Neck Lump Algorithm

Safety

Red Flags — Exclude Malignancy and Emergency Causes

Done

An unexplained neck lump in an adult should be assessed carefully for malignancy. Age, persistence, progression, site, associated symptoms and examination findings determine the urgency of referral. A soft or mobile lump does not exclude malignancy, particularly cystic metastatic disease.

Hard, fixed, non-tender or progressive lump Especially in a smoker/drinker. Refer promptly — do not observe for an arbitrary period → Suspected cancer: Head & Neck

Persistent unexplained neck lump Consider a suspected cancer pathway referral (NICE NG12): persistent unexplained neck lump in any adult (oral cancer); any unexplained neck lump at ≥45 (laryngeal cancer); unexplained thyroid lump (thyroid cancer) → Suspected cancer: Head & Neck / Thyroid

Associated dysphagia / odynophagia Neck lump with dysphagia or odynophagia requires urgent specialist assessment — select the head-and-neck or upper-GI pathway according to the site and nature of the swallowing difficulty; 999 if airway compromise or unable to swallow saliva → Suspected cancer: Head & Neck / UGI

Persistent unexplained hoarseness In adults aged 45 or over, consider a suspected cancer pathway referral (NICE NG12). Refer sooner if associated with a neck lump, dysphagia, haemoptysis or weight loss; stridor or airway compromise → 999/admit today → Suspected cancer: Head & Neck

Unexplained weight loss with neck mass → lymphoma or metastatic malignancy → Suspected cancer: Haematology or H&N

Unexplained lymphadenopathy or splenomegaly In an adult, consider suspected cancer referral even without B-symptoms. Record fever, night sweats, pruritus, weight loss, breathlessness and alcohol-induced node pain → Suspected cancer: Haematology

Airway compromise Stridor, drooling or inability to swallow saliva, muffled voice, rapidly progressive airway symptoms, severe respiratory distress, suspected deep-neck infection with systemic illness, anaphylaxis or collapse — e.g. Ludwig's angina or retropharyngeal abscess → 999

Rapidly enlarging lump Same-day hospital/ENT assessment if painful, febrile, fluctuant, systemically unwell, or with airway symptoms, neurological signs or vascular compromise → Same-day assessment. Rapidly enlarging painless thyroid or neck mass without emergency features → Suspected cancer pathway

Unexplained thyroid lump Consider a suspected cancer pathway referral (NICE NG12); higher concern if hard/fixed, hoarseness, previous neck radiotherapy or family history of medullary thyroid cancer → Suspected cancer: Endocrine/H&N

Supraclavicular node High risk. Aged ≥40: consider an urgent chest X-ray within 2 weeks (NICE NG12/local pathway) and consider suspected cancer referral by examination and symptoms. Do not assume the primary site from the side alone → Suspected cancer

New lateral cystic neck mass (adult) Not to be assumed a benign branchial cyst — cystic metastatic SCC (often HPV-related) can mimic it. Refer for specialist imaging/tissue diagnosis → Suspected cancer: Head & Neck

There is no general NICE rule that every neck lump presenting over 40 is malignant, but an unexplained adult neck lump needs careful assessment. NICE NG12 (updated April 2026) advises considering a suspected cancer pathway referral for a persistent unexplained neck lump at any age (oral cancer), for an unexplained neck lump at 45 and over (laryngeal cancer), and for an unexplained thyroid lump (thyroid cancer), and for unexplained lymphadenopathy or splenomegaly (lymphoma, weighing associated symptoms). NICE does not define a universal three-week observation period: a rapidly enlarging, hard, fixed or supraclavicular lump should not be observed, while a clearly improving reactive node with a documented infection may be reviewed clinically. B-symptoms (weight loss, fever, drenching night sweats) increase concern for lymphoma but are not required for referral. Ludwig's angina (spreading floor-of-mouth cellulitis) can close the airway within hours — stridor or drooling is a 999 emergency. Metastatic squamous cell carcinoma in a neck node may be the first presentation of an occult head and neck primary — prompt referral matters.

