Transformation Directorate

Using endoscopic mobile imaging to streamline head and neck cancer pathway referrals

2 week waiting (2WW) periods for a referral for suspected cancer had risen across all types of tumour, but the rate of cancers diagnosed remained the same.

Ear, nose and throat (ENT) clinicians felt increased pressure on the workforce and were struggling to keep on top of demand. This was made worse by pressures caused by COVID-19.

Some types of tumours have a high referral to diagnosis rate. In part because of images that inform patient assessments and referrals from primary care.

However, because of the vague and ambiguous symptoms associated with head and neck cancer, referrals were often high. GPs also lacked the appropriate tools to complete a more comprehensive assessment before referral.

Added to this, head and neck cancer is quite rare. This made it difficult for primary caregivers to pick up the subtle signs that point to cancer.


Throughout the COVID-19 pandemic, seeing patients face-to-face was not always possible.

Instead, risk calculators estimated the patient’s chance of having head and neck cancer. Details such as gender, smoking history and symptoms were put into the online calculator and users were given a probability percentage.

The tool split high and low-risk patients based on carefully analysed data collected from 10,000 patients.

Head and neck consultants could then prioritise high-risk patients and defer or reject low-risk patients.

This was acceptable at the height of the pandemic as it was assumed the pandemic would have a definite end point. However in the long-term, deferring or rejecting low-risk patients is unacceptable.

This approach also made clinicians anxious, as it was likely there were some cancers in the low-risk group which were missed.


The team wanted to create a new service using technology to support head and neck cancer diagnosis and exclusion in the community.


endoscope-i is a cloud-based smartphone app that combines the high-quality optics of endoscopes with the high definition of Apple iPhones. The app also has an adapter that securely fits an iPhone or iPad.

These high definition images are combined with a validated symptom score in the app. They are then sent securely through the cloud directly to the head and neck consultant for review.

Trained nurses perform the endoscopy in any primary or secondary healthcare setting. This means more patients are examined which increases the early diagnosis rates of head and neck cancer.

Images are still reviewed by the head and neck surgeon, ensuring the patient gets the best possible opinion despite having a virtual consultation.


Using this approach with low-risk patients, it takes an ENT consultant 1 minute to review the online consultation instead of 20 minutes.

Consultants now have more time to effectively pick out referrals presenting a high risk of cancer.

By reviewing low-risk patients using this new pathway, head and neck consultants can focus on seeing high-risk patients face-to-face much sooner. This significantly speeds up the diagnostic pathway, as cancer is found 4 to 5 times more frequently in a high-risk clinic.


The app:

  • works on iPhones
  • is cloud-based
  • takes high-quality endoscopic photos and videos with optimum focus and exposure
  • works with hospital patient records
  • stores images within patient records
  • is portable and secure


  • Patient history can be sent to clinicians.
  • The app enables communication between primary and secondary care for advice and guidance.
  • Videos can be stored and accessed for patients who are referred back into the pathway at a later date.


The app can be used:

  • by a trained healthcare practitioner
  • within a community or primary care setting
  • within a secondary care setting which has restricted access to endoscopy equipment

Key learning points

  • The service shows the importance of using an endoscope to help triage in primary care.
  • The 2WW risk calculator is helpful to a point but an endoscope is crucial for diagnosing a patient's condition and recording the findings. The software enables patients to seek an expert opinion remotely for their conditions.
  • The technology empowers primary and community clinicians to examine the patient and send the image to a consultant for a quicker diagnosis. This reduces pressure on secondary care.

Key figures

The team from University Hospitals North Midlands receives approximately 1,600 2WW referrals to ENT head and neck a year. Of these 1,600:

  • about 30% of referrals are for neck lumps
  • around 70% are sore throats, hoarse voices or conditions that could be investigated quickly using an endoscope

Find out more

Case study on streamlining 2WW suspected head and neck cancer referrals on the Wiley Online Library

Case study on remote digital otology referrals on the Wiley Online Library

Key contact

Mr Ajith George, Consultant ENT and Head and Neck Surgeon, University Hospitals of North Midlands

Mr Chris Coulson, ENT Consultant, Queen Elizabeth Hospital Birmingham