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Background: There is sparse literature on the effect of preoperative immunotherapy on complications after surgery for primary head and neck squamous cell carcinoma (HNSCC). The objectives are to compare complication rates in patients receiving surgery with and without neoadjuvant immune checkpoint inhibitors (nICI) for primary HNSCC and to evaluate factors associated with increased odds of surgical complications. Methods: A retrospective review of patients who underwent ablation and free flap reconstruction or transoral robotic surgery (TORS) for primary HNSCC between 2017–2021 was conducted. Complications were compared between patients who underwent surgery with or without nICI before and after propensity score matching. Regression analysis to estimate odds ratios was performed. Results: A total of 463 patients met inclusion criteria. Free flap reconstruction constituted 28.9% of patients and TORS constituted 71.1% of patients. nICI was administered in 83 of 463 (17.9%) patients. There was no statistically significant difference in surgical, medical, or overall complications between patients receiving surgery with or without nICI. In the unmatched cohort, multivariable model identified non‐White race, former/current smoking history, free flap surgery, and perineural invasion as factors significantly associated with increased complications. In the matched cohort, multivariable model identified advanced age and free flap surgery as factors significantly associated with increased complications. Plain Language Summary: It is safe to give immunotherapy before major surgery in patients who have head and neck cancer.Advanced age, non‐White race, current/former smoking, free flap surgery, and perineural invasion may be associated with increased the odds of surgical complications. In this study, neoadjuvant immune checkpoint inhibitors (nICI) did not increase the risk of overall complications after adjusting for important confounders. Definitive surgery can be conducted safely after nICI. [ABSTRACT FROM AUTHOR]

Objective: To assess if there is increased risk of free flap failure in renal failure patients undergoing head and neck reconstruction. We seek to primarily assess free flap outcomes based on stages of chronic kidney disease (CKD) and secondarily determine increased risk for postoperative complications. Methods: Retrospective chart review was performed at five tertiary care centers. Patients were identified that had undergone microvascular free flap reconstruction of the head and neck with diagnosis of renal failure, classified as Stage 3 CKD or higher. Demographic data was collected. Outcomes in the postoperative period were examined. Results: Seventy‐three patients met inclusion criteria. The average patient age was 69 years with a male predominance (n = 48). The majority of patients had CKD Stage 3 (n = 52). Overall flap failure rate was 12.33% (n = 9, CKD stage 3 = 7.69%, CKD stage 4 = 30%, CKD stage 5 = 18%). There was an increased risk of flap failure on multivariate analysis for CKD stage 4/5 patients when compared to CKD 3 patients (p = 0.0095). When compared to matched controls, there was an increased risk of flap failure in CKD patients (p = 0.01) as well as an increased risk of overall complications (p < 0.0001). Conclusions: Patients with CKD undergoing head and neck reconstruction are at a higher risk of flap failure and overall complications. When comparing CKD stages there may be increased risk of flap failure in later stages of CKD compared to CKD 3. Appropriate patient counseling is recommended pre‐operatively in this patient population with consideration for regional flaps in the appropriate patient. Level of Evidence: 3 Laryngoscope, 134:688–694, 2024 [ABSTRACT FROM AUTHOR]

Objectives: To analyze CD8+ and FoxP3+ T‐cell cellular density (CD) and intercellular distances (ID) in head and neck squamous cell carcinoma (HNSCC) samples from a neoadjuvant trial of durvalumab +/− metformin. Methods: Paired pre‐ and post‐treatment primary HNSCC tumor samples were stained for CD8+ and FoxP3+. Digital image analysis was used to determine estimated mean CD8+ and FoxP3+ CDs and CD8+‐FoxP3+ IDs in the leading tumor edge (LTE) and tumor adjacent stroma (TAS) stratified by treatment arm, human papillomavirus (HPV) status, and pathologic treatment response. A subset of samples was characterized for T‐cell related signatures using digital spatial genomic profiling. Results: Post‐treatment analysis revealed a significant decrease in FoxP3+ CD and an increase in CD8+ CDs in the TAS between patients receiving durvalumab and metformin versus durvlaumab alone. Both treatment arms demonstrated significant post‐treatment increases in ID. Although HPV+ and HPV− had similar immune cell CDs in the tumor microenvironment, HPV+ pre‐treatment samples had 1.60 times greater ID compared with HPV− samples, trending toward significance (p = 0.05). At baseline, pathologic responders demonstrated a 1.16‐fold greater CD8+ CDs in the LTE (p = 0.045) and 2.28‐fold greater ID (p = 0.001) than non‐responders. Digital spatial profiling revealed upregulation of FoxP3+ and cytotoxic T‐lymphocyte–associated antigen 4 (CTLA‐4) in the TAS (p = 0.006, p = 0.026) in samples from pathologic responders. Conclusions: Analysis of CD8+ and FoxP3+ detected population differences according to HPV status, pathologic response, and treatment. Greater CD8+‐FoxP3+ ID was associated with pathologic response. CD8+ and FoxP3+ T‐cell distributions may be predictive of response to immune checkpoint inhibition. ClinicalTrials.gov (Identifier NCT03618654). Level of Evidence: 3 Laryngoscope, 133:1875–1884, 2023 [ABSTRACT FROM AUTHOR]