Diagnose

Focused History — Characterise the Lump and Patient Risk

Done

The most important diagnostic tool is a structured history. Risk factors + lump characteristics together drive urgency.

Duration and change

Hours/days = reactive lymphadenopathy or abscess. Weeks–months = lymphoma, malignancy. Years, static = benign cyst or lipoma

Age and sex

<20: reactive lymphadenopathy, congenital cysts (branchial/thyroglossal), lymphoma. 20–40: thyroid disease, lymphoma, reactive. >40: metastatic SCC, thyroid cancer, lymphoma

Smoking and alcohol

Both are major risk factors for head and neck SCC. Pack-year history. HPV-associated oropharyngeal cancer is rising, including in non-smokers. Betel nut/paan use where culturally relevant

Associated symptoms

Sore throat / ear pain / oral ulcer: head and neck primary. Dysphagia: oesophageal/hypopharyngeal. Otalgia (referred ear pain): tongue base or tonsil cancer. Haemoptysis: thyroid/lung

Constitutional features

Fever, night sweats, weight loss (B-symptoms) → lymphoma. Fatigue + lymphadenopathy in young → EBV/CMV

Travel / infections

TB: country of origin, TB contacts, BCG status. Cat scratch disease: animal contact + LAP in axilla/groin/neck. HIV risk factors

Thyroid symptoms

Hyperthyroid: palpitations, weight loss, heat intolerance, tremor. Hypothyroid: fatigue, cold intolerance, constipation. Lump moving on swallowing = thyroid origin

Previous malignancy / radiotherapy

Prior head and neck cancer, lymphoma, or cervical radiotherapy significantly increases risk of new malignancy

HPV-positive oropharyngeal SCC is rising in the UK and often presents as a neck node in a younger non-smoker — this group must not be falsely reassured by absence of risk factors. Referred otalgia (pain in the ear without visible ear cause) is a classic presentation of base-of-tongue or tonsillar carcinoma — always check the oropharynx. BCG status and TB contact history are essential in a UK context given the high rates of TB-related lymphadenopathy in immigrant communities. Cat scratch disease (Bartonella henselae) is a treatable cause of prolonged lymphadenopathy often missed without specific enquiry about animal contact.

Diagnose

Classify by Anatomical Location and Lump Character

Done

Location narrows the differential significantly. Combine with consistency and mobility to generate a working diagnosis.

Anterior triangle

Reactive lymphadenopathy (commonest); metastatic SCC; lymphoma; branchial cyst (2nd arch, anterior to SCM — in an adult a new lateral cystic mass must not be assumed benign); carotid body tumour (pulsatile, transmitted)

Posterior triangle

Lymphoma; metastatic cancer (especially from posterior scalp/neck primary); TB lymphadenitis; lipoma; accessory nerve neuroma

Midline

Thyroglossal duct cyst (moves on tongue protrusion and swallowing — suggestive, not pathognomonic); dermoid cyst; submental lymphadenopathy; thyroid isthmus

Thyroid region

Multinodular goitre; toxic adenoma; thyroid cancer (especially if hard/fixed/hoarse); Hashimoto's thyroiditis (diffuse, firm); thyroid cyst

Parotid / submandibular

Pleomorphic adenoma (benign, slow-growing); Warthin's tumour (bilateral, smokers); mucoepidermoid carcinoma; submandibular sialadenitis; calculus

Characteristics: Benign

Clearly defined; mobile; tender; recent onset with recent URTI; spontaneously reduces. Soft or mobile does not exclude malignancy

Characteristics: Malignant concern

Hard; fixed to skin or deep structures; non-tender; progressive enlargement; rubbery (lymphoma); multiple nodes; persistent or progressive without explanation

