Practice patterns in transoral robotic surgery: results of an American head and neck society survey.

To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed > 25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n = 28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n = 27, 71.1%) over fixed subunit-based resection (n = 11, 28.9%). Most surgeons (n = 29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n = 34) routinely ligated external carotid artery branches. A minority of institutions (n = 17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n = 21, 55.3%), and the most common duration being 24 h or less (n = 22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.

Immediate postoperative non-invasive positive pressure ventilation following midface microvascular free flap reconstruction.

BACKGROUND: There is a rare need for postoperative non-invasive positive pressure ventilation (NIPPV) following microvascular reconstruction of the head and neck. In midface reconstruction, the free flap vascular pedicle is especially vulnerable to the compressive forces of positive pressure delivery. CASE: A 60 year old female with Amyotrophic Lateral Sclerosis (ALS) presented with squamous cell carcinoma of the anterior maxilla, for which she underwent infrastructure maxillectomy and fibula free flap reconstruction. To avoid tracheotomy, the patient was extubated postoperatively and transitioned to NIPPV immediately utilizing a full-face positive pressure mask with a soft and flexible sealing layer. The patient was successfully transitioned to NIPPV immediately after extubation. The free flap exhibited no signs of vascular compromise postoperatively, and healed very well. CONCLUSION: Postoperative non-invasive positive pressure ventilation can be successfully applied following complex microvascular midface reconstruction to avoid tracheotomy in select patients without vascular compromise of the free flap.

Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVE: To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary center. METHODS: A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. RESULTS: A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. CONCLUSIONS: Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.

Risk Factors for Laryngectomy for Dysfunctional Larynx After Organ Preservation Protocols: A Case-Control Analysis.

OBJECTIVE: (1) To identify factors associated with severe dysfunctional larynx leading to total laryngectomy after curative treatment of head and neck squamous cell carcinoma and (2) to describe swallowing and voice outcomes. STUDY DESIGN: Retrospective single-institution case-control study. SETTING: Tertiary care referral center. METHODS: A 10-year chart review was performed for patients who had previously undergone radiation or chemoradiation for head and neck mucosal squamous cell carcinoma and planned to undergo total laryngectomy for dysfunctional larynx, as well as a control group of matched patients. Controls were patients who had undergone radiation or chemoradiation for mucosal squamous cell carcinoma but did not have severe dysfunction warranting laryngectomy; these were matched to cases by tumor subsite, T stage, and time from last treatment to video swallow study. Main outcomes assessed were postoperative diet, alaryngeal voice, pharyngeal dilations, and complications. RESULTS: Twenty-six patients were scheduled for laryngectomy for dysfunctional larynx, of which 23 underwent surgery. Originally treated tumor subsites included the larynx, oropharynx, hypopharynx, oral cavity, and a tumor of unknown origin. The median time from end of cancer treatment to laryngectomy was 11.5 years. All cases were feeding tube or tracheostomy dependent or both prior to laryngectomy. As compared with matched controls, cases were significantly less likely to have undergone IMRT (intensity-modified radiotherapy) and more likely to have pulmonary comorbidities. Eighty-nine percent of cases with follow-up achieved functional alaryngeal voice, and all were able to have oral intake. CONCLUSION: Non-IMRT approaches and pulmonary comorbidities are associated with laryngectomy for dysfunction after radiation or chemoradiation.

Patient-reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation.

OBJECTIVE: The primary objective of this project was to retrospectively investigate the relationship between patient-reported and physiologic swallowing measures after chemoradiation therapy for head neck cancer (HNC). METHODS: Adult patients who underwent chemoradiation therapy for HNC and presented for videofluoroscopic swallow study were reviewed retrospectively. Surgically treated patients were excluded. Patient perception of swallowing-related outcomes was assessed via the MD Anderson Dysphagia Inventory (MDADI) on the same day that physiologic measures of swallow function were obtained. Using vidoefluoroscopic data, the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale yielded measures of safety (DIGEST-S: penetration/aspiration) and efficiency (DIGEST-E: residue). Statistical analysis for correlation coefficients was performed. RESULTS: Thirty patients met the inclusion criteria. The oropharynx was the most commonly affected site (70.0%), followed by the larynx (16.7%). The median radiation dose was 72 grays (Gy), and participants were assessed a mean of 4.6 (range 0-12) years following completion of treatment. There was no correlation between the MDADI and the DIGEST-E score (Pearson rho = -0.045, P = 0.812), DIGEST-S score (Pearson rho = 0.075, P = 0.695), or summary DIGEST grade (Pearson rho = 0.046, P = 0.810). MDADI scores did not change significantly with increasing time since radiation (P = 0.375), whereas the DIGEST-E scores, DIGEST-S score, and summary DIGEST grades worsened over time (P = 0.007, P = 0.002, and P = 0.0005, respectively). CONCLUSION: Assessment of swallowing physiology showed that function worsened after chemoradiation therapy, but this did not correlate with patient-reported quality-of-life measures. Reduced patient awareness of swallow dysfunction years after completion of chemoradiation has implications for management of dysphagia in the face of physiologic decline. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2059-2064, 2019.

