Systematic review of the free thoracodorsal artery perforator flap for head and neck reconstruction.

BACKGROUND: The thoracodorsal artery perforator (TDAP) flap has gained interest as a option for reconstruction of head and neck defects while minimizing donor site morbidity as compared to traditional workhorse flaps. The primary aim of this systematic review is to assess the postoperative outcomes and efficacy of this flap. METHODS: Several databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system. RESULTS: Twenty articles containing 168 patients undergoing at least one TDAP flap reconstruction met the inclusion criteria. There were no incidences of total flap failure and only 10 incidences of partial flap failure (5.95 %). Flap complications and donor site morbidity was low. The average MINORS score of the studies suggested a moderately high amount of bias. CONCLUSIONS: Based on limited quality evidence, this review suggests that TDAP flap is a safe and feasible option for head and neck reconstruction with comparable success rates as other commonly used flaps, with low complication rate and donor site morbidity. Further large-scale studies are warranted.

Submental flap for reconstruction of anterior skull base, orbital, and high facial defects.

PURPOSE: Large anterior skull base, orbital, and high facial defects can present a challenging reconstructive problem. Limited data exists in the literature on the use of a submental flap for reconstructing such defects. We aimed to describe the feasibility, success, and advantages of using variations of the submental flap for reconstruction of anterior skull base, orbital, and high facial defects. MATERIALS & METHODS: Outcomes measured included flap method, flap survival, flap size, reconstructive site complications, donor site complications, and length of hospital stay. RESULTS: Nine patients were identified that underwent submental flap reconstruction of anterior skull base, orbital, or high facial soft tissue defects. There were 5 pedicled, 2 hybridized, and 2 free submental flap reconstructions. Flap survival was 100%. One flap required leech therapy for early post-operative venous congestion. Average flap skin paddle size was 63.7 cm2. Average length of hospital stay was 7.3 days. No complications from the donor site were reported. CONCLUSIONS: Different variations on the submental flap are viable options for reconstruction of high defects in the head and neck. Such flaps have a number of unique qualities that are suitable for reconstruction of anterior skull base, orbital, and high facial defects.

Severe prolonged dysphagia following transoral resection of bilateral synchronous tonsillar carcinoma.

OBJECTIVES: Alert the reader to the complication of severe dysphagia following transoral laser microsurgery (TLM) or transoral robotic surgery (TORS) for bilateral simultaneous or synchronous tonsillar squamous cell carcinoma. METHODS: A case series of four patients treated at an academic tertiary center between 2008 and 2012 is presented; two treated with transoral laser microsurgery and two with transoral robotic surgery for biopsy-proven untreated bilateral primary squamous cell carcinoma. Main outcome measures included functional swallowing determined by the Functional Outcome Swallowing Scale. The incidence of significant postoperative complications was recorded. RESULTS: Two patients had surgery for discontiguous involvement of bilateral palatine tonsils with squamous cell carcinoma, while two patients had surgery for bilateral tonsillar squamous cell carcinoma with unilateral extension into the base of tongue. Complete swallowing failure as characterized by the Functional Outcome Swallowing Scale was seen postoperatively in 3/4 patients who underwent TLM or TORS for bilateral simultaneous tonsillar carcinoma, while one patient was lost to follow-up. CONCLUSIONS: Severe dysphagia in the setting of bilateral oropharyngectomy for simultaneous or synchronous tonsillar squamous cell carcinoma is rarely described but a significant concern. In an era with increased use of transoral surgery as de-escalation therapy, this unusual complication warrants consideration. We report that transoral bilateral pharyngectomy is quite harmful to near-term and intermediate-term swallowing outcomes. This paper serves to provide warning against primary surgical intervention in this setting, while demonstrating that non-surgical treatment may be the best viable option.

First Bite Syndrome in Transoral Surgery for Oropharyngeal Cancer.

