Head and Neck Cancer Symptoms: Red Flags and Referral

The red flag symptoms of head and neck cancer are a non-healing red or white mouth ulcer lasting more than 2 to 3 weeks, progressive difficulty or pain on swallowing, referred ear pain, nasal obstruction with bleeding, a persistent, hard or enlarging neck lump, and persistent hoarseness, stridor or unexplained weight loss. Any of these warrants a focused examination and prompt specialist referral, not another course of antibiotics.

Dr. Priyanka Raina, Senior Consultant (Head & Neck Surgery) - Surgical Oncology, Artemis Hospitals, Gurugram, India, built her teaching for first-contact doctors around three skills: recognising red flags, examining the mouth and neck systematically, and referring at the right speed. This article sets out each, along with her advice for doctors who work without PET-CT or MRI. For the wider picture of the specialty, see the complete guide to head and neck oncology.

Head and neck cancer symptoms that need immediate attention

Dr. Raina defined red flags as symptoms that deserve immediate attention and action:

• A non-healing ulcer, red or white, present for 2 to 3 weeks and not responding to symptomatic medication.
• Progressive dysphagia (difficulty swallowing), with or without odynophagia (pain on swallowing) or referred ear pain (otalgia).
• Nasal obstruction with bleeding, with or without pain transmitted to the head or ear.
• A neck mass that persists, especially an enlarging, hard or fixed lump.
• Persistent hoarseness, stridor or unexplained weight loss.

How cancers present by site

Different subsites announce themselves differently. Oral cavity malignancies, the most common, present as ulcers or growths in the mouth. Nasopharyngeal carcinoma typically presents with a cluster of nasal obstruction or nosebleed (epistaxis), hearing loss and a neck mass. Laryngeal and hypopharyngeal cancers present with stridor, hoarseness or difficulty swallowing.

What patients actually say at first contact

In the Q&A, Dr. Raina pointed out that the first complaint brought to a general practitioner or a dentist is usually a persistent toothache, a mobile tooth, a foreign body sensation in the throat or constant ear pain. In the mouth, the warning signs are a tooth that becomes mobile without another explanation, a growth that will not heal with any ointment or medication, or ear pain with something at the base of the tongue. Dentists, she stressed, are often the first clinicians to see these patients.

The 60-second oral examination

When a patient presents with any red flag, Dr. Raina follows a 60-second oral examination. The sequence is fixed so nothing is skipped:

1. Lips: look for crusting or induration (hardening).
2. Buccal mucosa: the inner lining of the cheeks.
3. Tongue.
4. Floor of the mouth.
5. Palate.
6. The "coffin corner": the posterior floor of the mouth, between the tongue and the inner (lingual) surface of the mandible. This area is often missed, and, as she put it, the culprit often hides there.
7. Neck: palpate for nodes and masses.
8. Throat: where available, a simple 70 or 90 degree Hopkins rod (rigid telescope) examination.

Finally, ask about function: swallowing, speech and mouth opening. A thorough examination also covers the oropharynx, thyroid, scalp and skin.

None of this needs expensive equipment. In resource-limited settings, Dr. Raina's advice was direct: rely on clinical skills. Twenty to thirty years ago, access to imaging was very difficult for every doctor, and a glove, a torch and a mirror still go a long way in head and neck cases.

A neck lump in an adult: not an infection until proven otherwise

In children, tonsillitis and other infections commonly enlarge the neck nodes. In adults, Dr. Raina warned against defaulting to antibiotics. A neck mass in an adult with no clear explanation should raise suspicion that something more serious is going on.

The work-up is straightforward:

• History: pain or recent infection, tobacco or alcohol use, and any associated difficulty swallowing or change in voice.
• Examination: oral cavity, oropharynx, thyroid, scalp and skin, as above.
• Action: prompt specialist referral. Imaging and needle sampling can be coordinated with the head and neck team.

Repeated empirical antibiotics should be avoided unless there are clear signs of bacterial infection. They waste the patient's time and consume the golden period in which treatment achieves the best results. As she put it in the Q&A, the delay caused by empirical treatment lets an early-stage cancer become advanced.

