Reviewed on : 11 Sep 2023

Reviewed by : Kate Ray, Hazel Blanchard & Gateway Editor

Expires : 11 Sep 2025

TWO WEEK REFERRAL SERVICES – HEAD AND NECK

Clinical Guidance for Primary Care

ORAL

Whom to refer

• Persistent Oral Ulceration > 3weeks
• Persistent lump on lip consistent with oral cancer
• Persistent red/white lesions in the oral cavity consistent with oral cancer

Whom not to refer:

• Persistent intermittent ulceration
• Recurrent oral ulceration with resolution between episodes
• Intermittent swelling of the lip
• Routine periodontal disease
• Intermittent red/white lesions which resolve and recur

Refer all these for routine maxillofacial appointment

NOTE: Urgent referrals for cysts and dental pathology should be made to the maxillofacial department and NOT referred via 2WW.

LARYNX – Persistent unexplained hoarseness lasting for > 3/52

Whom to refer

• Persistent and progressive change in voice, especially in smokers and it should be a constant symptom
• Unilateral persistent sore throat

Whom not to refer

• Intermittent croaky voice

Suggested Management

• Laryngitis after URTI- loss of voice
• Voice rest for a week. Steam inhalation, hydration
• Intermittent Voice symptoms-LPR and poor oral hydration
• PPI, lifestyle advice, increase frequent hydration for 6/52, routine ENT referral
• Long standing voice symptoms – Cyst/polyp/nodules
• Refer to routine ENT

PHARYNX – Unexplained, persistent sore throat for >3/52

Whom to refer

• Ask if discomfort or painful throat

Usually unilateral, progressive pain throat

• Pain while swallowing(odynophagia) – ipsilateral, persistent, and progressive
• Pain in ear while swallowing (referred otalgia) – usually ipsilateral to the side of the cancer

 Whom not to refer

• Repeated throat clearing
• Sensation of lump in throat
• Burning sensation in the lower throat

These could be caused by poor oral hygiene, LPR or Globus

Suggested Management

• Frequent hydration
• Gaviscon Advance for 6/52
• Lifestyle advice
• Stop repeated throat clearing
• Information leaflet
• If persistent after 6 weeks with no progressive or new symptoms, consider routine ENT referral
• If patient is around 40 years and develops red flag symptoms, refer on 2ww

PERSISTENT UNEXPLAINED LUMP IN NECK > 3/52

Whom to refer

• Palpable neck lump – firm, hard and non-tender
• Recently notices asymmetric tonsils
• With other red flag symptoms

Whom not to refer

Sensation of lump in throat (Globus) with no red flag symptoms

UNEXPLAINED THYROID LUMP

SALIVARY GLAND SWELLING 

Refer:

• Lump with no preceding infection
• Non tender, progressive, well defined palpable lump
• Previous skin or head and neck cancers with palpable lumps

Do not refer:

• Recent parotitis
• Recurrent parotitis
• Palpable or previous history of salivary calculi

ENT SYMPTOMS:

GLOBUS PHARYNGEUS ASSESSMENT & MANAGEMENT

TINNITUS & VERTIGO

• Not a cancer symptom – routine ENT referral
• If patient needs reassurance for U/L tinnitus – refer for routine MRI Internal Auditory Meatus to exclude Cerebello-pontine lesions

OTHER EAR PROBLEMS

• Suspected cholesteatoma should be referred urgently to otology and not via 2WW
• Suspected acoustic neuroma should be referred urgently to otology and not via 2WW
• Sudden onset unilateral deafness should be referred urgently to otology and not via 2WW

UNILATERAL NASAL BLOCKAGE

• UNLESS bloody discharge, patients should be referred to routine ENT clinics

ALLERGIC RHINITIS

This is not a cancer symptom and should be referred for a routine ENT appointment

• Follow link for further advice https://cks.nice.org.uk/topics/allergic-rhinitis/

Cancer Research UK

On referral consider handing the patient a Cancer Research UK Information Sheet – follow link

Two Week Wait referrals should now be processed through the NHS eReferral Service (previously known as Choose & Book)

2WW Referral Form 2022

To print form follow referral link right