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Importance: Adenotonsillectomy (ATE) is the primary surgical method for treating obstructive sleep apnea (OSA) in children. However, children with severe OSA have an increased risk for residual OSA after ATE. Previous studies indicate that adenopharyngoplasty (APP), a modified ATE with closure of the tonsillar pillars, might improve the surgical outcome, but the overall evidence is weak., Objective: To determine whether APP is more effective than ATE for treating severe OSA in otherwise healthy children., Design, Setting, and Participants: A blinded randomized clinical trial was conducted at the otorhinolaryngology department at Karolinska University Hospital, Stockholm, Sweden. Eighty-three children, aged 2 to 4 years, with an obstructive apnea-hypopnea index (OAHI) score of 10 or higher, were randomized to APP (n = 36) or ATE (n = 47). Participants were recruited from December 1, 2014, through November 31, 2016., Interventions: Adenotonsillectomy was performed in all 83 patients in both groups by the cold steel technique. The APP group also underwent closure of the tonsillar pillars with 2 inverted sutures on each side., Main Outcomes and Measures: The primary outcome was the difference between the groups in OAHI score change before and after surgery. A higher score indicates worse problems and a score of 10 or higher is defined as severe OSA. The outcome was evaluated per protocol and with intention-to-treat analysis. Secondary outcomes were other polysomnography variables and the Obstructive Sleep Apnea-18 (OSA-18) questionnaire (possible total symptom score range, 18-126; higher scores indicate worse quality of life). Polysomnography was performed and the OSA-18 questionnaire was completed preoperatively and 6 months postoperatively., Results: A total of 83 children (49 [59%] boys; mean [SD] age, 36.6 [9.2] months) were included in the study. Of these, 74 (89%) (APP, n = 30; ATE, n = 44) completed the study. The mean (SD) preoperative OAHI score was 23.8 (11.8) for APP and 23.8 (11.5) for ATE. Both the APP and ATE groups had a significant decrease in mean OAHI score after surgery (-21.7; 95% CI, -26.3 to -17.2; and -21.1; 95% CI, -24.5 to -17.7, respectively), but there was no significant difference between the groups (0.7; 95% CI, -4.8 to 6.1). Furthermore, no significant differences between the groups were seen regarding other polysomnography variables (eg, respiratory distress index: mean, 0.6; 95% CI, -5.0 to 6.3) or the OSA-18 questionnaire (eg, total symptom score: -0.5; 95% CI, -13 to 12). One patient from each group was readmitted owing to postoperative bleeding, but no other complications were seen., Conclusions and Relevance: This trial did not show that APP was more effective than ATE alone to treat otherwise healthy children with severe OSA. This finding suggests that ATE should continue to be the primary treatment for OSA in children., Trial Registration: ClinicalTrials.gov Identifier: NCT02315911.

Importance: Method of direct clinical monitoring of tissue perfusion in free tissue reconstruction of pharyngeal defects., Objective: To describe a novel and effective method of incorporating a cutaneous skin paddle into laryngopharyngectomy reconstruction for direct clinical monitoring of anterolateral thigh free flaps., Design: Retrospective review of pharyngoesophageal reconstruction for laryngopharyngectomy defects performed between August 1, 2008, and March 1, 2011, using the anterolateral thigh flap., Setting: Tertiary care academic medical center., Participants: Consecutive patients undergoing laryngopharyngectomy where free tissue transfer is indicated., Interventions: Anterolateral thigh free flap reconstruction with suprastomal cutaneous monitoring paddle., Main Outcome Measures: Postoperative complications, including flap failure, fistula, and stricture. Postoperative functional outcomes of swallowing and vocal capability were also measured., Results: Twenty-one patients (mean age, 62.2 years; range, 39-81 years) underwent total laryngectomy with near-total or total pharyngectomy and immediate reconstruction with an anterolateral thigh free flap. The reconstructions included a cutaneous monitor paddle distal to the pharyngoesophageal anastomosis. Twenty patients were treated for squamous cell carcinoma and received either adjuvant or neoadjuvant radiation therapy. There were no partial or total flap losses. A late pharyngocutaneous fistula occurred at 6 weeks in 1 patient (5%), requiring exploration, and anastomotic stricture occurred in 4 patients (19%). All patients except 1 were able to swallow solid foods at a mean follow-up of 11.1 months. Nineteen patients (90%) underwent tracheoesophageal puncture and attained an intelligible voice. One patient (5%) had stomal stenosis requiring surgical management., Conclusions and Relevance: The suprastomal cutaneous monitoring paddle enables direct monitoring of an otherwise buried reconstructive flap. This method allows direct clinical observation for microvascular compromise without a need for further procedures and without any increase in morbidity or compromise of speech and swallow functions., Level of Evidence: 4.

Objective: To determine the early risk factors for enlargement of the tracheoesophageal puncture (TEP) after total laryngectomy., Design: Retrospective cohort study., Setting: The University of Texas MD Anderson Cancer Center, Houston., Patients: The study included 194 patients who underwent total laryngectomy (with or without pharyngectomy) and TEP (2003-2008)., Main Outcome Measures: Multiple logistic regression methods were used to evaluate early risk factors for an enlarged TEP., Results: The incidence of an enlarged TEP was 18.6% (36 of 194 patients). After adjustment for follow-up time and radiotherapy history, patients with nodal metastases had a significantly higher risk of TEP enlargement (adjusted odds ratio, 6.6; 95% CI, 1.6-26.6) than those with node-negative disease. Total laryngopharyngectomy significantly increased the risk of an enlarged TEP (adjusted odds ratio, 4.5; 95% CI, 1.4-14.7) compared with simple total laryngectomy. Before multivariable adjustment, the preoperative body mass index was also significantly associated with enlargement (P for trend, .04)., Conclusions: These data suggest that 2 clinical factors-nodal staging and extent of resection-may help identify those at highest risk for TEP enlargement early after surgery. These simple indicators may ultimately aid in patient selection and prevention of an enlarged TEP after total laryngectomy.

