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Background: To analyze worldwide practices regarding the initiation of oral feeding after total laryngectomy (TL)., Methods: Online survey., Results: Among the 332 responses received, 278 from 59 countries were analyzed. Our results showed that 45.6% of respondents started water and 45.1% started liquid diet between postoperative days 7 and 10. Semi-solid feeds were initiated between days 10 and 14 for 44.9% of respondents and a free diet was allowed after day 15 for 60.8% of respondents. This timing was significantly delayed in cases of laryngo-pharyngectomy and after prior radiotherapy (p < 0.001). A greater proportion of respondents in Africa and Oceania allowed early oral feeding before day 6 as compared with the rest of the world (p < 0.001)., Conclusion: Despite increasing number of publications, there is still a lack of evidence to support early oral feeding. The majority of respondents preferred to delay its initiation until at least 7 days after surgery., (© 2022 Wiley Periodicals LLC.)

Background: Head and neck cancers occur predominantly in developing countries where access to care is poor. Sub-Saharan Africa has <20 head and neck surgeons for >1 billion people and has only two fellowship training programs., Methods and Results: The AfHNS Head and Neck Fellowship is being introduced to accelerate training of African surgeons to improve access to resource appropriate cancer care. By avoiding fixed time-in-training and single training sites, training can be offered at multiple centers in Africa, even with lower patient volumes. It also creates opportunities for accredited international surgical outreach programs to contribute to training., Conclusions: Having prescribed reading and appropriate Entrustable Professional Activities that are assessed through Workplace Based Assessment, and having a summative virtual oral examination ensures that fellows are fit-for-purpose to practice in an African resource-constrained setting. Other developing countries are encouraged to adopt a similar approach to expanding head and neck cancer services., (© 2021 Wiley Periodicals LLC.)

Background: International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources., Methods: Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined., Results: Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines., Conclusions: Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources., (© 2020 The Authors. Head & Neck published by Wiley Periodicals, Inc.)

Background: Surgical site infection (SSI) is defined as an infection that occurs after a surgical incision or organ manipulation during surgery. The frequency reported for clean head and neck surgical procedures without antimicrobial prophylaxis is <1%. In contrast, infection rates in patients undergoing complicated cancer surgery are high, ranging from 24% to 87% of patients without antimicrobial prophylaxis., Methods: Guidelines and recommendations about the use of antibiotics in head and neck surgery from 2004 to 2019 were reviewed., Results: Four guidelines from Oceania, 5 from South America, 5 from North America, 2 from the United Kingdom, 11 from Europe, 1 from Africa, 1 from the Middle East, and 3 from Asia were included. A total of 118 papers were included for analysis and recommendation., Conclusion: Antibiotic prophylaxis can decrease the incidence of SSI. However, the risks associated with antibiotic exposure and the risk of antibiotic resistance need to be taken into consideration., (© 2019 Wiley Periodicals, Inc.)

Background: There is an extreme shortage of head and neck surgeons in Africa. Fourteen head and neck surgeons have completed fellowships in Cape Town and Cameroon. This study determines whether such Africa-based fellowships are a good model for developing countries by making a sustainable impact on head and neck cancer care., Methods: An observational study was conducted by emailing questionnaires to past fellows., Results: All fellows had returned to teaching hospitals in their counties. Seven established new multidisciplinary cancer teams. Head and neck operations had increased by >335%, as had complexity of the surgery. There was effective transfer of surgical skills to trainees. All considered head and neck fellowships to be the best model to grow head and neck care., Conclusion: Head and neck fellowships in developing countries are effective models for establishing training programs and for increasing provision of specialized surgical services in a sustainable fashion., (© 2019 Wiley Periodicals, Inc.)

