Several studies in the recent literature would suggest that PTC found incidentally in the cervical lymphatics may be significant. By age alone, most of our head and neck cancer patients will fall into an intermediate risk group. There are also data to suggest that cervical metastasis from PTC may portend higher recurrence and mortality and that occult PTC may be a biologically significant situation. Many patients with cancer of the head and neck either have a good prognosis or don't follow the rules of their predicted prognosis, and for these patients living with the knowledge of an untreated thyroid, cancer may be an unnecessary concern. Other factors to be considered are that early PTC is probably curable disease and that there is real risk of transformation to higher grade or anaplastic cancer. Finally, there is no way to accurately predict the behavior of PTC. The decision to treat these cancers is ultimately made by the patient and the physician, and if there is a treatment with low morbidity that will alleviate concern of PTC recurrence, then this may outweigh the risk of treatment. Situations may exist when treating incidental PTC could be deferred. These include: a dismal prognosis for the head and neck primary when quality time outside of the hospital is the goal of the patient and the physician; or if the head and neck primary tumor requires external beam radiation therapy, because this may be adequate therapy for occult PTC. In summary, the scenario of PTC found incidentally in the neck treated for a head and neck SCC is unusual. Each patient will have a unique clinical situation based on the site and stage of the SCC, the age of the patient, and the treatment required for the SCC. Treatment options include total thyroidectomy, thyroid lobectomy, the administration of I131, and/or the use of external beam radiation, which must be weighed against the option of close clinical follow-up. In general, we recommend total thyroidectomy for PTC found incidentally in the cervical LNs for the reasons that have emerged from a recent review of the medical literature. We report 7 patients with synchronous head nad neck SCC and PTC who have all received surgical treatment for PTC (Table 1). In addition, we advocate postoperative radioiodine scanning with radioablation of metastatic or persistent PTC, or remnant ablation if uptake is greater than 2%. Our goal as head and neck surgeons should be to avoid inadequate therapy for incidental PTC.