OBJECTIVE: First bite syndrome (FBS) is a rare complication of transoral surgery (TOS) for oropharyngeal cancer (oropharyngeal squamous cell carcinoma [OPSCC]). Risk factors for developing this complication are not well described. In this study, we attempt to identify risks for developing FBS in TOS. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care medical center. METHODS: This study was exempted by the Mayo Clinic institutional review board. We performed a review from January 2017 to November 2022 of all patients who underwent TOS for OPSCC by a single provider. Exclusion criteria included less than 6 months follow up, prior treatment of head and neck cancer, or incomplete records. Demographic data, comorbidities, tumor characteristics, surgical details, adjuvant treatment details, functional outcomes, and oncologic outcomes were assessed. Fisher's Exact test and Kruskal-Wallis rank sum test were used to identify significant variables, and multivariable logistic regression was used to address confounding. RESULTS: One hundred and one patients were identified. Eighty-nine met the inclusion criteria. The mean follow-up was 34 months (median 33). Seven patients (7.9%) developed FBS. Palatine tumor primary (P = .041), resection of styloglossus/stylopharyngeus (P = .039), and parapharyngeal fat manipulation (P = .015) were associated with the presence of FBS. After adjusting for tumor location, manipulation of parapharyngeal fat maintained significance (P = .025). T and N staging, tumor volume, adjuvant radiation, and ligation of lingual/facial arteries were not associated with the development of FBS. Eighty-six percent (6/7) of patients had a resolution of FBS at an average of 11.3 months. CONCLUSION: Manipulation of the parapharyngeal space is independently associated with developing FBS in TOS in our cohort. Further confirmatory studies are warranted.

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery.

BACKGROUND: Velopharyngeal insufficiency (VPI) is a known complication of transoral surgery (TOS) for oropharyngeal HPV-mediated squamous cell carcinoma. Controversy exists regarding adequate resection margins for balancing functional and oncologic outcomes. METHODS: This retrospective study was exempted by the IRB. Patients who underwent TOS from January 2017 to October 2022 were included. Patient characteristics, treatment details, and oncologic and functional outcomes were evaluated. RESULTS: Fifty-five patients were included. Mean and median follow-up was 34 months. 98% of patients were AJCC stage I/II. Recurrence-free survival was 96% with no local recurrences. Univariate analysis demonstrated an association between VPI and pT stage (p = 0.035), medial pterygoid resection (p = 0.049), and palatal attachment sacrifice (p < 0.001). Multivariate analysis showed sacrifice of the palatal attachments remained a significant risk for VPI (p = 0.009). CONCLUSION: Loss of soft palate pharyngeal attachments is an independent risk factor for VPI. When oncologically appropriate, the palatal attachments to the pharynx may be preserved.

Comparison of carbon dioxide laser-assisted versus stapler-assisted endoscopic cricopharyngeal myotomy.

OBJECTIVES: We directly compared endoscopic carbon dioxide (CO2) laser and stapler treatment methods for both cricopharyngeal hypertrophy (CPH) and Zenker's diverticulum (ZD). METHODS: We performed a single-institution retrospective chart review of 153 patients who underwent either CO2 laser-assisted or stapler-assisted endoscopic cricopharyngeal myotomy (CPM). RESULTS: Isolated CPH was more likely to be treated with the CO2 laser than by stapler techniques. The ZD pouch size decreased significantly after surgery in both laser (p = 0.04) and stapler (p = 0.008) groups. The average duration of the procedure for CPM was longer for the laser than for the stapler (p = 0.01). Both techniques were successful when used in revision procedures. The overall complication rates were not statistically significantly different. Laser surgery trended toward a higher rate of major complications (2.4% versus 0%). Symptomatic recurrence was more likely after stapler surgery (p = 0.002). The rates of revision surgery were similar in the two groups (3.3% for laser and 4.3% for stapler). CONCLUSIONS: In the treatment of isolated CPH or ZD, stapler-assisted endoscopic surgery results in a shorter operative time, whereas laser-assisted CPM results in a decreased incidence of symptomatic recurrence.

Large mandibular mass with several floating teeth: granular cell ameloblastoma.

Ameloblastomas are benign, locally aggressive, odontogenic epithelial neoplasms. We present a patient with a rare granular cell ameloblastoma. This is a case report and literature review conducted from July 2022 to the present. Our 52-year-old male patient presented to the clinic with a several month history of right lower lateral lip swelling and dental complaints. On imaging and physical exam, we noticed a large heterogenous, multiloculated, expansile lesion of the right mandible with several floating teeth. After incisional biopsy confirmed multicystic granular cell ameloblastoma, the patient underwent successful surgical resection and osteocutaneous fibula free-flap reconstruction. At the time of writing this report, 7 years after resection, the patient is alive with no evidence of recurrence. The recognition and treatment of mandibular lesions can represent significant clinical challenges, especially for rarely seen subtypes such as the granular cell ameloblastoma. Special consideration must be given for the identification and treatment of these neoplasms.