Cystic character

Fluctuant, transilluminates — branchial cyst, thyroglossal, dermoid. NB: metastatic SCC can be cystic (especially HPV-associated)

Location is the single most discriminating feature after age. A midline mass that moves with swallowing and tongue protrusion is suggestive of a thyroglossal duct cyst, but diagnosis requires specialist assessment if persistent or clinically uncertain. In an adult, a new lateral cystic neck mass should not be assumed to be a benign branchial cyst. Refer for specialist assessment and appropriate imaging/tissue diagnosis, particularly if persistent, enlarging or associated with smoking, HPV-related symptoms, otalgia, dysphagia or mucosal abnormality. Rubbery, matted lymphadenopathy in the posterior triangle is characteristic of lymphoma and should prompt consideration of a suspected cancer referral. Parotid lumps: most are benign (pleomorphic adenoma), but facial nerve involvement or rapid growth is strongly concerning for malignant or invasive disease.

Diagnose

Targeted Examination — Systematic Head and Neck Assessment

Done

A structured head and neck examination significantly changes management.

Lump characterisation

Exact site, side and cervical level; maximum dimensions (measure in mm, ideally in three dimensions); duration and growth rate; consistency (soft/rubbery/hard/fluctuant), borders (smooth/irregular), mobility, overlying skin changes (erythema/tethering/punctum), tenderness, fluctuation, transilluminability

Lymph node chains

Palpate systematically: submental → submandibular → anterior cervical → posterior cervical → supraclavicular → parotid → occipital → axillary. Examine all cervical node levels and both supraclavicular fossae. Document number, size, character

Oropharynx

Inspect with good light: oral cavity, tongue, floor of mouth, tonsils (asymmetry, mass), posterior pharynx, tongue base. Record flexible nasendoscopy findings if performed. Don't miss a mucosal primary

Cranial nerves

Examine and record cranial nerve findings (including VII, X, XI, XII) — a cranial neuropathy with a neck lump is a red flag

Thyroid gland

Inspect from front — visible goitre. Palpate from behind. Assess swallowing — thyroid moves on swallowing. Note nodularity, tenderness, bruit. Check for tracheal deviation

Lump mobility test

Swallowing → moves = thyroid/thyroglossal. Tongue protrusion → moves = thyroglossal cyst. Fixation to skin or deep structures increases concern for malignancy or invasive infection but is not diagnostic

Salivary glands

Bimanual palpation of submandibular gland (calculus). Parotid mass — assess facial nerve function (VII). Any weakness is strongly concerning for malignant or invasive disease → urgent referral

Supraclavicular fossa

High risk — may reflect lymphoma, head-and-neck, lung, breast or gastrointestinal malignancy, or infection. Do not assume the primary site from the side alone. Aged ≥40: consider an urgent chest X-ray within 2 weeks per NICE NG12/local pathway and consider suspected cancer referral

General

Hepatosplenomegaly and other nodal stations (axillary, inguinal) where lymphoma is possible, skin for rash or primary tumour (melanoma, SCC). Temperature if infective cause considered

Facial nerve weakness with a parotid mass is strongly concerning for malignant or invasive disease (e.g. perineural invasion) and needs urgent referral. The oropharyngeal examination is critical and often omitted in primary care — a missed tonsillar asymmetry or base-of-tongue mass causes delayed diagnosis of curable HPV-associated cancer. Supraclavicular nodes (including Virchow's node, Troisier's sign) are high risk but do not identify the primary site — lymphoma, head-and-neck, lung, breast and GI malignancy and infection are all possible. Bimanual palpation of the floor of mouth can reveal submandibular duct calculi that will not be apparent on external examination alone. Systematic palpation of all node chains prevents the common error of fixating on the presenting lump and missing more sinister distant disease.

Diagnose

Investigations — Targeted Bloods and Imaging

Done

Initial tests only where useful, depending on the presentation. Investigations must not delay suspected cancer pathway referral and are not a substitute for tissue diagnosis. Order in parallel, not sequentially.

