What is the appropriate approach for a telephone call with a patient reporting a lump in her throat?

Telephone Approach for 57-Year-Old Patient with "Lump in Throat"

This patient meets high-risk criteria based on age alone (>40 years) and requires urgent in-person evaluation with imaging and specialist referral, not telephone management. 1

Immediate Telephone Assessment

Critical Red Flag Questions to Ask

Duration and characteristics:

• When did you first notice this sensation? Has it been present for more than 2-3 weeks? 2
• Is this an actual visible or palpable lump in your neck, or a sensation of something in your throat? 2
• Has it grown or changed in size? 2

High-risk symptoms requiring same-day/next-day evaluation:

• Voice changes or hoarseness? 2
• Difficulty or pain with swallowing (not just sensation)? 2
• Unilateral ear pain or hearing loss on the same side? 2
• Unexplained weight loss? 2
• Persistent sore throat that doesn't resolve? 2
• Coughing up blood or blood in saliva? 2
• Fever >101°F? 2

Cancer risk factors:

• Current or past tobacco use (amount and duration)? 2
• Alcohol consumption history (amount and duration)? 2
• Prior head and neck cancer or radiation exposure? 2
• Family history of head and neck cancer? 2

Distinguish functional from structural pathology:

• Can you swallow your saliva normally, or are you drooling? 2
• Does the sensation improve when you eat? (suggests globus pharyngeus) 2
• Do you have excessive throat clearing or sense of mucus buildup? 2

When to Schedule In-Person Examination

Schedule within 24-48 hours (urgent) if ANY of the following:

• Age >40 years (this patient already meets this criterion) 1
• Sensation present ≥2 weeks without fluctuation 2, 1
• Any of the red flag symptoms listed above 2
• Tobacco or alcohol use history 2, 1
• Actual palpable neck mass (not just sensation) 1

Schedule within 1 week if:

• Globus sensation with throat clearing but no other red flags 2
• Recent upper respiratory infection with persistent symptoms 2

Critical Pitfalls to Avoid

Do NOT prescribe empiric antibiotics over the phone without clear signs of bacterial infection (fever, purulent exudate, recent illness), as this delays cancer diagnosis. 2, 1

Do NOT reassure and dismiss based on telephone assessment alone in a patient >40 years old—this is a high-risk population requiring physical examination. 1

Do NOT assume this is "just globus" without excluding structural pathology first through direct visualization and palpation. 2

What the In-Person Examination Must Include

When the patient comes in, perform or arrange:

• Visual and digital examination of oral cavity (tongue, floor of mouth, tonsils) 2
• Neck palpation for masses >1.5 cm, firm consistency, or fixation 2, 1
• Visualization of larynx, base of tongue, and pharynx (may require flexible laryngoscopy by specialist) 2
• Skin and scalp examination for cutaneous malignancy 2
• Cranial nerve assessment if any neurologic symptoms 2

If high-risk features are confirmed on examination:

• Order contrast-enhanced CT or MRI of neck immediately 1
• Refer to ENT/head and neck specialist within days 1
• Do NOT perform open biopsy before imaging and specialist evaluation 1

Telephone Counseling Points

Explain to the patient now:

• Given your age and symptom duration, you need an in-person examination that cannot be adequately performed by phone 1
• This does not mean you have cancer, but we need to rule out serious causes 2
• The examination will include looking in your mouth and throat and feeling your neck 2
• You may need imaging (CT scan) and specialist referral depending on findings 1
• Do not delay this appointment—early evaluation improves outcomes if anything serious is found 2