Use of recombinant bone morphogenetic protein 2 in free flap reconstruction for osteonecrosis of the mandible.

PURPOSE: Osteoradionecrosis of the mandible is a debilitating consequence of radiation therapy for head-and-neck malignancy. It can result in pain, bone exposure, fistula formation, and pathologic fracture. Recombinant human bone morphogenetic protein 2 (rhBMP-2) has shown promise in reconstruction of bone defects. The purpose of this study is to determine whether the addition of rhBMP-2 at the union of vascularized bone and native bone improves surgical outcomes in patients with osteonecrosis of the mandible. MATERIALS AND METHODS: This study was a retrospective analysis of patients who were treated between 2006 and 2010 for osteonecrosis of the mandible. Patients requiring definitive reconstruction after failure of a course of conservative management were included. Patients were divided into 2 cohorts depending on whether rhBMP-2 was used during the reconstruction. The primary outcome measure was defined as stable mandibular union. RESULTS: Seventeen patients were included. The development of malunion was similar in both groups (13% for rhBMP-2 group vs 11% for non-rhBMP-2 group). Infectious complications were similar between the groups (25% in rhBMP-2 group vs 56% in non-rhBMP-2 group, P = .33). The rates of hardware removal were similar for the 2 groups (33% in non-rhBMP-2 group vs 25% in rhBMP-2 group, P = .10). No cancer recurrences were observed in patients receiving rhBMP-2. CONCLUSIONS: The use of rhBMP-2 is safe in free flap reconstruction of the mandible, but its ability to significantly improve patient outcomes, as measured by rates of malunion, reoperation, or infection, is still unknown.

Transoral robotic parapharyngeal approach to the submandibular space.

The aim of the study was to demonstrate a novel transoral parapharyngeal approach to the submandibular space. The method used was the clinical case of a patient presenting with an anteriorly based tumor in the left submandibular space. The video shows the transoral robotic technique for access to the submandibular space through the parapharyngeal space for removal of the tumor. This approach allows for high definition visibility and complete access to structures in the submandibular space including the submandibular gland. For robotic head and neck surgeons performing lateral oropharyngectomies, the anatomy is familiar, and the technique avoids potential access issues with traditional floor of mouth incisions. Furthermore, it provides a novel technique for identification of the hypoglossal nerve for potential preservation in oropharyngeal malignancy. The transoral robotic parapharyngeal approach to the submandibular space is safe, reproducible, and avoids unnecessary cervical incisions.

Functional outcomes after transoral robotic surgery for head and neck cancer.

OBJECTIVE: To evaluate functional outcomes following transoral robotic surgery for head and neck cancer. STUDY DESIGN: Case series with planned data collection. SETTING: Academic hospital. SUBJECTS AND METHODS: Between March 2007 and December 2008, 54 of 62 candidate patients underwent transoral robotic tumor resection. Outcomes include airway management, swallowing (MD Anderson Dysphagia Inventory), and enterogastric feeding. RESULTS: Tumors were most commonly oropharynx (61%) or larynx (22%) and T1 (35%) or T2 (44%). Many received radiotherapy (22% preoperatively, 41% postoperatively) and chemotherapy (31%). Endotracheal intubation was retained (22%) for up to 48 hours, tracheostomy less frequently (9%), and all were decannulated by 14 days. Most commenced oral intake prior to discharge (69%) or within two weeks (83%). A worse postoperative Dysphagia Inventory score was associated with retained feeding tube (P=0.020), age>60 (P=0.017), higher T stage (P=0.009), laryngeal site (P=0.017), and complications (P=0.035). At a mean 12 months' follow-up, 17 percent retained a feeding tube (9.5% among primary cases). Retained feeding tube was associated with preoperative tube requirement (P=0.017), higher T stage (P=0.043), oropharyngeal/laryngeal site (P=0.034), and recurrent/second primary tumor (P=0.008). Complications including airway edema (9%), aspiration (6%), bleeding (6%), and salivary fistula (2%) were managed without major sequelae. CONCLUSION: Transoral robotic surgery provides an emerging alternative for selected primary and salvage head and neck tumors with low morbidity and acceptable functional outcomes. Patients with advanced T stage, laryngeal or oropharyngeal site, and preoperative enterogastric feeding may be at increased risk of enterogastric feeding and poor swallowing outcomes.

