Recurrent laryngeal motor nerve conduction studies in a rat model: Establishing an objective measure for investigating laryngeal innervation.

INTRODUCTION/AIMS: Disease or injury can cause neuromuscular changes to the larynx that can affect voice, breathing, and swallowing. Motor nerve conduction studies have had limited use in the study of laryngeal neurophysiology, despite their importance in other anatomic sites. The aim of this study was to explore the feasibility of performing recurrent laryngeal motor nerve conduction studies (rlMNCS) in a rat model. METHODS: rlMNCS were performed in 15 rats under anesthesia. A bipolar stimulating electrode was placed on the recurrent laryngeal nerve (RLN) 5 mm below the cricoid cartilage. Via direct laryngoscopy, a recording electrode was placed transorally into the thyroarytenoid muscle. The RLN was maximally stimulated to determine the compound muscle action potential (CMAP). Three consecutive trials were averaged. RESULTS: The mean stimulating threshold to the RLN to achieve a CMAP from the thyroarytenoid was 1.7 ± 0.6 mA. RLN stimulation caused a visible adductor twitch of the vocal fold in all animals. The mean negative amplitude was 2.0 ± 0.8 mV, and the total area was 1.0 ± 0.4 mV ms. The CMAP latency and negative duration were 1.0 ± 0.1 ms and 0.9 ± 0.2 ms, respectively. DISCUSSION: rlMNCS are feasible and may be useful in understanding laryngeal neurophysiology with disease or injury. This work could provide a tractable animal model for studying and monitoring treatment of neuromuscular conditions affecting voice, breathing, and swallowing.

Gorilla endoscopic sinus surgery: a life-saving collaboration between human and veterinary medicine.

BACKGROUND: Chronic rhinosinusitis is a common disease process in humans; however, in the primate population of gorillas, it has rarely been described. This case describes lifesaving sinus surgery on a critically ill gorilla performed by a human otolaryngology team in collaboration with the gorilla's veterinary medicine team. METHODS: The 35-year-old western silverback gorilla was treated for 3 months with aggressive medical therapy for a worsening sinus infection. When his condition became severe, a computed tomography (CT) scan was performed showing advanced chronic rhinosinusitis with nasal polyps vs other masses and some bone erosion. As his condition deteriorated further, a tertiary otolaryngology team performed sinus surgery using the latest technology available, including image guidance, steroid-eluting sinus stents, and balloon sinus dilation. The postoperative course was complicated by subcutaneous infection and eventual fistulization. Fortunately, with culture-directed antibiotic therapy his condition gradually improved. One year later he required revision sinus surgery. At that point allergy testing was performed followed by appropriate allergy medical therapy. Now, 3 years out from his initial surgery, he continues to do well and has fathered a young female gorilla. RESULTS: This case represents a unique collaboration between human physicians and veterinarians. The combined medical approach was critical to heal this ailing gorilla. This case discusses many of the challenges and offers recommendations for physicians who may be involved with similar care of animals in the future. CONCLUSION: The success of the surgical and medical treatment of this gorilla's life-threatening sinus infection required many experts, careful planning, and corporate generosity. The interaction between human and animal medicine would not have been successful without the close and trusting collaborations between human and veterinary health providers. We encourage human healthcare providers to seek volunteer opportunities through their local zoos by engaging in discussions with their local veterinarians.

Risk stratification in endoscopic airway surgery: is inpatient observation necessary?

PURPOSE: To compare post-operative complication rates between inpatient and outpatient endoscopic airway surgery in patients with laryngotracheal stenosis. Secondary objectives included characterization of a cohort of patients with this disease. METHODS: Retrospective review of patients with laryngotracheal stenosis in a tertiary care laryngology practice over a 5-year period. RESULTS: Ninety-one patients underwent 223 endoscopic airway surgeries. Of 114 outpatient interventions, 1 patient (0.8%) sought emergent medical care following discharge for respiratory distress. Of 109 procedures resulting in admission, no patients required transfer to a higher level of care, endotracheal intubation or placement of a surgical airway. There was no statistically significant difference in complication rates between patients treated as outpatients or inpatients (p=0.33, chi square). There were no cardiopulmonary events. There were no pneumothoraces despite frequent use of jet ventilation. The most common etiologic category was idiopathic (58%), followed by granulomatosis with polyangiitis (16%) and history of tracheotomy (12%). Most patients with idiopathic disease were female (p<0.001, Fisher's exact test). CONCLUSION: Patients undergoing endoscopic surgery for airway stenosis rarely have post-operative complications, and outpatient surgery appears to be a safe alternative to post-operative admission and observation.

