• Cross-sectional imaging with computed tomography of the head, neck and chest is necessary for all patients; magnetic resonance imaging of the primary site is useful particularly in advanced disease; and computed tomography and positron emission tomography to look for distant disease. (R)

• Careful evaluation of the upper and lower extents of the disease is necessary, which may require contrast swallow or computed tomography and positron emission tomography imaging. (R)

• Formal rigid endoscopic assessment under general anaesthetic should be performed. (R)

• Nutritional status should be proactively managed. (R)

• Full and unbiased discussion of treatment options should take place to allow informed patient choice. (G)

• Early stage disease can be treated equally effectively with surgery or radiotherapy. (R)

• Endoscopic resection can be considered for early well localised lesions. (R)

• Bulky advanced tumours require circumferential or non-circumferential resection with wide margins to account for submucosal spread. (R)

• Offer primary surgical treatment in the setting of a compromised larynx or significant dysphagia. (R)

• Midline lesions require bilateral neck dissections. (R)

• Consider management of silent nodal areas usually not addressed for other primary sites. (G)

• Reconstruction needs to be individualised to the patients’ needs and based on the experience of the unit with different reconstructive techniques. (G)

• Consider tumour bulk reduction with induction chemotherapy prior to definitive radiotherapy. (R)

• Consider intensity modulated radiation therapy where possible to limit the consequences of wide field irradiation to a large volume. (R)

• Use concomitant chemotherapy in patients who are fit enough and consider epidermal growth factor receptor blockers for those who are less fit. (R)

• Sinonasal tumours are best treated de novo and unusual polyps should be imaged and biopsied prior to definitive surgery. (G)

• Treatment of sinonasal malignancy should be carefully planned and discussed at a specialist skull base multidisciplinary team meeting with all relevant expertise. (G)

• Complete surgical resection is the mainstay of treatment for inverted papilloma and juvenile angiofibroma. (R)

• Essential equipment is necessary and must be available prior to commencing endonasal resection of skull base malignancy. (G)

• Endoscopic skull base surgery may be facilitated by two surgeons working simultaneously, utilising both sides of the nose. (G)

• To ensure the optimum oncological results, the primary tumour must be completely removed and margins checked by frozen section if necessary. (G)

• The most common management approach is surgery followed by post-operative radiotherapy, ideally within six weeks. (R)

• Radiation is given first if a response to radiation may lead to organ preservation. (G)

• Radiotherapy should be delivered within an accredited department using megavoltage photons from a linear accelerator (typical energies 4–6 MV) as an unbroken course. (R)

• All patients with more than one of: chronic otalgia, bloody otorrhoea, bleeding, mass, facial swelling or palsy should be biopsied. (R)

• Magnetic resonance and computed tomography imaging should be performed. (R)

• Patients should undergo audiological assessment. (R)

• Carotid angiography is recommended in select patients. (G)

• The modified Pittsburg T-staging system is recommended. (G)

• The minimum operation for cancer involving the temporal bone is a lateral temporal bone resection. (R)

• Facial nerve rehabilitation should be initiated at primary surgery. (G)

• Anterolateral thigh free flap is the workhorse flap for lateral skull base defect reconstruction. (G)

• For patients undergoing surgery for squamous cell carcinoma, at least a superficial parotidectomy and selective neck dissection should be carried out. (R)

• Royal College of Pathologists minimum datasets for NMSC should be adhered to in order to improve patient care and help work-force planning in pathology departments. (G)

• Tumour depth is of critical importance in identifying high-risk cutaneous squamous cell carcinoma (cSCC), and should be reported in all cases. (R)

• Appropriate imaging to determine the extent of primary NMSC is indicated when peri-neural involvement or bony invasion is suspected. (R)

• In the clinically N0 neck, radiological imaging is not beneficial, and a policy of watchful waiting and patient education can be adopted. (R)

• Patients with high-risk NMSC should be treated by members of a skin cancer multidisciplinary team (MDT) in secondary care. (G)

• Non-infiltrative basal cell carcinoma (BCC) <2 cm in size should be excised with a margin of 4–5 mm. Smaller margins (2–3 mm) may be taken in sites where reconstructive options are limited, when reconstruction should be delayed. (R)

• Where there is a high risk of recurrence, delayed reconstruction or Mohs micrographic surgery should be used. (R)

• Surgical excision of low-risk cSCC with a margin of 4 mm or greater is the treatment of choice. (R)

• High-risk cSCC should be excised with a margin of 6 mm or greater. (R).

