Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer.

BACKGROUND: In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines. METHODS: This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively. RESULTS: In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery. CONCLUSIONS: We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.

Circulating Tumor DNA in Head and Neck Squamous Cell Carcinoma: Association with Metabolic Tumor Burden Determined with FDG-PET/CT.

BACKGROUND: The detection of circulating tumor DNA (ctDNA) with next-generation sequencing (NGS) in venous blood is a promising tool for the genomic profiling of head and neck squamous cell carcinoma (HNSCC). The association between ctDNA findings and metabolic tumor burden detected with FDG-PET/CT imaging is of particular interest for developing prognostic and predictive algorithms in HNSCC. METHODS: Twenty-six prospectively enrolled HNSCC patients were eligible for further analysis. All patients underwent tumor tissue and venous liquid biopsy sampling and FDG-PET/CT before definitive oncologic treatment. An NGS-based commercial panel was used for a genomic analysis of the samples. RESULTS: Maximum variant allele frequency (VAF) in blood correlated positively with whole-body (WB) metabolic tumor volume (MTV) and total lesion glycolysis (TLG) (r = 0.510, p = 0.008 and r = 0.584, p = 0.002, respectively). A positive liquid biopsy was associated with high WB-TLG using VAF ≥ 1.00% or ≥5.00% as a cut-off value (p = 0.006 or p = 0.003, respectively). Additionally, ctDNA detection was associated with WB-TLG when only concordant variants detected in both ctDNA and tissue samples were considered. CONCLUSIONS: A high metabolic tumor burden based on FDG imaging is associated with a positive liquid biopsy and high maximum VAF. Our findings suggest a complementary role of metabolic and genomic signatures in the pre-treatment evaluation of HNSCC.

Complications in lymph node excision in the head and neck area.

BACKGROUND: Although needle biopsy is widely used in work-up of lymphadenopathy, lymph node excision (LNE) is often required especially in lymphoma diagnostics. LNE is an invasive procedure, which carries a potential risk of complications. However, comprehensive studies evaluating the spectrum and occurrence of complications are lacking. AIMS/OBJECTIVES: This study addresses the role of preoperative needle biopsies in patients who underwent LNE. Furthermore, surgical complications related to LNE are analyzed. MATERIALS AND METHODS: Altogether 321 patients, who underwent LNE in two-year period in 2018-19, and fulfilled our study criteria, were included. Patients' data were retrieved from the electronic patient records. RESULTS: The surgical complication rate was 5.9%. Most of the complications (n = 16; 84.2%) were categorized as minor (I-II) according to the Clavien-Dindo scale. The remaining three (15.8%), all hemorrhages, were categorized as major complications and required intervention. Preoperative needle biopsy might have avoided the need for LNE in some patients, which we discuss in this study. CONCLUSIONS AND SIGNIFICANCE: Surgical complications after LNE in the head and neck area are rare and mostly minor. Needle biopsy is often recommended preoperatively to avoid unnecessary operations and to refrain performing LNE for patients with non-lymphatic malignancy.

Local delivery of interleukin 7 with an oncolytic adenovirus activates tumor-infiltrating lymphocytes and causes tumor regression.

Cytokines have proven to be effective for cancer therapy, however whilst low-dose monotherapy with cytokines provides limited therapeutic benefit, high-dose treatment can lead to a number of adverse events. Interleukin 7 has shown promising results in clinical trials, but anti-cancer effect was limited, in part due to a low concentration of the cytokine within the tumor. We hypothesized that arming an oncolytic adenovirus with Interleukin 7, enabling high expression localized to the tumor microenvironment, would overcome systemic delivery issues and improve therapeutic efficacy. We evaluated the effects of Ad5/3-E2F-d24-hIL7 (TILT-517) on tumor growth, immune cell activation and cytokine profiles in the tumor microenvironment using three clinically relevant animal models and ex vivo tumor cultures. Our data showed that local treatment of tumor bearing animals with Ad5/3- E2F-d24-hIL7 significantly decreased cancer growth and increased frequency of tumor-infiltrating cells. Ad5/3-E2F-d24-hIL7 promoted notable upregulation of pro-inflammatory cytokines, and concomitant activation and migration of CD4+ and CD8 + T cells. Interleukin 7 expression within the tumor was positively correlated with increased number of cytotoxic CD4+ cells and IFNg-producing CD4+ and CD8+ cells. These findings offer an approach to overcome the current limitations of conventional IL7 therapy and could therefore be translated to the clinic.

