Note: the below protocol is presented for historical purposes

INITIAL EVALUATION

1. History
   1. Identify timing and nature of symptoms. Determine if the patient will need an urgent/emergent procedure (eg, tracheotomy for airway obstruction, carotid blow-out precaution).
   2. If outside treatment has been completed, contact referring physician and obtain all records including pathology slides, operative record, radiation records, and imaging studies.
   3. Complete medical history is performed, including review of systems and coexisting medical problems to assess risk of surgical intervention.
2. Physical
   1. Complete head and neck examination especially noting clinical stage and nodal status of disease.
   2. Complete physical to further assess general health and risk of procedure and to evaluate for potential donor sites for reconstructive flaps.
3. Laboratory Analysis and Further Studies
   1. Blood: CBC, PT, PTT, electrolytes, BUN/creatinine, liver functions; coagulation studies (PT, PTT, platelets, INR)
   2. EKG: any male over 45 years and female over 50 years or patients with heart symptoms in past or present
   3. Urinalysis
   4. Pulmonary function test for selected patients with existing lung disease
4. Imaging and Other Studies
   1. Chest x-ray is used to evaluate cardiopulmonary status and review for metastatic disease (may not be needed if CT Chest done)
   2. CT scan with contrast is useful to examine extent of disease at the primary site and further evaluate nodal status.
   3. MRI is useful especially in parotid tumors and in patients with poor renal function or contrast allergy.
   4. PET (Positron emission tomography) has become standard for all advanced (Stage III, IV) and selected less advanced cases.
   5. Photographs are especially useful to document the pretreatment lesion.
      1. Intraoral and superficial lesion are amenable to photos in clinic.
      2. Laryngeal or pharyngeal photos may be obtained by videoendoscopy or at the time of direct laryngoscopy.
   6. Panendoscopy is useful in all cases of mucosal squamous cell carcinoma to further stage, obtain biopsy, and observe for synchronous lesions. Often panendoscopy may be done at the same time as surgical resection (see Panendoscopy protocol). Advances in (in-clinic) imaging as with transnasal esophagoscopy has made the need for a separate anesthetic for panedoscopy less viable. However, a separate anesthetic is reasonable if PEG placement, tooth extractions, tracheotomy, and panedoscopy can be done to shorten the duration of the definitive resection and reconstruction.
5. Consultations Commonly Required
   1. Radiation oncology
   2. General medicine consult to determine overall risk of surgical procedure. These recommendations may be important to help patient decide between various treatment modalities.
   3. Dental evaluation is helpful in all cases in which radiation fields involve the dentition.
   4. Dental prosthodontics consultation is necessary for all sinonasal cases requiring palatal resection.
   5. Speech pathology consultation is useful when treatment alters normal swallow or speech; especially useful for preoperative counseling to laryngectomy patients.
   6. Medical oncology consultation is needed for cases involving treatment with combined chemotherapy/radiotherapy or in cases to offer palliative treatment with chemotherapy.
   7. Nutrition consultation to assess nutritional status and determine adequate caloric needs ishelpful.
   8. Social services are helpful to arrange care after discharge and assist patients with financial difficulties.
6. Assess Likely Reconstructive Needs (depending on size and functional site of defect)
   1. Primary closure
   2. Healing by secondary intention
   3. Split thickness skin graft coverage
   4. Pedicle flap
   5. Free flap
7. Tumor Board
   1. See Tumor board protocol

FOLLOW-UP

1. Patients are followed at frequent intervals during their initial therapy, whether they receive radiation or surgical treatment. After the initial interventional period, follow-up is continued at intervals listed below. Modifications in the general plan are commonplace and directed individually.
2. Appointment intervals have been substantially modified from that listed below and are individualized:
   1. Year 1: every 6 weeks
   2. Year 2: every 10 weeks
   3. Year 3: every 3 months
   4. Years 4 and 5: every 6 months
   5. Yearly after fifth year
3. Labs and Imaging Studies simiarly have been modified with questions as to value of low dose non-contrast chest CT in patients with history of tobacco use; CXR still useful for monitoring for aspiration and other reasons.
   1. Chest x-ray: yearly to evaluate for metastatic disease
   2. TSH (Thyroid Stimulating Hormone) in patients who received neck radiation or had a laryngectomy with thyroid lobectomy
   3. CT scan/MRI studies depending on individual patient situations or symptoms to evaluate for persistence or recurrence
   4. Liver function studies of questionable value
   5. PET imaging is generally targeted for 3-4 months after completion of XRT and then at 1 year following XRT.

REFERENCES

Boysen M, Natvig K, Winther O, Tausjo J. Value of routine follow-up in patients treated for squamous cell carcinoma of the head and neck. Otolaryngol. 1985;14:4.

Keyes J, Watson N, Williams D, Greven K, McGuirt F. FDG PET in head and neck cancer. Am J Radiol. 1997;169:1663-1669.

Korver K, Graham S, Funk G, McCulloch T, Hoffman H. Liver function studies in the assessment of head and neck cancer patients, Head Neck. 1995;17:531-534.

Snow G. Follow-up in patients treated for head and neck cancer: how frequent, how thorough and for how long? Eur J Cancer. 1992;28:315-316.