Voice disorders in the workplace: productivity in spasmodic dysphonia and the impact of botulinum toxin.

OBJECTIVES/HYPOTHESIS: The impact of the disordered voice on standard work productivity measures and employment trends is difficult to quantify; this is in large part due to the heterogeneity of the disease processes. Spasmodic dysphonia (SD), a chronic voice disorder, may be a useful model to study this impact. Self-reported work measures (worked missed, work impairment, overall work productivity, and activity impairment) were studied among patients receiving botulinum toxin (BTX) treatments for SD. It was hypothesized that there would be a substantial difference in work-related measures between the best and worst voicing periods. In addition, job types, employment shifts, and vocal requirements during the course of vocal disability from SD were investigated for each individual, and the impact of SD on these patterns was studied. STUDY DESIGN: A total of 145 patients with SD, either adductor or abductor, who were established in routine therapeutic BTX injections agreed to participate in a self-administered questionnaire study. Seventy-two participants were currently working and provided highly detailed information on work-related measures. Their answers characterized the effect of SD on their employment status, productivity at work, activity impairment outside of work, employment retention or change, and whether the individual perceived that BTX therapy affected these measures. Patients were asked to complete the Work Productivity and Activity Impairment (WPAI) instrument to determine these measures for their best and worst voicing weeks over the duration since their previous BTX injection. Voice-specific quality of life instruments (Voice Handicap Index-10) and perceptual assessments (Consensus Auditory Perceptual Evaluation of Voice) were elicited to provide correlations of work measures with patient-perceived voice handicap and clinician-perceived voice quality. METHODS: Cross-sectional analysis using self-administered questionnaire. RESULTS: A total of 108 patients reported ever working during their diagnosis and treatment of SD, and 72 patients were currently working and had undergone BTX therapy for at least 1 year at the time of the analysis. Currently employed patients reported a mean 4.4% decrease in work missed (absenteeism), a 28.1% decrease in work impairment (presenteeism), a 29.4% decrease in work productivity, and a 21.4% decrease in activity impairment (P <.001) in their best, as compared to their worst voicing period over their last BTX injection cycle. Presenteeism accounted for the major component of the percent work productivity impairment calculation. There was neither apparent shift in job categories nor any change in the vocal demands of their employment over the course of their disease. Among patients that have worked during their diagnosis of SD, greater than 98% report that BTX injections helped them at work. CONCLUSIONS: Patients with SD reported that their vocal dysfunction caused a significant negative effect on work productivity and increase in activity impairment. There was a significant improvement in their voice-related work parameters from their worst to best voicing periods over their last BTX injection cycle. Patients undergoing long-term BTX treatment report a positive effect of this treatment in their workplace. Spasmodic dysphonia is a meaningful model in which to study the effects of voice disorders on work productivity and employment patterns.

Battery ingestion leading to bilateral vocal cord paresis.

IMPORTANCE: Disk battery ingestion is common in the pediatric population, with over 50,000 ingestions reported annually. In the upper aerodigestive tract, consequences of such ingestions vary widely from superficial mucosal ulcerations to death from erosion through vital structures. This report describes a battery ingestion complication, vocal cord paralysis, to our knowledge not previously described in the otolaryngology literature. OBSERVATIONS: We describe a patient who presented with biphasic stridor and drooling after upper esophageal disk battery ingestion. The battery was removed 5 hours after ingestion, but stridor with respiratory distress persisted. To stabilize the airway, a tracheotomy was performed after a several-week period of inpatient observation. Two years after ingestion, the patient is tracheostomy dependent. CONCLUSIONS AND RELEVANCE: Disk battery ingestion has the potential for recurrent laryngeal nerve damage and vocal cord paralysis. Expeditious battery removal and long-term care are crucial for successful ingestion management, as ingestion complications can be significant.

Disease-specific self-efficacy in spasmodic dysphonia patients.