FBC ± film + CRP/ESR Unexplained lymphadenopathy

Consider FBC with differential/blood film and CRP or ESR according to the clinical picture and local pathway; do not delay suspected cancer referral while awaiting results. Consider a very urgent FBC (within 48 hours) if features suggest leukaemia (generalised lymphadenopathy, hepatosplenomegaly, unexplained bruising, bleeding, petechiae, persistent fatigue or unexplained fever — NICE NG12). Atypical lymphocytes → EBV; mature lymphocytosis → CLL; pancytopenia + LAP → marrow infiltration

LDH, urate, U&E, LFTs Selected patients

Not a diagnostic lymphoma screen. Consider LDH, urate, renal function and liver function in patients with substantial, widespread or rapidly progressive lymphadenopathy, systemic illness or suspected haematological malignancy, usually in discussion with the haematology pathway

Paul-Bunnell / monospot

If infectious mononucleosis is clinically suspected, use the local laboratory EBV testing pathway. Interpret early negative tests cautiously — a negative result does not exclude EBV. Consider FBC, liver enzymes and alternative diagnoses according to the presentation

TSH ± FT4/FT3 Thyroid lump

TSH alone is generally the first test in adults (NICE NG145). If TSH raised, add FT4; if TSH suppressed, add FT4 and FT3. Ultrasound is not a generic thyroid test — it is indicated for palpable thyroid enlargement or focal nodularity when malignancy is suspected (NG145), using an established risk-stratification (U-grade) system with ultrasound-guided FNAC according to the result (NICE NG230), usually via the specialist/suspected cancer pathway. Don't delay referral waiting for TFTs

Chest X-ray Aged ≥40

Consider an urgent direct-access chest X-ray (within 2 weeks) for adults aged 40 and over with supraclavicular or persistent cervical lymphadenopathy (NICE NG12/local pathway), while considering suspected cancer referral on the wider clinical picture. May show mediastinal widening, hilar LAP or a lung primary

HIV test

Offer where clinically indicated (e.g. unexplained or generalised lymphadenopathy) or as part of local opt-out testing. Persistent generalised lymphadenopathy is a recognised HIV presentation

Mantoux / IGRA test

TB testing and referral only when epidemiology and clinical features support it (endemic country of origin, immunosuppression, TB contact). IGRA and Mantoux assess TB infection and do not exclude active TB (UKHSA). If tuberculous lymphadenitis is suspected, discuss urgently with the local TB service and pathology/microbiology team before sampling where possible. Diagnostic lymph-node aspirate or biopsy may be required; send specimens for histology, mycobacterial microscopy/culture and nucleic-acid amplification testing as advised (NICE NG33)

Do NOT order

Do not arrange CT, MRI, PET-CT or biopsy routinely for an unexplained neck lump if this would delay referral or duplicate the suspected cancer pathway — follow the local pathway; specialist teams usually arrange cross-sectional imaging and tissue diagnosis. Do not perform or arrange blind biopsy in primary care: tissue diagnosis should be image-guided via the head-and-neck, thyroid or haematology pathway (with microbiology, flow cytometry and/or mycobacterial studies as the specialist team advises if TB or lymphoma is possible). No tumour markers without indication

Investigations in neck lump are largely to characterise systemic disease and should not delay specialist referral for suspected malignancy. LDH is a prognostic marker once lymphoma is diagnosed (it forms part of the International Prognostic Index) rather than a diagnostic screen. Blind biopsy of a neck node risks inadequate sampling and, in TB lymphadenitis, sinus formation — but suspected TB nodes may still need aspirate or biopsy, coordinated with the TB and pathology teams (NICE NG33). Image-guided sampling in secondary care is the standard route to tissue diagnosis. Monospot/Paul-Bunnell tests have high false-negative rates in early infection and in children — a negative result does not exclude EBV in the first week.