Background: Pharyngocutaneous fistula is a major wound complication of total laryngectomy. Surgical sealants may be used to increase the strength and/or integrity of surgical repairs. The purpose of this study was to present our evaluation of the feasibility and utility of the application of sealant to the pharyngeal repair with the aim of reducing pharyngocutaneous fistula incidence., Methods: This was a prospective single-blind randomized controlled study; patients undergoing primary total laryngectomy for advanced carcinoma of the larynx were randomized into control and treatment (albumin-polyaldehyde sealant applied to pharyngeal repair) groups. Relevant patient, disease, and management-related factors were recorded., Results: Forty-five patients were included (23 controls and 22 who received treatments). No difference in the incidence of pharyngocutaneous fistula was observed between the 2 groups. No treatment-related complications occurred., Conclusion: Feasibility of application of an albumin-polyaldehyde surgical sealant to the pharyngeal repair was demonstrated, however, a pharyngocutaneous fistula-preventative effect was not observed. Larger animal and clinical studies are encouraged to clarify this finding., (© 2018 Wiley Periodicals, Inc.)

Background: Cancer poses a health crisis in the developing world where surgery is the mainstay of treatment for head and neck cancers. However, a shortage of surgeons with appropriate skills exists. How do we train head and neck surgeons in developing countries and avoid a brain drain? The ideal model provides appropriate affordable training leading to establishment of head and neck cancer centers that teach and train others., Methods: Different head and neck surgery training models are presented based on the personal experiences of the authors. Surgical exposure of head and neck fellows in Cape Town and (potentially) in Nairobi is benchmarked against programs in the United States., Results: Surgical exposure in Cape Town is equivalent to that in the United States, but more appropriate to a developing world setting., Conclusion: Training can be achieved in a number of ways, which may be complimentary. Fellowship training is possible in developing countries. © 2016 Wiley Periodicals, Inc. Head Neck 39: 605-611, 2017., (© 2016 Wiley Periodicals, Inc.)

Background: The purpose of this study was to evaluate the efficacy of cloth stoma covers (bibs) to compensate for breathing unconditioned air after laryngectomy and loss of heat-moisture-exchange (HME) functions of the upper airways, which, to the best of our knowledge, has never been reported. In addition, we compared the efficacy of inexpensive, simple, locally made, noncommercial fabric bibs with commercial bibs and stick-over-the-stoma HME devices and to determine whether wetting the bib improves the tracheal climate., Methods: Tracheal temperature and humidity were studied in 25 patients who underwent a laryngectomy with a purpose-built sampling device., Results: Noncommercial and commercial bibs effectively heat and humidify inspired air (p < .05). Both bibs compare favorably with commercial HME devices. There is no benefit in using a commercially produced Buchanan Bib over an inexpensive noncommercial bib. Wetting a bib proved to be counterproductive., Conclusion: Inexpensive, noncommercial bibs are effective and improve tracheal climate and benefit patients with laryngectomies. © 2015 Wiley Periodicals, Inc. Head Neck 38: E480-E487, 2016., (© 2015 Wiley Periodicals, Inc.)

Background: Pharyngocutaneous fistula is a common complication of total laryngectomy. We hypothesized that perioperative proton pump inhibitor (PPI) treatment could reduce the incidence of pharyngocutaneous fistulae., Methods: This prospective placebo-controlled double-blind randomized controlled trial compared PPI treatment (14 days enteral omeprazole) with a placebo in patients undergoing primary total laryngectomy., Results: Forty patients were randomized into PPI (n = 21) and placebo arms (n = 19). One of 21 patients receiving omeprazole developed a fistula in comparison to 6 of 19 patients in the placebo group (p = .04). No other statistically significant risk factors for pharyngocutaneous fistula were identified. The mean hospital stay of patients with and without a fistula was 32 and 7.5 days, respectively., Conclusion: Pharyngocutaneous fistulae result in prolonged hospitalization and morbidity. We observed a statistically significant reduction in fistulae with PPI prophylaxis. Further research to better define the role of reflux and antacid management is suggested., (© 2014 Wiley Periodicals, Inc.)

