Synopsis
Recognise persistent mucosal and neck-node presentations, protect the airway and nutrition, obtain diagnosis without compromising the neck, stage HPV- and site-specific disease and coordinate curative or palliative multidisciplinary treatment.
- Persistent unexplained oral ulceration, unilateral throat symptoms, hoarseness, dysphagia, referred otalgia or adult neck lump requires urgent head-and-neck assessment; pain is not required.
- First-line specialist assessment is full oral and neck examination plus flexible nasendoscopy; image and sample a suspicious node without proceeding to an unplanned open neck biopsy.
- Ultrasound-guided fine-needle aspiration is often the first nodal sample; core biopsy is useful when cytology is non-diagnostic or lymphoma is possible.
- The diagnostic reference standard is adequate histology from the primary or metastatic node, with p16 testing for oropharyngeal squamous cancer and other site-directed viral testing when appropriate.
- Contrast CT or MRI defines local and nodal anatomy; PET-CT is used for selected advanced staging, an occult primary and post-chemoradiotherapy response assessment.
- Do not begin treatment before airway, dental, nutrition, speech-and-language, hearing, renal, performance and psychosocial assessment have been integrated by the specialist MDT.
- Early disease may be treated with one modality, usually transoral or open surgery or radiotherapy; locally advanced disease commonly needs surgery plus risk-adapted adjuvant therapy or definitive chemoradiotherapy.
- Cisplatin is a key radiosensitiser for eligible patients, but renal impairment, hearing loss, neuropathy and frailty may make another regimen or radiotherapy alone safer.
- HPV-positive oropharyngeal cancer has a better average prognosis, but smoking history, anatomical stage and patient factors still matter and HPV status does not justify off-protocol de-escalation.
- Rehabilitation, smoking and alcohol support, oral care, swallowing exercises and late-effect surveillance are components of cancer treatment, not optional extras.
Key red flags
Stridor, drooling, tripod posture, cyanosis, exhaustion or reduced consciousness indicates critical upper-airway obstruction.
Persistent unexplained neck lump, oral ulcer, unilateral throat pain, dysphagia, odynophagia, hoarseness or referred otalgia requires urgent cancer assessment.
A pulsatile sentinel bleed from mouth, neck wound or tracheostomy can precede carotid blowout and needs immediate specialist haemorrhage planning.
Trismus, cranial-nerve deficit, Horner syndrome, fixed nodal disease or severe deep pain suggests skull-base, neural or carotid-space invasion.
Weight loss, dehydration, aspiration, recurrent chest infection or inability to swallow medication requires same-day nutritional and airway assessment.
Stridor, secretion intolerance, rapid respiratory fatigue or sentinel tumour bleeding requires immediate multidisciplinary rescue rather than routine clinic investigation.
Investigation priorities
Inspect all accessible mucosa, vocal-cord movement and the upper airway and identify a primary or synchronous lesion.
Obtain cytology from a suspicious cervical node while defining its solid, cystic and vascular features.
Management branches
The patient has stridor, secretion intolerance, respiratory fatigue, expanding swelling or major bleeding.
- Call senior anaesthesia and head-and-neck surgical teams and move to a monitored area while keeping the patient upright, calm and oxygenated with suction available.
- Agree a primary airway or haemorrhage plan and a failed-plan rescue before sedation, transfer or instrumentation; use theatre and interventional radiology support where indicated.
- After physiological control, obtain targeted imaging and biopsy without delaying definitive airway, embolisation, surgery, antibiotics or transfusion required for the emergency.