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Stricture formation is a serious complication following pharyngeal reconstruction. These strictures can be life-threatening and can severely impact quality of life. In this article, the existing literature on surgical risk factors linked to neopharyngeal stricture formation is reviewed. Intraoperative preventative measures reconstructive surgeons should consider are also discussed. Finally, this article will describe the evaluation and management of pharyngoesophageal strictures, including the challenges and options when dealing with refractory strictures.

Negative pressure wound therapy (NPWT) has had an expanded role in the management of complex wounds including its increasing use for complex wounds in the head and neck region. Challenges for use in the head and neck region include variations in surface topography and the proximity of sensitive mouth, nose, ear, eye, and tracheal openings. Despite these challenges, NPWT has been used in the head and neck immediately following free flap surgery, to prepare wounds for skin grafting or local flaps, to treat orocutaneous and pharyngocutaneous fistulas, to treat necrotizing and deep neck space infections, to temporize and palliate, and to treat chronic wounds with exposed bone and hardware among others. This review demonstrates the proven track record of successful uses of NPWT in the aforementioned scenarios, provides suggestions to improve efficacy, as well as an algorithm for use in certain clinical situations.

We evaluated outcomes in 131 patients with cutaneous melanoma (median follow-up, 3.6 years) considered at high risk of recurrence after surgery alone treated with surgery and postoperative radiotherapy. Eligible patients had one or more of the following: recurrence after surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, or in-transit metastases. 102 patients received hypofractionated radiotherapy and 29 had conventional fractionation. 10-year outcomes were: in-field local-regional control, 87%; local regional control, 72%; distant metastasis-free survival, 48%; cause-specific survival, 44%; and overall survival, 31%. Three patients experienced acute toxicities while 6 experienced late toxicities.

Purpose There is controversy about the need to target the mucosa of the larynx and hypopharynx during radiation therapy (RT) for squamous cell carcinoma of an unknown primary site (SCCA-UP). By 1997, the policy in our department was to target only the oropharynx and nasopharynx in patients with SCCA-UP metastatic to the level II cervical nodes. The purpose of this study was to report the rate of cancer recurrence in the larynx or hypopharynx using an approach that excluded these areas from the RT target volumes. Methods and Materials The inclusion criteria for this study were RT in our department for SCCA-UP between January 1, 1997, and December 31, 2019; no history of surgery that could disrupt the cervical lymphatics; predominant adenopathy in level IIA; and neck stage N1-2c. We excluded N3 because the incidental dose to the larynx and hypopharynx is usually high in patients with a >6-cm nodal conglomerate. Results The study population was comprised of 50 patients with a median follow-up after RT of 7.1 years. No patient developed recurrent cancer in a mucosal site (0/50), 2% (1/50) developed a neck recurrence in a high-dose area with synchronous distant metastases, and 2% (1/50) developed distant metastases with no evidence of local or regional recurrence. Conclusions When delivering RT for SCCA-UP metastatic predominantly to level IIA, it is not necessary to target the mucosa of the larynx or hypopharynx. The extent to which the incidental RT dose to these areas contributes to cancer control is not evaluated in this study.

Background The tongue is an essential organ for human interaction, communication and survival. To date, there is a paucity of objective functional, patient reported, or quality of life outcomes of patients undergoing a total glossectomy with preservation of the larynx (TGLP). Objective To examine prospectively collected objective, self‐reported functional and quality of life (QOL) data in patients undergoing TGLP and free flap reconstruction. Methods Sixteen TGLP patients were identified in the prospective head and neck cancer and functional outcomes database between January of 2009 and December 2017. Data collection included patient age, sex, performance status, TNM staging, diagnosis and adjuvant treatment. Swallowing and speech functions were measured and prospectively recorded pre‐ and postoperatively. Patient reported outcomes were measured with the Speech Handicap Index (SHI) and the M.D. Anderson Dysphagia Inventory (MDADI). Results All patients had a significant reduction in their objective swallowing (P = 0.035), sentence (P = 0.001) and word intelligibility (P