Regional pedicled flap salvage options for large head and neck defects: The old, the new, and the forgotten.

Objectives: The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting. Methods: Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options. Results: Specific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap. Conclusions: Regional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations.

A Prospective Study of Mucosal Sparing Radiation Therapy in Resected Oropharyngeal Cancer Patients.

PURPOSE: Our objective was to report the prospective results of mucosal sparing radiation therapy in human papillomavirus-related oropharyngeal squamous cell carcinoma. METHODS AND MATERIALS: From March 2016 through May 2019, patients were enrolled in this institutional review board-approved prospective cohort study at a multisite institution. Inclusion criteria included p16+ American Joint Committee on Cancer seventh edition pathologic T1 or T2, N1 to N3, and M0 oropharyngeal cancers. Proton therapy (PT) was delivered to at-risk nodal regions, excluding the primary mucosal site. Secondary to insurance denial for PT, intensity modulated radiation therapy (IMRT) was allowed. European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module and Patient-Reported Outcomes Measurement Information System surveys (quality of life [QOL]) and modified barium swallowing impairment profiles (MBSImP) were obtained at baseline before radiation therapy, then 3 and 12 months after radiation therapy. Kaplan-Meier estimates were calculated for time-to-event clinical outcomes, and repeated measures mixed models were used to explore changes in QOL over time. A comparison of QOL and swallowing outcomes with standard-of-care treatment was analyzed. RESULTS: There were 61 evaluable patients with a median follow-up of 38 months (range, 10-64); 44 (72%) were treated with PT and 17 (28%) were treated with IMRT. The 2-year local control, locoregional control, distant metastasis-free survival, and overall survival were 98%, 97%, 98%, and 100%, respectively. There were 6 grade ≥3 events related to treatment. Two IMRT patients required percutaneous endoscopic gastrostomy tube placement during treatment secondary to significant nausea due to dysgeusia. Patients noted significant QOL improvement over time in the pain, swallowing, speech, social eating, social contact, mouth opening, and use of pain medication domains (all P < .02). The MBSImP overall severity score as well as oral and pharyngeal impairment scores showed stability with no significant change over time. For the 44 patients treated with PT, the mean D95 to the primary target was 10.7 Gy (standard deviation = 12.5 Gy). CONCLUSIONS: Mucosal sparing radiation is well tolerated in select resected human papillomavirus-related oropharyngeal squamous cell carcinoma with a low risk of recurrence at the mucosal primary site, a low rate of percutaneous endoscopic gastrostomy tube placement, and few radiation-related grade ≥3 adverse events.

Emerging workforce readiness in regenerative healthcare.

The biology of regenerative medicine has steadily matured, providing the foundation for randomized clinical trials and translation into validated applications. Today, the growing regenerative armamentarium is poised to impact disease management, yet a gap in training next-generation healthcare providers, equipped to adopt and deliver regenerative options, has been exposed. This special report highlights a multiyear experience in developing and deploying a comprehensive regenerative curriculum for medical trainees. For academicians and institutions invested in establishing a formalized regenerative medicine syllabus, the Regenerative Medicine and Surgery course provides a patient-focused prototype for next-generation learners, offering a dedicated educational experience that encompasses discovery, development and delivery of regenerative solutions. Built with the vision of an evolving regenerative care model, this transdisciplinary endeavor could serve as an adoptable education portal to advance the readiness of the emergent regenerative healthcare workforce globally.

Bipedicled submental musculofascial "hammock" flap for salvage laryngectomy closure reinforcement.