• Mohs micrographic surgery has a role in some high-risk cSCC cases following MDT discussion. (R)

• Delayed reconstruction should be used in high-risk cSCC. (G)

• Intra-operative conventional frozen section in cSCC is not recommended. (G)

• Radiotherapy (RT) is an effective therapy for primary BCC and cSCC. (R)

• Re-excision should be carried out for incompletely excised high-risk BCC or where there is deep margin involvement. (R)

• Incompletely excised high-risk cSCC should be re-excised. (R)

• Further surgery should involve confirmed marginal clearance before reconstruction. (R)

• P+ N0 disease: Resection should include involved parotid tissue, combined with levels I–III neck dissection, to include the external jugular node. (R)

• P+ N+ disease: Resection should include level V if that level is clinically or radiologically involved. (R)

• Adjuvant RT should include level V if not dissected. (R)

• P0 N+ disease: Anterior neck disease should be managed with levels I–IV neck dissection to include the external jugular node. (R)

• P0 N+ posterior echelon nodal disease (i.e. occipital or post-auricular) should undergo dissection of levels II–V, with sparing of level I. (R)

• Consider treatment of the ipsilateral parotid if the primary site is the anterior scalp, temple or forehead. (R)

• All patients should receive education in self-examination and skin cancer prevention measures. (G)

• Patients who have had a single completely excised BCC or low-risk cSCC can be discharged after a single post-operative visit. (G)

• Patients with an excised high-risk cSCC should be reviewed three to six monthly for two years, with further annual review depending upon clinical risk. (G)

• Those with recurrent or multiple BCCs should be offered annual review. (G)

• At-risk individuals should be warned about the correlation between ultraviolet radiation (UVR) exposure and skin cancer, and should be given advice on UVR protection. (R)

• Dermatoscopy can aid in the diagnosis of cutaneous melanoma. (R)

• Histological examination after biopsy is essential to confirm the diagnosis and the tumour thickness. (G)

• Excisional biopsy is method of choice. (G)

• Staging investigations can be performed for both regional and distant disease. (R)

• Scanning (computed tomography (CT) and/or magnetic resonance imaging) is recommended for patients with high-risk melanoma. (G)

• Patients with signs or symptoms of disease relapse should be investigated by imaging. (R)

• Imaging of the brain should be performed in patients who have stage IV disease. (G)

• Patients with melanoma of unknown primary should be thoroughly examined and investigated for a potential primary source. (R)

• Primary cutaneous invasive melanoma should be excised with a surgical margin of at least 1 cm. (G)

• The maximum recommended excision margin is 3 cm. (R)

• The actual margin of excision depends upon the depth of the melanoma and its anatomical site. (G)

• Ultrasound-guided fine needle aspiration (FNA) or core biopsy of suspected lymphadenopathy is more accurate than ‘blind’ biopsy. (R)

• Open biopsy should only be performed if FNA or core biopsy is inadequate or equivocal. (R)

• Prior to lymph node dissection, staging by CT scan should be carried out. (R)

• If parotid disease is present without neck involvement, both parotidectomy and neck dissection should ideally be performed. (R)

• There is no role for elective lymph node dissection. (R)

• Sentinel lymph node biopsy (SLNB) can be considered in stage IB and above by specialist skin cancer multidisciplinary teams. (G)

• Patients should be made aware that SLNB is a staging procedure, and should understand that it has, as yet, no proven therapeutic value. (R)

