3
Diagnostic And Therapeutic Surgical
Procedures
➤ 2.1: Patients should undergo a complete operative upper
aerodigestive tract evaluation of mucosal sites at-risk (oral cavity,
nasopharynx, oropharynx, hypopharynx, and larynx) including directed
biopsy of any suspicious areas. Random biopsies of non-suspicious
areas have a low yield and should not be performed. Intraoperative
advanced visualization techniques may be used to investigate
potential primary sites for targeted biopsy. (Strong recommendation;
EB-B-I)
➤ 2.2: For patients with unilateral lymphadenopathy, if a primary site
is not confirmed on initial evaluation, the surgeon should perform
ipsilateral palatine tonsillectomy. If palatine tonsillectomy fails to
identify a primary, ipsilateral lingual tonsillectomy may be performed.
Bilateral palatine tonsillectomy may be considered according to
clinical suspicion, at the discretion of the surgeon. (Moderate
recommendation; EB-B-I)
➤ 2.3: For patients with bilateral lymphadenopathy, if a primary site is
not confirmed on endoscopic examination, the surgeon may perform
unilateral lingual tonsillectomy on the side with the greater nodal
burden and may perform contralateral lingual tonsillectomy if the
ipsilateral procedure fails to identify a primary. Bilateral palatine
tonsillectomy after bilateral lingual tonsillectomy should be avoided.
(Moderate recommendation; EB-B-I)
➤ 2.4: For patients in whom the primary tumor is identified during
operative upper aerodigestive tract evaluation and definitive surgical
management is intended (including neck dissection), clinicians should
make every effort to resect the identified primary using transoral
techniques to a negative surgical margin. (Strong recommendation;
EB-B-I)
➤ 2.5: Tissue specimens from suspected primary sites (biopsies,
palatine and lingual tonsillectomies) should be entirely submitted for
histologic examination. Resection specimens should be anatomically
oriented by the surgeon, and margin evaluation should be performed.
p16 immunohistochemistry may aid in evaluation of atypical or
cauterized tissue for HPV-related squamous cell carcinoma. (Strong
recommendation; EB-B-I)
➤ 2.6: Intraoperative frozen section of biopsies of suspicious primary
sites may be performed to confirm the presence of tumor prior to
resection. Intraoperative frozen section evaluation of palatine or
lingual tonsillectomy specimens should be performed when the
primary tumor remains clinically undetected. The tissue should
be entirely submitted for frozen section examination. Resection
specimens should be anatomically oriented by the surgeon, and
margin evaluation should be performed intraoperatively. (Strong
recommendation; EB-B-I)