OBJECTIVE: Self-efficacy (SE) is an optimistic self-belief that one can perform a novel task. This concept involves empowerment, self-esteem, and adaptation to a stressful situation. SE is a strong predictor of health behaviors. Our objectives were to study SE in spasmodic dysphonia (SD) and to develop a disease-specific SE-SD scale. STUDY DESIGN: Prospective study. SETTING: Academic hospital. SUBJECT AND METHODS: Disease-specific SE-SD items were developed with laryngologists, speech pathologists, and SD patients. These items, General SE Scale, Voice Handicap Index-10 (VHI-10), Consensus Auditory Perceptual Evaluation of Voice (CAPE-V), and Hospital Anxiety and Depression Scale (HADS), were administered to SD patients who presented for botulinum toxin injections. RESULTS: One hundred forty-five SD patients (mean age 59.5 ± 13.6 years) had a general SE score (Cronbach's α = 0.894) of 33.4 ± 5.2 out of 40. This was negatively correlated with HADS-A (r = -0.42, P < 0.001) and HADS-D (r = -0.42, P < .001), but not correlated with VHI-10 (r = -0.098, P = .243) and CAPE-V (r = -0.047, P = .57). Factor analysis selected 8 items from the general SE scale and 5 disease-specific SE-SD items to generate a 13-item disease-specific SE-SD scale (Cronbach's α = 0.907). Disease-specific SE-SD score was 42.1 ± 6.9 out of 52 and was negatively correlated with VHI-10 (r = -0.19, P = .005), HADS-A (r = -0.43, P < .001), and HADS-D (r = -0.57, P < .001), but not correlated with CAPE-V (r = -0.024, P = .60). CONCLUSION: SD patients established on botulinum toxin injections have high degrees of general and disease-specific SE. Patients with higher SE-SD demonstrate lower vocal handicap and lower levels of anxiety and depression. A 13-item disease-specific SE-SD scale has been developed.

Hunsaker Mon-Jet tube ventilation: a 15-year experience.

OBJECTIVE/HYPOTHESIS: The Hunsaker Mon-Jet tube (HMJT) (Xomed, Jacksonville, FL) has been used effectively for subglottic ventilation. We previously reported a series of 552 patients over a 10-year period with no major complications. This is a continuation of that series with an additional 5 years of cases. STUDY DESIGN: Retrospective consecutive case series. METHODS: Patients who were ventilated with the HMJT for microlaryngeal surgery at the University of Washington Medical Center over a 15-year period (1995-2010) were identified from the Voice Disorders database. Charts were reviewed for demographic data, laryngeal diagnosis, and anesthetic parameters. Main outcome measure was the rate of complications. RESULTS: Fifty-seven complications occurred in 49 cases out of 839 cases (5.8% complication rate). In descending order, the complications were hypoxia (SpO(2) <90%, n = 30, 3.6%), hypercarbia (end tidal CO(2) of >60 mm Hg, n = 17, 2.0%), airway obstruction (n = 4, 0.5%), barotrauma (n = 2, 0.2%), seeding of blood into trachea (n = 2, 0.2%), submucosal injection of air (n = 1, 0.1%), and mucosal damage (n = 1, 0.1%). Factors associated with complications included high body mass index (P = .04), American Society of Anesthesiology class III or IV (P = .01), history of heart disease (P = .02), history of previous laryngeal surgery (P = .02), longer duration of case (P = .006), and laser use (P = .005). CONCLUSIONS: Although subglottic ventilation via an HMJT is a safe alternative to traditional endotracheal intubation in an appropriately selected population, practitioners should remain vigilant about the known complications.

A novel model for examining recovery of phonation after vocal nerve damage.

OBJECTIVES/HYPOTHESIS: Recurrent laryngeal nerve injury remains a dominant clinical issue in laryngology. To date, no animal model of laryngeal reinnervation has offered an outcome measure that can reflect the degree of recovery based on vocal function. We present an avian model system for studying recovery of learned vocalizations after nerve injury. STUDY DESIGN: Prospective animal study. METHODS: Digital recordings of bird song were made from 11 adult male zebra finches; nine birds underwent bilateral crushing of the nerve supplying the vocal organ, and two birds underwent sham surgery. Songs from all the birds were then recorded regularly and analyzed based on temporal and spectral characteristics using computer software. Indices were calculated to indicate the degree of similarity between preoperative and postoperative song. RESULTS: Nerve crush caused audible differences in song quality and significant drops (P<0.05) in measured spectral and, to a lesser degree, temporal indices. Spectral indices recovered significantly (mean=43.0%; standard deviation [SD]=40.7; P<0.02), and there was an insignificant trend toward recovery of temporal index (mean=28.0%; SD=41.4; P=0.0771). In five of the nine (56%) birds, there was a greater than 50% recovery of spectral indices within a 4-week period. Two birds exhibited substantially less recovery of spectral indices and two birds had a persistent decline in spectral indices. Recovery of temporal index was highly variable as well, ranging from persistent further declines of 45.1% to recovery of 87%. Neither sham bird exhibited significant (P>0.05) differences in song after nerve crush. CONCLUSION: The songbird model system allows functional analysis of learned vocalization after surgical damage to vocal nerves.

