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Background: There is sparse literature on the effect of preoperative immunotherapy on complications after surgery for primary head and neck squamous cell carcinoma (HNSCC). The objectives are to compare complication rates in patients receiving surgery with and without neoadjuvant immune checkpoint inhibitors (nICI) for primary HNSCC and to evaluate factors associated with increased odds of surgical complications. Methods: A retrospective review of patients who underwent ablation and free flap reconstruction or transoral robotic surgery (TORS) for primary HNSCC between 2017–2021 was conducted. Complications were compared between patients who underwent surgery with or without nICI before and after propensity score matching. Regression analysis to estimate odds ratios was performed. Results: A total of 463 patients met inclusion criteria. Free flap reconstruction constituted 28.9% of patients and TORS constituted 71.1% of patients. nICI was administered in 83 of 463 (17.9%) patients. There was no statistically significant difference in surgical, medical, or overall complications between patients receiving surgery with or without nICI. In the unmatched cohort, multivariable model identified non‐White race, former/current smoking history, free flap surgery, and perineural invasion as factors significantly associated with increased complications. In the matched cohort, multivariable model identified advanced age and free flap surgery as factors significantly associated with increased complications. Plain Language Summary: It is safe to give immunotherapy before major surgery in patients who have head and neck cancer.Advanced age, non‐White race, current/former smoking, free flap surgery, and perineural invasion may be associated with increased the odds of surgical complications. In this study, neoadjuvant immune checkpoint inhibitors (nICI) did not increase the risk of overall complications after adjusting for important confounders. Definitive surgery can be conducted safely after nICI. [ABSTRACT FROM AUTHOR]

Background: Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx. Methods: Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed. Results: Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post‐operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30‐day readmissions. At three months after operation, all patients who were not tube feed‐dependent prior to surgery returned to oral intake. Of the four patients who were tube feed‐dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre‐ and postoperatively with no voice changes. Conclusions: Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long‐term morbidity. Level of Evidence: 4 Laryngoscope, 134:1227–1233, 2024 [ABSTRACT FROM AUTHOR]

Objective: To identify practices in microvascular techniques in routine and challenging scenarios. Study Design: Cross‐sectional study. Methods: A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. Results: The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2–13) and median flaps per year was 35 (22–50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). Conclusions: This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. Level of Evidence: 5 Laryngoscope, 134:1265–1277, 2024 [ABSTRACT FROM AUTHOR]

Background: Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap (PMFF) has not been well studied in reconstruction of orbital defects. Methods: Retrospective review of patients who underwent reconstruction of periorbital defects with PMFF between 2016 and 2021. Variables were ocular adnexal asymmetry, functional outcomes, and orbital complications. Results: Eighteen patients met inclusion criteria. Mean defect size was 11.1 ± 7.5 cm. The most common subsite involved was medial canthus in 88.9% of patients. There was no statistically significant difference between mean medial canthus to midline ratio and mean medial brow to midline ratio when compared to the assumed normal of 1. The medial canthus to pupil ratio and medial canthus to lateral canthus ratio had a statistically significant mean difference from 1.0 (p = 0.003 for both). In 22.2% of patients, the orbit was functional with impairment; the remaining had no impairment. Surgical sequelae occurred in 12/18 (66.7%) of patients, most commonly epiphora in 9/18 (50%) of patients, and ectropion in 5/18 (27.7%). Conclusion: The PMFF is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity. Level of Evidence: 4 Laryngoscope, 133:2584–2589, 2023 [ABSTRACT FROM AUTHOR]

Objective: Patients with recurrent oropharyngeal cancer can achieve survival benefits from surgical salvage, and often require simultaneous free‐flap reconstruction. Resection and reconstruction can impact function, leading to tube dependence. Primary objective: describe rates of tracheostomy and gastrostomy tube dependence after oropharyngeal resection and free flap after prior radiation. Secondary objective: evaluate patient, tumor, and treatment factors associated with tube dependence. Study Design: Retrospective, multi‐institutional cohort study. Patients treated from 2003 to 2020. Average follow‐up 21.4 months. Setting: Five tertiary care centers. Methods: Consecutive cohort of patients undergoing resection and simultaneous free‐flap reconstruction for oropharyngeal squamous cell carcinoma after head and neck radiation. Primary outcomes: gastrostomy tube dependence and tracheostomy or tracheostoma 1 year after surgery. Univariable and multivariable logistic regression were performed to identify factors associated with dependence. Results: 89 patients underwent oropharyngectomy and free‐flap reconstruction; 18 (20%) underwent total laryngectomy as part of tumor extirpation. After surgery, 51 patients (57%) lived 12 months. Among patients alive at 12 months, 22 (43%) were at least partially‐dependent on gastrostomy tube, and 15 (29%) had either tracheostomy or tracheostoma. On multivariable analysis, extensive glossectomy (OR 16.6, 95% CI 1.83–389, p = 0.026) and total laryngectomy (OR 11.2, 95% CI 1.71–105, p = 0.018) were associated with long‐term gastrostomy tube. No factors were associated with long‐term tracheostomy on multivariable analysis. Conclusion: Even among long‐term survivors after salvage resection and free‐flap reconstruction, rates of tube dependence are significant. This multi‐institutional review is the largest such study to the date and may help inform shared decision‐making. Level of Evidence: 4 Laryngoscope, 133:2141–2147, 2023 [ABSTRACT FROM AUTHOR]

