Tonsillotomy for Periodic Fever Syndrome: A Randomized and Controlled Trial.

OBJECTIVE: Tonsillectomy is an effective treatment for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Tonsillotomy has a milder operative risk profile and postoperative morbidity in children than tonsillectomy. We aimed to compare the efficacy of tonsillotomy to observation-only in children with PFAPA syndrome at a 3-month follow-up. METHODS: This was a randomized multicenter trial with sequential design. Participants were randomized into a tonsillotomy group and a control group that was only observed. The trial started in 1/2017 and was accomplished in 12/2021 with 16 patients (10 boys, six girls, the mean age 4.2 years). The symptoms were monitored with daily symptom diaries. RESULTS: After the 3-month follow-up, 7/8 patients (87.5%) in the tonsillotomy group and 2/8 (25%) patients in the control group were free from PFAPA symptoms (95% CI 13% to 87%; p = 0.0021). The mean number of days with fever was 2.6 (SD 3.7) in the tonsillotomy group and 8.0 (SD 6.5) days in the control group (n = 8) (p = 0.06). Mean number of fever days compatible with PFAPA syndrome was 0.8 (SD 1.4) in the tonsillotomy group and 6.5 (SD 6.0) in the control group (95%CI -10% to -1%; p = 0.007). Rescue tonsillectomy was needed for all patients in the control group and none of the patients in the tonsillotomy group. CONCLUSIONS: Tonsillotomy might be an effective treatment option for children with PFAPA syndrome. Further studies are needed to clarify the long-term efficacy of tonsillotomy for treating PFAPA. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:968-972, 2024.

Novel human lymph node-derived matrix supports the adhesion of metastatic oral carcinoma cells.

BACKGROUND: 3D culture is increasingly used in cancer research, as it allows the growth of cells in an environment that mimics in vivo conditions. Metastases are the primary cause of morbidity and mortality in cancer patients, and solid tumour metastases are mostly located in lymph nodes. Currently, there are no techniques that model the pre-metastatic lymph node microenvironment in vitro. In this study, we prepared a novel extracellular matrix, Lymphogel, which is derived from lymph nodes, mimicking the tumour microenvironment (TME) of metastatic carcinoma cells. We tested the suitability of the new matrix in various functional experiments and compared the results with those obtained using existing matrices. METHODS: We used both commercial and patient-derived primary and metastatic oral tongue squamous cell carcinoma (OTSCC) cell lines. We characterized the functional differences of these cells using three different matrices (human uterine leiomyoma-derived Myogel, human pre-metastatic neck lymph node-derived Lymphogel (h-LG), porcine normal neck lymph node-derived Lymphogel (p-LG) in proliferation, adhesion, migration and invasion assays. We also performed proteomic analyses to compare the different matrices in relation to their functional properties. RESULTS: OTSCC cells exhibited different adhesion and invasion patterns depending on the matrix. Metastatic cell lines showed improved ability to adhere to h-LG, but the effects of the matrices on cell invasion fluctuated non-significantly between the cell lines. Proteomic analyses showed that the protein composition between matrices was highly variable; Myogel contained 618, p-LG 1823 and h-LG 1520 different proteins. The comparison of all three matrices revealed only 120 common proteins. Analysis of cellular pathways and processes associated with proteomes of each matrix revealed similarities of Myogel with h-LG but less with p-LG. Similarly, p-LG contained the least adhesion-related proteins compared with Myogel and h-LG. The highest number of unique adhesion-related proteins was present in h-LG. CONCLUSIONS: We demonstrated that human pre-metastatic neck lymph node-derived matrix is suitable for studying metastatic OTSCC cells. As a whole-protein extract, h-LG provides new opportunities for in vitro carcinoma cell culture experiments.

Programmed death-ligand 1 and tumor-infiltrating lymphocytes (TILs) - low TIL density may predict poorer long-term prognosis in T1 laryngeal cancer.

