Tag: hoarseness

Lung, Suspicion of Cancer Referral

Scott McLaughlin
Lung Cancer

More than 90% of patients with lung cancer are symptomatic at the time of diagnosis. However, many symptoms associated with lung cancer (particularly cough and fatigue) are common presentations in primary care, associated with chronic diseases such as chronic obstructive pulmonary disease (COPD). It is therefore important that changes in symptoms are identified and acted upon.

Chest x-ray findings are abnormal in over 96% of symptomatic patients with lung cancer. In most cases where lung cancer is suspected, it is appropriate to arrange an urgent chest x-ray before urgent referral to a chest physician. However, a normal chest x-ray does not exclude a diagnosis of lung cancer. If the chest x-ray is normal but there is a high suspicion of lung cancer, patients should be offered urgent referral to a respiratory physician. In patients with a history of asbestos exposure, mesothelioma should be considered.

Urgent chest x-ray

Any haemoptysis

Unexplained/persistent (more than 3 weeks)

  • change in cough
  • dyspnoea
  • chest/shoulder pain
  • weight loss
  • chest signs
  • hoarseness
  • fatigue in a smoker over 50 years

Finger Clubbing

Features suggestive of metastatic disease

Cervical and/or persistent supraclavicular lymphadenopathy

Any person who has been referred for an urgent chest x-ray and has been found with consolidation should have a repeat chest x-ray no more than 6 weeks later to confirm resolution.

Urgent suspicion of cancer referral

Any symptoms or signs detailed above persisting for longer than 6 weeks despite a normal chest x-ray.

Chest x-ray suggestive/suspicious of lung cancer (including pleural effusion, pleural mass and slowly resolving consolidation)

Persistent haemoptysis in smokers/ex-smokers over 50 years of age

Mesothelioma

In mesothelioma, 80 – 90% of patients will have a history of asbestos exposure and it is essential that a career history is taken to identify any possible asbestos exposure.

Urgent suspicion of cancer referral

Individuals over 50 years with history of asbestos exposure and recent onset of:

  • chest pain
  • dyspnoea
  • unexplained systemic symptoms

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN 137: Management of Lung Cancer
Lead Cancer Clinician: Dr Stuart Baird, Lead Physician for Lung Cancer NHS Lanarkshire
Review Date April 2017

Head and Neck, Suspicion of Cancer Referral

Scott McLaughlin

Head and Neck Cancers

The incidence of head and neck cancer is increasing and around 1,200 people are diagnosed with a head and neck cancer each year in Scotland, of which around 240 are thyroid cancers. The incidence of oropharyngeal cancer is increasing in the younger population, and appears to be associated with human papilloma virus (HPV) infection.

Risk factors for head and neck cancers (excluding thyroid) include: smoking, HPV, alcohol, poor diet, social deprivation, tobacco chewing habits (including Betel, Gutkha and Pan) and older age. The risk of developing nasopharyngeal cancer is higher in patients of Chinese origin and a higher index of suspicion should be used in these patients.

All patients with features suspicious of malignancy should be referred to a team specialising in the management of head, neck or thyroid cancers, depending on local arrangements

With the changing pattern of disease, age, non-smoking or non-drinking status should not be a barrier to referral.

Emergency Referral

Stridor

Urgent suspicion of cancer referral

Head and Neck Cancer
  • Persistent unexplained head and neck lumps for >3 weeks.
  • Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks.
  • All red or mixed red and white patches of the oral mucosa persisting for >3 weeks.
  • Persistent hoarseness lasting for >3 weeks (request a chest x-ray at the same time).
  • Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks.
  • Persistent pain in the throat lasting for >3 weeks.
Thyroid Cancer
  • Solitary nodule increasing in size.
  • Thyroid swelling in a pre-pubertal patient.
  • Thyroid swelling with one or more of the following risk factors:
    • neck irradiation
    • family history of endocrine tumour
    • unexplained hoarseness
    • cervical lymphadenopathy.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 90 – Diagnosis and Management of Head and Neck Cancer
Clinical Lead Mr Andrew Carton, Head and Neck Surgeon, Monklands DGH
Review Date March 2017

ENT Cancer Referral

Scott McLaughlin

Consider referral to ENT when the patient presents with any of the following signs or symptoms:

  • Hoarseness persisting for more than 3 weeks
  • High dysphagia persisting for more than 3 weeks
  • Unresolved neck masses for more than 3 weeks
    • (** Also refer to Monklands or Hairmyres Hospital for ultrasound and or FNA **)
  • Persistent unilateral unexplained throat pain
  • Unilateral nasal obstruction particularly when associated with purlent discharge
  • Unexplained ear pain particularly with any of the above

Stridor should be referred as an emergency

Consider referral to Maxillofacial when the patient presents with any of the following signs or symptoms:

  • Ulceration of oral mucosa persisting for more than 3 weeks
  • Oral swellings persisting for more than 3 weeks
  • All red or red and white patches of the oral mucosa
  • Unexplained tooth mobility not associated with peridontal disease

Consider referral to Ophthalmology when the patient presents with any of the following signs or symptoms

  • Orbital masses

Consider referral to General Medicine when the patient presents with any of the following signs or symptoms

  • Cranial neuropathies

CCI Guidelines

The CCI Referral Guidelines can be found at ENT Referral Pathways.