A Next-Generation Single-Port Robotic Surgical System for Transoral Robotic Surgery: Results From Prospective Nonrandomized Clinical Trials.

IMPORTANCE: Transoral endoscopic head and neck surgery now plays an important role in the multidisciplinary management of oropharyngeal carcinoma. Previous generations of robotic surgical systems used a multiport system with a rigid stereo-endoscope and 2 wristed instruments that facilitated transoral robotic surgery. OBJECTIVE: To evaluate a new single-port robotic surgical system in head and neck surgery prospectively through concurrent nonrandomized clinical trials. DESIGN, SETTING, AND PARTICIPANTS: Two prospective clinical trials were conducted from December 16, 2016, to December 26, 2017, to assess the safety, feasibility, and performance of a flexible single-port robotic surgical system in 4 institutions, including 3 in the United States and 1 in Hong Kong. A total of 47 patients with tumors of the oropharynx were enrolled and underwent surgery. All patients were classified as having American Society of Anesthesiologists class I to III status and Eastern Cooperative Oncology Group status 0 to 1. An initial cohort of 7 patients underwent staging and endoscopic procedures for benign disease. The remaining 40 patients all had malignant tumors of the oropharynx. MAIN OUTCOMES AND MEASURES: Safety was measured by the incidence of device-related serious adverse events. Feasibility and performance were measured by the conversion rate from the use of the single-port robotic surgical system to either open surgery or the use of any other transoral technology required to complete the planned procedure. Secondary end points of swallowing function and surgical margins were also measured. RESULTS: All 47 patients (8 women and 39 men; mean [SD] age, 61 [8] years) safely underwent transoral resection with the single-port robotic surgical system without conversion to open surgery, laser surgery, or multiport robotic surgery. There were no intraoperative complications or device-related serious adverse events. Mean (SD) estimated intraoperative blood loss per procedure was 15.4 (23.9) mL; no patients received a transfusion. Two patients underwent a planned tracheotomy owing to medical comorbidity (previous chemoradiotherapy; obesity and severe sleep apnea). Two patients (4%) had grade III or IV postoperative hemorrhage, requiring a return to the operating room; however, both patients had medical comorbidities requiring the use of antithrombotic medication. The incidence of positive margins for patients with oropharyngeal malignancy was 3% (1 of 40). Within 30 days, 45 patients (96%) were eating by mouth and without the need for a percutaneous endoscopic gastrostomy tube. CONCLUSIONS AND RELEVANCE: This study describes the results of phase 2 clinical testing of a next-generation, robotic surgical system using a single-port architecture. The use of the device appears to be feasible, safe, and effective for transoral robotic surgery of oropharyngeal tumors. TRIAL REGISTRATION: ClinicalTrials.gov identifiers: NCT03010813 and NCT03049280.

Sensitivity and specificity of fluorescent immunoguided neoplasm detection in head and neck cancer xenografts.

OBJECTIVES: To determine whether fluorescently labeled anti-epidermal growth factor (EGFR) antibody could be used to detect residual disease and to guide surgical resections by comparing the sensitivity and specificity of optical fluorescence imaging with the sensitivity and specificity of histopathologic evaluation. DESIGN: A preclinical model of head and neck squamous cell carcinoma. SUBJECTS: Mice xenografted with SCC-1 tumor cells. INTERVENTIONS: The mice underwent systemic injection with anti-EGFR antibody (cetuximab) conjugated to an optically active fluorophore (Cy5.5). Both a subcutaneous flank model (n = 18) and an orthotopic murine model (n = 15) were used to assess for the presence of residual disease by fluorescent stereomicroscopy after subtotal resections of tumors. Histologic analysis was performed to confirm the presence or absence of disease. RESULTS: In the subcutaneous flank model, a diagnostic dose (50 microg) and therapeutic dose (250 microg) of fluorescent-labeled anti-EGFR were administered. When a diagnostic dose was given, the sensitivity was 86%, which was less than the 91% sensitivity when the higher dose was given. Tumor biopsy specimens in which disease was detected by histologic analysis but not by fluorescence (false-negative result) averaged 166 cells (range, 50-350 cells). The specificity of optical fluorescence to predict the presence of tumor in both groups was 100%. In the floor of the mouth model, we demonstrated a sensitivity of 81% and a specificity of 100%. False-negative results were obtained in a tumor fragment measuring less than 0.5 mm in diameter. CONCLUSION: These data support further investigation of fluorescently labeled anti-EGFR antibody to detect disease in the surgical setting.