To compare survival outcomes between primary surgery and primary radiation therapy (RT) in patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC).A retrospective observational cohort study.National Cancer Database.A National Cancer Database review was conducted of 2635 patients with HPV-negative OPSCC who underwent surgery or RT ± chemotherapy between 2010 and 2014. Univariate analysis was performed on all variables and entered into a multivariate model. The main outcome was overall survival (OS).A total of 2635 patients with HPV-negative OPSCC were organized into 4 groups based on cancer staging. In group 1 (T1-2 N0-1; n = 774), up-front surgery had significantly better 5-year OS (76.2%) than RT (56.8%; adjusted hazard ratio [aHR], 1.76; P = .009; 95% CI, 1.15-2.69) and chemoradiation therapy (CRT; 69.5%; aHR, 1.56; P = .019; 95% CI, 1.08-2.26). In group 2 (T3-4 N0-1; n = 327), no significant difference existed between surgery and CRT (5-year OS, 51.3% vs 52.4%; aHR, 0.96; P = .88; 95% CI, 0.54-1.69). In group 3a (T1-2 N2-3; n = 807), surgery with adjuvant treatment showed significantly better 5-year OS than CRT (78.6% vs 68.8%; aHR, 1.51; P = .027; 95% CI, 1.05-2.18). In group 3b (T3-4 N2-3; n = 737), surgery with adjuvant treatment was not statistically associated with better 5-year OS as compared with CRT (61.0% vs 43.7%; aHR, 1.53; P = .06; 95% CI, 0.98-2.39).Primary surgery may provide improved survival outcomes in many cases of HPV-negative OPSCCs. These data should be used in weighing treatment options and may serve as a basis to better delineate treatment algorithms for HPV-negative disease.

Background The aim of the study was to update our experience treating patients with glottic carcinoma in situ (CIS) with curative radiotherapy (RT). Methods Fifty patients received continuous-course RT using once-daily fractionation. Twenty-eight (56%) had recurrent or persistent CIS after resection. Median total dose was 63.0 Gy; median dose per fraction was 2.25 Gy. Median follow-up was 9.6 years for all patients and 8.4 years for survivors. Results After RT, 5 patients (10%) recurred locally; salvage surgery was performed in 4 (1 refused). Five-year outcomes were as follows: local control, 91%; ultimate local control (including patients successfully salvaged after local recurrence), 100%; ultimate local control with larynx preservation, 93%; local-regional control, 91%; ultimate local-regional control, 100%; distant metastases-free survival, 100%; cause-specific survival, 100%; and overall survival, 81%. No patient experienced a severe complication. Conclusion RT is an excellent treatment for patients with CIS recurrent after transoral excision and those with previously untreated CIS who are unsuitable for partial laryngectomy.

Background Selective neck dissection (SND) is a mainstay of head and neck cancer treatment. A common sequela is shoulder syndrome from spinal accessory nerve (SAN) trauma. Extensive dissection in neck levels 2 and 5 leads to SAN dysfunction. However, it is not known whether limited level 2 dissection reduces SAN injury. The purpose of this double-blind randomized controlled trial was to determine whether omitting level 2b dissection would improve shoulder-related quality of life and function. Methods Patients with head and neck cancers undergoing surgery were randomized 1:1 to SND without level 2b dissection (group 1) or with it (group 2) on their dominant-hand side. Patients, caregivers, and assessors were blinded. The primary outcome was the change in the Neck Dissection Impairment Index (NDII) score after 6 months. An a priori calculation of the minimally important clinical difference in the NDII score was determined to establish a sample size of 15 patients per group (power = 0.8). Secondary outcomes included shoulder strength and range of motion (ROM) and SAN nerve conduction. The trial was registered at ClinicalTrials.gov (NCT00765791). Results Forty patients were enrolled, and 30 were included (15 per group). Six months after the surgery, group 2 demonstrated a significant median decrease in the NDII from the baseline (30 points) and in comparison with group 1, whose NDII dropped 17.5 points (P = .02). Shoulder ROM and SAN conduction demonstrated significant declines in group 2 (P ≤ .05). No adverse events occurred. Conclusions Level 2b should be omitted in SND when this is oncologically safe and feasible. This allows for an optimal balance between function and cancer cure.

