Urgent referral:

• an unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
• an unexplained persistent swelling in the parotid or submandibular gland
• an unexplained persistent sore or painful throat
• unilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but a normal otoscopy
• unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks
• unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleeding.

For patients with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, make an urgent referral.

Refer urgently to a dentist patients with unexplained tooth mobility persisting for more than 3 weeks

Refer urgently for chest X-ray patients with hoarseness persisting for more than 3 weeks, particularly smokers aged older than 50 years and heavy drinkers.

• if there is a positive finding, refer urgently to a team specialising in the management of lung cancer. If there is a negative finding, refer urgently to a team specialising in head and neck cancer

Refer non-urgently a patient with unexplained red and white patches of the oral mucosa that are not painful, swollen or bleeding (including suspected lichen planus)

Refer immediately patients with symptoms of tracheal compression including stridor due to thyroid swelling

Refer urgently patients with a thyroid swelling associated with any of the following:

• a solitary nodule increasing in size
• a history of neck irradiation
• a family history of an endocrine tumour
• unexplained hoarseness or voice changes
• cervical lymphadenopathy
• very young (pre-pubertal) patient
• patient aged 65 years and older

Notes:

• request thyroid function tests in patients with a thyroid swelling without stridor or any of the features listed above. Refer patients with hyper- or hypothyroidism and an associated goitre, non-urgently, to an endocrinologist. Patients with goitre and normal thyroid function tests without any of the features listed above should be referred non-urgently
• the level of suspicion is further increased if the patient is a heavy alcohol drinker or heavy smoker and is aged over 45 years and male. The chewing of tobacco (called Gutkha in India) or the chewing of Paan Masala or Betel should also increase the level of suspicion (2)
• hoarseness
  • the previous NHS Urgent Cancer referral guidance also suggested urgent referral if voice hoarseness persisted for greater than six weeks (2)
  • local guidance may vary with respect to length of duration of hoarseness before a two week referral should be initiated - Coventry PCT suggest more than three weeks duration requires a two week referral (3)

Reference:

1. NICE (June 2005). Referral Guidelines for Suspected Cancer
2. Referral Guidelines for Suspected Cancer (April 2000). NHS Executive.
3. Coventry PCT (2007). Head and neck cancer - two week referral guidance.