We evaluated the prognostic role of programmed death-ligand 1 (PD-L1) and tumor-infiltrating lymphocytes (TILs) in T1 glottic laryngeal squamous cell carcinoma (LSCC). T1 glottic LSCC patients (n = 174) treated at five Finnish university hospitals between 2003 and 2013 were included. Tissue microarray (TMA) blocks were used for PD-L1 immunohistochemistry. TILs were scored from intratumoral and stromal regions in whole tissue sections. Of 174 patients, 92 (53%) had negative, 66 (38%) intermediate, and 16 (9%) high PD-L1 levels. Of 80 patients whose TILs were analyzed, 50 (63%) had low and 30 (38%) high stromal TIL density. Patients with a local recurrence or a new primary tumor of the larynx had lower TIL density than had other patients (p = 0.047). High PD-L1 expression with low stromal TIL density was associated with inferior 5-year disease-specific survival (85% vs. 100%, p = 0.02). In conclusion, in patients treated for T1 glottic LSCC, low stromal TIL density was associated with local recurrences and new primary tumors of the larynx. High PD-L1 expression with low stromal TIL density may be associated with worse survival in T1 glottic LSCC.

Timing and frequency of oropharyngeal squamous cell carcinoma recurrences after treatment with curative intent.

BACKGROUND: The increasing number of patients under surveillance after treatment of human papillomavirus-related oropharyngeal squamous cell carcinoma (OPSCC) places a great burden on healthcare providers. AIMS/OBJECTIVES: The aim of this study was to explore OPSCC recurrences in a long follow-up period: their site, frequency and timepoint after primary treatment, treatment and outcome. The secondary aim was to investigate if the recurrences are diagnosed on routine follow-up visits, and if the p16 status will have an effect on the pattern of recurrences. MATERIAL AND METHODS: We analyzed recurrences within a 10-year follow-up period after completed curatively intended treatment among OPSCC patients in Finland treated between 2000 and 2009. Patient-, tumor-, treatment- and follow-up -related parameters were investigated. RESULTS: Out of 495 patients with no residual tumor during the first six months, 71 (14%) were diagnosed with a recurrence, of which 47 were locoregional and 28 were treated with curative intent. Of the recurrences, 86% were diagnosed during the first 36 months after primary treatment. Only ten recurrences appeared after 36 months. The median OS after recurrence was 10.9 months. CONCLUSIONS AND SIGNIFICANCE: Routine follow-up longer than three years after treatment seems not to be effective in terms of detecting OPSCC recurrences.

Patient and health care delays in large (class T3-T4) oral, oropharyngeal, and laryngeal carcinomas.

BACKGROUND: Head and neck cancers (HNCs) are often diagnosed at an advanced stage. We investigated the lengths and factors associated with patient, primary health care (PHC), and specialist care (SC) delays in T3-T4 oral, oropharyngeal, and laryngeal cancer. METHODS: A nationwide prospective questionnaire-based study (n = 203) with the 3-year long data collection period. RESULTS: The median patient, PHC and SC delays were 58, 13, and 43 days, respectively. Lower level of education, heavy alcohol use, hoarseness, difficulties breathing, and eventual palliative treatment associated with a longer patient delay. A lump on the neck or facial swelling associated with a shorter PHC delay. Conversely, if symptoms were treated as an infection, PHC delay was longer. The treatment modality and tumor site affected SC delay. CONCLUSIONS: Patient delay stands as the most notable factor contributing to delays before treatment. HNC symptom awareness thus remains especially important among HNC risk groups.

Quality of life after free flap reconstruction for the cancer of the head and neck: Comparison between five-year survivors and non-survivors.