Background Larynx preservation with chemoradiotherapy (CRT) is used frequently in the treatment of locally advanced hypopharyngeal/laryngeal squamous cell carcinoma (LSCC). Multiple large retrospective analyses have shown that CRT is associated with worse overall survival (OS) compared to total laryngectomy (TL) in patients with T4a disease. Burgeoning evidence suggests HPV status may play a prognostic role in patients with LSCC. We aimed to determine if HPV status influences OS among patients with T4a LSCC, and, if so, if it may be useful in selecting patients for CRT. Methods Using the National Cancer Database (NCDB), we identified 810 patients with T4a N0-3 M0 squamous cell carcinoma of the larynx or hypopharynx with known HPV status who received either definitive CRT (to 66–81.6 Gy with any chemotherapy) or definitive TL (with the addition of 60–70 Gy of adjuvant RT). We evaluated differences in OS using the Kaplan–Meier method and Cox proportional hazards analyses. Results On multivariate analysis, HPV-negative status (HR = 1.42, p = 0.02) and receipt of CRT (HR = 1.34, p = 0.01) were associated with worse OS when compared to HPV-positive patients and patients receiving TL, respectively. Among patients receiving CRT, 5-year OS was lower among HPV-negative patients (33.4%) when compared to HPV-positive patients (50.6%). Conclusions These data suggest that HPV status may be a prognostic factor in patients with T4a LSCC. Further, it supports further investigation into the usefulness of HPV status as a selection factor for larynx preservation with CRT in these patients.

Objective The total oral tongue (anterior 2/3 glossectomy) defect is seldom addressed in the literature. This is the first series to describe a consistent technique for its reconstruction. The aim of the study is to describe the use of the beavertail modified radial forearm free flap (BTRFFF) to reconstruct a total oral tongue defect and the functional and quality of life outcomes associated with it. Study design Retrospective review of prospectively collected data from 2000 to 2010. Methods All patients at the University of Alberta undergoing head and neck free flap surgery are enrolled in a prospective functional outcomes program. Pre-operatively and at set post-operative time points patients complete videofluoroscopic swallowing studies (VFSS), speech evaluations and quality of life questionnaires (EORTC H&N-35). Peri-operative outcomes were also measured. Results 17 consecutive patients were included. All were gastrostomy tube free at 12 months post-operatively and tolerating a full soft diet with aspiration scores of 0. Swallowing transit times increased by a mean of 0.4 s (p = 0.32). Speech intelligibility remained high with mean sentence intelligibility at 75% and single word intelligibility at 62%. Quality of life scores returned to baseline and remained satisfactory. Complications related to the BTRFFF were limited to scarring. Conclusions The BTRFFF provides a robust reconstructive option for the total oral tongue defect with excellent long term functional outcomes and quality of life.

Objective To determine the two-dimensional (2D) characteristics of flaps necessary to create three-dimensional (3D) tongue anatomy. Methods Dissection of 11 fresh, nonpreserved human cadavers was performed. Six defects in each were created: total tongue, total oral tongue, hemiglossectomy, oral hemiglossectomy, total base of tongue, and hemi-base of tongue. The resections were debulked to create flat, 2D mucosal flaps. The dimensions and shapes of these flaps were determined. Results Each specimen showed consistent dimensions and geometry between cadavers. The total tongue was pear-shaped, the total oral tongue was egg-shaped, the oral hemi-tongue was bullet-shaped, the hemi-tongue resembled a dagger, the total base of tongue was rectangular, and the hemi-base of tongue was hour-glass shaped. Conclusion Typical dimensions and shapes of common tongue defects were determined. It is conceivable that customizing reconstructive flaps based on these data will increase the accuracy of neo-tongue reconstruction, and thus, improve functional outcomes.

Objectives: A shift in the microbiota of chronic rhinosinusitis has been described after radiotherapy to the sinonasal cavity and skull base. There is a paucity of literature characterizing the bacteriology of post radiation sinusitis using next-generation gene sequencing techniques. This study aims to describe and compare the microbial flora of rhinosinusitis after radiotherapy using both culture and molecular techniques for microbial DNA detection. Methods: The medical records of patients treated with external beam radiation for sinonasal, nasopharyngeal, or skull base malignancy were reviewed at a tertiary care facility. Patients’ sinonasal cavities were swabbed for routine culture or brushed for molecular gene sequencing. Swab specimens were processed for standard microbial culture, and brush specimens were sent for gene sequencing at Micro GenX Laboratory (Lubbock, Texas, USA). Results: Twenty-two patients were diagnosed with chronic sinusitis after undergoing radiotherapy. Staphylococcus aureus was the most common organism identified by both culture and gene sequencing, followed by Pseudomonas aeruginosa. Several additional organisms were detected by gene sequencing that were not isolated by routine culture techniques. Gene sequencing identified pathogens differing from culture results in 50% of patients examined. Conclusion: The bacteriology of post radiation sinusitis appears to resemble the microorganisms responsible for chronic sinusitis in healthy adults. Next generation gene sequencing techniques may reveal additional organisms responsible for sinusitis and provide complementary results that may impact the medical treatment of post radiation sinusitis.