In vivo detection of head and neck cancer orthotopic xenografts by immunofluorescence.

PURPOSE: To determine whether Cy5.5-labeled antiepidermal growth factor (EGFR) antibody could be used to detect head and neck squamous cell carcinoma (HNSCC) xenografts in vivo. METHODS: AntiEGFR antibody (cetuximab) was labeled with Cy5.5, a fluorophore with emission in the near infrared range. The cetuximab-Cy5.5 conjugate was systemically administered in subtherapeutic doses (50 microg) to mice bearing orthotopically xenografted HNSCC cell lines (SCC1, CAL27, and FaDu). As a control, isotype-matched human immunoglobulin (Ig)G1k antibody labeled with Cy5.5 was systemically injected in parallel experiments. All tumor regions (n = 6) were imaged by fluorescent stereomicroscopy at 0, 6, 24, 48, or 72 hours. Tumor size was measured by high-frequency ultrasonography at 72 hours. Transcervical partial and near-total resections were then performed with stereomicroscopic imaging after each resection. The mandible and associated structures were then resected, paraffin embedded, and then serial sectioned for analysis. RESULTS: Tumors could be clearly visualized by near infrared fluorescent stereomicroscopy at 48 and 72 hours after systemic administration of cetuximab-Cy5.5 but not after administration with the labeled isotype control antibody, IgG1k-Cy5.5. Ultrasound measurement of tumors (n = 5) correlated with fluorescent measurements of tumor (Spearman's coefficient, 0.92, P

Transoral robotic surgery for oropharyngeal and tongue cancer in the United States.

OBJECTIVES/HYPOTHESIS: To compare the clinical and cost outcomes of transoral robotic surgery (TORS) versus open procedures following the U.S. Food and Drug Administration approval in December 2009. STUDY DESIGN: Retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2011. METHODS: Elective partial pharyngectomies and partial glossectomies for neoplasm were identified by International Classification of Diseases, 9th Revision, Clinical Modification code. RESULTS: TORS represented 2.1% in 2010 and 2.2% in 2011 of all transoral ablative procedures. Patients undergoing open partial pharyngectomy for oropharyngeal neoplasms (n = 1426) had more severe illness compared to TORS (n = 641). However, after controlling for minor-to-moderate severity of illness, open partial pharyngectomy was associated with longer hospital stay (5.2 vs. 3.7 days, P < 0.001), higher charge ($98,228 vs. $67,317, P < 0.001), higher cost ($29,365 vs. $20,706, P < 0.001), higher rates of tracheostomy and gastrostomy tube placement, and more wound and bleeding complications. TORS was associated with a higher rate of dysphagia (19.5% vs. 8.0%, P < 0.001). The lower cost of TORS remained significant in the major-to-extreme severity of illness group but was associated with higher complication rates when compared to open cases of the same severity of illness. A similar analysis of TORS partial glossectomy for base of tongue tumors had similar cost and length of stay benefits, whereas TORS partial glossectomy for anterior tongue tumors revealed longer hospital stays and no benefit in charge or cost compared to open. CONCLUSIONS: Early data demonstrate a clinical and cost benefit in TORS partial pharyngectomy and partial glossectomy for the base of tongue but no benefit in partial glossectomy of the anterior tongue. It is likely that anatomic accessibility and extent of surgery factor into the effectiveness of TORS.

Free tissue transfer versus pedicled flap in head and neck reconstruction.

