How should I approach a telephone call with a patient presenting with a lump in the throat, and what questions should I ask to determine the need for an office examination?

Telephone Assessment of "Lump in Throat" Complaint

This 57-year-old patient requires an urgent in-person examination within days, as age >40 years automatically places her at increased risk for malignancy and mandates thorough evaluation including visualization of the larynx and pharynx. 1

Immediate Telephone Triage Questions

Duration and Characteristics

• When did the sensation start, and has it been present for more than 2-3 weeks? A mass or sensation lasting ≥2 weeks without significant fluctuation is a high-risk feature requiring urgent workup. 2, 1, 3
• Is it constant or intermittent? Does swallowing food make it better or worse? Globus that improves with eating suggests functional etiology, while worsening with swallowing suggests structural pathology. 4, 5

Red Flag Symptoms Requiring Same-Day/Next-Day Evaluation

Ask specifically about each of these alarm features 2, 1:

• Voice changes or hoarseness (suggests laryngeal involvement)
• Difficulty or pain with swallowing (odynophagia/dysphagia) (suggests pharyngeal or esophageal pathology)
• Unilateral ear pain or hearing loss (referred pain from pharyngeal malignancy)
• Unexplained weight loss (systemic malignancy concern)
• Persistent sore throat (mucosal lesion)
• Coughing up blood or blood in saliva (urgent malignancy concern)
• Fever >101°F (infectious process)

Cancer Risk Factor Assessment

The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting 2, 1:

• Current or past tobacco use (quantity and duration)
• Alcohol consumption history (quantity and duration)
• Prior head and neck cancer or radiation exposure to head/neck
• Family history of head and neck cancer
• History of HPV-related risk factors (multiple sexual partners, oral sex)

Associated Symptoms

• Recent upper respiratory infection or illness? (suggests reactive lymphadenopathy if actual mass present)
• Visible or palpable neck mass? (if yes, this is a neck mass evaluation, not just globus)
• Mouth sores, tooth pain, or skin lesions on scalp/face/neck? (primary tumor sites) 2
• Nasal congestion or unilateral epistaxis? (nasopharyngeal involvement) 2

Decision Algorithm for In-Person Examination Timing

Schedule URGENT evaluation (within 1-3 days) if ANY of the following 1, 3:

• Age >40 years (this patient automatically qualifies)
• Any red flag symptom present
• Tobacco or alcohol use history
• Sensation present ≥2-3 weeks
• Prior head and neck cancer

Same-day/emergency evaluation if:

• Dyspnea, stridor, or respiratory distress 6
• Severe dysphagia with inability to swallow secretions
• Hemoptysis
• High fever with neck swelling (possible deep space infection)

What to Tell the Patient on This Call

Explain the necessity of in-person examination: "Given your age and the symptom you're describing, I need to examine your throat and neck in person to make sure we're not missing anything serious. While this could be something benign like reflux, we need to rule out more concerning causes." 1

Set clear expectations: "I'm going to schedule you for an appointment within the next few days. During that visit, I'll need to look in your mouth and throat with a bright light, feel your neck, and possibly look at your voice box. If I see anything concerning, I may need to order imaging or refer you to a specialist." 2, 1

Provide interim safety instructions: "If you develop difficulty breathing, severe trouble swallowing, or cough up blood before your appointment, go to the emergency department immediately." 6

Required In-Person Examination Components

When she comes in, the American Academy of Otolaryngology-Head and Neck Surgery mandates 2, 1:

• Visual and digital examination of oral cavity (remove dentures, inspect all surfaces, palpate floor of mouth and tongue)
• Neck palpation for masses (thyroid, lymph nodes—note that nontender masses are more suspicious for malignancy than tender ones)
• Visualization of larynx, base of tongue, and pharynx (requires laryngoscopy if not fully visualized with tongue depressor and light)
• Inspection of scalp, face, and skin for pigmented lesions or ulcerations

Critical Pitfall to Avoid

Do NOT prescribe empiric antibiotics or proton pump inhibitors over the phone without examination. This delays cancer diagnosis if malignancy is present. 3 While gastroesophageal reflux is a common cause of globus 4, 5, the patient's age >40 years mandates ruling out malignancy first through direct visualization. 1

Next Steps After In-Person Examination

If high-risk features are confirmed on examination, order contrast-enhanced CT or MRI of the neck and refer to ENT/head and neck specialist within days. 1, 3 If examination is incomplete (cannot visualize base of tongue, larynx, or pharynx adequately), refer to specialist for flexible laryngoscopy. 2