• All patients with cutaneous melanoma should have their original tumour checked for BRAF gene status, and their subsequent targeted biological therapy based on this. (R)

• Patients who develop brain metastases should be considered for stereotactic radio-surgery. (R)

• Ultrasound guided fine needle aspiration cytology is recommended for all salivary tumours and cytology should be reported by an expert histopathologist. (R)

• Adjuvant radiotherapy (RT) following surgery is recommended for all malignant submandibular tumours except in cases of small, low-grade tumours that have been completely excised. (R)

• For benign parotid tumours complete excision of the tumour should be performed and offers good cure rates. (R)

• In the event of intra-operative tumour spillage, most cases need long-term follow-up for clinical observation only. These should be raised in the multidisciplinary team to discuss the merits of adjuvant RT. (G)

• As a general principle, if the facial nerve function is normal pre-operatively then every attempt to preserve facial nerve function should be made during parotidectomy and if the facial nerve is divided intra-operatively then immediate microsurgical repair (with an interposition nerve graft if required) should be considered. (G)

• Neck dissection is recommended in all cases of malignant parotid tumours except for low-grade small tumours. (R)

• Where malignant parotid tumours lie in close proximity to the facial nerve there should be a low threshold for adjuvant RT. (G)

• Adjuvant RT should be considered in high grade or large tumours or in cases where there is incomplete or close resection margin. (R)

• Adjuvant RT should be prescribed on the basis of clinical factors in addition to histology and grade, e.g. stage, pre-operative facial weakness, positive margins, peri-neural invasion and extracapsular spread. (R)

• Ultrasound scanning (USS) of the nodule or goitre is a crucial investigation in guiding the need for fine needle aspiration cytology (FNAC). (R)

• FNAC should be considered for all nodules with suspicious ultrasound features (U3–U5). If a nodule is smaller than 10 mm in diameter, USS guided FNAC is not recommended unless clinically suspicious lymph nodes on USS are also present. (R)

• Cytological analysis and categorisation should be reported according to the current British Thyroid Association Guidance. (R)

• Ultrasound scanning assessment of cervical nodes should be done in FNAC-proven cancer. (R)

• Magnetic resonance imaging (MRI) or computed tomography (CT) should be done in suspected cases of retrosternal extension, fixed tumours (local invasion with or without vocal cord paralysis) or when haemoptysis is reported. When CT with contrast is used pre-operatively, there should be a two-month delay between the use of iodinated contrast media and subsequent radioactive iodine (I131) therapy. (R)

• Fluoro-deoxy-glucose positron emission tomography imaging is not recommended for routine evaluation. (G)

• In patients with thyroid cancer, assessment of extrathyroidal extension and lymph node disease in the central and lateral neck compartments should be undertaken pre-operatively by USS and cross-sectional imaging (CT or MRI) if indicated. (R)

• For patients with Thy 3f or Thy 4 FNAC a diagnostic hemithyroidectomy is recommended. (R)

• Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter or tumours of any size in association with any of the following characteristics: multifocal disease, bilateral disease, extrathyroidal spread (pT3 and pT4a), familial disease and those with clinically or radiologically involved nodes and/or distant metastases. (R)

• Subtotal thyroidectomy should not be used in the management of thyroid cancer. (G)

• Central compartment neck dissection is not routinely recommended for patients with papillary thyroid cancer without clinical or radiological evidence of lymph node involvement, provided they meet all of the following criteria: classical type papillary thyroid cancer, patient less than 45 years old, unifocal tumour, less than 4 cm, no extrathyroidal extension on ultrasound. (R)

• Patients with metastases in the lateral compartment should undergo therapeutic lateral and central compartment neck dissection. (R)

• Patients with follicular cancer with greater than 4 cm tumours should be treated with total thyroidectomy. (R)

• I131 ablation should be carried out only in centres with appropriate facilities. (R)

• Serum thyroglobulin (Tg) should be checked in all post-operative patients with differentiated thyroid cancer (DTC), but not sooner than six weeks after surgery. (R)

