The final step in evaluating the patient is to perform endoscopy of the upper aerodigestive tract under general anesthesia. This examination consists of inspection and palpation of the oral cavity and the oropharynx, direct laryngoscopy, bronchoscopy, esophagoscopy, and nasopharyngoscopy. Suspicious areas of mucosa (e.g., leukoplakia, erythroplasia, or mucosal irregularities seen on prior physical examination or on imaging studies) should be biopsied. If no such lesions are seen, random biopsies should be performed on mucosal sites with the known highest probability of harboring a tumor (i.e., nasopharynx, tonsil, tongue base, pyriform sinus).7,23 The use of toluidine blue has not proved effective in identifying possible early mucosal carcinoma.20 If the primary lesion has not been found on physical examination or on radiologic studies, most lesions detected at endoscopy are found in the tonsil or tongue base (80%).22

The issue of performing an ipsilateral tonsillectomy during this evaluation has been controversial.20 However, there is growing evidence that such a procedure should be done, as a tumor located in the depths of the tonsil may be missed on a simple biopsy. In a report by Righi and Sofferman29 6 of 19 patients had occult carcinoma in an ipsilateral tonsil which was diagnosed only by examination of the whole tonsil. Microscopy demonstrated that all six tonsils had extensive areas of normal squamous epithelium overlying the malignancies suggesting that simple random biopsies might well have missed the lesion. CT scanning, inspection, and palpation showed no evidence of disease in all of these six patients. There are other reports in the literature supporting such a recommendation.22,30

The combination of CT, MRI scanning, and endoscopy with directed biopsies will demonstrate the presence of approximately 20% of occult tumors.7

The issue of carcinoma in a branchial cleft cyst may arise in a situation where a cystic neck mass is found to contain squamous cell carcinoma and no obvious primary lesion is found despite appropriate evaluation.1,31 This concept of carcinoma in a branchial cleft cyst was first reported by Von Volkmann in 1882.32 Since then, there has been ongoing controversy regarding this issue. Most authorities believe that if this lesion occurs at all, it is very rare indeed.1 Guidelines for establishing such a diagnosis were outlined by Martin, Morfit, and Ehrlich in 19 5 0:33 (1) cervical tumor occurs along a line from the tragus extending along the anterior border of the sternocleidomastoid muscle to the clavicle, (2) histology should demonstrate branchial vertigia, (3) no primary lesion is found after 5 years of follow-up, and (4) there is histologic evidence of cancer developing in the wall of an epithelium-lined cyst.

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