OBJECTIVE Chemoradiotherapy (cRT) and total laryngectomy (TL) are acceptable treatments for locally advanced laryngeal squamous cell carcinoma (LSSC). We aimed to compare the outcomes in patients receiving full-dose treatment. METHODS We identified 11,237 patients in the National Cancer Database treated 2004 to 2015 for T3-4N0-3 LSCC with either TL (with 60 to 80 Gy of adjuvant RT) or cRT (70 to 80 Gy). We evaluated differences in overall survival (OS) using Kaplan-Meier and Cox proportional hazards modeling. RESULTS For patients with T3 disease, there was no difference in OS regardless of N stage (N0: hazard ratio [HR]=0.94, P=0.38; N+: HR=0.92, P=0.19). TL was associated with improved OS in patients with T4 disease (N0: HR=1.39, P

OBJECTIVES/HYPOTHESIS Head and neck cancer pain is a prevalent problem, and the current opioid crisis has highlighted concerns raised in chronic pain management. This study assessed the characteristics of opioid use in patients undergoing treatment for oropharynx cancer and identified risk factors associated with chronic opioid use. STUDY DESIGN Retrospective cohort study. METHODS A study was conducted of 198 eligible patients who underwent radiotherapy as part of their treatment for oropharynx cancer at a single institution from 2012 to 2017. p16/human papillomavirus (HPV) status was determined by pathology report review. Opioid use was recorded. Statistical analysis was performed to assess risk factors for chronic opioid use and effect on overall survival. RESULTS The average age was 62 years, and the mean follow-up was 38 months. Eighty-three percent of patients had stage III/IV disease, and 73% received chemoradiotherapy. Sixty-nine percent were HPV/p16 positive. Fifty-seven (29%) patients had preexisting chronic pain conditions. Chronic opioid use was observed in 53% of the patients. Age ≤ 62 years (P < .0001), history of depression (P = .0356), p16 negative status (P = .0097), opioid use at pretreatment visit (P = .0021), and presence of a preexisting chronic pain condition at time of diagnosis (P = .0181) were associated with chronic opioid use using univariate analysis. On multivariate analysis, T stage and anxiety/depression were associated with chronic opioid use. Overall survival was worse for patients who had chronic opioid use, but was not significant when recurrence was taken into consideration. CONCLUSIONS More than 50% of the patients treated for oropharynx squamous cell carcinoma in this cohort were chronic opioid users after treatment. Identifying patients at greatest risk for chronic opioid use prior to treatment may help with long-term pain management in this patient population. LEVEL OF EVIDENCE 4 Laryngoscope, 129:2087-2093, 2019.

To evaluate the difference in overall survival (OS) in patients with retromolar trigone squamous cell carcinoma (RMT SCC) treated with surgery alone versus surgery plus postoperative radiotherapy (PORT) versus surgery plus postoperative chemoradiotherapy (POCRT).Retrospective cohort study of patients from 1,500 US facilities reporting to the National Cancer Database (NCDB) registry. Participants were adult patients treated with surgery as primary treatment modality for RMT SCC (n = 2,877). Exposures were primary definitive surgery versus surgery + PORT versus surgery + POCRT. Outcomes included OS after diagnosis and treatment of RMT SCC. A multivariate Cox proportional hazards model was constructed to compare survival between the three treatment modalities. Subgroup analysis was performed by T classification and overall staging.There were 1,415 (50%) patients treated with surgery alone, 870 (30%) patients treated with surgery + PORT, and 572 (20%) treated with surgery + POCRT. Treatment with surgery + PORT was associated with improved OS compared to surgery alone (relative hazard: 1.25, 95% CI: 1.01, 1.54, p = 0.042). Patients treated with surgery + POCRT also had improved OS compared with surgery alone (relative hazard: 1.89, 95% CI 1.45, 2.43, p 0.001). Patients with T3/4 tumors had improved OS when treated with surgery + PORT (relative hazard 1.39, 95% CI: 1.05, 1.84, p = 0.022) or surgery + POCRT (relative hazard 2.27, 95% CI: 1.66, 3.15, p 0.001). Patients with T1 or T2 disease had no significant difference in survival in both the surgery + PORT (p = 0.331) and surgery + POCRT treatment groups (p = 0.134). Therefore, there was no difference in OS for patients with stage I or II disease treated with surgery + PORT (p = 0.451), nor with surgery + POCRT (p = 0.853).Treatment with surgery + PORT +/- chemotherapy appears to be associated with significantly improved OS compared to surgery alone for advanced RMT SCCa.

