1. DIAGNOSTIC EVALUATION
2. TREATMENT
3. FOLLOW UP
4. BIBLIOGRAPHY

I.DIAGNOSTIC EVALUATION:

Clinical Evaluation:

• Complete history and physical examination.
  
  Recording the presence and duration of symptoms such as pain, soreness of throat, otalgia, odynophagia, dysphagia, trismus and hoarseness. It should include history of risk factors such as the use of tobacco and alcohol, the occurrence an extent of weight loss and of all other medical conditions.

• Complete examination of the head and neck
  
  Includes examination of all the areas of the oral cavity, pharynx, and indirect laryngoscopy. If indirect laryngoscopy is not adequate, fiberoptic examination of the larynx and pharynx is necessary. Palpation of the floor of the mouth, tongue, base of the tongue and or tonsil to evaluate the "base" or depth of the tumor and its proximity to the mandible. The examination includes an assessment of the status of the mandible and the dentition, as well as an evaluation of the status of the airway. Palpation of the neck bilaterally, recording the location (Group or Level I - VI), size, mobility, and relationship of the node(s) to adjacent structures. The staging of the primary and of the cervical lymph nodes must be documented.

• Biopsy of primary.
  
  The biopsy can usually be performed in the office with local anesthesia or may be performed during the examination under anesthesia.

• Fine needle aspiration biopsy of suspected metastatic disease may be performed in selected cases. (Open surgical biopsy of suspected metastatic disease is not indicated)

Imaging Studies:

• Panoramic x-ray (Panorex) of the mandible and/or dental X-rays.

  When necessary to adequately assess the status of the patient's dentition or mandibular invasion. In anticipation of radiation therapy or the need for a mandibulotomy.

• Chest radiographs, PA and lateral

  To rule out (1) A synchronous pulmonary tumor, (2) Acute or chronic pulmonary disease (3) Metastatic tumor. Abnormal findings on chest x-ray with suspicions lesions may need further imaging including a chest CT.

• CT scan / MRI of the primary and neck

  May be needed to assess the extent of the primary, its relation to the mandible, and to evaluate if there is any mandibular involvement.

  In the absence of palpable adenopathy, they may be useful to assess the status of the cervical lymph nodes in patients that are obese or have a thick, muscular neck.

  When a large node is palpable in the neck, may be useful to clarify its relationship to the carotid artery, the paraspinal muscles or the cervical spine.

• Barium swallow at the discretion of the physician.

Laboratory Tests:

• Pre-anesthesia laboratory tests (will follow institutional guidelines)

• Baseline liver function tests (optional).

Consultations:

• Radiation therapy consult
  
  In anticipation of possible need for post-operative radiation therapy or to use radiation therapy as a definitive primary modality of treatment in early stage tumors.

• Dental consultation:
  
  To assess the status of the teeth and make recommendations considering that radiation therapy may be indicated. The evaluating dentist should be versed in the effects of radiotherapy on dentition. This evaluation should be done with knowledge of the treatment portals planned for the radiotherapy.

Optional:

• Speech pathology
  
  For preoperative counseling regarding possible postoperative speech and swallowing rehabilitation.

• Internal Medicine, Cardiology, Pulmonology or Anesthesiology
  
  As needed to evaluate coexisting conditions that may preclude or increase the risk of general anesthesia.

Examination under anesthesia:

To rule out the existence of other primary tumors in the aerodigestive tract, and to confirm the extent of the primary tumor, particularly, its relationship to the midline, the base of the tongue, and the mandible. It includes:

• Palpation of the tongue and oro/nasopharynx.

• Direct laryngoscopy and pharyngoscopy (optional unless preoperative examination not possible).

• Esophagoscopy (optional unless symptoms present).

• Flexible or rigid bronchoscopy.

• Bronchoscopy if indicated by clinical or radiographic findings.

II.TREATMENT:

Acceptable treatment modalities include surgery and radiation therapy.

Surgery:

Primary tumor:

• Excision with adequate margins. Frozen section examination as needed.
• The surgical defect can be repaired by primary closure, a skin graft, a tongue flap regional or "free" flaps. Some defects may be allowed to heal by secondary intention.

Neck:

Neck dissection, unilateral for clearly lateralized lesions; bilateral, for lesions that are located in the tip of the tongue, and those that approach or cross the midline.

The surgical treatment includes:

• Frozen section evaluation of margins as needed to ensure adequate resection.

• Tracheostomy at the discretion of the surgeon.

• Dental extractions if necessary.

• Insertion of a feeding tube (optional).

• Insertion of suction drain(s).

• Orientation of the primary and neck dissection specimen for the pathologist, by the surgeon.

• Perioperative care includes:

• Antibiotics

• Hospitalization for 3-10 days.

• Tube feedings.

• Low pressure suction to drains.

• Removal of drains usually when output <35-50ml/24 hrs.

• Oral care with power sprays or rinses 2-3 times a day.

• Suture removal of neck wound in 5 - 10 days.

• Postoperative Radiation:

Indications:

• Microscopically positive margins

• Presence of extensive perineural or intravascular invasion.

• More than two or three histologically positive nodes.

• Positive nodes at multiple levels in the neck.

• Presence of extranodal extension of tumor.

Timing:

• Radiation is initiated within a reasonable period after healing has occurred.

       Total dose and fractionation:

• These are determined by the clinical and pathological findings. The usual range is 50 - 70Gy in daily fractions of 1.8 to 2.0 Gy in 5 to 8 weeks. This may include a brachytherapy boost when indicated by pathological findings such as unsatisfactory margins.

Radiation Therapy:

The primary tumor may be treated by external beam radiation, brachytherapy or a combination of both   depending upon the size, location and extent of the tumor. External beam irradiation is generally indicated for the treatment of the neck.

III.FOLLOW UP:

Follow-up appointments are scheduled on an individual basis determined by the risk of recurrence, to survey for the development of second primary tumors, to deal with morbidity from treatment (i.e. speech and swallowing problems as well as wound care), to provide social and psychological support, and to deal with comorbidity not directly related to the cancer itself.

• Periodic examinations by the head and neck surgeon may be necessary during radiation therapy in patients experiencing difficulty with nutritional intake, airway or pain control.

• Periodic examinations by the radiation oncologist and a dentist in patients that received radiation therapy

• After all treatment is completed a general formula which is modified according to the individual patient's characteristics is:
  
  

  1st year post treatment:	1-3 months
  2nd year post treatment:	2-4 months
  3rd year post treatment:	3- 6 months
  4th and 5th years:	4- 6 months
  After 5 years:	Every 12 months

• Chest radiographs, yearly.

• Liver enzymes, yearly.

• Thyroid function tests, yearly, in patients that received radiation to the lower neck.

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