BACKGROUND: Free flap surgery due to the cancer of the head and neck includes high risk of postoperative complications and a five-year mortality up to 50%. We aimed to study the relation between the quality of life (QoL) reported two years after the operation and the mortality during a next three-year follow-up. We aimed to study the relation between the quality of life (QoL) reported two years after the operation and the mortality during a next three-year follow-up. METHODS: The QoL of 53 patients was assessed using RAND-36, UW-QOL, EORTC-C30 and H&N-35 tools two years after the operation. The assessed QoL was compared between the five-year survivors and the non-survivors. RESULTS: A total of 14 (26.4%) patients died during the follow-up. The RAND-36 scores of the deceased were lower in domains "general health", "energy", "emotional role functioning" and "emotional well-being". In UW-QOL tool, the domains "swallowing" and "mood", as well as experienced QoL were lower in the non-survivors. In EORTC QLQ assessment the non-survivors reported lower QoL in domains "global health status", "physical functioning", "role functioning", "swallowing", and "felt ill". CONCLUSION: Based on our results, poor long-term survival is related to poor QoL reported two years after surgery. The difference was found in general domains of QoL tools indicating that poor QoL is a surrogate of chronic health problems having an impact on the long-term survival.

Quality of life in head and neck cancer patients at 5 years after free flap reconstruction: a significant decline during the follow-up.

PURPOSE: Free flap reconstructions following head and neck tumor resection are known to involve more than 50% rate of complications and other adverse events and up to 50% mortality during a 5-year follow-up. We aimed to examine the difference in the long-term quality of life (QoL) between the 2-year and 5-year assessments after free flap surgery for cancer of the head and neck. METHODS: A total of 28 of the 39 eligible patients responded to the survey. QoL was assessed at 5 years after operation and compared with the assessment performed at 2 years after the operation using RAND-36, EORTC-C30 and H&N-35, and SWAL-QOL tools. RESULTS: The criteria for poor QoL using RAND-36 tool was met in 11 (39.3%) patients in contrast to 4 (14.3%, P = 0.003) patients in the 2-year assessment. EORTC-C30 global score was decreased from 83.9 (SD16.4) to 64.6 (SD 24.0, P < 0.001) during the follow-up. In both RAND-36 and EORTC-C30 surveys, decline was found in physical and role functioning together with energy and emotional well-being domains. SWAL-QOL showed poor swallowing-related QoL in both assessments. CONCLUSION: We found a significant decline in QoL during a 5-year follow-up after free flap surgery for cancer of the head and neck.

T1 glottic laryngeal cancer: the role of routine follow-up visits in detecting local recurrence.

PURPOSE: We assessed the treatment outcome and the benefits of routine follow-up visits in T1 glottic laryngeal squamous cell carcinoma (LSCC). METHODS: Medical records of patients diagnosed with stage T1 glottic LSCC (N = 303) in five Finnish university hospitals between 2003 and 2015 were reviewed. Moreover, data from the Finnish Cancer Registry and the Population Register Center were collected. RESULTS: Of all 38 recurrences, 26 (68%) were detected during a routine follow-up visit, and over half (21 of 38, 55%) presented without new symptoms. Primary treatment method (surgery vs. radiotherapy) was not connected with 5-year disease-specific survival (DSS) or laryngeal preservation rate. CONCLUSION: The majority of recurrences were detected on a routine follow-up visit, and local recurrences often presented without new symptoms. Routine post-treatment follow-up of T1 glottic LSCC seems beneficial. TRIAL REGISTRATION: Trial registration number and date of registration HUS/356/2017 11.12.2017.

Tracheobronchial stents in patients with malignant airway disease: Finnish tertiary care experience.

OBJECTIVES: Tracheobronchial stenting has an established role in the palliation of malignant central airway obstruction (CAO). The purpose of this study is to describe the experience with self-expanding metal airway stents in 2 tertiary referral centres, covering a third of the population of Finland. METHODS: Patients referred to and treated with airway stenting for malignant CAO using self-expanding metal-stents were identified from electronic patient records, and data were collected using a structured Endoscopic Lower Airway Management instrument. Statistical analysis to reveal factors affecting patient benefit and survival was carried out. RESULTS: A total of 101 patients (mean age 65.8) and 116 procedures were identified. Procedure-related mortality was rare (3/101 patients) and complications infrequent. The median survival was 2.3 months [95% confidence interval (CI): 1.4-3.1). Stent benefit was not significantly affected by clinical characteristics. Survival was impacted by the use of adjunct procedures [hazard ratio (HR) 0.36, 95% CI: 0.23-0.58, P < 0.001), procedural urgency (HR 0.40; 95% CI: 0.23-0.71, P = 0.002) and post-treatment chemoradiotherapy (HR 0.29, 95% CI: 0.15-0.56, P < 0.001). CONCLUSIONS: The beneficial impact observed supports the further use of tracheobronchial stenting in malignant CAO. The use of self-expanding metal stents is encouraged.

