Head and neck cancer: red flags and urgent referral
- Topic
Some mouth, throat, voice, ear and neck symptoms that do not go away can be an early sign of cancer and need a specialist's look soon.
What it is
Most head and neck cancers start in the lining of the mouth, throat, larynx, nose and sinuses, and the first symptoms look like common, harmless complaints. What makes them suspicious is that they persist, are on one side only and occur in a person with risk factors (tobacco, alcohol, HPV for the oropharynx, EBV for the nasopharynx). This page lists the red flags by site and says who refers, how fast and what not to do while waiting. The disease itself is on the condition pages.
Red flags by site (persistent, usually one-sided)
| Site | Red flag | Think of |
|---|---|---|
| Oral cavity | Non-healing ulcer, red or white patch, lump, loose teeth or dentures that no longer fit, numbness of tongue | Oral cavity carcinoma |
| Oropharynx | Persistent sore throat, pain on swallowing, earache, neck lump | Oropharyngeal carcinoma (often HPV-related) |
| Larynx | Persistent hoarseness, stridor or difficulty breathing, earache | Laryngeal carcinoma |
| Hypopharynx and oesophagus | Progressive dysphagia, pain on swallowing, weight loss | Hypopharyngeal or oesophageal carcinoma |
| Nasopharynx | Neck lump, one-sided ear fullness or hearing loss (middle ear fluid), nasal blockage, nosebleeds | Nasopharyngeal carcinoma (EBV) |
| Nose and sinuses | One-sided nasal blockage that does not clear, bloody discharge, eye problems, upper tooth pain | Sinonasal carcinoma |
| Neck | Firm, painless, growing lump, especially in a smoker or drinker | Lymph node metastasis |
In clinical practice
- Treating a red flag with repeated courses of antibiotics or reflux medicine without looking at the larynx or pharynx delays diagnosis; guidelines advise against antireflux medicine or corticosteroids for hoarseness before the larynx is seen.
- Imaging is not the first step for a voice complaint: the larynx is looked at first (laryngoscopy), then imaging if needed.
- An adult with fluid behind one eardrum and no recent cold needs the nasopharynx examined.
Next step / Initial management
- Examine the whole mouth (lift the tongue, palpate the floor of the mouth), the oropharynx and the neck in every patient with a persistent complaint; record size and location of any lesion.
- Ask about tobacco, alcohol, weight loss and how long the symptom has lasted; a symptom present for more than two weeks without a clear cause counts as persistent.
- Do not perform an open biopsy of a neck lump in primary care; fine-needle aspiration and the search for the primary are done by the specialist.
- Refer urgently (same week, through the suspected-cancer route of the health insurer) to otolaryngology or head and neck surgery: persistent oral ulcer or patch, hoarseness over 4 weeks, unexplained neck mass, one-sided otalgia with a normal ear, one-sided nasal blockage with bleeding.
- Refer the same day to the emergency service if there is stridor, breathing difficulty or inability to swallow saliva.
Test yourself
Think of the answer, then tap the question to see it.
A 58-year-old smoker has had hoarseness for 6 weeks without a cold. What is the next step?
Laryngoscopy (or referral to someone who can do it): hoarseness that does not improve within 4 weeks needs the larynx visualised, sooner in a smoker.
A 50-year-old man has right earache; the ear canal and eardrum are normal. What must be examined?
The oropharynx, hypopharynx and larynx: earache with a normal ear can be referred pain from a tumour of the throat or larynx.
An adult has new fluid behind one eardrum and a neck lump. Which cancer is suspected?
Nasopharyngeal carcinoma: a tumour near the opening of the auditory tube blocks it and causes middle ear fluid; it is linked to Epstein-Barr virus.
Why should an open biopsy of a suspicious neck lump in an adult be avoided as the first step?
Because it may be a metastasis from a head and neck primary; the primary is searched for first (endoscopy, imaging, fine-needle aspiration) and open surgery comes only after.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Oral Cancer (National Institute of Dental and Craniofacial Research (NIH), 2024); Head and Neck Cancers (National Cancer Institute (NIH), 2021); Clinical Practice Guideline: Hoarseness (Dysphonia) (Update) Executive Summary (Otolaryngol Head Neck Surg) (PubMed, US National Library of Medicine, 2018); HPV and Oropharyngeal Cancer (Centers for Disease Control and Prevention (CDC), 2024); Laryngeal Cancer (StatPearls (NCBI Bookshelf), 2024).
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Representative model, for educational purposes only.