Influence of age and gender on dose and effectiveness of botulinum toxin for laryngeal dystonia.

OBJECTIVES/HYPOTHESIS: To evaluate the influence of age and gender on the required dose and resulting efficacy of botulinum toxin injection for adductor laryngeal dystonia. DESIGN: Retrospective chart review. METHODS: All patients treated with botulinum toxin for laryngeal dystonia at the University of Washington Medical Center between 1991 and 2008 were identified from a large clinical database. Only patients undergoing thyroarytenoid muscle injection for adductor laryngeal dystonia were included in this study. Each patient's gender, age at treatment, stable dose of botulinum toxin, and patient-reported duration of beneficial effect was recorded. RESULTS: A total of 155 patients (50 males, 105 females) were identified, with average ages of 50.6 years for men and 54.4 years for women. The mean treatment doses of botulinum toxin were 1.85 +/- 0.84 U for males and 2.15 +/- 1.40 U for females. The associated mean durations of beneficial effect were 12.8 +/- 7.7 weeks for males and 13.9 +/- 7.3 weeks for females. Neither the difference in dose nor in duration was found to be statistically significant (P = .395 and P = .511, respectively). When analyzed by age, the mean doses of botulinum toxin were 1.87 +/- 1.00 U for patients younger than 50 years and 2.20 +/- 1.41 U for the older group. The associated mean durations of beneficial effect were 13.7 +/- 7.4 weeks for the younger group and 13.5 +/- 7.4 weeks for the older group. Again, neither difference was found to be statistically significant (P = .113 and P = .730, respectively). CONCLUSIONS: Dosage and duration of beneficial effect of botulinum toxin in treatment of adductor laryngeal dystonia do not appear to vary with age or gender.

Recommendations of the Neurolaryngology Study Group on laryngeal electromyography.

The Neurolaryngology Study Group convened a multidisciplinary panel of experts in neuromuscular physiology, electromyography, physical medicine and rehabilitation, neurology, and laryngology to meet with interested members from the American Academy of Otolaryngology Head and Neck Surgery, the Neurolaryngology Subcommittee and the Neurolaryngology Study Group to address the use of laryngeal electromyography (LEMG) for electrodiagnosis of laryngeal disorders. The panel addressed the use of LEMG for: 1) diagnosis of vocal fold paresis, 2) best practice application of equipment and techniques for LEMG, 3) estimation of time of injury and prediction of recovery of neural injuries, 4) diagnosis of neuromuscular diseases of the laryngeal muscles, and, 5) differentiation between central nervous system and behaviorally based laryngeal disorders. The panel also addressed establishing standardized techniques and methods for future assessment of LEMG sensitivity, specificity and reliability for identification, assessment and prognosis of neurolaryngeal disorders. Previously an evidence-based review of the clinical utility of LEMG published in 2004 only found evidence supported that LEMG was possibly useful for guiding injections of botulinum toxin into the laryngeal muscles. An updated traditional/narrative literature review and expert opinions were used to direct discussion and format conclusions. In current clinical practice, LEMG is a qualitative and not a quantitative examination. Specific recommendations were made to standardize electrode types, muscles to be sampled, sampling techniques, and reporting requirements. Prospective studies are needed to determine the clinical utility of LEMG. Use of the standardized methods and reporting will support future studies correlating electro-diagnostic findings with voice and upper airway function.

The Hunsaker Mon-Jet tube with jet ventilation is effective for microlaryngeal surgery.