Purpose Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treatment outcomes are re-defining management. Traditional margins, the role of extranodal extension (ENE) and adjuvant treatment intensity continue to be debated. This study aimed to determine the impact of margins, ENE and adjuvant therapy on survival following transoral robotic surgery (TORS). Methods Patients treated with TORS at an academic center were retrospectively identified (2013–2019). Survival outcomes were evaluated using Kaplan-Meier curves. Results 48 patients were included. 40 (83%) were male. Mean age was 61.2 years. 43 (90%) were stage I. 22 (45.8%) had ENE. 31 (65%) had margins >1 mm. 38 (79%) had indications for radiation therapy; 9 (24%) refused. Chemotherapy was recommended in 36 (75%) patients; 24 (67%) refused. Locoregional control was 98%, metastasis-free survival was 96%, and disease-specific survival was 100% at 5-years. Overall survival was 95%. Conclusions Given the high survival rate seen after TORS, it is likely that margins, ENE and adjuvant treatment may not significantly contribute to outcomes.

Organ preservation versus total laryngectomy for advanced laryngeal cancer continues to be hotly debated. This review presents evidence-based decision making points for these patents.

OBJECTIVES To elucidate predictive factors in the perioperative period resulting in gastrostomy tube (G-tube) dependence for patients undergoing primary surgical treatment of oropharyngeal squamous cell carcinoma (OPSCC) in the modern era. METHODS Two hundred and thirty patients with known OPSCC treated with primary surgery were screened and selected from a retrospective database spanning from 2002 to 2012 at The Ohio State University Wexner Medical Center (Columbus, Ohio), with univariable and multivariable logistic regression modeling used to determine independent predictive factors resulting in G-tube dependence (defined as tube persistence/presence 1 year after surgery). RESULTS Surgical approach, baseline characteristics, tumor (T)-nodal-metastasis stage, human papillomavirus status, extent of tissue resected, surgical complications, reconstructive technique, preoperative G-tube presence, and adjuvant treatment were recorded. Patients undergoing open surgery for OPSCC without adjuvant treatment had 42.9% G-tube dependence (44.6% with adjuvant chemoradiation [CRT]) compared to 0% for those undergoing transoral nonrobotic surgery (8.1% with adjuvant CRT) and 0% for those undergoing transoral robotic surgery (10.3% with adjuvant CRT). In multivariable analysis, greater than 25% of the oral tongue resected (odds ratio [OR] 12.29; P = 0.03), an open surgical approach (OR 5.72; P

BACKGROUND Thirty-day hospital readmissions have become a measure of quality of care. Many readmissions enter through the emergency department. The purposes of this study were to determine the rate, risk factors, and costs of 30-day returns to the emergency department (30dEDRs) after head and neck surgery. METHODS All adult patients undergoing head and neck surgery at the University of Florida from 2012 to 2014 were reviewed. Univariate and multivariate logistic regression analyses were performed to identify risk factors for 30dEDRs. RESULTS We found 1065 patients who underwent 1173 procedures. There were 88 cases (7.5%) that resulted in 30dEDRs and 55 patients (4.7%) who had 30-day unplanned readmissions (30dURs). Significant predictors of 30dEDRs included: smoking; hypothyroidism; and intensive care unit (ICU) stays. Significant predictors of readmission from an emergency department visit were Charlson Comorbidity Index (CCI) and cancer stage. Total costs of 30dEDRs and any subsequent readmissions topped $500 000. CONCLUSION The rate of 30dEDRs after head and neck surgery is low; however, these visits increase the hospitals' financial burden as well as patient morbidity. Predictors of 30dEDRs may be utilized to formulate preventative measures.

Patients undergoing head and neck reconstruction require complex, multidisciplinary postoperative care which may include wound care, flap monitoring, tracheostomy management, and management of comorbid conditions. Historically, patients undergoing major resection of a head and neck or aerodigestive tract malignancy with regional or free flap reconstruction were routinely admitted to the ICU. Although head and neck cancer patients may have multiple medical comorbidities that may require postoperative critical care, the current trend in many institutions is to transfer stable and less medically complex patients to non-intensive care-level units with specialty trained nursing staff. These units have been shown to decrease the total cost of care without compromising the quality of care, length of stay, or postoperative complications.

