• A patient who presents with symptoms suggestive of head and neck or thyroid cancer should be referred to an appropriate specialist or the neck lump clinic, depending on local arrangements (D).
• Any patient with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made should be referred or followed up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, an urgent referral should be made (D).
• Primary healthcare professionals should advise all patients, including those with dentures, to have regular dental checkups (D).

• An urgent referral should be made for a patient who presents with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are:
• Painful, or
• Swollen, or
• Bleeding
• A non-urgent referral should be made in the absence of these features. If oral lichen planus is confirmed, the patient should be monitored for oral cancer as part of routine dental examination* (C).
• In patients with unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks, an urgent referral should be made (C).
• In adult patients with unexplained tooth mobility persisting for more than 3 weeks, an urgent referral to a dentist should be made (C).
• In any patient with hoarseness persisting for more than 3 weeks, particularly smokers 50 years of age and older and heavy drinkers, an urgent referral for a chest X-ray should be made. Patients with positive findings should be referred urgently to a team specialising in the management of lung cancer. Patients with a negative finding should be urgently referred to a team specialising in head and neck cancer (C).
• In patients with an unexplained lump in the neck which has recently appeared or a lump which has not been diagnosed before that has changed over a period of 3 to 6 weeks, an urgent referral should be made (C).
• In patients with an unexplained persistent swelling in the parotid or submandibular gland, an urgent referral should be made (D).
• In patients with unexplained persistent sore or painful throat, an urgent referral should be made (D).
• In patients with unilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but with normal otoscopy, an urgent referral should be made (D).

*See NICE guideline on Dental recall: recall interval between routine dental examinations (www.nice.org.uk/CG019) [NICE, 2004].

• With the exception of persistent hoarseness, investigations for head and neck cancer in primary care are not recommended as they can delay referral (D).

• In patients presenting with symptoms of tracheal compression including stridor due to thyroid swelling, immediate referral should be made (D).
• In patients presenting with a thyroid swelling associated with any of the following, an urgent referral should be made: (D)
• 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) patients
• Patients 65 years of age and older
• In patients with a thyroid swelling without stridor or any of the features listed above, the primary healthcare professional should request thyroid function tests. Patients with hyper- or hypothyroidism and an associated goitre are very unlikely to have thyroid cancer and could be referred, non-urgently, to an endocrinologist. Those with goitre and normal thyroid function tests who do not have any of the features listed above should be referred non-urgently (D).
• Initiation of other investigations by the primary healthcare professional, such as ultrasonography or isotope scanning, is likely to result in unnecessary delay and is not recommended (D).

The referral timelines used in this guideline are as follows:

• Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
• Urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks).
• Non-urgent: all other referrals.