ENT Head and Neck Surveillance Template

Otorhinolaryngologist (ENT Specialist) Diagnosis Primary diagnosis of Squamous Cell Carcinoma of the right tonsil, T2N1M0, Stage III, p16 positive. Histological findings revealed moderately differentiated squamous cell carcinoma with clear margins (2mm closest margin), no perineural invasion, and no lymphovascular invasion. This represents a primary diagnosis. Treatment Patient underwent right tonsillectomy and selective neck dissection (levels II-IV) on 15 June 2023. Post-operatively, received intensity-modulated radiation therapy (IMRT) to a dose of 60 Gy in 30 fractions concurrently with weekly cisplatin at 40 mg/m2 for 6 cycles. No significant treatment-related complications were reported during the acute phase beyond Grade 2 mucositis and dysphagia, which resolved post-treatment. Patient reports mild persistent xerostomia and occasional dysphagia to solids. Current Status Currently, the patient demonstrates stable disease with no evidence of recurrence. Performance status is ECOG 0. Symptom review reveals mild persistent xerostomia, occasional dysphagia (solids require more effort), and mild fatigue. No odynophagia, dysphonia, trismus, otalgia, nasal obstruction, epistaxis, neck swelling, or cranial nerve symptoms. Clinical examination shows a well-healed right tonsillar fossa with no suspicious lesions. Oropharynx and nasopharynx are clear. Larynx appears normal on fibreoptic nasolaryngoscopy. Neck examination reveals soft, supple neck with no palpable lymphadenopathy. Cranial nerve assessment is intact. Recent PET-CT (1 October 2024) shows no metabolically active disease. Plan Ongoing surveillance with clinical review and fibreoptic nasolaryngoscopy every 3 months for the first year, then every 6 months for the next two years. Follow-up MRI neck with contrast scheduled for 1 February 2025. Discussion of potential MDT review if any suspicious findings arise. Patient referred to speech and swallowing therapy for ongoing management of dysphagia and xerostomia. Encouraged smoking cessation and alcohol moderation; provided resources for support. Patient advised on potential late effects of treatment and instructed to report any new or worsening symptoms. Safety netting provided regarding emergency contact for acute symptoms.