Background The purpose of this study is to determine the incidence and risk factors for bilateral tonsillar cancers treated with transoral robotic surgery (TORS) and to determine the morbidity of the procedure. Methods Patients undergoing TORS for known tonsillar cancer were retrospectively reviewed. Perioperative variables and surgical outcomes were analyzed to determine predictive factors for bilateral disease and morbidity rates. Results Seventy-nine consecutive patients with tonsillar cancers underwent primary TORS radical tonsillectomy. Thirty of these patients also underwent contralateral tonsillectomy. Three patients (10%) were found to have contralateral tonsillar cancers on final pathology. These were not identified on preoperative positron emission tomography (PET)-CT or clinical examination. There were no differences in complications, gastrostomy tube (G-tube) rates, or length of stay (P > .05). Blood loss was 11.5 cc more in the contralateral tonsillectomy group (P = .001). Conclusion All patients undergoing primary TORS for tonsillar cancers should also undergo contralateral tonsillectomy to optimize oncologic outcomes with no increase in morbidity.

To report the outcomes of patients with previously untreated cutaneous Merkel cell carcinoma (MCC) managed with curative intent.Between December 1984 and August 2015, 59 patients with previously untreated cutaneous MCC were managed with curative intent with surgery and adjuvant radiotherapy (54 patients) or radiotherapy alone (5 patients) at the University of Florida. Primary sites included head and neck (45 patients), extremities (11 patients) and trunk (3 patients). Adjuvant chemotherapy was employed in 14 patients. Patients were staged according to the AJCC staging system: stage I, 25 patients; stage IIA, 7 patients; and, stage III, 27 patients. No patients had distant metastases. Median follow-up for all patients was 3.2 years (range, 0.3-20.9 years). Median follow-up for survivors was 6.7 years (range, 1.6-20.9 years).The 5-year outcomes were as follows: local control, 91%; regional control, 79%; local-regional control, 77%; disease metastasis-free survival, 60%; cause-specific survival, 53%; and overall survival, 39%. The 5-year outcomes for patients with stage I-IIA versus stage-III disease were the following: local-regional control, 90% versus 57% (p = .0115); distant metastasis-free survival, 78% versus 36% (p = .0002); cause-specific survival, 68% versus 35% (p = .0050); and overall survival, 48% versus 27% (p = .0377). Local-regional recurrences occurred in 12 patients; no patients were successfully salvaged. Severe late complications were observed in four patients.Although radiotherapy alone or combined with surgery results in a relatively high likelihood of local-regional control, the majority of recurrences are distant and approximately half of patients are cured. Patients with regional disease at diagnosis have significantly worse outcomes.

Objectives/Hypothesis Head and neck free flap patients require complex postoperative care. The quality of care for these patients often depends on their management from the time they leave the operating room. The purpose of this study was to investigate the impact of a postoperative inpatient coordinator (IC) for head and free flap patients on quality outcomes: length of stay (LOS), 30-day unplanned return to the emergency department (30dRED), 30-day unplanned readmissions (30dUR), and complication rates. Study Design Retrospective cohort study. Methods One hundred eighty-eight consecutive patients who underwent head and neck free flap surgery between January 2012 and January 2016 were reviewed using a prospective database. Patients had an IC for their entire hospitalization (group 1) or for less than their entire hospitalization (group 2). Logistic regression analysis was performed to identify risk factors for quality outcomes. Results Mean LOS was 13.8 days and 17.3 days in groups 1 and 2, respectively (P = .002). The 30dRED rate was 12% and 22%, respectively (P = .04). Group 2 had an increased LOS by 4.1 days (P = .001) and a 2.4 fold increased 30dRED (P = .03). 30dUR and complications were not influenced by the IC (P > .05). Conclusions An IC may help decrease LOS and 30dRED in head and neck free flap patients. Level of Evidence 4 Laryngoscope, 2017