PURPOSE: Microlaryngeal surgery involves a delicate balance between airway control and appropriate visualization of laryngeal anatomy. When the self-centering, laser-safe Hunsaker Mon-Jet tube (Xomed, Jacksonville, FL) was introduced in 1994, to provide subglottic ventilation, the needs of both anesthesiologist and surgeon appeared to have been adequately met. However, limited data exists regarding the efficacy of this device in a large patient series. The aim of this cohort study was to explore the spectrum of patients and procedures for which this technique could be used. METHODS: We report a retrospective study of 552 patients who had undergone microlaryngeal surgery between January 1995 and June 2005, utilizing the Hunsaker Mon-Jet tube and automated jet ventilator to provide subglottic ventilation. In addition to patient demographics, overall success of ventilation and several perioperative outcomes were evaluated, including the incidence of complications. RESULTS: In combination with an automatic jet ventilator, the Hunsaker Mon-Jet tube was successfully utilized in more than 98% of the 552 patients, including those with severe co-morbidities, obesity and difficult airway access, providing optimal visualization of the vocal cords and excellent surgical access for a wide range of laryngeal disorders, including laser treatment. In less than 2% of patients, hypoxia, hypercarbia, or both, necessitated exchange of the Hunsaker Mon-Jet tube for a standard or laser-safe endotracheal tube with rapid resolution of the precipitating cause. CONCLUSIONS: Subglottic ventilation via the Hunsaker Mon-Jet tube with an automated jet ventilator may be considered an effective, safe and versatile technique for the anesthetic management of microlaryngeal surgery.

Dosage changes in patients with long-term botulinum toxin use for laryngeal dystonia.

OBJECTIVE: To investigate the dosage consistency of botulinum toxin injections in patients with long-term treatment for laryngeal dystonia. STUDY DESIGN: Chart review. SUBJECTS AND METHODS: Patients with laryngeal dystonia who had received at least 20 injections to the thyroarytenoid muscle were selected. Change of botulinum toxin dose, patient-reported effective weeks, and intervals between injections were investigated; data from the first five injections were excluded to eliminate initial dose titration. RESULTS: Fifty-five patients with an average follow-up of 12.5 years were identified. Mean dose of botulinum toxin was 2.37 +/- 1.6 U at the sixth injection; there was a decrease in mean dose over time, which became statistically significant at the 13th injection with a mean dose of 2.02 +/- 1.16 U. Mean duration of good effect and treatment intervals showed no significant change over time. CONCLUSION: Botulinum toxin dose needed for a constant response in treatment of laryngeal dystonia decreases over time, without any accompanying change in effective weeks and intervals.

A new electromyographic definition of laryngeal synkinesis.

Laryngeal synkinesis involves the misdirected reinnervation of an injured recurrent laryngeal nerve to vocal fold abductor and adductor musculature. The resultant laryngeal dyscoordination can cause vocal fold immobility and airway compromise. Although this entity is sometimes considered in the differential diagnosis, it is only demonstrable with laryngeal electromyography (EMG). We propose a new EMG definition of synkinesis to assist in its identification during workup of vocal fold immobility. A retrospective chart review from 1992 to 1997 in the Voice Disorders Clinic identified 10 patients with laryngeal synkinesis. Five patients had bilateral immobility, and 5 had unilateral immobility. Monopolar EMG was performed on all patients. Fine-wire EMG was performed when monopolar EMG did not elucidate the cause of the immobility. The EMG studies revealed synkinetic reinnervation in all subjects. On the basis of the EMG results, 7 of the 10 patients were treated with botulinum toxin to weaken the undesired reinnervation. Three of the 7 patients had benefit from this therapy. Laryngeal synkinesis should be considered as part of the differential diagnosis of vocal fold immobility. Awake laryngeal EMG is the only method to demonstrate synkinesis of the larynx. The diagnosis of synkinesis is clinically significant in cases of immobility to identify patients who might benefit from botulinum toxin therapy. Additionally, the presence of synkinesis in cases of unilateral immobility may be a contraindication to laryngeal reinnervation procedures. The benefit of botulinum toxin therapy is likely greater in the treatment of bilateral as opposed to unilateral immobility.

Findings of multiple muscle involvement in a study of 214 patients with laryngeal dystonia using fine-wire electromyography.

