A unilateral neck lump gets a careful examination on the side it is on. The contralateral neck, the nasopharynx and the base of tongue frequently do not, because the finding that brought the patient in has already organised the consultation.
Make the sequence fixed rather than led by the complaint: both necks by level, the oral cavity including the floor of mouth and the tongue base by palpation, then flexible nasendoscopy including the postnasal space and both pyriform fossae. Palpating the tongue base is the step most often skipped and the one that most often finds the primary in a patient presenting with a node. In a smoker or a betel-quid chewer with a level II node and no obvious primary, an incomplete examination is what delays the diagnosis by a clinic cycle.
Record what you examined and found normal, not only what was abnormal. A letter that says 'right level II node, 3 cm' tells the next clinician nothing about whether the tongue base was felt.
- Examine both sides of the neck by level, every time.
- Palpate the tongue base and the floor of mouth; do not rely on inspection.
- Include the postnasal space and both pyriform fossae on nasendoscopy.
- Ask about betel quid, areca nut and smokeless tobacco separately from smoking.
- Record the normal findings as well as the abnormal ones in the letter.
Why it matters
The presenting lump organises the consultation, and the primary is usually somewhere the complaint did not point you.
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