Objectives/hypothesis To evaluate the long-term disease control, survival, and complications after definitive radiotherapy (RT) alone or combined with adjuvant chemotherapy with or without planned neck dissection for base of tongue squamous cell carcinoma (SCC). Study design We retrospectively reviewed the medical records of 467 patients treated at the University of Florida with definitive RT alone or combined with adjuvant chemotherapy between 1964 and 2011 for base of tongue SCC. Methods Median follow-up was 5.6 years. Median total dose to the primary site was 74.4 Gy. Eighty-seven patients (19%) were treated with once-daily fractionation, and 380 (81%) received altered fractionation schedules. Intensity-modulated RT was used in 128 patients (27%). Chemotherapy was administered to 173 (37%) patients. Planned neck dissection after RT was performed in 226 patients (48%). Data regarding p16 pathway activation were available for 25 patients. Results At 5 years, the local, local-regional, and regional control rates were 85.5%, 80.0%, and 90.0%, respectively. The 5-year overall, cause-specific, and distant metastasis-free survival rates were 59.1%, 71.5%, and 84.1%, respectively. Sixty-four patients (14%) developed one or more severe late complications. Fifty patients (11%) required late gastrostomy tube placement. Conclusions This study supports the continued use of RT alone or combined with adjuvant chemotherapy for patients with base of tongue SCC, as this treatment yields high rates of cause-specific survival and disease control, with a relatively low rate of late complications. Level of evidence 4. Laryngoscope, 127:1589-1594, 2017.

Background Recent historical management of oropharyngeal squamous cell carcinoma typically includes radiotherapy with/without chemotherapy. Novel surgical techniques such as robotic surgery have made primary surgery more frequent; however, postoperative radiotherapy may be recommended. We aimed to assess adherence to guidelines for postoperative therapy following robotic surgery. Methods Using the National Cancer Database, we analyzed the frequency of radiotherapy following robotic surgery for cT1-3cN0-2cM0 squamous cell carcinoma of the oropharynx, specifically in the presence of widely accepted indications for postoperative radiotherapy and/or chemotherapy. Results Approximately two-thirds of patients received radiotherapy after robotic surgery for early-intermediate stage oropharyngeal cancer. One in five patients with an indication for adjuvant radiotherapy and 1/3 with an indication for adjuvant chemotherapy did not receive recommended adjuvant therapy. Conclusions A high proportion of patients require radiotherapy after robotic surgery for early-intermediate stage oropharyngeal cancer. Patients with an indication for further adjuvant therapy commonly do not receive it.

OBJECTIVE To determine the rate and risk factors for osteoradionecrosis (ORN) in osseous free flaps after postoperative radiation therapy (PORT). To describe the treatment of free flap ORN. METHODS Seventy-four patients undergoing osseous free flap reconstruction were analyzed. Thirty-eight completed PORT. Patients were followed for ≥6 months. RESULTS The rate of ORN was 34% overall; 0% with 50 to 59.9 Gy; 8% with 60 Gy; 40% with 66 Gy; 56% with 70 to 74.4 Gy. Mean time to ORN was 13.1 months. 0/28 patients without PORT developed free flap osteonecrosis. Multivariate analysis found the only factor predicting ORN: PORT >60 Gy, which increased the risk 21-fold. Treatment included PENTACLO, hyperbaric oxygen, and surgical debridement with 75% within 2 years. CONCLUSION PORT >60 Gy is significantly associated with free flap ORN. As the dose of adjuvant RT increases beyond 60 Gy, the risk of ORN in free flaps rises. Consideration should be given to lower PORT doses or delaying free flap reconstruction when feasible.

PURPOSE To evaluate the rate and risk factors of isolated leptomeningeal progression in sinonasal carcinomas. METHODS We retrospectively reviewed imaging and clinical records to determine progression patterns, and estimated rates using the Kaplan-Meier method. We evaluated risk factors using proportional hazard regression. RESULTS We analyzed 120 patients who received adjuvant or primary radiotherapy for sinonasal carcinomas. Most patients had T4 disease (68%) and underwent surgery (84%) and chemotherapy (72%). Twenty-seven (23%) patients developed distant metastases (DM), including 20 (17%) with isolated DMs. Leptomeningeal progression was the most common site of isolated DMs (n = 9; 45%) with an average disease-free interval of 1.2 years (0.1-4.3 years). High-grade histology (P = 0.0003), intracranial invasion (P

Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated.Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay.In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P.05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P.05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay.DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient's closest family. Understanding limitations of the patient's insurance may help plan DC destination. Optimizing hospital resources when available should be a focus.Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team's overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.

