and head and neck cancer symptoms, particularly in those with hoarseness (caused by recurrent laryngeal nerve palsy in lung cancer). Please see the Lung and pleural cancer referral guideline for when to arrange a chest X-ray.

Dysphagia should be referred in line with the Upper gastrointestinal cancer guideline in the absence of any of the symptoms above.

 

Dental practitioners:

Dentists play a key role in the identification of head and neck cancers. There should be systems in place for USC referral pathways for dentists. If there is any uncertainty about the significance of an abnormality in the mouth it may be appropriate to seek a General Dental Practitioner (GDP) opinion in the first instance. This should be done as quickly as possible, with a direct referral made for any significant concern.

 

Rare head and neck cancers:

Sinonasal and ear cancers are rare. The associated clinical features include progressive or new unilateral nasal obstruction in association with one or more of proptosis, epistaxis, dental pain or loosening dentures, cranial nerve palsy or nasal (not facial) pain. However, sinus and nasal symptoms are common presenting features in primary care and are frequently benign (e.g. rhinosinusitis or benign nasal polyps). If there is concern that there is a nasal or paranasal cancer a USC referral should be made to the Head and Neck Service.

 

Background

Head and neck cancer:

This is an umbrella term encompassing multiple types of cancer including pharynx (oropharynx, hypopharynx, nasopharynx), larynx, oral cavity, nasal, paranasal, and salivary gland.

Approximately 1,400 head and neck cancers are diagnosed each year in Scotland1. Incidence for head and neck cancer rises from the age of 35 (more than 99% of new cases are aged 35 years or over) and there are over twice as many cases in males compared with females1.

Groups with worse outcomes and higher rates of emergency presentation include people from more deprived areas, those from ethnic minority groups, older people, and those with multiple comorbidities41-44.

Risk factors for head and neck cancers 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).

 

Thyroid cancer:

People with suspected thyroid cancer are referred to the Head and Neck Service. There are around 320 new cases of thyroid cancer a year in Scotland1. Thyroid cancers can occur at any age and are more common in females and those with a history of neck irradiation1,45.