Objective: Evaluate the effect of p16 status on disease-free survival (DFS) and overall survival (OS) in patients with sinonasal squamous cell carcinoma (SCC) undergoing treatment with curative intent; and to assess how p16 status may affect patterns of recurrence. Study Design: Retrospective cohort study. Setting: Tertiary medical center. Methods: Patients with sinonasal SCC treated with curative intent from 2012 to 2018 were identified. Independent variable of interest was p16 status, which was assessed using immunohistochemistry (IHC) with a 70% staining cutoff for positivity. Kaplan Meier survival curve was plotted to assess correlation between p16 status and DFS and OS. Association between recurrence patterns and p16 status was conducted using chi square and fisher's exact tests. Multivariable Cox proportional hazard analysis was conducted to assess association between independent variables and DFS. Results: Fifty patients with sinonasal SCC met inclusion criteria. Patients were p16 positive in 28/50 (56%) of cases. Kaplan Meier survival curve revealed no statistically significant association between p16 status and DFS or OS survival (P =.780, P =.474). There was no difference in recurrence patterns in patients with p16 positive versus negative tumors. Conclusion: p16 status did not have prognostic value on DFS and OS in our cohort of patients with sinonasal SCC undergoing treatment with curative intent. There was no difference in recurrence patterns between the 2 populations. Based on the results of this study, p16 status should not impact counseling of patients as it relates to their prognosis from SNM. [ABSTRACT FROM AUTHOR]

Objectives: To analyze CD8+ and FoxP3+ T‐cell cellular density (CD) and intercellular distances (ID) in head and neck squamous cell carcinoma (HNSCC) samples from a neoadjuvant trial of durvalumab +/− metformin. Methods: Paired pre‐ and post‐treatment primary HNSCC tumor samples were stained for CD8+ and FoxP3+. Digital image analysis was used to determine estimated mean CD8+ and FoxP3+ CDs and CD8+‐FoxP3+ IDs in the leading tumor edge (LTE) and tumor adjacent stroma (TAS) stratified by treatment arm, human papillomavirus (HPV) status, and pathologic treatment response. A subset of samples was characterized for T‐cell related signatures using digital spatial genomic profiling. Results: Post‐treatment analysis revealed a significant decrease in FoxP3+ CD and an increase in CD8+ CDs in the TAS between patients receiving durvalumab and metformin versus durvlaumab alone. Both treatment arms demonstrated significant post‐treatment increases in ID. Although HPV+ and HPV− had similar immune cell CDs in the tumor microenvironment, HPV+ pre‐treatment samples had 1.60 times greater ID compared with HPV− samples, trending toward significance (p = 0.05). At baseline, pathologic responders demonstrated a 1.16‐fold greater CD8+ CDs in the LTE (p = 0.045) and 2.28‐fold greater ID (p = 0.001) than non‐responders. Digital spatial profiling revealed upregulation of FoxP3+ and cytotoxic T‐lymphocyte–associated antigen 4 (CTLA‐4) in the TAS (p = 0.006, p = 0.026) in samples from pathologic responders. Conclusions: Analysis of CD8+ and FoxP3+ detected population differences according to HPV status, pathologic response, and treatment. Greater CD8+‐FoxP3+ ID was associated with pathologic response. CD8+ and FoxP3+ T‐cell distributions may be predictive of response to immune checkpoint inhibition. ClinicalTrials.gov (Identifier NCT03618654). Level of Evidence: 3 Laryngoscope, 133:1875–1884, 2023 [ABSTRACT FROM AUTHOR]