Carotid interposition in patients with head and neck tumors: clinical experience of 13 cases reconstructed with a great saphenous vein autograft.

BACKGROUND: Carotid interposition graft (CIG) surgery in the setting of head & neck cancer (HNC) is a rare procedure with a limited number of cases described in the literature. AIMS/OBJECTIVES: To assess the outcomes of the surgery at Helsinki University Hospital. MATERIALS AND METHODS: Patients who underwent CIG in a head and neck tumor surgery were retrospectively analyzed over 15 years. Overall-survival (OS) was calculated until 1 May 2020. The primary-outcome was to measure the 30-day OS, postoperative stroke rate, and other complications. The secondary-outcome was to measure 1-, 2-, and 5-year OS. RESULTS: Thirteen patients were identified, 11 with HNC and two with Shamblin III Carotid Body Tumors. The great saphenous vein was used for all vascular reconstructions, and shunting was routinely performed. The 30-day stroke incidence was nil. Two graft-blowouts were encountered, one of which lead to death and the other was successfully managed. For HNC patients, the locoregional recurrence-rate was 36%. The 5-year OS was 46.2%. CONCLUSION AND SIGNIFICANCE: CIG in HNC setting can achieve oncologic-control with an acceptable rate of complications. Routine shunting, heparinization, and elevating blood-pressure during closure seem to be safe protocols to maintain cerebral-circulation perioperatively. A moderate graft-blowout risk should be considered.

Adenovirus Encoding Tumor Necrosis Factor Alpha and Interleukin 2 Induces a Tertiary Lymphoid Structure Signature in Immune Checkpoint Inhibitor Refractory Head and Neck Cancer.

Immune checkpoint inhibitors (ICI) have provided significant improvement in clinical outcomes for some patients with solid tumors. However, for patients with head and neck cancer, the response rate to ICI monotherapy remains low, leading to the exploration of combinatorial treatment strategies. In this preclinical study, we use an oncolytic adenovirus (Ad5/3) encoding hTNFα and hIL-2 and non-replicate adenoviruses (Ad5) encoding mTNFα and mIL-2 with ICI to achieve superior tumor growth control and improved survival outcomes. The in vitro effect of Ad5/3-E2F-D24-hTNFa-IRES-hIL-2 was characterized through analyses of virus replication, transgene expression and lytic activity using head and neck cancer patient derived cell lines. Mouse models of ICI naïve and refractory oral cavity squamous cell carcinoma were established to evaluate the local and systemic anti-tumor immune response upon ICI treatment with or without the non-replicative adenovirus encoding mTNFα and mIL-2. We delineated the mechanism of action by measuring the metabolic activity and effector function of CD3+ tumor infiltrating lymphocytes (TIL) and transcriptomic profile of the CD45+ tumor immune compartment. Ad5/3-E2F-D24-hTNFa-IRES-hIL-2 demonstrated robust replicative capability in vitro across all head and neck cell lines screened through potent lytic activity, E1a and transgene expression. In vivo, in both ICI naïve and refractory models, we observed improvement to tumor growth control and long-term survival when combining anti-PD-1 or anti-PD-L1 with the non-replicative adenovirus encoding mTNFα and mIL-2 compared to monotherapies. This observation was verified by striking CD3+ TIL derived mGranzyme b and interferon gamma production complemented by increased T cell bioenergetics. Notably, interrogation of the tumor immune transcriptome revealed the upregulation of a gene signature distinctive of tertiary lymphoid structure formation upon treatment of murine anti-PD-L1 refractory tumors with non-replicative adenovirus encoding mTNFα and mIL-2. In addition, we detected an increase in anti-tumor antibody production and expansion of the memory T cell compartment in the secondary lymphoid organs. In summary, a non-replicative adenovirus encoding mTNFα and mIL-2 potentiates ICI therapy, demonstrated by improved tumor growth control and survival in head and neck tumor-bearing mice. Moreover, the data reveals a potential approach for inducing tertiary lymphoid structure formation. Altogether our results support the clinical potential of combining this adenovirotherapy with anti-PD-1 or anti-PD-L1.

Antizyme inhibitor 2 (AZIN2) associates with better prognosis of head and neck minor salivary gland adenoid cystic carcinoma.

