STEP 2: Presentation, initial investigations and referral

Signs and symptoms

The following signs and symptoms should be investigated if they persist for more than 3 weeks, especially if more than one symptom is present:

  • mouth ulcer or mass
  • unexplained tooth mobility and/or nonhealing dental extraction site
  • white or red patches of the oral mucosa – leukoplakia
  • persisting lip ulcers or patches
  • changes in the voice, such as hoarseness
  • persistent sore throat (particularly together with earache) or cough
  • difficulty or pain when swallowing or chewing
  • coughing up blood (including spitting up blood)
  • persistent unexplained neck or parotid lump or sore
  • pain, pressure, unilateral ringing in the ear or hearing loss
  • unilateral paralysis of the muscles in the face
  • unilateral numbness, tingling, pins and needles or formication (feeling of insects crawling on the skin)
  • unilateral blockage of the nose, especially if associated with swelling or other problems with the eyes such as
  • double vision
  • trismus (lockjaw) or reduced jaw opening
  • unexplained weight loss.

Initial investigations may include:

  • structural imaging with ultrasound, CT and/or MRI
  • ultrasound-guided fine-needle aspiration cytology (USgFNAC) of a node, if malignancy is suspected or a neck lump persists or grows (including lumps in the thyroid, salivary gland or lymph node).

Excisional biopsy of potentially malignant lesions should not be undertaken.

Appropriately trained practitioners can consider biopsy of a primary site, but this should not delay referral. Lymph nodes should not have incisional or excisional biopsy without specialist input.

Referral options

At the referral stage, the patient’s GP or other referring doctor should advise the patient about their options for referral, waiting periods, expertise, if there are likely to be out-of-pocket costs and the range of services available. This will enable patients to make an informed choice of specialist and health service.

Patients with head and neck cancer should only be referred to specialists who regularly participate in subspecialty head and neck multidisciplinary meetings. The patient must be informed about the improved outcomes achieved at centres that treat higher numbers of complex head and neck cases.


The GP’s responsibilities include:

  • explaining to the patient and/or carer who they are being referred to and why
  • supporting the patient and/or carer while waiting for specialist appointments
  • informing the patient and/or carer that they can contact Cancer Council on 13 11 20.



Signs and symptoms should be investigated if they persist for more than 3 weeks, especially if more than one symptom is present.

The first specialist appointment should take place within 2 weeks of the initial referral from the general or dental practitioner.