“It’s just a gland up from a cold — it’ll go down, won’t it?”

A neck lump persisting beyond about 3–4 weeks is UNEXPLAINED — a reactive node from a cold settles within 2–3 weeks — and must be taken seriously, examined and routed, not assumed to be a post-viral "gland". The examinable danger here is the HIGH-RISK head & neck profile: a heavy smoker and drinker (synergistic risk factors for head & neck squamous cell cancer) with a persistent neck lump PLUS a few weeks of hoarseness/throat discomfort. NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026): 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; consider one for oral cancer (persistent unexplained neck lump) and thyroid cancer (unexplained thyroid lump); consider one for lymphoma with unexplained lymphadenopathy, taking B symptoms and alcohol-induced node pain into account (an FBC is a baseline, not the NG12 route); and consider an urgent chest X-ray at 40 and over with persistent cervical lymphadenopathy (lung). Arrange a face-to-face examination of the neck, mouth, oropharynx and thyroid; screen the broader differential (reactive, haematological, thyroid, benign) rather than labelling it benign from the chair; and address smoking and alcohol with brief intervention, not a lecture. The hidden agenda is avoidance — a self-employed man who never attends, doesn’t want to lose the business or hear bad news, minimising a lump and a hoarse voice he has half-noticed, with the spouse’s push the reliable signal. Elicit the downplayed symptoms, refer urgently with honesty but no panic, support the risk factors, and safety-net and follow up.