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Management of Enlarging tracheoesophageal fistula (TEF) with Voice Prosthesis in Laryngectomized Head and Neck Cancer Patients. Objectives: An enlarging TEF following voice prosthesis placement impacts patient quality of life, risks airway compromise, and can lead to aspiration pneumonia. Pharyngoesophageal strictures have previously been reported to be associated with TEF enlargement and leakage. We describe a series of patients with enlarging TEFs after Tracheoesophageal puncture (TEP) for voice prosthesis who required pharyngoesophageal reconstruction. Methods: Retrospective case series of laryngectomized H&N cancer patients with primary or secondary TEP who underwent surgical management for enlarging TEF site between 6/2016–11/2022. Results: Eight patients were included. The mean age was 62.8 years old. Seven patients had a history of hypothyroidism. Of seven with prior H&N radiation history, two had both historical and adjuvant radiation. Two of the eight TEPs were placed secondarily. Mean time from TEP to enlarging TEF diagnosis was 891.3 days. Radial forearm‐free flaps were used in five patients. Six had stenosis proximal to the TEF whereas one had distal stenosis and one had no evidence of stenosis. Mean length of stay was 12.3 days. Mean follow‐up was 400.4 days. Two required a second free flap for persistent fistula. Conclusion: Surgical reconstruction of enlarging TEFs due to TEP/VP placement is effective in combination with addressing underlying pharyngeal/esophageal stenosis contributing to TEF enlargement and leakage. Radial forearm‐free flaps have the additional benefit of a long vascular pedicle to access more distant and less‐irradiated recipient vessels. Many fistulae are resolved after the first flap reconstruction, but some may require subsequent reconstruction in case of failure. Level of Evidence: 4 Laryngoscope, 134:198–206, 2024 [ABSTRACT FROM AUTHOR]

Minimum surgical times are positive and often large. The lognormal distribution has been proposed for modeling surgical data, and the three-parameter form of the lognormal, which includes a location parameter, should be appropriate for surgical data. We studied the goodness-of-fit performance, as measured by the Shapiro-Wilk p-value, of three estimators of the location parameter for the lognormal distribution, using a large data set of surgical times. Alternative models considered included the normal distribution and the two-parameter lognormal model, which sets the location parameter to zero. At least for samples with n> 30, data adequately fit by the normal had significantly smaller skewness than data not well fit by the normal, and data with larger relative minima (smallest order statistic divided by the mean) were better fit by a lognormal model. The rule "If the skewness of the data is greater than 0.35, use the three-parameter log- normal with the location parameter estimate proposed by Muralidhar & Zanakis (1992), otherwise, use the two-parameter model" works almost as well at specifying the lognor- mal model as more complex guidelines formulated by linear discriminant analysis and by tree induction. [ABSTRACT FROM AUTHOR]