Although uncommon, cancer of an unknown primary (CUP) metastatic to cervical lymph nodes poses a range of dilemmas relating to optimal treatment. The ideal resolution would be a properly designed prospective randomized trial, but it is unlikely that this will ever be conducted in this group of patients. Accordingly, knowledge gained from retrospective studies and experience from treating patients with known head and neck primary tumors form the basis of therapeutic strategies in CUP. This review provides a critical appraisal of various treatment approaches described in the literature. Emerging treatment options for CUP with metastases to cervical lymph nodes are discussed in view of recent innovations in the field of head and neck oncology and suitable therapeutic strategies for particular clinical scenarios are presented. For pN1 or cN1 disease without extracapsular extension (ECE), selective neck dissection or radiotherapy offer high rates of regional control. For more advanced neck disease, intensive combined treatment is required, either a combination of neck dissection and radiotherapy, or initial (chemo)radiotherapy followed by neck dissection if a complete response is not recorded on imaging. Each of these approaches seems to be equally effective. Use of extensive bilateral neck/mucosal irradiation must be weighed against toxicity, availability of close follow-up with elective neck imaging and guided fine-needle aspiration biopsy (FNAB) when appropriate, the human papillomavirus (HPV) status of the tumor, and particularly against the distribution pattern (oropharynx in the majority of cases) and the emergence rate of hidden primary lesions (<10% after comprehensive workup). The addition of systemic agents is expected to yield similar improvement in outcome as has been observed for known head and neck primary tumors., (Copyright © 2011 Wiley Periodicals, Inc.)

In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important., (Copyright © 2011 Wiley Periodicals, Inc.)

The goal of treatment for supraglottic cancer is to achieve cure and to preserve laryngeal function. Organ preservation strategies include both endoscopic and open surgical approaches as well as radiation and chemotherapy. The challenge is to select the correct modalities for each patient. Endoscopic procedures should be limited to tumors that can be completely visualized during diagnostic microlaryngoscopy. If complete resection can be achieved, the oncologic results of transoral laser surgery appear to be comparable to those of classic supraglottic laryngectomy. In addition, functional results of transoral laser resection are superior to those of the conventional open approach, in terms of the time required to restore swallowing, tracheotomy rate, incidence of pharyngocutaneous fistulae, and shorter hospital stay. The management of the neck remains of paramount importance, as survival of patients with supraglottic cancer depends more on cervical metastasis than on the primary tumor. Most authors advocate bilateral elective neck dissection. However, in selected cases (T1,T2 clinically negative [N0] lateral supraglottic cancers), ipsilateral selective neck dissection could be performed without compromising survival. The authors conclude that with careful selection of patients, laser supraglottic laryngectomy is a suitable, and often the preferred, treatment option for supraglottic cancer.

For most patients with head and neck squamous cell cancer, a treatment decision concerning the neck is required. Since detection of small metastases in lymph nodes is difficult, many of the patients with no detectable metastases receive elective treatment of the neck. Additional information on the metastatic potential of the primary tumor before treatment may be useful to reduce the number of these elective procedures. Biomarkers may supply such information. Molecules involved in several pathways have been studied, but the complexity of the metastatic process makes it unlikely that a single marker for metastasis can de identified. Techniques allowing the study of many factors simultaneously seem to be the most promising ones. In recent years, microarray expression profiling and comparative genomic hybridization studies have yielded interesting results. If these results can be confirmed in larger studies, they may play a role in future clinical decision making on treatment of the clinically N0 neck.

Malignant ethmoid and maxillary sinus tumors frequently involve the orbit. Orbital involvement is an important prognostic predictor of recurrence-free, disease-specific, and overall survival. Most authors agree that orbital preservation as opposed to orbital exenteration or clearance does not result in significant differences in local recurrence or actuarial survival. The eye can be safely preserved in most patients with ethmoid or maxillary sinus cancer invading the orbital wall, including malignancies that invade the orbital soft tissues with penetration through the periorbita provided that they can be completely dissected away from the orbital fat. Malposition of the globe and nonfunctional eyes frequently result when patients have not had adequate rigid reconstruction of the orbital floor, particularly if they have received postoperative radiotherapy. This underscores the importance of such reconstruction. Isolated defects following orbital exenteration may be reconstructed with a temporalis muscle flap. Microvascular free-tissue transfer is the best option for repair of defects following orbital exenteration and total maxillectomy, although an obturator still has a role in selected patients.

