Head And Neck Initial Evaluation

A full history and physical should be obtained from the patient. Important points on history include: smoking and alcohol habits, a history of chewing tobacco, betel nuts, paan or arecca. Presenting symptoms are varied and range by site. There may be a change in voice quality, dysphagia, odynophagia, referred otalgia, bleeding, ulcer, weight loss and a painless neck mass. It is also important to get an idea of the patient's performance status as this may give an indication of how well a patient may tolerate an aggressive treatment.

Physical exam is also guided on presenting symptoms, but should include a full general exam. A full neck exam of all lymphatic stations should be completed. Lymph nodes should be described in terms of size, mobility, and consistency. An oral exam includes examining the oral and buccal mucosa and evaluating the dentition. The pallatine fossas can be examined. Manual palpation of the base of tongue is required if this is a suspected site of tumor. Laryngoscopy should be performed to evaluate the nasopharynx, oropharnx and hypopharynx. Vocal cords, base of tongue and epiglottis can be visualized.

Initial work-up includes biopsy of either the primary mass or a palpable lymph node. A fine needle aspirate is adequate for diagnosis. Routine blood work includes a CBC, electrolytes, Ca, Phosphate and Mg, liver function, renal function, baseline TSH, PT/PTT/INR. HPV testing can be considered. A CT scan of the neck and chest should be part of the initial imaging. MRI of the neck will help stage the tumor and evaluate for soft tissue invasion. A PET-CT can be performed particularly if there are borderline suspicious lymph nodes, but is not indicated as a routine for all patients.

Finally, the patient may need evaluation by medical oncology, dentistry, audiology, gastroenterology (or radiology) for prophylactic PEG placement in patients receiving chemotherapy and a consult to GI for pan-endoscopy to rule out synchronous primaries.