• Patients who have undergone total or near total thyroidectomy should be started on levothyroxine 2 µg per kg or liothyronine 20 mcg tds after surgery. (R)

• The majority of patients with a tumour more than 1 cm in diameter, who have undergone total or near-total thyroidectomy, should have I131 ablation. (R)

• A post-ablation scan should be performed 3–10 days after I131 ablation. (R)

• Post-therapy dynamic risk stratification at 9–12 months is used to guide further management. (G)

• Potentially resectable recurrent or persistent disease should be managed with surgery whenever possible. (R)

• Distant metastases and sites not amenable to surgery which are iodine avid should be treated with I131 therapy. (R)

• Long-term follow-up for patients with differentiated thyroid cancer (DTC) is recommended. (G)

• Follow-up should be based on clinical examination, serum Tg and thyroid-stimulating hormone assessments. (R)

• Patients with suspected medullary thyroid cancer (MTC) should be investigated with calcitonin and carcino-embryonic antigen levels (CEA), 24 hour catecholamine and nor metanephrine urine estimation (or plasma free nor metanephrine estimation), serum calcium and parathyroid hormone. (R)

• Relevant imaging studies are advisable to guide the extent of surgery. (R)

• RET (Proto-oncogene tyrosine-protein kinase receptor) proto-oncogene analysis should be performed after surgery. (R)

• All patients with known or suspected MTC should have serum calcitonin and biochemical screening for phaeochromocytoma pre-operatively. (R)

• All patients with proven MTC greater than 5 mm should undergo total thyroidectomy and central compartment neck dissection. (R)

• Patients with MTC with lateral nodal involvement should undergo selective neck dissection (IIa–Vb). (R)

• Patients with MTC with central node metastases should undergo ipsilateral prophylactic lateral node dissection. (R)

• Prophylactic thyroidectomy should be offered to RET-positive family members. (R)

• All patients with proven MTC should have genetic screening. (R)

• Radiotherapy may be useful in controlling local symptoms in patients with inoperable disease. (R)

• Chemotherapy with tyrosine kinase inhibitors may help in controlling local symptoms. (R)

• For individuals with anaplastic thyroid carcinoma, initial assessment should focus on identifying the small proportion of patients with localised disease and good performance status, which may benefit from surgical resection and other adjuvant therapies. (G)

• The surgical intent should be gross tumour resection and not merely an attempt at debulking. (G)

• Computed tomographic or magnetic resonance imaging is mandatory for staging neck disease, with choice of modality dependant on imaging modality used for the primary site, local availability and expertise. (R)

• Patients with a clinically N0 neck, with more than 15–20 per cent risk of occult nodal metastases, should be offered prophylactic treatment of the neck. (R)

• The treatment choice of for the N0 and N+ neck should be guided by the treatment to the primary site. (G)

• If observation is planned for the N0 neck, this should be supplemented by regular ultrasonograms to ensure early detection. (R)

• All patients with T1 and T2 oral cavity cancer and N0 neck should receive prophylactic neck treatment. (R)

• Selective neck dissection (SND) is as effective as modified radical neck dissection for controlling regional disease in N0 necks for all primary sites. (R)

• SND alone is adequate treatment for pN1 neck disease without adverse histological features. (R)

• Post-operative radiation for adverse histologic features following SND confers control rates comparable with more extensive procedures. (R)

• Adjuvant radiation following surgery for patients with adverse histological features improves regional control rates. (R)

• Post-operative chemoradiation improves regional control in patients with extracapsular spread and/or microscopically involved surgical margins. (R)

• Following chemoradiation therapy, complete responders who do not show evidence of active disease on co-registered positron emission tomography–computed tomography (PET–CT) scans performed at 10–12 weeks, do not need salvage neck dissection. (R)

• Salvage surgery should be considered for those with incomplete or equivocal response of nodal disease on PET–CT. (R)

