Symptom-directed selective endoscopy and cost containment for evaluation of head and neck cancer

Panendoscopy is commonly used for diagnosing synchronous primary neoplasms of the head and neck, although the yield and cost effectiveness has been questioned. To compare symptom-directed selective endoscopy to panendoscopy, 100 consecutive patients with newly diagnosed and untreated squamous cell carcinoma were prospectively evaluated. Symptoms were used to select which studies might have been performed to discover synchronous primary lesions. All patients were subsequently evaluated with chest x-ray, barium esophagram, direct pharyngolaryngoscopy, esophagoscopy, and bronchoscopy with bronchial washings. Seven synchronous primary neoplasms were discovered in six patients with one patient having three separate tumors. There were five synchronous pharyngeal and one oral cavity neoplasms with two of the pharyngeal tumors being asymptomatic. Two primary cervical esophageal tumors and one synchronous esophageal tumor were found in three patients all of whom had symptoms of dysphagia and odynophagia. Two pulmonary metastasis were discovered by chest x-ray in patients with normal bronchoscopies with bronchial washings. Selective symptomatic evaluations would have resulted in one-third savings in total cost and would have minimized excessive procedures and potential morbidity. Direct pharyngolaryngoscopy and chest x-rays are recommended for patients with squamous cell carcinoma of the head and neck but esophagoscopy, esophagogram, and bronchoscopy might be reserved for patients with associated symptoms. Bronchial washings are not recommended.