Refer

Referral Criteria — Urgency and Destination

Done

Use NICE NG12 criteria. When in doubt, refer — the cost of over-referral is far less than missed malignancy.

999

Stridor or severe respiratory distress; drooling or inability to swallow saliva; muffled 'hot potato' voice; rapidly progressive airway swelling; suspected deep-neck abscess with airway risk; severe sepsis or haemodynamic instability; anaphylaxis (Ludwig's angina, epiglottitis, retropharyngeal abscess)

Same-day ED

Rapidly enlarging neck mass if painful, febrile, fluctuant, associated with systemic illness, airway symptoms, neurological signs or vascular compromise. A rapidly enlarging painless thyroid or neck mass (possible anaplastic thyroid cancer or lymphoma) without emergency features → urgent suspected cancer referral

Suspected cancer: Head & Neck

Consider a suspected cancer pathway referral (NICE NG12, updated April 2026): persistent unexplained neck lump at any age (oral cancer); unexplained neck lump or persistent unexplained hoarseness at ≥45 (laryngeal cancer). Refer promptly if unexplained, progressive, hard/fixed, supraclavicular, or with mucosal or neurological symptoms — do not delay to complete an arbitrary observation period. New lateral cystic neck mass in an adult (specialist assessment). Persistent parotid/submandibular swelling. Associated dysphagia/odynophagia (head-and-neck or upper-GI pathway by site), unilateral otalgia, oral ulcer, haemoptysis, weight loss or cranial neuropathy. All suspected head and neck SCC

Suspected cancer: Haematology

Unexplained lymphadenopathy or splenomegaly in an adult — consider suspected cancer referral even without B-symptoms (NICE NG12). Mediastinal widening on CXR. Lymphadenopathy + pancytopenia. Consider a very urgent FBC (within 48 hours) if features suggest leukaemia. Suspected Hodgkin's or NHL

Suspected cancer: Endocrine/H&N

Unexplained thyroid lump → consider a suspected cancer pathway referral (NICE NG12). Higher concern: hard/fixed nodule, hoarseness, rapid growth, previous neck irradiation, family history MEN2 / medullary thyroid cancer. Nodule size alone does not determine malignancy risk

Urgent routine ENT

Confirmed benign congenital cyst with no red flags (a new lateral cystic mass in an adult goes via specialist assessment, not assumed branchial). Thyroglossal cyst (surgical excision needed — Sistrunk procedure). Salivary calculus. Pleomorphic adenoma (non-urgent surgical removal)

Routine GP management

Reactive lymphadenopathy with a clear infective cause that is improving — document the presumed diagnosis, findings, review date and escalation criteria. Refer if not resolving as expected rather than repeating antibiotics

NICE NG12 (updated April 2026) advises considering 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, and for oral cancer in people with a persistent and unexplained lump in the neck. The key error in GP practice is watching a neck lump for too long — delays of weeks to months before ENT referral are a recurring finding in UK audits of head and neck cancer diagnosis. Thyroglossal duct cysts require the Sistrunk procedure (excision of cyst + central hyoid bone + tract to tongue base) — simple excision alone carries a higher recurrence risk. Pleomorphic adenoma, while benign, carries a risk of malignant transformation over time — elective surgical excision is usually recommended.

Treat

Primary Care Treatment — Infective and Benign Causes

Done

Most primary care management is conservative. Do not give antibiotics for an unexplained neck lump — only for a convincing acute bacterial infection. Avoid repeated antibiotic courses for an unexplained persistent mass.

Bacterial lymphadenitis

Antibiotic per current local antimicrobial guideline Only if convincing bacterial syndrome

Choice depends on source (including dental), severity, allergy, pregnancy and local guidance (e.g. Local antimicrobial guidance). Review within 48–72 hours if systemically unwell or within 5–7 days if managed in the community. Fluctuant abscess → same-day ENT for drainage rather than repeated antibiotics alone.