The key regulator of the polyamine biosynthetic pathway is ornithine decarboxylase (ODC). ODC is activated by antizyme inhibitor 1 (AZIN1) and 2 (AZIN2). AZIN1 and recently AZIN2 have been related to cancer; however, their functions in adenoid cystic carcinoma (ACC) have not been studied. We performed immunohistochemical study on minor salivary and mucous gland ACC tissue samples of patients treated at the Helsinki University Hospital (Helsinki, Finland) during 1974-2012. We scored AZIN1 and 2 immunoexpression in 42 and 45 tumor tissue samples, respectively, and correlated them with clinicopathological factors and survival. Enhanced AZIN2 expression was associated with better survival. In addition, both AZINs were seen more commonly in cribriform and tubular than in solid growth patterns. AZIN1 expression did not correlate with the studied clinicopathological factors. It seems that AZIN2 expression is higher in cancer tissue with secretory functions. In ACC tissue, high AZIN2 expression could be related to well-differentiated histological type which still has a functioning vesicle transportation system. Thus, AZIN2 could be a prognostic factor for better survival of ACC patients.

Tracheostomy complications in otorhinolaryngology are rare despite the critical airway.

PURPOSE: To identify complications of surgical tracheostomies in otorhinolaryngologic patients and adjust our processes to be properly prepared in the future. METHODS: We reviewed retrospectively all surgical tracheostomies (n = 255) performed by otolaryngologist-head and neck surgeons at Helsinki University Hospital between Jan 2014 and Feb 2017. Patient demographics, surgical details, surgical and medical complications, and tracheostomy-related mortality were recorded from the hospital charts. Risk factors for complications were assessed. RESULTS: Altogether, 55 (22%) complications were identified in 39 (15%) patients, with pneumonia, accidental decannulation, and bleeding being the most common. No patient or surgery-related factor reached significance in overall complication risk factor analysis. Medical complications were more common after elective tracheostomies compared to emergency procedures (10.6% vs. 3.5%, p < 0.05). Majority of complications (78%) were classified as mild or moderate according to Clavien-Dindo. Only 2 (0.8%) tracheostomy-related deaths were recorded. CONCLUSION: In otorhinolaryngologists service, severe complications and tracheostomy-related deaths are very rare. Reducing their prevalence even further with careful planning is possible.

Positive airway pressure therapy for obstructive sleep apnea in patients with Osteogenesis imperfecta: a prospective pilot study.

BACKGROUND: Obstructive sleep apnea (OSA) is prevalent in individuals with Osteogenesis imperfecta (OI). To date, no study has investigated treatment of OSA in adult individuals with OI using positive airway pressure (PAP). This observational pilot study examined the adherence of adults with OI to treatment of OSA with PAP therapy, and the evolution of self-experienced sleepiness and depression symptoms before and after treatment. METHODS: We included 20 patients, with a mean age of 51 years, who represented varying severity of OI and displayed an apnea and hypopnea index ≥ 5 /sleeping hour as recorded by an overnight polysomnography. PAP therapy was proposed to all patients. Epworth Sleepiness Scale (ESS) questionnaire to evaluate daytime sleepiness, and a validated self-rating depression questionnaire to identify possible depression, were completed prior to PAP therapy and repeated after a minimum of one year. The datasets supporting the conclusions of this article are included within the article. RESULTS: From the 20 patients, 15 initiated PAP therapy, and two patients later interrupted it. The mean PAP follow-up period was 1230 days. At baseline, an abnormally high ESS score was reported by 29% of the respondents, and an abnormally high number of symptoms suggesting depression by 29%. Follow-up questionnaires were completed by 60% of the patients, of whom 83% were adherent to PAP treatment. ESS score and depression symptoms did not decrease significantly with PAP therapy. CONCLUSIONS: Patients with OI accepted well PAP therapy and remained compliant. Sleepiness and depression persisted unaltered despite good PAP adherence. These unexpectedly poor improvements in symptoms by PAP therapy may be due to subjective depression symptoms and the complexity of factors underlying persisting sleepiness in OI. Further research is needed to confirm this novel finding.

Enteral tube feeding of head and neck cancer patients undergoing definitive chemoradiotherapy in the Nordic Countries: Survey of the Scandinavian Society for Head and Neck Oncology.