Perioperative Risk Factors for One-Year Mortality in Patients With Free-Flap Reconstruction Due to Cancer of the Head and Neck.

PURPOSE: Head and neck cancer requiring free-flap reconstruction is associated with relatively high mortality. We aimed to evaluate perioperative risk factors for 1-year mortality in this patient group. METHODS: This is a single-center retrospective analysis of 204 patients operated during 2008 to 2018. RESULTS: A total of 47 (23.0%) patients died within 1 year. In univariate analysis, there were no differences in the intraoperative course between 1-year survivors and nonsurvivors. Among the 1-year nonsurvivors, preoperative albumin level was lower (39 [36 to 43] vs 42 [39 to 44], P = .032) and the Sequential Organ Failure Assessment admission score was higher (4 [3 to 5] vs 3 [2 to 4], P = .003) than those of the 1-year survivors. Among the nonsurvivors, the preoperative and postoperative levels of leukocytes were higher (7.6 [6.7 to 9.5] vs 6.9 [5.5 to 8.4], P = .002; 11.4 [9.0 to 14.2] vs 8.7 [7.2 to 11.3], P < .001). The highest odds ratios for 1-year mortality in multivariate analysis were American Society of Anesthesiologists A classification greater than 2 (3.9 CI 1.4 to 10.5), male gender (4.0 CI 1.5 to 11), and increase in leukocyte count (1.3 CI 1.1 to 1.5). CONCLUSIONS: One-year nonsurvivors had higher American Society of Anesthesiologists classification and were more often men. The postoperative inflammatory markers were higher in nonsurvivors, while the intraoperative course did not have a significant impact on the 1-year mortality.

Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome: Relapse and Tonsillar Regrowth After Childhood Tonsillectomy.

OBJECTIVES/HYPOTHESIS: Tonsillectomy is an effective treatment for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome, but the role of adenoidectomy, as well as later tonsillar regrowth, is unclear. To find out if the volume of lymphoid tissue is pivotal to the efficacy, we analyzed the association between the relapse of the symptoms of PFAPA syndrome and regrowth of tonsillar tissue after tonsillectomy or adenotonsillectomy. STUDY DESIGN: Prospective cohort study of operated PFAPA pateints. METHODS: We invited all patients that had undergone tonsillectomy or adenotonsillectomy due to PFAPA syndrome at the Oulu University Hospital, Oulu, Finland, between the years 1990 and 2007, at the age of ≤12 years, to a follow-up visit, after an average period of 9.8 years after their diagnoses. Out of the 132 invited, 94 (71%) participated in the follow-up study. RESULTS: At the follow-up study visit, 5 (5%) of the 94 PFAPA syndrome cases experienced recurrent fevers. The regrowth of palatine tonsillar tissue was seen in four of them (80%) as compared to 19/89 (21%) of symptom-free patients (P = .006). Two of the patients with clear PFAPA relapse at the time of the study visit were reoperated with clear effect on the symptoms. At the time of the study visit, 59/63 (94%) of the patients who had undergone adenotonsillectomy and 30/31 of the patients (97%) who had undergone tonsillectomy earlier were free of fever flares (P = .99). CONCLUSION: Palatine tonsil regrowth was associated with PFAPA syndrome relapse after tonsillectomy. Reoperation might be a treatment option in these patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2149-E2152, 2021.