OBJECTIVES: Free flaps are often criticized as being medically risky for the patient, expensive, and too time-consuming when compared with the traditional rotational flap repair. Perhaps the costs do not outweigh the benefits. The study analyzes many aspects of resource utilization and patient outcome to determine whether these criticisms hold true. STUDY DESIGN: Retrospective patient review. METHODS: Sixty-five patient charts were reviewed. The following data were abstracted: flap type, tumor location and stage, preoperative American Society of Anesthesiologists score, preoperative irradiation, postoperative medical complications, flap outcome, length of hospital stay, date of first intake by mouth, and date of decannulation. The data were analyzed for free flaps and rotational flaps. Then data were analyzed again for free and rotational flaps performed for only patients who underwent a composite resection, to further standardize the results. RESULTS: For all defect types, free flap operative time was statistically greater (9 h 35 min for free flaps vs. 4 h 58 min for rotational flaps). Regarding hospital charges, only patients who had a free flap after composite resection differed in amount charged when free versus rotational flaps were compared (53,585 dollars for free flaps vs. 32,984 dollars for rotational flaps). Length of intensive care unit stay differed between patients having composite resection of the two flap types (0.1 d after rotational flap vs. 1.4 d after free flap). CONCLUSIONS: The differences between the two reconstruction methods are only a few. We do not think that longer operative time, longer length of intensive care unit stay, and increased hospital charges are significant enough to deny a patient a superior repair. We also think that as surgeons' experience increases, these differences may one day no longer hold true.

The effects of upper airway surgery for obstructive sleep apnea on nasal continuous positive airway pressure settings.

OBJECTIVES/HYPOTHESIS: The objectives were to determine whether upper airway surgery lowers nasal continuous positive airway pressure (CPAP) settings for patients who require CPAP postoperatively for unresolved obstructive sleep apnea and to assess CPAP tolerability after upper airway surgery. STUDY DESIGN: Retrospective chart review. METHODS: Patients who underwent upper airway surgery with preoperative and postoperative polysomnography at the University of Alabama at Birmingham (Birmingham, AL) between 1995 and 2000 were the focus of the study. Upper airway surgery was defined as uvulopalatopharyngoplasty alone or in addition to septoplasty and turbinoplasty. Recommended CPAP settings were recorded from preoperative and postoperative polysomnography studies to determine whether CPAP settings were decreased following surgery. A response to surgery was defined as a decrease of the recommended CPAP setting by at least 1 cm of water. A telephone interview was conducted to determine whether upper airway surgery improved CPAP comfort. RESULTS: In 51.4% of the patients, CPAP settings were decreased following surgery. Continuous positive airway pressure settings were increased in 28.6% of patients and unchanged in 20%. Of the six patients who consistently used CPAP before and after surgery, four reported increased comfort postoperatively. CONCLUSION: Upper airway surgery does not predictably reduce CPAP settings in the patient who requires postoperative CPAP for unresolved obstructive sleep apnea. Upper airway surgery may improve CPAP tolerability.

Hardware removal after osseous free flap reconstruction.

OBJECTIVE: Identifying risk factors for hardware removal in patients undergoing mandibular reconstruction with vascularized osseous free flaps remains a challenge. The purpose of this study is to identify potential risk factors, including osteocutaneous radial forearm versus fibular flap, for need for removal and to describe the fate of implanted hardware. STUDY DESIGN: Case series with chart review Setting Academic tertiary care medical center. SUBJECTS AND METHODS: Two hundred thirteen patients undergoing 227 vascularized osseous mandibular reconstructions between the years 2004 and 2012. Data were compiled through a manual chart review, and patients incurring hardware removals were identified. RESULTS: Thirty-four of 213 evaluable vascularized osseous free flaps (16%) underwent surgical removal of hardware. The average length of time to removal was 16.2 months (median 10 months), with the majority of removals occurring within the first year. Osteocutaneous radial forearm free flaps (OCRFFF) incurred a slightly higher percentage of hardware removals (9.9%) compared to fibula flaps (6.1%). Partial removal was performed in 8 of 34 cases, and approximately 38% of these required additional surgery for removal. CONCLUSION: Hardware removal was associated with continued tobacco use after mandibular reconstruction (P = .03). Removal of the supporting hardware most commonly occurs from infection or exposure in the first year. In the majority of cases the bone is well healed and the problem resolves with removal.