BACKGROUND: The aim of the study was to describe a novel technique for reinforcement of salvage laryngectomy closure using a bipedicled musculofascial submental flap. METHODS: A retrospective cohort study design identified patients who underwent salvage laryngectomy reinforcement with a bipedicled submental hammock flap between January 2008 and December 2016 were compared to salvage laryngectomy patients treated with primary closure of the neopharynx during the same time period. Pharyngocutaneous fistula rates were compared between groups. RESULTS: Pharyngocutaneous fistula rate in the submental hammock group (2/31, 6.5%) was significantly lower compared to the primary closure group (14/45, 31%, P < .05). CONCLUSION: The bipedicled musculofascial submental hammock flap is a viable method for reinforcement of salvage laryngectomy defects. It has a favorable pharyngocutaneous fistula rate compared to primary closure alone and has unique advantages over conventional methods of reinforcement.

A Graduate-Level Interdisciplinary Curriculum in CAR-T Cell Therapy.

OBJECTIVE: To evaluate the impact of a novel interdisciplinary graduate-level course in chimeric antigenic receptor-T cell therapy on students' knowledge and interests in translational science. MATERIALS/PARTICIPANTS AND METHODS: The course ran November 12 to 16, 2018. Students were surveyed before and after the course. The survey included questions regarding background, self-perceived knowledge/confidence in skills, and interests/predicted behaviors. Students were assigned to work in collaborative interdisciplinary teams to develop a research proposal. RESULTS: A total of 25 students taking the course for graduate-level credit were surveyed. Of these, all 25 (100%) completed the surveys. Students came from variable backgrounds and were at different stages of graduate training. After completion of the course, there was a statistically significant increase in self-perceived knowledge of immunotherapy (mean score of 3.6 postcourse vs 2.6 precourse, on a 5-point Likert scale; P<.001), knowledge of the bench to clinic translational process (3.7 postcourse vs 3.0 precourse; P<.001), confidence in critical reading skills (4.3 postcourse vs 4.0 precourse; P=.008), confidence in immunotherapy-focused grant writing skills (3.6 postcourse vs 2.8 precourse; P<.001), and interest in working in interdisciplinary teams (4.8 postcourse vs 4.6 precourse; P=.02). CONCLUSION: The structure of this innovative and comprehensive course serves as a platform for educational courses in interdisciplinary translational research and helps trainees build knowledge and interest in the fields of chimeric antigenic receptor-T cells, regenerative sciences, and immunotherapy.

Regenerative medicine curriculum for next-generation physicians.

Regenerative sciences are poised to transform clinical practice. The quest for regenerative solutions has, however, exposed a major gap in current healthcare education. A call for evidence-based adoption has underscored the necessity to establish rigorous regenerative medicine educational programs early in training. Here, we present a patient-centric regenerative medicine curriculum embedded into medical school core learning. Launched as a dedicated portal of new knowledge, learner proficiency was instilled by means of a discovery-translation-application blueprint. Using the "from the patient to the patient" paradigm, student experience recognized unmet patient needs, evolving regenerative technologies, and ensuing patient management solutions. Targeted on the deployment of a regenerative model of care, complementary subject matter included ethics, regulatory affairs, quality control, supply chain, and biobusiness. Completion of learning objectives was monitored by online tests, group teaching, simulated clinical examinations along with longitudinal continuity across medical school training and residency. Success was documented by increased awareness and proficiency in domain-relevant content, as well as specialty identification through practice exposure, research engagement, clinical acumen, and education-driven practice advancement. Early incorporation into mainstream medical education offers a tool to train next-generation healthcare providers equipped to adopt and deliver validated regenerative medicine solutions.

Outcomes Following Transoral Laser Microsurgery With Resection of Cartilage for Laryngeal Cancer.