Purpose To update our experience treating benign head-and-neck paragangliomas (PGs) with radiotherapy (RT). Methods A total of 149 patients with 176 PGs received curative-intent RT; 126 received RT to 1 PG and 23 to 2 or more PGs. The most common dose fractionation schedule was 45 Gy/25 once-daily fractions/5 weeks which was used to treat 147 PGs (83.5%) in 123 patients (82.6%). Patients were followed with physical examination and CT/MRI. The median follow-up for all patients was 10.6 years (range, 0.2-50.4 years); the median follow-up for surviving patients was 11.1 years (range, 0.2-50.4). Results The 5-year, 10-year, and 15-year outcomes were: local control, 99%, 96%, and 95%; distant metastasis-free survival, 99%, 99%, and 99%; cause-specific survival, 98%, 98%, and 98%; and overall survival, 90%, 75%, and 64%, respectively. No patient developed a moderate or severe complication, or a radiation-induced second tumor or malignant transformation of the benign PG. Conclusion RT is an effective treatment for head-and-neck PGs with a low risk of complications.

Over 4500 North Americans will be affected by advanced laryngeal cancer in 2018. As cancer treatments have progressed, treatment paradigms have shifted from “survival at all costs” to “survival with maximum functional and quality of life outcomes.” Treatment options range from organ preservation with chemo-radiation therapy (CRT) to total laryngectomy (TL) with adjuvant RT. The question is: which treatment options offers the optimal balance between cure, function and quality of life?

Current research is elucidating how the addition of depth of invasion (DOI) to the 8th edition of the American Joint Committee on Cancer (AJCC) TNM staging for oral cavity squamous cell carcinoma influences its prognostic accuracy. However, there is limited research on survival in pT3N0M0 oral tongue SCC (OTSCC) patients when stratifying by DOI.Determine 5-year overall survival (OS), and cancer-specific survival (CSS) for patients with pT3N0M0 oral OTSCC based on shallow DOI (10 mm) and deep DOI (10-20 mm).Retrospective review involving three tertiary care cancer centers in North America. cT3N0M0 OTSCC patients receiving primary surgical treatment from 2004 to 2018 were identified. Inclusion: age 18 years old and confirmation of pT3N0M0 OTSCC on surgical pathology. Exclusion: patients undergoing palliative treatment or previous head and neck surgery/radiotherapy. Analysis comprised two groups: shallow pT3 (tumor diameter 4 cm, DOI 10 mm) and deep pT3 (DOI 10 mm-20 mm).One hundred and four patients with pT3N0M0 OTSCC were included. Mean age was 59.1 years (range: 18-80.74). Age, gender, and Charlson Comorbidity Index were similar between the two groups (p 0.05). Recurrence, LVI, PNI, and positive margins were more common in deep T3 tumors (P 0.05). 5-year OS (50% vs 26%, p = 0.006) and CSS (72% vs 24%, p = 0.005) were worse in deep pT3 tumors. Deep pT3 disease was an independent predictor of OS (p = 0.004) and CSS (p = 0.01) on Cox-Regression analysis.DOI is an independent predictor of poor survival in pT3N0M0 OTSCC patients. Consideration should be given to escalating adjuvant therapy for deep pT3N0M0 OTSCC patients.

Purpose Post-radiation therapy salvage surgeries are challenging for surgeons due to tissue fibrosis. The woody hardness classification is valuable in differentiating the degree of neck stiffness, but its clinical utility has not been evaluated. We applied it to patients undergoing salvage laryngectomy to study the impact of woody hardness on postoperative outcomes. Materials and methods A retrospective observational study was performed on patients undergoing salvage laryngectomy between 2014 and 2019. Patients were assigned into the A (extremely woody hard), B (moderately woody hard), or C (mildly woody hard) woody hardness class. The primary outcome was pharyngoesophageal stricture development. Secondary outcomes included time to pharyngoesophageal stricture, pharyngocutaneous fistula development, time to pharyngocutaneous fistula, development of post-operative complications, and tracheoesophageal puncture complications. Results Fifty-one patients were included in the study: Class A 1 patient, Class B 30 patients, and Class C 20 patients. The single Class A patient was grouped with the Class B patients. The development of a pharyngoesophageal stricture shows consistent negative association with woody hardness despite most analyses not reaching statistical significance. These associations are robust to a number of confounding variables in multivariate logistic and time to event analyses. Furthermore, the time to event analysis controlling for squamous cell carcinoma diagnosis led to a statistically significant association between woody hardness (i.e., A/B higher risk) and time to stricture (HR=5, p=0.02). Conclusions This study suggests that this classification may be useful in predicting pharyngoesophageal stricture formation in salvage laryngectomy patients and could be used to implement stricture preventive measures.