When to refer suspected head and neck cancer: three tiers

Dr. Raina triages suspected head and neck cancer into three tiers.

Emergency: refer immediately.

• Stridor or severe breathing difficulty.
• Inability to manage secretions, with severe pooling in the throat.
• Major bleeding.
• Rapidly worsening airway symptoms.

Urgent: expedited referral.

• A suspicious oral lesion.
• A persistent neck mass in an adult.
• Progressive dysphagia.
• Persistent hoarseness.

Document and track.

• Record when symptoms began and the patient's risk factors.
• Take photographs of visible lesions, with consent.
• Confirm the referral appointment and track it.

Two delays are avoidable: waiting for routine blood tests that will not change the decision, and waiting because symptoms temporarily improve.

In the Q&A she translated the tiers into site-specific triggers. For the larynx, any new breathing difficulty is an emergency. For the thyroid, new difficulty swallowing, a change in breathing pattern or a change in voice calls for immediate referral. For the mouth and tongue, drooling, bleeding, or a large or rapidly growing lesion calls for emergency referral.

Diagnosis when PET-CT and MRI are not available

Asked how doctors should proceed where PET-CT and other imaging are scarce, Dr. Raina gave a practical hierarchy built on what is widely available:

• Ultrasound is accessible almost everywhere. For a suspected thyroid problem, a thyroid function test and an ultrasound of the neck bring the doctor close to the diagnosis.
• CT is more widely available than MRI. For any lesion of the oral cavity, or wherever the mandible or larynx may be involved, CT is the first modality of choice: contrast-enhanced where possible, plain CT where that is all that exists, with a high-resolution CT of the chest.
• MRI, if available, is best for soft tissue lesions.

Tests should never hold up a referral. Patients sometimes wait for local CT or MRI appointments when the clinical picture already makes malignancy highly likely; referring at once protects the time that matters most. The role of PET-CT, biopsy and biomarker testing once the patient reaches a specialist centre is covered in the article on diagnosis, staging and treatment.

Screening for head and neck and oral cancer

Asked whether screening tests exist, Dr. Raina described screening as clinical, layered and targeted:

1. Select the at-risk patient: anyone who chews or smokes tobacco or drinks alcohol.
2. Self-examination: teach the public to examine their own mouth and neck, as women are taught breast self-examination.
3. Clinician examination: where population-level self-examination is not feasible, train general practitioners, dentists and ENT surgeons in clinical examination of the oral cavity and neck, with a Hopkins examination for the throat.
4. Advanced techniques: narrow band imaging adds value, but the basic, essential tool is clinical examination.

Her team applies the same approach in awareness camps for other cancers: breast self-examination and clinical breast examination, mammography, Pap smears for cervical cancer, and awareness of warning signs such as difficulty eating or a change in bowel habits in families with a history of colon or oesophageal cancer. Related diagnostic red flags for other cancers are discussed in a separate article on lung, colon, liver and oral cancer red flags.

What a good head and neck cancer referral contains

Dr. Raina listed the information that moves a patient through the referral channel fastest:

• Patient identifiers and a preferred communication channel.
• A timeline: when the first symptom started and how it progressed.
• Prior treatments already given.
• Clinical notes: site, size, neck nodes and airway status.
• Pathology reports, if any; otherwise imaging reports.
• The current medication list.
• An explicit question: the suspected diagnosis, the urgency, and the decision needed.

She organises cross-border referral in three steps:

1. Local first contact. Stabilise emergencies first, identify the red flags, document them and initiate the referral.
2. Triage. Prepare a clinical summary with the pathology and original imaging, and agree the next step with the receiving team.
3. Treatment and return. Plan realistic timelines, costs, caregiver support, and rehabilitation and continuity of care after the patient returns home.

Using secure channels and with the patient's consent, both doctors should confirm travel and visa feasibility, infection control needs, continuity of medication, and who will manage complications after the patient returns. The patient should also understand what to expect from travelling to the treating centre. As Dr. Raina put it, a referral is a partnership, not simply a transfer.

The full questions and answers from the session, including how to raise and act on suspicion in resource-constrained settings, are on the Live Discussion page. Dr. Raina's training and surgical practice are described on her profile.