Clinical factors predicting for prolonged enteral supplementation in patients with oropharyngeal cancer treated with chemoradiation.

OBJECTIVES: The purpose of this study is to determine the pre-treatment clinical factors associated with prolonged enteral feeding in patients with oropharyngeal cancer treated with chemoradiation. MATERIALS AND METHODS: One hundred and nine patients with stage III-IVB oropharyngeal carcinoma treated with definitive chemoradiation were analyzed. Feeding tube usage was defined as the duration of active usage for nutritional purposes. RESULTS: Median follow-up was 4.4 years and median feeding tube usage was 2.5 months. On multivariate analysis, increasing duration of feeding tube usage was associated with narcotic use before treatment (p = 0.04), living alone at the time of treatment (p = 0.04), and larger pre-treatment decrease in body-mass index (p = 0.01). Prolonged feeding tube usage was associated with decreased overall survival (p = 0.06) and disease-free survival (p = 0.02) in univariate analysis. CONCLUSIONS: By identifying patients at risk for prolonged feeding tube usage, aggressive measures can be attempted to prevent feeding tube dependence.

Pharyngoesophageal stricture after treatment for head and neck cancer.

BACKGROUND: The purpose of this study was to report the risk of pharyngoesophageal stricture after treatment for head and neck cancer. METHODS: Human studies on radiation therapy with or without chemotherapy for head and neck cancer published in peer-reviewed journals with assessment of pharyngoesophageal stricture with barium swallow or endoscopy were included. RESULTS: A total of 4727 patients from 26 studies treated between 1989 and 2008 were eligible for analysis. The reported overall risk of stricture was 7.2%. The risks of pharyngoesophageal stricture in both conventional and intensity-modulated radiation therapy (IMRT) studies were 5.7% and 16.7%, respectively (p < .001). Use of concurrent (p < .001) and taxane (p = .01) chemotherapy was associated with the IMRT technique. Prospective studies reported a 3.3-fold increased risk of stricture compared with that of retrospective studies (odds ratio: 3.3; 95% confidence interval: 2.3-4.8; p < .001). CONCLUSIONS: Pharyngoesophageal stricture after IMRT and chemotherapy treatment for head and neck cancer is not uncommon. Videofluoroscopic swallow study should be performed prospectively to evaluate swallowing function.

Hypertrophic anterior cervical osteophytes causing dysphagia and airway obstruction.

Hyperostosis of anterior cervical vertebral osteophytes can produce otolaryngological symptoms ranging from mild dysphagia, dysphonia, and foreign body sensation to severe food impaction and stridulous dyspnea. Airway compromise necessitating a tracheostomy is very rare. We discuss the case of an elderly man who presented with progressive dysphagia and a large hypopharyngeal mass as his initial manifestations of hypertrophic anterior cervical osteophytes. After a biopsy of the mass, the patient went into airway distress due to bilateral vocal fold fixation by the enlarging mass and consequently required a surgical airway. A combined team approach to the removal of the osteophytes successfully resolved his symptoms. The clinical, diagnostic, radiologic, and therapeutic principles involved in this case are presented and discussed. The recognition of hypertrophic osteophytes as a potential cause of common otolaryngological symptoms in the elderly population is paramount, as these symptoms can rapidly progress and lead to life-threatening airway obstruction. Medical and surgical interventions can be employed for the treatment of hypertrophic anterior cervical osteophytes, and they often result in favorable outcomes.