Although there are many IA modalities (e.g., sevoflurane, desflurane or isoflurane with remifentanil) as the authors listed, we stated within our Methods that all IA patients had maintenance of general anesthesia with sevoflurane. We appreciate the comments on our publication "Cost of Total Intravenous Anesthesia versus Inhalation Anesthesia in Obstructive Sleep Apnea Surgery" by Onal et al.[[1]] The first point raised was that the anesthetic agents used with the inhalation anesthesia (IA) definitions are not standardized. An anesthesia provider can hemodynamically monitor patients to assess anesthesia depth as both a reliable and cost-effective method. [Extracted from the article]

Background: Transoral robotic surgery (TORS) lingual tonsillectomy and hypoglossal nerve stimulation (HGNS) are effective surgical interventions for well-selected patients with obstructive sleep apnea (OSA) intolerant to continuous positive airway pressure (CPAP) therapy. Previous publications have demonstrated that HGNS patients have a lower postoperative apnea-hypopnea index (AHI) and length of hospital stay than TORS patients. No prior study has investigated the differences in costs between HGNS and TORS., Objectives: This study aims to compare surgery-related costs in patients undergoing HGNS versus TORS lingual tonsillectomy for OSA intolerant to CPAP., Methods: A retrospective study on OSA patients intolerant to CPAP that underwent HGNS or TORS from 2015 to 2022 at a tertiary care center. Cost was defined as the dollar amount associated with providing a specific service prior to the application of insurance., Results: This study included 395 patients (375 UAS and 20 TORS). Average total cost was significantly higher in the UAS group than the TORS group (UAS: $25,582.60; TORS: $5832.60; p < 0.001). Operating room costs were also significantly higher in the UAS group (UAS: $1978.20; TORS: $1490.90; p = 0.001). The TORS cohort averaged higher costs for pharmacy (UAS: $201.30; TORS: $416.60; p < 0.001) and anesthesia (UAS: $139.00; TORS: $307.60; p < 0.001)., Discussion: The total cost was significantly higher in the UAS group compared to the TORS group. When making management decisions, it is important to consider the cost of care provided as well as patient-centered outcomes to optimize the value of care., Level of Evidence: N/A Laryngoscope, 2024., (© 2024 The Author(s). The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Free flap (FF) reconstruction of traumatic injuries to the head and neck is uncommon., Methods: Multi-institutional retrospective case series of patients undergoing FF reconstruction for a traumatic injury (n = 103)., Results: Majority were gunshot wounds (GSW; 85%, n = 88) and motor vehicle accidents (11%, n = 11). Majority underwent osseous reconstruction (82%, n = 84). FF failures (9%, n = 9/103) occurred in GSW patients (100%, n = 9/9) and when multiple subsites were injured (89%, n = 8/9). Preoperative antibiotics correlated with lower rates of a neck washouts (4% vs. 19%) (p = 0.01) and 30-day readmissions (4% vs. 17%) (p = 0.02)., Conclusions: All FF failures occurred in the setting of a GSW and the majority involved multiple subsites. Preoperative antibiotics correlated with lower rates of postoperative washout procedures and 30-day readmission., (© 2024 The Author(s). Head & Neck published by Wiley Periodicals LLC.)

Purpose: We hypothesize that the addition of the phosphodiesterase-5 inhibitor tadalafil to the PD-1 inhibitor nivolumab, is safe and will augment immune-mediated antitumor responses in previously untreated squamous cell carcinoma of the head and neck (HNSCC)., Patients and Methods: We conducted a two-arm multi-institutional neoadjuvant randomized trial in any-stage resectable HNSCC (NCT03238365). Patients were stratified at randomization by human papillomavirus (HPV) status. Patients in both arms received nivolumab 240 mg intravenously on days 1 and 15 followed by surgery on day 28. Those in the combination therapy arm also received tadalafil 10 mg orally once daily for 4 weeks. Imaging, blood, and tumor were obtained pretreatment and posttreatment for correlative analysis., Results: Neoadjuvant therapy was well-tolerated with no grade 3 to 5 adverse events and no surgical delays. Twenty-five of 46 (54%) evaluable patients had a pathologic treatment response of ≥20%, including three (7%) patients with a complete pathologic response. Regardless of HPV status, tumor proliferation rate was a negative predictor of response. A strong pretreatment T-cell signature in the HPV-negative cohort was a predictor of response. Tadalafil altered the immune microenvironment, as evidenced by transcriptome data identifying enriched B- and natural killer cell gene sets in the tumor and augmented effector T cells in the periphery., Conclusions: Preoperative nivolumab ± tadalafil is safe in HNSCC and results in more than 50% of the patients having a pathologic treatment response of at least 20% after 4 weeks of treatment. Pretreatment specimens identified HPV status-dependent signatures that predicted response to immunotherapy while posttreatment specimens showed augmentation of the immune microenvironment with the addition of tadalafil., (©2021 The Authors; Published by the American Association for Cancer Research.)