Objective: To study the safety and oncological outcome of salvage surgery for local tumor recurrence after previous maxillary swing nasopharyngectomy., Setting: University hospital., Patients: Between 1998 and 2011, a total of 252 patients who had local tumor recurrence after previous nasopharyngectomy were recruited for the study., Main Outcome Measures: The locations of the recurrent tumor, operability, and surgical details of resection and reconstruction, as well as the complications and oncological results, were studied., Results: The local recurrence rate after nasopharyngectomy was 13.1%, the risk of which was significantly higher in patients with positive resection margins (39.6% vs 6.9%; P = .006). The chance of the development of local recurrence was significantly lower in patients who had received postoperative chemoradiation therapy than in patients who did not (29.4% vs 64.3%; P = .04). Overall, 63.6% of the patients with local recurrence were amenable to further surgery. Depending on the location of the tumor, remaxillary swing (n = 10), contralateral maxillary swing (n = 8), or central palatal resection (n = 3) was performed. Free-flap coverage of the exposed skull base and the petrosal internal carotid artery was required in 12 patients. There was no evidence of hospital mortality or major complications associated with the surgery. The mean duration of follow-up was 22.4 months, and the overall disease-specific survival in the group of patients who underwent surgery was 80.9%., Conclusions: Surgical salvage for local tumor recurrence after previous nasopharyngectomy is safe, with a good oncological outcome. In the presence of previous maxillary swing surgery, reswing or contralateral swing operation is feasible, without major complications.

Background: Recurrence of nasopharyngeal carcinoma after initial therapy has been reported to range between 18% and 54%. As an alternative to surgical salvage, patients with recurrent nasopharyngeal carcinoma are offered a second course of radiation therapy. If this second course fails, patients may be candidates for surgical resection., Objective: To identify the effectiveness and morbidity of surgical resection of recurrent nasopharyngeal carcinoma in patients who have received 2 cycles of external beam radiation., Design and Setting: Retrospective survey of 6 patients in a university-based practice who underwent resection of recurrent nasopharyngeal carcinoma after 2 courses of radiation therapy., Patients: Our study group comprised 4 women and 2 men aged between 35 and 67 years. All patients underwent 2 courses of radiation with a mean total dose of 11 500 rad (115 Gy) (range, 9500-13 200 rad [95-132 Gy]) delivered to the nasopharynx prior to resection. The mean duration between the second course of radiation and resection is 21 months (range, 8-52 months). The mean follow-up period is 7.2 years (range, 4.2-11.5 years)., Intervention: Nasopharyngectomy after failure of 2 courses of radiation therapy., Main Outcome Measures: Postoperative clinical outcome and morbidity., Results: Five years after resection, 1 patient died of disease. The remaining 5 patients (83%) are alive with no evidence of disease. Osteomyelitis is the most common complication, affecting 5 patients. Three of the 5 patients with osteomyelitis required operative debridement of the nasopharynx and split-thickness skin grafting. Other complications include oronasal fistula (2 patients), chronic otitis media (2 patients), and nasopharyngeal stenosis (1 patient)., Conclusion: Although poor wound healing is evident, the overall 5-year survival of 83% is encouraging.

Objectives: To determine the incidence of dysphagia (defined as the inability to manage a diet of normal consistencies) at hospital discharge and beyond 1 year postsurgery and examine the impact of persistent dysphagia on levels of disability, handicap, and well-being in patients., Design: Retrospective review and patient contact., Setting: Adult acute care tertiary hospital., Patients: The study group, consecutively sampled from January 1993 to December 1997, comprised 55 patients who underwent total laryngectomy and 37 patients who underwent pharyngolaryngectomy with free jejunal reconstruction. Follow-up with 36 of 55 laryngectomy and 14 of 37 pharyngolaryngectomy patients was conducted 1 to 6 years postsurgery., Main Outcome Measures: Number of days until the resumption of oral intake; swallowing complications prior to and following discharge; types of diets managed at discharge and follow-up; and ratings of disability, handicap, and distress levels related to swallowing., Results: Fifty four (98%) of the laryngectomy and 37 (100%) of the pharyngolaryngectomy patients experienced dysphagia at discharge. By approximately 3 years postsurgery, 21 (58%) of the laryngectomy and 7 (50%) of the pharyngolaryngectomy patients managed a normal diet. Pharyngolaryngectomy patients experienced increased duration of nasogastric feeding, time to resume oral intake, and incidence of early complications affecting swallowing. Patients experiencing long-term dysphagia identified significantly increased levels of disability, handicap, and distress. Patients without dysphagia also experienced slight levels of handicap and distress resulting from taste changes and increased durations required to complete meals of normal consistency., Conclusions: The true incidence of patients experiencing a compromise in swallowing following surgery has been underestimated. The significant impact of impaired swallowing on a patient's level of perceived disability, handicap, and distress highlights the importance of providing optimal management of this negative consequence of surgery to maximize the patient's quality of life.