Intraluminal negative pressure wound therapy for optimizing pharyngeal reconstruction.

IMPORTANCE: Pharyngocutaneous fistula formation after pharyngeal reconstruction is one of the most common and challenging problems to manage. Despite many advances in management, the published success rates indicate a role for any adjuvant therapy that could potentially decrease this complication. OBJECTIVE: To describe the use of intraluminal negative pressure dressings (NPDs) in pharyngeal reconstruction. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series at a tertiary care academic hospital. Twelve laryngectomy patients underwent pharyngeal reconstruction augmented by placement of an intrapharyngeal NPD in combination with the introduction of vascularized tissue from August 2011 to May 2012. All patients had potential risk factors for compromised wound healing defined as previous radiation therapy, hypothyroidism, diabetes mellitus, compromised nutrition, or established pharyngocutaneous fistula. INTERVENTIONS: An NPD was placed in an intraluminal position spanning the length of the pharyngeal defect as part of the reconstructive procedure. The negative pressure sponge was attached to a standard nasogastric tube to which negative pressure was applied. External closure of the pharynx was then achieved with regional or free tissue transfer. MAIN OUTCOMES AND MEASURES: Pharyngeal closure rates, timing until return to oral diet, identification of wound healing risk factors, and adverse events related to use of the device. RESULTS: Eleven of 12 patients (92%) achieved pharyngeal closure with reconstruction using negative pressure wound therapy. All patients had at least 1 potential risk factor for compromised wound healing, with 11 of 12 (92%) having 2 or more. Seven patients had an established pharyngocutaneous fistula, and 5 patients underwent primary reconstruction after laryngopharyngectomy. In 6 of these 7 patients undergoing fistula repair, pharyngeal closure was achieved, and they resumed an oral diet at 1 week postoperatively. The other had successful leak repair initially, but 1 week later developed a separate area of wound breakdown and a second fistula. All 5 patients in whom an intraluminal NPD was placed at the time of initial vacularized tissue reconstruction were able to resume an oral diet by 3 weeks postoperatively, with 3 of them eating by mouth at 1 week postoperatively. No serious adverse events could be attributed to the use of intraluminal NPDs. CONCLUSIONS AND RELEVANCE: Intraluminal negative pressure wound therapy is feasible and safe. Future research should be conducted to determine its potential in optimizing pharyngeal reconstruction in high-risk patients.

Learning curve for transoral robotic surgery: a 4-year analysis.

IMPORTANCE: As new institutions incorporate transoral robotic surgery (TORS) into their everyday practice, it is helpful to have a timeline reference of expected goals to follow as their experience increases. This article evaluates a single tertiary care academic institution's experience with TORS for head and neck tumors and reports its 4-year learning curve. OBJECTIVE: To evaluate a single institution's experience with TORS over a 4-year period and report treatment trends and clinical outcomes. DESIGN: Prospective case study. SETTING: A single tertiary care academic institution. PARTICIPANTS: A total of 168 patients underwent TORS for tumors of the head and neck at University of Alabama at Birmingham between March 2007 and September 2011. The total group was subdivided into 4 consecutive groups (42 patients each). Patients were monitored throughout their hospital stay and up to 4.5 years postoperatively (mean follow-up duration, 14 months). INTERVENTION: Transoral robotic surgery. MAIN OUTCOMES AND MEASURES: Data points were collected and compared over time, including feasibility, operative time, tumor type, stage, subsite, length of intubation, need for tracheostomy, feeding tube use, hospital stay, margin status, neck dissection performed, and postoperative complications. RESULTS: Significant decreases in operative time, length of intubation, and hospital stay were seen as TORS experience increased. Overall, the mean operative time decreased by 47% (group 4, 86 minutes; group 1, 183 minutes). Total mean intubation time decreased by 87% (group 1, 12.9 hours; group 4, 1.7 hours) and mean hospital stay decreased from 3.0 days to 1.4 days. There was not a significant difference between groups in number of cases unable to be performed robotically (7-9 per group), tumor stage (majority T1/T2), tumor subsite (majority oropharynx), positive margin status (2-5 per group), number of salvage cases performed (7-9 per group), and number of tracheostomies (2-4 per group) or feeding tubes (22-25 per group) required. CONCLUSIONS AND RELEVANCE: This is the first multiyear prospective study to document a single institution's TORS experience over time and demonstrate particular areas of expected improvement as case number increases.