• • All patients presenting with confirmed cervical lymph node metastatic squamous cell carcinoma and no apparent primary site should undergo:

  • ○ Positron emission tomography-computed tomography whole-body scan. (R)

  • ○ Panendoscopy and directed biopsies. (R)

  • ○ Bilateral tonsillectomy. (R)

• • Tongue base mucosectomy can be offered if facilities and expertise exists. (G)

• • Concomitant chemotherapy with radiation should be considered in patients with an unknown primary. (R)

• • Concomitant chemotherapy with radiation should be offered to suitable patients in the post-operative setting, where indicated. (R)

• • Neo-adjuvant chemotherapy can be used in gross ‘unresectable’ disease. (R)

• • Patients should be followed up at least two months in the first two years and three to six months in the subsequent years. (G)

• • Patients should be followed up to a minimum of five years with a prolonged follow up for selected patients. (G)

• • Positron emission tomography–computed tomography scan at three to four months after treatment is a useful follow-up strategy for patients treated by chemoradiation therapy. (R)

• All multidisciplinary teams should have rehabilitation patient pathways covering all stages of the patient's journey including multidisciplinary and pre-treatment clinics. (G)

• Clinicians treating head and neck cancer patients should consult the National Cancer Rehabilitation Pathway for head and neck cancers. (G)

• All head and neck cancer patients should have a pre-treatment assessment of speech and swallowing. (G)

• A programme of prophylactic exercises and the teaching of swallowing manoeuvres can reduce impairments, maintain function and enable a speedier recovery. (R)

• Continued speech and language therapist input is important in maintaining voice and safe and effective swallow function following head and neck cancer treatment. (R)

• Disease recurrence must be ruled out in the management of stricture and/or stenosis. (R)

• Continuous radial expansion balloons offer a safe, effective dilation method with advantages over gum elastic bougies. (R)

• Site, length and completeness of strictures as well as whether they are in the presence of the larynx or not, need to be assessed when establishing the likelihood of surgically improved outcome. (G)

• Primary surgical voice restoration should be offered to all patients undergoing laryngectomy. (R)

• Attention to surgical detail and long-term speech and language therapist input is required to optimise speech and swallowing after laryngectomy. (G)

• Patients should commence wearing heat and moisture exchange devices as soon as possible after laryngectomy. (R)

• Consider baseline and serial scanning with computed tomography and/or magnetic resonance (CT and/or MR) to detect recurrence in high-risk patients. (R)

• Patients with head and neck cancer recurrence being considered for active curative treatment should undergo assessment by positron emission tomography combined with computed tomography (PET–CT) scan. (R)

• Patients with recurrence should be assessed systematically by a team experienced in the range of management options available for recurrence including surgical salvage, re-irradiation, chemotherapy and palliative care. (R)

• Management of patients with laryngeal recurrence should include input from surgeons with experience in transoral surgery and partial laryngectomy for recurrence. (G)

• Expertise in transoral surgery and partial laryngectomy for recurrence should be concentrated to a few surgeons within each multidisciplinary teams. (G)

• Transoral or open partial laryngectomy should be offered as definitive treatment modality for highly-selected patients with recurrent laryngeal cancer. (R)

• Patients with OPC recurrence should have p16 human papilloma virus status assessed. (R)

• Patients with OPC recurrence should be considered for salvage surgical treatment by an experienced team, with reconstructive expertise input. (G)

• Transoral surgery appears to be an effective alternative to open surgery for the management of OPC recurrence in carefully selected patients. (R)

• Consider elective selective neck dissections in patients with recurrent primaries with N0 necks, especially in advanced cases. (R)

• Selective neck dissection (with preservation of nodal levels, especially level V, that are not involved by disease) in patients with nodal (N+) recurrence appears to be as effective as modified or radical neck dissections. (R)

• Use salivary bypass tubes following salvage laryngectomy. (R)

• Use interposition muscle-only pectoralis major or free flap for suture line reinforcement if performing primary closure following salvage laryngectomy. (R)

