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With significant increase in head and neck cancer in the last decade, attributed to HPV, fast-track referrals from primary care have markedly increased, adding further to the burden on the NHS. Whether or not unilateral tonsillar enlargement alone, without red flag symptoms indicates a serious cancer possibility, is the question flagged up in this study. Of nearly 5000 referrals over two years, 1.9% (95) patients presented with unilateral tonsillar enlargement. Of these, 35.8% were diagnosed as benign in the first clinic; 6.3% were followed up for observation. Urgent imaging alone diagnosed one, and three were diagnosed by biopsy under local anaesthesia. Six were diagnosed by tonsillectomy, carried out in 32 patients. Thus, out of 95 referrals, 10 proved to have malignancy, five having SCC and the other five lymphoma. Cancer was found only in those patients who presented with ‘red flag’ symptoms additional to unilateral tonsillar enlargement, such as tonsillitis, neck lump, sore throat, persistent hoarseness, otalgia and feeling of something in the throat. None of the patients presenting with only unilateral tonsillar enlargement had cancer. This evokes a thought whether those without the six red flag symptoms even merit a fast-track referral. However, such a distinction may be difficult at primary care level for excluding a potentially serious condition.

The isolated symptom of unilateral tonsillar enlargement has a limited value in adults with a suspected head and neck cancer pathway.
Lau KL, Rajgor A, Muzzamil A, et al.
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Madhup K Chaurasia

Mid and South Essex NHS Foundation Trust, UK.

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