Free flap reconstruction of lateral mandibular defects: indications and outcomes.

OBJECTIVE: To compare outcomes following osteocutaneous radial forearm and fibula free flap reconstruction of lateral mandibular defects. STUDY DESIGN: Retrospective case-controlled study. SETTING: Historical cohort study. SUBJECTS AND METHODS: All patients who underwent free flap reconstruction of lateral mandibular defects from 1999 to 2010 were included in this study. Patients were classified into 2 groups based on type of reconstruction: (1) osteocutaneous radial forearm (n = 73) and (2) fibula free flap reconstruction (n = 51). Patient characteristics, length of hospital stay, recipient and donor site complications, and long-term outcomes including postoperative diet were evaluated. RESULTS: Most patients were male (68%) and presented with advanced T-stage (71%) squamous cell carcinoma (94%) involving the alveolus (21%), retromolar trigone (23%), or oral tongue (21%). Median length of hospital stay was 8 days (range, 4-22 days). The recipient site complication rate approached 27% and included infection (n = 11), mandibular malunion (n = 9), exposed bone or mandibular plates (n = 9), and flap failure (n = 5). Most patients demonstrated little to no trismus following reconstruction (94%) and were able to resume a regular or edentulous diet (73%). No difference in complication rates or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups (P > .05). One patient underwent dental implantation following osteocutaneous radial forearm free flap reconstruction. No patients from the fibula free flap group underwent dental implantation. CONCLUSION: The osteocutaneous radial forearm and fibula free flap provide equivalent wound healing and functional outcomes in patients undergoing lateral mandibular defect reconstruction.

Patient-perceived and objective functional outcomes following transoral robotic surgery for early oropharyngeal carcinoma.

OBJECTIVE: To evaluate changes in patient-perceived swallowing function over time following transoral robotic surgery (TORS) for primary T1 and T2 oropharyngeal squamous cell carcinomas. DESIGN: Prospective case series. SETTING: Academic tertiary referral center. PATIENTS: Forty-two patients with T1 or T2 oropharyngeal squamous cell carcinomas. INTERVENTION: TORS-assisted resection of indicated tumors. MAIN OUTCOME MEASURES: Changes in patient-perceived swallowing function over time (using the M. D. Anderson Dysphagia Inventory) and gastrostomy tube dependence. RESULTS: Between March 19, 2007, and April 21, 2010, forty-two patients with primary T1 or T2 oropharyngeal squamous cell carcinomas underwent TORS-assisted resection. Most (76% [32 of 42]) patients had stage III disease; 93% (39 of 42) of patients underwent staged neck dissection. The median postoperative follow-up time was 17 months (range, 4-40 months). There were no complications or tumor recurrences. Postoperative chemotherapy use predicted gastrostomy tube retention for longer than 3 months (P = .01). Immediate mean postoperative M. D. Anderson Dysphagia Inventory scores in each assessed domain (global, emotional, physical, and functional) decreased compared with preoperative baseline scores; however, ongoing improvement in all domains was observed over time. Nodal status (P = .049), follow-up time of less than 12 months (P = .03), and preoperative physical scores of less than 100 (P = .01) predicted poorer physical M. D. Anderson Dysphagia Inventory outcomes. Positive pathological margins predicted poorer functional scores (P = .03). CONCLUSIONS: After TORS-assisted resection of T1 and T2 oropharyngeal squamous cell carcinomas, approximately one-third of patients will experience a sustained decrease in perceived swallowing function. However, ongoing improvement of swallowing function over time is likely even after 12 months. Patients receiving adjuvant chemotherapy after TORS should be counseled about the possibility of prolonged gastrostomy tube dependence.

Dynasplint for the management of trismus after treatment of upper aerodigestive tract cancer: a retrospective study.