• Use inlaid pedicled or free flap to close wound if there is tension at the anastomosis following laryngectomy. (R)

• Perform secondary puncture in post chemoradiotherapy laryngectomy patients. (R)

• Triple therapy with platinum, cetuximab and 5-fluorouracil (5-FU) appears to provide the best outcomes for the management of patients with recurrence who have a good performance status and are fit to receive it. If not fit, then combinations of platinum and cetuximab or platinum and 5-FU may be considered. (R)

• Patients with non-resectable recurrent disease should be offered the opportunity to participate in phases I–III clinical trials of new therapeutic agents. (R)

• Chemo re-irradiation appears to improve locoregional control, and may have some benefit for overall survival, at the risk of considerable acute and late toxicity. Benefit must be weighed carefully against risks, and patients must be counselled appropriately. (R)

• Target volumes should be kept tight and elective nodal irradiation should be avoided. (R)

• Best supportive care should be offered routinely as part of the management package of all patients with recurrent cancer even in the case of those who are being treated curatively. (R)

• Microsurgical free flap reconstruction should be the primary reconstructive option for most defects of the head and neck that need tissue transfer. (R)

• Free flaps should be offered as first choice of reconstruction for all patients needing circumferential pharyngoesophageal reconstruction. (R)

• Free flap reconstruction should be offered for patients with class III or higher defects of the maxilla. (R)

• Composite free tissue transfer should be offered as first choice to all patients needing mandibular reconstruction. (R)

• Patients undergoing salvage total laryngectomy should be offered vascularised flap reconstruction to reduce pharyngocutaneous fistula rates. (R)

• Palliative and supportive care must be multidisciplinary. (G)

• All core team members should have training in advanced communication skills. (G)

• Palliative surgery should be considered in selected cases. (R)

• Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R)

• All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G)

• Pain relief should be based on the World Health Organization pain ladder. (R)

• Specialist pain management service involvement should be considered early for those with refractory pain. (G)

• Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G)

• Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G)

• Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R)

• Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R)

• ‘Do not attempt cardiopulmonary resuscitation’ orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G)

• Patients should be followed up to a minimum of five years with a prolonged follow-up for selected patients. (G)

• Patients should be followed up at least two monthly in the first two years and three to six monthly in the subsequent years. (G)

• Patients should be seen in dedicated multidisciplinary head and neck oncology clinics. (G)

• Patients should be followed up by dedicated multidisciplinary clinical teams. (G)

• The multidisciplinary follow-up team should include clinical nurse specialists, speech and language therapists, dietitians and other allied health professionals in the role of key workers. (G)

• Clinical assessment should include adequate clinical examination including fibre-optic rigid or flexible nasopharyngolaryngoscopy. (R)

• Magnetic resonance imaging and positron emission tomography combined with computed tomography imaging should be used when recurrence is suspected. (R)

• Narrow band imaging can be used in the follow-up in selected sites. (R)

• Second primary tumours should be part of rationale of follow-up and therefore adequate screening strategies should be used to detect them. (G)

• Patients should be educated with regard to the appearance and detection of recurrences. (G)

• Patients with persistent pain should be investigated to exclude recurrent disease. (R)

• Patients should be offered support with tobacco and alcohol cessation services. (R)

• All cancer patients should meet a clinical nurse specialist at the point of diagnosis. (R)

• Clinical nurse specialists must act as gate keeper to the patients' cancer pathway to provide a seamless journey. (R)

• Holistic needs assessment should be completed at different stages of the patient's pathway to reflect the changes of the patients' needs. (R)

• Clinical nurse specialists to be part of local and national initiatives for health promotion and raising awareness in the public domain. (G)

• Clinical nurse specialists should lead in redesigning of services and policies to ensure they are responsive to patient's needs for the future. (G)

• Treatment summaries should become part of practice to provide good communication between primary and secondary care to enable continuity of care for the patient. (G)

• Trainees applying for head and neck surgical oncology consultant posts should have completed additional training in the subspecialty.