INTRODUCTION: The ability to treat more advanced laryngeal cancers by transoral approaches has expanded significantly in the past several decades. Transoral management of laryngeal cancers that require removal of the laryngeal framework is controversial. Resecting cartilage through endoscopic means carries inherent technical challenges and the question of oncologic safety. METHODS: We describe a retrospective review of patients undergoing resection of the thyroid cartilage during transoral laser microsurgery (TLM) for laryngeal cancer over a 10-year period. Only patients with 5-year follow-up were included. RESULTS: Fourteen patients were identified that underwent attempted endoscopic resection of the thyroid cartilage. Preoperative staging ranged from T1 to T4 laryngeal cancers. Most patients underwent resection of the thyroid cartilage either for close proximity of the tumor to cartilage or microscopic involvement of the inner perichondrium, although 6 patients had gross invasion of the cartilage. Twelve patients underwent successful endoscopic clearance. Two patients were converted to total laryngectomy either at the time of surgery or shortly after due to extent of disease that was deemed not amenable to endoscopic resection. Overall 5-year survival was 71%. Disease-free survival was 62% at 5 years. The majority of patients avoided gastrostomy and tracheostomy tube dependence. One patient underwent total laryngectomy following initial TLM for chronic aspiration. CONCLUSION: We conclude that TLM for laryngeal cancer performed with removal of thyroid cartilage is feasible. Both oncologic and functional outcomes are reasonable in a select group of patients. This paper describes that cartilage can be resected endoscopically in the appropriate setting and not necessarily that cartilage invasion should routinely be treated with TLM.

American Joint Committee on Cancer eighth edition human papilloma virus positive oropharyngeal cancer staging system: Discordance between clinical and pathological staging systems.

BACKGROUND: The American Joint Committee on Cancer (AJCC) eighth edition introduces a staging system specific for human papilloma virus positive oropharyngeal cancer with separate clinical (AJCC 8c) and pathological (AJCC 8p) criteria. METHODS: In this retrospective cohort study, preoperative imaging and pathology reports were used to stage patients based on the AJCC 8c and AJCC 8p criteria, respectively. The primary endpoint was agreement between AJCC 8c and AJCC 8p. RESULTS: A total of 213 patients met inclusion criteria. Kappa statistics showed poor agreement (κ = 0.3275) between AJCC 8c and AJCC 8p. In total, 30.3% of patient's preoperative AJCC 8c stage changed based on the postoperative pathologic staging (AJCC 8p) with 73.4% of those being upstaged. CONCLUSION: These data suggest that disagreement exists between AJCC 8c and AJCC 8p, in part due to the separate clinical and pathological staging criteria. This discrepancy should be considered as the new system is implemented.

Postoperative bleeding in transoral laser microsurgery for upper aerodigestive tract tumors.

OBJECTIVES: To report the incidence, cause, and outcome of bleeding after transoral laser microsurgery. STUDY DESIGN: A two-center prospective case series analysis. SUBJECTS AND METHODS: Seven hundred one patients underwent transoral laser microsurgery for tumors of the oral cavity, pharynx, and larynx from June 1996 through September 2006. RESULTS: Ten patients (1.4%) experienced postoperative bleeding between 0 and 17 days after surgery. Five patients had previously untreated tumors, and five patients had salvage surgery. Two patients (0.3%) had minor bleeding and required observation only. Five patients (0.7%) experienced major bleeding requiring exploration under general anesthesia. Three patients (0.4%) had catastrophic life-threatening bleeds, two of whom died. The bleeding vessel was identified as the lingual artery in four patients, the superior laryngeal artery in two, the facial artery in two, and unknown in two. CONCLUSIONS: Bleeding after transoral laser microsurgery is rare but potentially life-threatening.

Transoral laser microsurgery for recurrent laryngeal and pharyngeal cancer.

STUDY DESIGN AND SETTING: A two-center prospective case series analysis. PATIENTS: One hundred fourteen patients with previously treated laryngeal or pharyngeal squamous cell carcinoma who underwent salvage transoral laser microsurgery (TLM). INTERVENTIONS: TLM in 114 patients, neck dissection in 22 (19%) patients, adjuvant radiotherapy in 12 (11%) patients. RESULTS: Ninety-one (80%) patients had recurrent primary tumors whereas 23 (20%) patients had second primary tumors occur within a previously irradiated field. The minimum follow-up was 1 year (median, 3 years). The distribution of tumor location was oropharynx 52 (46%), glottic and subglottic larynx 44 (39%), supraglottic larynx 11 (10%), and pyriform/hypopharynx 7 (6%). Overall, three-year local and locoregional control estimates were 70 percent and 67 percent, respectively; and three-year survival and disease-free survival estimates were 62 percent and 64 percent, respectively. The average duration of hospitalization was 2.3 days. Four (3.5%) patients had significant postoperative bleeding. Two (<2%) patients had treatment-related deaths. CONCLUSIONS: Transoral laser microsurgery offers select patients an attractive alternative salvage surgical therapy to the recurrent and second primary tumor site.