Infectious mononucleosis (EBV)

Supportive — no antibiotics

Manage supportively (paracetamol/ibuprofen for fever/pain). Avoid aminopenicillins when EBV is suspected unless there is a separate clear indication. Give activity advice based on clinical recovery and risk of splenic injury; seek specialist advice for abdominal pain, haemodynamic symptoms or suspected splenic rupture.

Reactive lymphadenopathy (viral URTI)

Watch and wait

Document the presumed benign diagnosis, examination findings, review date and explicit escalation criteria. Advise to return immediately if enlarging, hard, or associated red flags develop. Set safety-net clearly in writing. Refer if not resolving as expected.

Thyroid nodule (benign on USS)

Specialist risk-stratification pathway

Do not prescribe a fixed 12-month ultrasound schedule for all benign thyroid nodules. Follow the specialist ultrasound/FNAC risk-stratification pathway (NICE NG230). Repeat imaging if symptoms worsen, compression develops, malignancy becomes suspected or the specialist pathway recommends surveillance. Levothyroxine suppression not recommended.

TB lymphadenitisRefer suspected active TB urgently to the local TB service — do not initiate empirical TB treatment in primary care unless directed by the specialist TB team; treatment depends on microbiology, resistance, site, interactions and hepatic/renal function. Coordinate tissue sampling with the TB team. Active TB is notifiable — contact the local Health Protection Team according to local arrangements.

Hyperthyroid goitreRefer endocrinology. If clinically significant thyrotoxic symptoms are present, consider symptomatic treatment while awaiting specialist advice, using the local thyroid pathway and checking contraindications (asthma/COPD, heart failure, bradycardia/heart block, hypotension, pregnancy, interacting medicines). Definitive treatment is specialist-directed (NICE NG145). Do not delay urgent referral where malignancy or airway compromise is suspected.

Next steps: see Glandular fever · Haematological cancers · Hyperthyroidism

Antibiotic prescribing for reactive lymphadenopathy is common and inappropriate — most cases in children and young adults are viral. Aminopenicillins in EBV commonly cause a maculopapular rash (not true allergy) and should be avoided if mononucleosis is suspected unless there is a separate clear indication. Splenic rupture in EBV is rare and usually associated with contact sport or trauma — give individualised activity advice based on clinical recovery and splenic enlargement risk. Active TB is notifiable — contact the local Health Protection Team according to local arrangements. Empirical antibiotics for suspected TB lymphadenitis can sterilise the node and make microbiological diagnosis impossible.

Lifestyle

Health Promotion and Cancer Risk Reduction

Done

While the lump is under investigation, use the consultation as an opportunity for primary prevention of head and neck cancer — but do not allow prevention counselling to delay diagnostic referral.

Smoking cessation Tobacco is a major modifiable risk factor for head and neck SCC. Offer smoking cessation advice and signpost to the local NHS stop-smoking service.

Alcohol reduction Alcohol and smoking together markedly increase head and neck cancer risk. Offer alcohol-risk advice and signpost to local NHS services. Target: ≤14 units/week. Refer to alcohol service if hazardous use.

HPV vaccination status HPV is an important cause of oropharyngeal SCC. Check HPV vaccination status according to the current NHS programme and advise eligible patients who have not been vaccinated. HPV vaccination is prevention, not a treatment for an existing neck lump.

Safe oral practices Ask about betel nut/paan use where culturally relevant — a risk factor for oral SCC. Advise cessation. Regular dental check-ups for oral mucosal examination.

Symptom awareness Advise (as in the Step 9 safety-net): call 999 for breathing difficulty or inability to swallow saliva; same day for new hoarseness or voice change, new difficulty swallowing or a rapidly enlarging lump; book an urgent GP appointment for ear pain without ear cause, an oral ulcer >3 weeks, unexplained weight loss, drenching night sweats or new neck swelling.