PURPOSE: We assessed current policies and perceptions of enteral tube feeding in head and neck cancer (HNC) patients undergoing chemoradiotherapy (CRT). A web-based survey was used to compare the timing and method of tube feeding within and between the five Nordic countries, covering a population of 27 million. METHODS: From each of the 21 Nordic university hospitals, one oncologist and one otorhinolaryngology-head and neck (ORL-HN) surgeon responded to a survey. The respondents were asked whether tube insertion before the onset of CRT, or during CRT as required (prophylactic vs. reactive) was preferred. The use of a pretreatment nutritional screening tool and the choice of feeding route (nasogastric vs. gastrostomy tube) were assessed. In total, we analyzed responses from 21 oncologists and 21 ORL-HN surgeons. RESULTS: A tendency was observed towards decreasing the use of a PEG tube. Of the 21 university hospitals, only 2 (10%) reported using a prophylactic PEG tube in over half of HNC patients undergoing definitive CRT. The preferred method for reactive tube feeding was by a NG tube in 14 of 21 (67%), and by a PEG in 7 of 21 (33%). In general, both oncologists and ORL-HN surgeons were content with their current policy. CONCLUSIONS: The practices for enteral tube feeding in HNC management vary within and between the Nordic countries. We suggest that unified protocols for tube feeding should be developed for this patient population.

Trends in the Management of Non-Vestibular Skull Base and Intracranial Schwannomas.

The aim of this review is to analyze the latest trends in the management of non-vestibular skull base and intracranial schwannomas in order to optimize tumor control and quality of life. Non-vestibular cranial nerve schwannomas are rare lesions, representing 5-10% of cranial nerve schwannomas. Management decisions should be individualized depending on tumor size, location and associated functional deficits. Generally, large sized schwannomas exerting significant mass effect with increased intracranial pressure are treated surgically. In some cases, even after optimal skull base resection, it is not possible to achieve a gross total resection because tumor location and extent and/or to reduce morbidity. Thus, subtotal resection followed by stereotactic radiosurgery or fractioned radiotherapy offers an alternative approach. In certain cases, stereotactic radiosurgery or radiotherapy alone achieves good tumor control rates and less morbidity to gross total resection. Finally, given the slow growth rate of most of these tumors, observation with periodic radiographic follow-up approach is also a reasonable alternative for small tumors with few, if any, symptoms.

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.

No changes in nocturnal respiration with hypoglossal neurostimulation therapy for obstructive sleep apnoea.

STUDY OBJECTIVES: We initiated Hypoglossal Neurostimulation therapy (HGNS) at the Helsinki University Hospital in late 2014. Here, we report our experience. METHODS: We included all 15 HGNS patients. All patients had previously failed both CPAP and oral appliance therapy for sleep apnoea. Overnight polysomnography parameters were analysed before and at 1.5 years with HGNS. RESULTS: Mean ± SD patient age was 53 ± 6 years; 2 women and 13 men were included. Mean ± SD efficient CPAP level was 11.4 ± 3.4 cm H2 O. Implantation technically succeeded in all patients. There were no significant changes of AHI and ODI4 after HGNS [median (quartile) 29.2/h (19.8-38.7) versus 30.1/h (15.6-52.6) and 15.0/h (5.9-20) versus 12.5/h (6.9-30.2) respectively]. CONCLUSION: We did not observe significant changes in AHI and ODI4 indices with HGNS therapy. Larger multicentre randomised controlled trials are necessary before wider international use of HGNS.

Matrix metalloproteinase-7, -8, -9, -15, and -25 in minor salivary gland adenoid cystic carcinoma.

Knowledge on the role of matrix metalloproteinases (MMPs) in adenoid cystic carcinoma (ACC) is limited. MMPs are capable of degrading almost all extracellular and pericellular components to promote invasion and metastasis. This study aimed to evaluate the immunohistochemical expression of MMP-7, -8, -9, -15, and -25 in ACC and to relate the results with clinicopathological factors and survival. The study included 68 patients with minor salivary gland ACC treated at the Helsinki University Hospital (Helsinki, Finland) in 1974-2012. Samples from 52 patients were available, consisting of 44 primary tumours and eight recurrent tumours. We scored immunostaining of MMP-7, -8, -9, -15, and -25 and analysed the immunoscore against clinical and pathological parameters using statistical correlation test. MMP-9 immunoexpression in pseudocysts of ACC and in peritumoural inflammatory cells associated with better survival and fewer treatment failures. High tumoural MMP-7 and -25 associated with better survival. High tumoural MMP-15 associated with poorer survival and high tumoural MMP-9 with advanced stage and regional recurrences. Tumour cells did not show MMP-8 immunopositivity. These results suggest that MMP-9 may contribute to ACC carcinogenesis in different roles. MMP-7, -8, and -9 can stimulate signalling pathways that may promote tissue modulation and metastatic potential. MMP-15 and -25 may reflect prognosis.