Gastro-omental free flap reconstruction of the head and neck.

OBJECTIVE: To present the use of an infrequently used tool, gastro-omental free flaps, available to head and neck surgeons in the modern reconstruction era. METHODS: In this case series, 25 gastro-omental free flaps were performed. The technical aspects of harvest are reviewed, and the advantages and disadvantages of this flap are described, as well as illustrative cases displaying this flap's utility when other donor sites cannot be harvested. RESULTS: Flap survival was 96%, with 1 flap being successfully salvaged after the development of a venous thrombosis and 1 flap failing as a result of a kink in the arterial pedicle. Exteriorization of the omentum as an external marker heralded vascular compromise in both cases. Complications included 2 delayed gastric outlet obstructions, 1 salivary leak, 1 delayed abscess and fistula formation 7 months following reconstruction, and 1 case of mild superficial bleeding from the transplanted gastric mucosa. CONCLUSION: The gastro-omental flap has proven to be a reliable and valuable tool in head and neck reconstruction, particularly in complex oropharyngeal wounds with large soft tissue components.

Transoral surgery (TOS) in oropharyngeal cancer: Different tools, a single mini-invasive philosophy.

Surgery with or without adjuvant therapy and radiotherapy with or without chemotherapy have traditionally represented the possible treatment options for oropharyngeal cancer. The adverse effects of non-surgical treatments and recent technical innovations have prompted a new interest in the surgical approach. However, in parallel to the possibility of achieving radical cancer clearance, we should remember the impact that traditional open surgery has on the patient's cosmesis, functionality and quality of life. As a result, transoral surgery is an attractive option for oropharyngeal tumors. The term "transoral surgery" only indicates that the tumor is accessed and resected via the oral cavity, but the surgeon can choose among different resection methods, such as transoral laser microsurgery, transoral robotic surgery, transoral videolaryngoscopic surgery, endoscopic laryngo-pharyngeal surgery, and transoral ultrasound surgery. The aim of this paper is to review the recent literature on the transoral treatment of oropharyngeal cancer, to standardize the terminology of transoral procedures, analyzing the common aspects, main differences and future perspectives of the various forms of transoral surgery.

Post-acute care use after major head and neck oncologic surgery with microvascular reconstruction.

OBJECTIVES: Post-acute care (PAC) centers, such as skilled nursing facilities, unskilled nursing facilities, lower acuity hospitals, and rehabilitation centers, serve to optimize recovery after acute care hospitalization. We aimed to identify factors associated with PAC utilization among patients undergoing head and neck cancer surgery with microvascular reconstruction because it may be helpful for patient decision making, discharge planning, and resource allocation. METHODS: Retrospective linked analysis of the 2011 to 2015 National Surgical Quality Improvement Program. Eligible patients were identified and stratified by discharge disposition (home or PAC) after their postoperative acute-care hospitalization. After an initial univariate screen of demographic and clinical variables, a multivariable logistic regression analysis was performed modelling discharge to PAC. RESULTS: Of the 1,652 identified patients, 261 (15.8%) were discharged to PAC. Those admitted to PAC were older, had a higher burden of comorbidity, and were more likely to be functionally dependent. They also had longer surgeries, longer hospitalizations, higher rates of reoperation, and higher rates of postoperative complications. After multivariate analysis, factors independently associated with PAC discharge included increasing age (odds ratio [OR] 2.12 per 10-year increase; 95% confidence interval [CI], 1.81-2.48), active smoking status (odds ratio (OR) 1.61; 95% confidence interval (CI), 1.13-2.29), prolonged hospitalization (OR 1.04; 95% CI, 1.02-1.07), and postoperative pulmonary complications (OR 2.02; 95% CI, 1.36-2.99). CONCLUSION: Of the patients undergoing surgery for head and neck cancers with microvascular reconstruction, 15.8% are discharged to PAC. Age, active smoking status, prolonged hospitalization, and postoperative pulmonary complications (vs. comorbidity, functional status, or primary tumor site) are independently associated with discharge to PAC. LEVEL OF EVIDENCE: Level 2c. Laryngoscope, 2532-2538, 2018.