What is the optimal management for a 60‑year‑old man with a history of surgically resected base‑of‑tongue squamous cell carcinoma treated with adjuvant chemoradiotherapy who now presents with a fluctuating submental mass, progressive dysphagia, worsening cough, and morning‑predominant voice changes?

Urgent Evaluation for Locoregional Recurrence or Second Primary Malignancy

This patient requires immediate comprehensive workup with head and neck endoscopy, contrast-enhanced CT or MRI of the neck, and tissue biopsy of the fluctuating submental mass to rule out locoregional recurrence or second primary tumor, as the constellation of progressive dysphagia, voice changes, worsening cough, and an enlarging neck mass in a post-treatment head and neck cancer patient strongly suggests recurrent disease. 1

Critical Red Flags in This Presentation

The clinical picture raises immediate concern for several life-threatening complications:

• Fluctuating submental mass in a previously treated head and neck cancer patient suggests either lymphedema with superimposed infection/abscess OR recurrent nodal disease 1
• Progressive dysphagia after chemoradiotherapy can indicate pharyngeal stricture, chronic radiation changes, or tumor recurrence—the worsening trajectory over months favors recurrence over stable late radiation effects 1, 2, 3
• Morning-predominant voice changes suggest pooling of secretions overnight, indicating either pharyngeal dysfunction or laryngeal involvement 1
• Worsening cough may represent aspiration from dysphagia or direct laryngeal involvement 1, 2

Immediate Diagnostic Algorithm

Step 1: Urgent Multidisciplinary Evaluation

A multidisciplinary team assessment must be established immediately, as recommended for all head and neck cancer surveillance 1

Step 2: Physical Examination Priorities

• Neck palpation to assess the submental mass for size, fixation to surrounding structures, and mobility—fixed nodes suggest extracapsular extension or invasion of adjacent structures indicating higher-stage disease 4
• Flexible laryngoscopy to evaluate vocal cord mobility, pooling of secretions, and mucosal changes at the primary site and hypopharynx 1
• Oral cavity and oropharyngeal examination to assess for second primary tumors, as the aim of follow-up is early detection of locoregional recurrence and potentially curable second primary tumors 1

Step 3: Imaging Studies

• Contrast-enhanced CT or MRI of the head and neck to evaluate extent of the submental mass, assess for deep tissue invasion, and evaluate the primary site 1, 4
• Chest CT should be included to rule out metastatic disease, particularly given the progressive symptoms 1
• Consider FDG-PET/CT if imaging suggests recurrent disease, as this modality is recommended for advanced nodal disease to detect distant metastases 4

Step 4: Tissue Diagnosis

• Fine needle aspiration or core biopsy of the submental mass is mandatory if imaging suggests solid tissue rather than pure fluid collection 1
• Endoscopic biopsy of any suspicious mucosal lesions at the primary site or elsewhere in the upper aerodigestive tract 1

Management Based on Findings

If Recurrent Disease is Confirmed

For resectable locoregional recurrence:

• Surgical salvage with neck dissection followed by consideration of additional therapy based on pathologic findings 1, 4
• If extracapsular extension or positive margins are found on pathology, postoperative chemoradiotherapy with single-agent platinum (cisplatin 100 mg/m² every 3 weeks) is indicated 5, 4

For unresectable recurrence:

• Palliative chemotherapy is the standard option 1
• First-line treatment should be cetuximab plus cisplatin or carboplatin plus 5-fluorouracil, which provides median survival of 10.1 months versus 7.4 months with platinum/5-FU alone 4
• For poor performance status, weekly methotrexate monotherapy may be considered 1, 4

If No Recurrence but Severe Dysphagia

Functional assessment is critical:

• Modified barium swallow (MBS) study to objectively assess swallowing physiology and aspiration risk, as aspiration rates of up to 40% occur in unselected cohorts and up to 80% in symptomatic patients after chemoradiotherapy 1
• Much aspiration is "silent" (>50% of patients who aspirate) due to sensory impairment, so instrumental evaluation is mandatory even if the patient denies aspiration symptoms 1

Management of chronic dysphagia:

• Dysphagia after chemoradiotherapy most commonly results from edema, fibrosis, and sensory alterations, with dysfunction varying by total dose, schedule, and radiation field size 1
• Dose to the middle pharyngeal constrictor muscle, supraglottic larynx, and tongue musculature correlates with late dysphagia severity 2, 3
• At least 7.5% of patients develop late progressive dysphagia beyond one year after treatment 3

If Lymphedema/Abscess Without Malignancy

• Drainage if abscess is confirmed
• Lymphedema management with compression therapy and physical therapy
• However, tissue diagnosis remains mandatory before attributing symptoms solely to benign causes in this high-risk population

Critical Pitfalls to Avoid

• Do not attribute worsening symptoms to "expected late effects" without ruling out recurrence—the progressive nature over months and enlarging mass demand tissue diagnosis 1
• Do not delay endoscopy and imaging—95% of local recurrences are detected within 5 years, and early detection of recurrence offers the only chance for curative salvage 6
• Do not rely on clinical examination alone for dysphagia assessment—instrumental swallowing evaluation is required as silent aspiration is common 1
• Do not assume a fluctuating mass is benign—necrotic tumors can have fluid components and may fluctuate in size 1

Nutritional and Supportive Care

Regardless of the underlying diagnosis, this patient's nutritional status must be urgently addressed:

• Patients with difficulty swallowing before or during treatment are at higher risk for chronic dysphagia and permanent feeding tube dependency 1
• Prolonged intervals of nothing per oral for more than 2 weeks are associated with poorer swallowing outcomes 1
• Consider temporary feeding tube placement if aspiration risk is high on MBS study while definitive diagnosis and treatment are pursued 1