A detection dog for obstructive sleep apnea: could it work in diagnostics?

PURPOSE: We have previously demonstrated that dogs can be trained to distinguish the urine of patients with obstructive sleep apnea (OSA) from that of healthy controls based on olfaction. Encouraged by these promising results, we wanted to investigate if a detection dog could work as a screening tool for OSA. The objective of this study was to prospectively assess the dogs' ability to identify sleep apnea in patients with OSA suspicion. METHODS: Urine samples were collected from 50 patients suspected of having OSA. The urine sample was classified as positive for OSA when the patient had a respiratory event index of 5/h or more. The accuracy of two trained dogs in identifying OSA was tested in a prospective blinded setting. RESULTS: Both of the dogs correctly detected approximately half of the positive and negative samples. There were no statistically significant differences in the dogs' ability to recognize more severe cases of OSA, as compared to milder cases. CONCLUSION: According to our study, dogs cannot be used to screen for OSA in clinical settings, most likely due to the heterogenic nature of OSA.

Factors influencing patient and health care delays in Oropharyngeal Cancer.

BACKGROUND: The incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is increasing. Patients with HPV-associated and HPV-unassociated OPSCC differ in many aspects, which may also impact their diagnostic and management timelines. This study aims at studying the patient, primary health care (PHC) and specialist-care (SC) delays and possible differences between these two patient groups in seeking medical care. METHODS: We reviewed all new patients with OPSCC treated between 2016 and 2018 at our institute, which covers a referral area of 1.6 million people. We collected data on patients' symptoms and factors influencing why they sought medical care using a patient-reported questionnaire and hospital records. We compared delays based on patient and tumor characteristics. RESULTS: In our study population of 83 patients, the median patient delay was 30 days (range, 0-366), with a median PHC delay of 15 days (range, 0 days-2.5 years), and a median SC delay of 54 days (range, 12-231). The SC delay was further divided into diagnostic hospital delay and treatment delay, each with a median length of 16 days (range, 0-237) and 29 days (range, 0-73), respectively. Furthermore, we found that p16 status did not associate with delays. A longer patient delay associated with specific tumor factors, such as a larger primary tumor and a lower UICC 7th edition stage. Patients that had multiple visits or did not have a follow-up visit scheduled at the initial appointment had longer PHC delays. Treatment delay was significantly longer for patients scheduled for (chemo-)radiotherapy than for those undergoing surgery with or without (chemo-)radiotherapy. CONCLUSIONS: Although delays remained short for the majority of OPSCC patients, long delays require further evaluation and improvement of management. Awareness of presenting symptoms among cancer risk patients and prompt referral practice or a follow-up visit at PHC represent key factors to shortening these delays. Ultimately, the causes for delays in SC appear multifactorial and require institutional quality control.

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.

Comparison of intubation and tracheotomy in adult patients with acute epiglottitis or supraglottitis.

PURPOSE: In acute epiglottitis (AE) or acute supraglottitis (AS), the management of the airway is crucial. We hypothesized that tracheotomized patients recover faster than intubated patients do. METHODS: We retrospectively reviewed all adult AE and AS patients, who underwent intubation or tracheotomy between 2007 and 2018 in a tertiary care center. Patient demographics, treatment, and complications were analyzed. RESULTS: The cohort comprised 42 patients. The airway was secured with intubation in 50% and with tracheotomy in 50%. All intubated patients (n = 21) and three tracheotomized patients were treated in the intensive care unit (p < 0.0001). Procedure-related complications were encountered in three intubated and eight tracheotomized patients (p = 0.892). Median overall treatment cost was 11.547 € and 5.856 € in the intubated and tracheotomized patient groups, respectively (p < 0.001). The median duration of sick leave after discharge from hospital was 13 days in the tracheotomy group and 7 days in the intubation group (p = 0.097). CONCLUSION: Tracheotomy resulted in a less expensive management in securing the airway in AE or AS, but tracheotomized patients had a trend towards more complications and longer sick leaves compared to intubated patients. LEVEL OF EVIDENCE: 2b.