Although perceptual and stroboscopic data help in diagnosing and classifying laryngeal dystonia, these measures do not aid the voice clinician in targeting which specific muscles to treat with botulinum toxin. Most patients achieve smoother, less effortful voicing with standard injection regimens. However, there is a notable failure rate. We performed fine-wire electromyography on 214 consecutive patients with laryngeal dystonia. We correlated voice ratings, stroboscopy data, and fine-wire electromyography data. Videostroboscopy was successful in visually demonstrating most of the audible findings in isolated vocal tremor, but it was much less successful in identifying breaks alone or a combination of breaks and tremor. Fine-wire electromyography revealed that the thyroarytenoid muscle was significantly more likely than the lateral cricoarytenoid muscle to be the predominant muscle associated with adductor spasmodic dysphonia, and that the thyroarytenoid and lateral cricoarytenoid muscles were equally likely to be predominantly involved in tremor spasmodic dysphonia. In addition, several patients in both the adductor spasmodic dysphonia and the tremor spasmodic dysphonia groups presented with interarytenoid muscle predominance. All of the intrinsic laryngeal muscles are capable of being the predominant muscle in laryngeal dystonia, and there are patterns of muscle abnormalities that differ between adductor spasmodic dysphonia and tremor spasmodic dysphonia. Some of the failures in treating adductor spasmodic dysphonia with botulinum toxin, and the greater difficulty with success in treating patients with tremor spasmodic dysphonia, are due to failure to deliver toxin to the appropriate muscles.

Treatment of the interarytenoid muscle with botulinum toxin for laryngeal dystonia.

The treatment of laryngeal dystonia with botulinum toxin has provided various degrees of relief to the majority of patients with adductor dysphonia; however, a significant number of patients have limited or no improvement with this type of therapy. It remains unclear why some patients respond to the routine administration of toxin to the thyroarytenoid muscles whereas others do not. Injections into the lateral cricoarytenoid muscles have provided an improved voice in some patients who were unresponsive to injections into the thyroarytenoid muscles. Fine-wire electromyography can demonstrate the particular dystonic activity of these muscles to help determine which muscle is predominantly involved. It can also demonstrate dramatic dystonic activity in the interarytenoid (IA) muscle in many patients. We present the results of 23 patients treated with injections to the IA muscle after demonstration of dystonic IA activity. Ten have benefited from IA therapy. Five of these 10 patients did not have a good result from botulinum toxin until IA injections were added to the treatment plan. In 8 patients, IA therapy provided no improvement, and 5 patients were lost to adequate follow-up. According to fine-wire electromyography and clinical response, the IA muscle is an active dystonic muscle in some patients with laryngeal dystonia and should be treated with botulinum toxin in selected patients.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle.

Tremor laryngeal dystonia is a clinical entity distinct from adductor laryngeal dystonia, according to perceptual, stroboscopic, and fine-wire electromyographic findings. Treatment with botulinum toxin has proven more difficult for tremor laryngeal dystonia than for adductor laryngeal dystonia, yet no treatment variations have been considered that might produce improved clinical results. We present 81 patients with a clinical presentation of tremor laryngeal dystonia who were treated with a variety of approaches with botulinum toxin. On the basis of both fine-wire electromyographic findings and clinical response, currently 44 of those patients are being followed up after at least 3 injections. Twenty-one patients (48%) are maintained on lateral cricoarytenoid injections, and 23 (52%) are maintained on thyroarytenoid muscle injections. The electromyographic findings of this group are presented along with their clinical outcome. According to our findings, the majority of patients with tremor laryngeal dystonia can be successfully treated with botulinum toxin if the practitioner includes injections to the lateral cricoarytenoid muscle as a treatment option.

Postradiotherapy surveillance practice for head and neck squamous cell carcinoma--too much for too little?

INTRODUCTION: Limited information is available regarding surveillance patterns after head and neck cancer radiotherapy. We cataloged follow-up for a specified patient cohort treated at three neighboring university, community, and Veterans Administration institutions. METHODS: One hundred fifteen patients were treated with curative intent between 1994-1998 with definitive or postoperative radiotherapy for newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx. One hundred patients had continuous follow-up at their treating institution and were included for analysis. Median follow-up until disease recurrence or censorship was 28.5 months. RESULTS: Median follow-up frequency was 5.7 visits/year and was highly variable. Although visit frequency correlated with disease stage and the presence of high-risk disease features, this association was lost when patients with early recurrences were removed from analysis. Procedure and test utilization closely mirrored visit frequency, resulting in a wide range of estimated yearly charges (0-15,668 dollars/year; median, 1,772 dollars/year). Actuarial 3-year overall survival for the study group was 71%. Eighty-six percent (19 of 22) of potentially salvageable locoregional failures were discovered secondary to symptomatic complaint rather than by test results. Disease failure, whether detected by symptom or testing, predicted for poor survival (22% at 24 months after recurrence). CONCLUSIONS: Postradiotherapy surveillance for head and neck cancer is inconsistently pursued. A proven correlation between intensive follow-up and improved patient survival is lacking. Surveillance directed by patient symptoms should be investigated as an alternative approach.