Since the original data from the Department of Veterans Affairs Laryngeal Cancer Study Group demonstrated that nonsurgical therapy could achieve survival rates comparable to total laryngectomy in selected cases, there has been a progressive increase in employment of nonsurgical therapy for the management of advanced laryngeal cancer. Both neoadjuvant chemotherapy followed by conventionally fractionated or hyperfractioned radiotherapy for chemotherapy responders, or simultaneously administered chemoradiation has resulted in a significant number of patients who achieved cure while preserving their larynges. Nevertheless, combined chemotherapy and external beam radiation is associated with a variety of acute and chronic sequelae that can have a debilitating impact on function and quality of life. Although no therapeutic option is without risk, the decision regarding the modality of therapy for a patient with advanced laryngeal cancer should prompt a careful review of the current surgical techniques available for treatment. Data on quality of life and aging, as well as advances in minimally invasive surgical techniques, are available today that were not available at the time of the Veterans study. Selection of optimal therapy is often complex and raises the question whether the pendulum may have swung too far in the direction of nonsurgical therapy for advanced laryngeal cancer. This article reviews the current options available for a patient with advanced laryngeal cancer and discusses the impact of therapy., (Copyright (c) 2007 Wiley Periodicals, Inc.)

Background: Tracheoesophageal fistula speech may be complicated by granulation tissue around the puncture site. Treatment includes antibiotics, antifungals, chemical or electrocautery, and surgical excision of the granulation tissue. Chemical cautery generally requires repeated treatment sessions., Methods: We report our technique and results of CO(2) laser ablation of granulation tissue at the tracheoesophageal puncture site performed as an outpatient office procedure., Results: Seven of 9 patients (78%) were cured with a single treatment. The prosthesis was replaced immediately after laser ablation of granulation tissue. Of the remaining 2 patients, 1 had a recurrence a year later, requiring repeated laser. The second patient had a large mass requiring 4 laser ablations. There were no complications., Conclusions: CO(2) laser has the following advantages compared with other methods of treating stomal granulation tissue: office procedure; 78% cured with single treatment; and the extent of tissue necrosis is predictable., (Copyright 2000 John Wiley & Sons, Inc.)

Background: Cartilage invasion adversely affects the outcome of laryngeal carcinoma treated with radiotherapy. The UICC and American Joint Committee on Cancer (AJCC) classify laryngeal carcinoma with cartilage invasion as T4 or stage IV., Methods: This study examines the prognostic significance of cartilage involvement in T3,4 N0,1 glottic carcinoma treated with total laryngectomy. Patients with tumor extension to pharynx, tongue, and thyroid gland, extracapsular spread, positive resection margins, and less than 2 years' follow-up were excluded., Results: Sixty-seven pT3 (cartilage free of tumor) and 37 pT4 (cartilage invaded by tumor) cases were studied. The difference between the pT3 and pT4 groups in terms of local or regional recurrence, distant metastasis, and determinate survival was not significant., Conclusions: The results of this study question the use of cartilage invasion as a staging parameter for surgically treated laryngeal carcinoma. However, further studies with larger sample sizes are required to fully elucidate the prognostic significance, if any, of cartilage invasion in surgically treated cancer of the larynx.

Background: A review of 16 juvenile nasopharyngeal angiofibromas, managed at the University of Pittsburgh, is presented., Methods: A retrospective chart review was done. Surgical approaches and factors affecting recurrence are analyzed., Results: Endoscopic transnasal, transpalatal, medial maxillectomy, facial translocation, and infratemporal fossa approaches, with or without craniotomy, were employed. The 37.5% recurrence rate reflects the advanced stage of the tumors. A major risk factor for recurrence was tumor involvement of the cranial base., Conclusions: The surgical approach should be selected according to tumor location and effectiveness of embolization. In young patients, the approach should minimize the potential for facial growth retardation. Tumors confined to the nasopharynx, nasal cavity, and paranasal sinuses may be removed endoscopically. Medial maxillectomy is recommended for tumors that extend to the medial intratemporal fossa or medial cavernous sinus. Significant involvement of the infratemporal fossa, cavernous sinus, or middle cranial fossa requires infratemporal fossa or transfacial approaches.