In order to evaluate the Dynasplint Trismus System (DTS) for the relief of trismus secondary to the treatment of head and neck cancer, we conducted a retrospective chart review of patients who had undergone DTS therapy during a 1-year period. Our inclusion criteria were cancer of the upper aerodigestive tract; treatment with radiation, chemotherapy, and/or surgery; and a maximal incisal opening (MIO) of less than 30 mm. MIO and the rate of improvement of trismus ("gain") were measured at selected intervals. Twenty-six patients met our study criteria; their pretherapy mean MIO was 19.3 mm. At the time of their most recent measurement, the mean MIO had increased to 25.5 mm-a measured gain of 32%. Although the initial rate of gain was 0.36 mm/day during the first 6 weeks, improvement leveled off over time, and the overall rate of gain was 0.16 mm/day. We conclude that the DTS is effective in increasing the mandibular range of motion at a rate of change that is maximized during initial treatment.

Robot-assisted surgery for upper aerodigestive tract neoplasms.

OBJECTIVES: To assess the feasibility and safety of performing robot-assisted resections of head and neck tumors, and to predict which variables lead to successful robot-assisted resection and better functional outcome. DESIGN: Prospective nonrandomized clinical trial. SETTING: Academic tertiary referral center. PATIENTS: Thirty-six patients with oral cavity, oropharyngeal, hypopharyngeal, or laryngeal tumors. INTERVENTION: Robot-assisted resection of indicated tumors. MAIN OUTCOME MEASURES: Ability to perform robot-assisted resection, final pathologic margin status, ability to extubate postoperatively, need for tracheotomy tube, and need for gastrostomy tube. Any clinically significant complications were recorded. RESULTS: Thirty-six patients participated in the study. Eight patients had previously been treated for head and neck cancer. Twenty-nine patients (81%) underwent successful robotic resection. Negative margins were obtained in all 29 patients. Twenty-one of 29 patients were safely extubated prior to leaving the operating room. One patient required short-term tracheotomy tube placement. A total of 9 patients were gastrostomy tube dependent (2 preoperatively, 7 postoperatively). Factors associated with successful robotic resection were lower T classification (P = .01) and edentulism (P = .07). Factors associated with gastrostomy tube dependence were advanced age (P = .02), tumor location in the larynx (P < .001), higher T classification (P = .02), and lower preoperative M. D. Anderson Dysphagia Inventory score (P = .04). CONCLUSIONS: Robot-assisted surgery is feasible and safe for the resection of select head and neck tumors. This clinical series demonstrates that robotic surgery can be utilized successfully in patients with T1 to T4 lesions located in the oral cavity, oropharynx, hypopharynx, and larynx with good preservation of swallow function.

Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer.

PURPOSE: The use of altered fractionation radiotherapy (RT) regimens, as well as concomitant chemotherapy and RT, to intensify therapy for locally advanced head-and-neck cancer can lead to increased rates of long-term dysphagia. METHODS AND MATERIALS: We identified 122 patients who had undergone definitive RT for locally advanced head-and-neck cancer, after excluding those who had been treated for a second or recurrent head-and-neck primary, had Stage I-II disease, developed locoregional recurrence, had <12 months of follow-up, or had undergone postoperative RT. The patient, tumor, and treatment factors were correlated with a composite of 3 objective endpoints as a surrogate for severe long-term dysphagia: percutaneous endoscopic gastrostomy tube dependence at the last follow-up visit; aspiration on a modified barium swallow study or a clinical diagnosis of aspiration pneumonia; or the presence of a pharyngoesophageal stricture. RESULTS: A composite dysphagia outcome occurred in 38.5% of patients. On univariate analysis, the primary site (p = 0.01), use of concurrent chemotherapy (p = 0.01), RT schedule (p = 0.02), and increasing age (p = 0.04) were significantly associated with development of composite long-term dysphagia. The use of concurrent chemotherapy (p = 0.01), primary site (p = 0.02), and increasing age (p = 0.02) remained significant on multivariate analysis. CONCLUSION: The addition of concurrent chemotherapy to RT for locally advanced head-and-neck cancer resulted in increased long-term dysphagia. Early intervention using swallowing exercises, avoidance of nothing-by-mouth periods, and the use of intensity-modulated RT to reduce the dose to the uninvolved swallowing structures should be explored further in populations at greater risk of long-term dysphagia.