Sun protection Lip SCC and skin primary with nodal metastasis — advise SPF ≥30 on face/neck, avoid midday sun, check moles. Melanoma can present as neck node.

Nutrition and immunity In EBV/reactive LAP: adequate fluids, rest, return to normal activity gradually. Advise no immune-suppressants (high-dose steroids) without specialist guidance in lymphoma.

Psychological support Investigation for suspected neck malignancy causes significant anxiety. Acknowledge this. Offer access to a cancer clinical nurse specialist (CNS) from the point of suspected cancer pathway referral where the local pathway provides one. Signpost Macmillan / CRUK.

Head and neck cancer incidence is rising in the UK, primarily driven by HPV-associated oropharyngeal cancer. Primary prevention and prompt referral of suspicious symptoms both matter, and patient symptom awareness helps avoid repeated consultations before referral. Betel nut/areca nut chewing is an under-recognised risk factor in British South Asian communities; oral submucous fibrosis is a direct precancerous consequence. HPV vaccination programme coverage remains suboptimal in catch-up cohorts — every consultation is an opportunity.

Safety

Follow-Up, Safety-Netting and Monitoring

Done

If you decide NOT to refer immediately, you accept responsibility for structured review. The safe observation period depends on the working diagnosis — a rapidly enlarging or unexplained mass should be referred immediately rather than observed.

If observing

Only for a presumed benign cause: document the presumed diagnosis, examination findings, review date and explicit escalation criteria. Review earlier if the lump enlarges, becomes hard/fixed, new symptoms develop or the patient becomes systemically unwell. If not resolving as expected → refer rather than repeatedly prescribing antibiotics

48–72 h / 5–7 days

Bacterial lymphadenitis on antibiotics — review within 48–72 hours if systemically unwell, or 5–7 days if managed in the community; confirm improving. Abscess formation (fluctuance) → same-day ENT drainage

EBV review

No routine FBC/LFTs for every patient. Review if symptoms are worsening or prolonged, jaundice develops, significant abdominal pain develops, there is marked thrombocytopenia or anaemia, diagnostic uncertainty remains, or lymphadenopathy persists or progresses. Reiterate individualised activity advice

Thyroid nodule

No routine "TSH every six months" or annual ultrasound for every benign thyroid lump unless part of a specialist-approved local pathway. Re-refer if symptoms worsen, compression develops or malignancy becomes suspected

Safety-net 999

Stridor or breathing difficulty; severe swelling, unable to swallow saliva; rapidly enlarging lump over hours; collapse or anaphylaxis

Safety-net same-day

Rapidly enlarging lump; new fever + increased pain or fluctuance; new hoarseness or voice change; new dysphagia; skin tethering appearing

Documentation

Document: lump size in mm (three dimensions), site, side, cervical level, character, growth rate. Date of first presentation. Safety-net advice given. Date of next review or suspected cancer pathway referral sent. Mandatory for medicolegal protection

Suspected cancer referral tracking

Record suspected cancer pathway referral date in notes. Check patient has received appointment. Local process (e.g. Local, not national guidance): contact the secretary if no response within 5 working days

The "watch and wait" approach in neck lumps is a common source of delayed diagnosis — NICE NG12 (updated April 2026) advises considering a suspected cancer pathway referral for a persistent unexplained neck lump (oral cancer) and, at age 45 and over, for an unexplained neck lump (laryngeal cancer); NICE does not set a universal three-week observation period — an unexplained, progressive or suspicious lump should be referred rather than watched. A second course of antibiotics for a non-resolving neck lump is inappropriate and causes diagnostic delay — this is a recurrent theme in head and neck cancer inquests. Documentation of lump size in mm at initial presentation is essential medicolegally — if the lump is later found malignant, a contemporaneous record of size demonstrates whether there was unreasonable delay. Many suspected cancer pathway referrals prove benign — this is acceptable given the consequences of missing malignancy.