Long-term Quality of Life After Treatment of Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVES: To analyze the long-term quality of life (QOL) among oropharyngeal squamous cell carcinoma (OPSCC) survivors. STUDY DESIGN: Retrospective chart analysis and patient response to European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (EORTC QLQ-C30), Head and Neck Module (EORTC QLQ-H&N35), and M.D. Anderson Dysphagia Inventory (MDADI) survey questionnaires. METHODS: All survivors of OPSCC diagnosed and treated between 2000 and 2009 in Finland were included. There were 263 survivors (44.2% of all curatively treated patients), of which a total of 164 participated in this study (62.4%). Median follow-up was 11.79 years (range = 8.59-18.53 years, interquartile range [IQR] = 4.64 years). The mean age of the participants was 67.9 years (standard deviation = 8.0 years) at QOL follow-up. RESULTS: Most survivors reported a good QOL. The EORTC QLQ-C30 global health status median was 75.00 (IQR = 31.25). The single modality treatment group had significantly better QOL outcomes than the combined treatment group. Nonsmokers and previous smokers had significantly better QOL outcomes than patients who smoked at the time of diagnosis. A history of heavy alcohol use resulted in significantly worse QOL outcomes. The p16-positive cancer patients had significantly better QOL outcomes than p16-negative patients. Percutaneous endoscopic gastrostomy (PEG) tube-dependent patients reported a significantly worse QOL than patients without a PEG tube. CONCLUSIONS: Long-term QOL in OPSCC survivors is generally good. In line with previous literature, single modality treatment was superior to combined treatment in long-term QOL outcomes, and it should be pursued whenever possible. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1172-E1178, 2021.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Tonsil Mycobiome in PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis) Syndrome: A Case-Control Study.

Periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA) is the most common periodic fever syndrome in children with unknown etiology, effectively treated with tonsillectomy. Earlier we have shown that tonsil microbiome is different in patients with PFAPA as compared to that in controls. Recently, fungal microbiome, mycobiome, has been linked to the pathogenesis of inflammatory diseases. We now investigated the role of mycobiome of tonsils in PFAPA. Random forest classification, a machine learning approach, was used for the analysis of mycobiome data. We examined tonsils from 30 children with PFAPA and 22 control children undergoing tonsillectomy for non-infectious reasons. We identified 103 amplicon sequence variants, mainly from two fungal phyla, Ascomycota and Basidiomycota. The mean relative abundance of Candida albicans in the tonsil mycobiome was 11% (95% CI: 19 to 27%) in cases and 3.4 % (95% CI: -0.8% to 8%) in controls, p =0.104. Mycobiome data showed no statistical difference in differentiating between PFAPA cases and controls compared to a random chance classifier (area under the curve (AUC) = 0.47, SD = 0.05, p = 0.809). In conclusion, in this controlled study, tonsillar mycobiome in children with PFAPA syndrome did not differ from that of the controls.

A descriptive study highlighting the differences in the treatment protocol for oral tongue cancer in Sweden and Finland.

Background and aims: Stage II cancer of the tongue is mostly managed surgically both locally and regionally. However, indications for postoperative radiotherapy and reconstructive options vary between centers. This paper aims to describe differences in treatment in a geographically homogenous cohort.Methods: A retrospective comparison was made between two cohorts of clinical T2N0 tongue cancer from Finland and Sweden. The Finnish cohort included 75 patients and the Swedish 54. All patients had curative intent of treatment and no previous head and neck cancer. Data analyzed consisted of pathological stage, size and thickness of tumor, frequency of reconstruction, radiotherapy delivered, and survival.Results: The Finnish cohort included a higher proportion of patients managed with reconstructive surgery (67%) than the Swedish cohort (0%), p < .00001. More patients were treated with postoperative radiotherapy (84%) in the Swedish cohort than in the Finnish (54%), p < .0002. The Finnish cohort had a higher level of survival and included more frequent downstaging (cTNM to pTNM).Conclusions and significance: Our data indicate a major difference in the management of T2N0 oral tongue cancer. The optimal cut-off size and growth pattern of the tumor warranting reconstruction should be further evaluated in a prospective manner considering both survival and quality of life.

Swallowing-related quality of life after free flap surgery due to cancer of the head and neck.

PURPOSE: Treatment of head and neck cancers (HNC) often leads to impairment in speech and swallowing functions. This study evaluated swallowing problems and the impact of complications on swallowing-related QOL after free flap surgery for HNC. METHODS: Swallowing-related QOL was assessed using MDADI and SWAL questionnaires. RESULTS: Of 45 assessed patients, 25 (45.5%) had at least one postoperative complication. Patients reported less than < 86 points in 8/9 SWAL-QOL domains. The SWAL-QL total score or MDADI composite scores were not related to surgical complications. Those with medical complications had lower scores in SWAL-QOL domains of mental health (82.8 (21.8) vs 65.5 (24.2), p = 0.024) and sleep (77.6 (23.0) vs 52.3 (24.3), p = 0.003). CONCLUSIONS: In conclusion, swallowing related QOL is significantly impaired after 2 years of the tumor resection and free flap reconstruction for cancer of the head and neck, when using the cut-off value of 86 points in SWAL-QOL assessment tool. Surgical complications did not have an impact on swallowing-related QOL but medical complications were related to impairment in general QOL-related domains.

Surgical quality assurance in head and neck cancer trials: an EORTC Head and Neck Cancer Group position paper based on the EORTC 1420 'Best of' and 24954 'larynx preservation' study.

Quality improvement of care for patients with head and neck cancer remains a constant objective for the multidisciplinary team of physicians managing these patients. The purpose of quality assurance (QA) for head and neck surgical oncology and surgical trials however differs. While QA for the general head and neck patient aims to improve global outcome through structural changes of health-care systems, QA for surgical trials pursues the goal to help providing meaningful results from a clinical trial through the definition of structure, process and outcome measures within the trial. Establishing a QA program for surgical trials is challenging largely due to the variation in the execution of surgical techniques. Within this article, we describe the surgical QA program, which was developed for the phase III European Organisation for Research and Treatment of Cancer (EORTC) 1420 study, a trial assessing swallowing function after transoral surgery compared with radiation therapy. We propose based on our experience to further develop surgical QA for surgical clinical trials by introducing two separate components, one adaptable and one non-adaptable. The adaptable is tailored to the scientific question and specific procedure; the non-adaptable consists of minimal structural requirements of the clinical unit to participate in surgical trials at EORTC as well as guidelines and incentives for protocol adherence based on our experience in EORTC 24954. Finally, we strongly believe that surgical QA designed for clinical trials may serve as a basis for the development of QA surgical guidelines in clinical practice.

Quality of life after free flap surgery for cancer of the head and neck in patients with or without postoperative complications.

BACKGROUND: Despite advances in surgical techniques, postoperative complications are frequent after free flap surgery for cancer of the head and neck. The present study assessed quality of life (QOL) in patients with and without postoperative complications. METHODS: QOL was evaluated using RAND-36, EORTC-C30 and H&N-35, and UW-QOL questionnaires. RESULTS: Of 53 assessed patients, 29 (54.7%) had at least one complication. Those with medical complications (n = 12, 22.6%) had significantly lower QOL in all domains of RAND-36 except emotional well-being. They also reported lower scores in EORTC-C30 domains of financial difficulties, pain, and insomnia and UW-QOL domains of pain, activity, and recreation. The QOL for patients without complications was comparable to the general population. CONCLUSION: QOL after free flap surgery for cancer of the head and neck is reduced in patients with postoperative medical complications.

Transoral Robotic Surgery in the Nordic Countries: Current Status and Perspectives.

Background: The five Nordic countries with a population of 27 M people form a rather homogenous region in terms of health care. The management of head and neck cancer is centralized to the 21 university hospitals in these countries. Our aim was to gain an overview of the volume and role of transoral robotic surgery (TORS) and to evaluate the need to centralize it in this area as the field is rapidly developing. Materials and Methods: A structured questionnaire was sent to all 10 Departments of Otorhinolaryngology-Head and Neck Surgery in the Nordic countries having an active programme for TORS in December 2017. Results: The total cumulative number of performed robotic surgeries at these 10 Nordic centers was 528 and varied between 5 and 240 per center. The median annual number of robotic surgeries was 38 (range, 5-60). The observed number of annually operated cases remained fairly low (<25) at most of the centers. Conclusions: The present results showing a limited volume of performed surgeries call for considerations to further centralize TORS in the Nordic countries.