Objective: To assess whether preoperative tracheostomy (PreOT) increases risk of complications after total laryngectomy (TL) and to determine if timing of tracheostomy creation is associated with an increased risk. Study Design: Retrospective cohort study. Setting: Tertiary care hospital between 2007 and 2020. Methods: Inclusion criteria were patients who underwent primary or salvage TL for oncologic treatment. Dependent variables of interest included surgical complications, such as wound dehiscence, infection, hematoma, complete flap failure, fistula formation, and stoma stenosis, as well as medical complications. Categorical variables were compared with chi‐square test or Fisher exact test, and continuous variables were compared with an independent t test. Multivariable regression was conducted to assess predictors of complications after laryngectomy. Results: A total of 306 patients were included. Primary TL was performed in 161 (53%) patients and salvage in 145 (47%) patients. Of the patients undergoing primary laryngectomy, 105 (65%) received a PreOT. Of the patients undergoing salvage laryngectomy, 86 (59%) received a PreOT. In both primary and salvage cases, there was no association between PreOT and surgical or medical complications. Additionally, there was no significant association between timing of tracheostomy and surgical complications. On multivariable analysis, the presence of a PreOT was not associated with surgical complications. In salvage cases, those with a PreOT had a significantly longer average length of stay than those without a PreOT (12 vs 9 days, P =.008). Conclusion: PreOT in patients undergoing primary and salvage laryngectomies was not associated with surgical or medical complications postlaryngectomy. Timing of tracheostomy in relation to laryngectomy was not found to adversely affect clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Few standardized methods exist for evaluating the postoperative outcomes of osteocutaneous free flaps. We propose an anatomic‐based scoring system for midface free flap reconstruction. Methods: One hundred and twelve patients across four institutions underwent osteocutaneous reconstruction of the midface. Postoperative scans were scored based on the number of independent osseous subunits reconstructed (Subunit Score), the number of different bony appositions with bony contact (Contact Score), and the number of osseous segments in anatomic position (Position Score). These were added together to create a Total Score. Results: Osteocutaneous radial forearm flaps had the lowest Subunit Score (p = 0.001). Fibula flaps had the highest Contact Score (p = 0.0008) and Position Score (p = 0.001). Virtual surgical planning was associated with an increased Subunit Score (p = 0.02) and Total Score (p = 0.04). Conclusions: We propose a novel scoring system for osseous midface reconstruction based on postoperative imaging scans. This can help guide management decisions and create a common language to compare outcomes. [ABSTRACT FROM AUTHOR]

Objective: Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction. Study Design: Retrospective review of prospectively collected databases. Methods: Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n = 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death). Results: The mean age of patients discharged home was lower (60 SD ± 13, n = 1450) compared to those discharged to an SNF (68 SD ± 14, n = 168) or a rehabilitation facility (71 SD ± 14, n = 200; p < 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p < 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p < 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p = 0.006), thromboembolism (59% vs. 80%; p = 0.001), a pulmonary complication (46% vs. 81%; p < 0.0001), a cardiac complication (46% vs. 80%; p < 0.0001), or a cerebral vascular event (25% vs. 80%; p < 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty‐day readmission rates were similar when stratified by discharge destination. Conclusion: There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination. Level of Evidence: 4 Laryngoscope, 133:95–104, 2023 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: We aim to 1) evaluate trends in adjuvant treatment of human papilloma virus (HPV)‐related oropharyngeal cancer; 2) assess change in complications and functional outcomes over time; and 3) assess change in overall and disease‐free survival (DFS) over time. Study Design: Retrospective analysis. Methods: Charts of patients who underwent transoral robotic surgery for HPV‐related oropharyngeal cancer between 2011 and 2019 were reviewed. Trend analysis was used to compare rate of adjuvant treatment over time. The Kaplan–Meier method was conducted to analyze overall survival (OS) and DFS. Results: Three hundred and forty‐two patients met inclusion criteria. One hundred and sixty‐three (47.7%) patients underwent adjuvant radiation, and 90 (26.3%) patients underwent adjuvant chemoradiation. Rate of extranodular extension decreased significantly from 38.9% to 24.0% (P =.004). Rate of adjuvant therapy decreased significantly from 90.9% to 62.5% between 2011 and 2019 (P =.001). In patients who received adjuvant treatment, rate of adjuvant chemoradiation therapy decreased significantly from 40.0% to 20.0% (P <.0005). There was a decrease in rate of 1‐year gastrostomy tube dependence in patients treated in 2015 to 2019 versus 2011 to 2014 (2.2% vs. 7.1%, P =.025). In 2011 to 2014, 2‐year OS and DFS were 96% and 89%, respectively; in 2015 to 2019, 2‐year OS and DFS were 96% and 94%, respectively. There was no difference in OS or DFS between the two time periods. Conclusions: The rate of adjuvant therapy, particularly chemotherapy, has decreased over time. One‐year gastrostomy tube dependence rate has decreased significantly from 2011 to 2014 to 2015 to 2019. There was no change in OS and DFS over this time period. Level of Evidence: 3 Laryngoscope, 132:806–812, 2022 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To describe multidimensional quality of life (QOL) outcomes in patients with sinonasal malignancies (SNM). To elucidate factors predicting worse QOL in this population. Study Design: Retrospective chart review at tertiary institution. Methods: A retrospective chart review on patients treated for SNM from 2006 to 2019 at a tertiary medical center was conducted. QOL outcomes were measured using the Hospital Anxiety and Depression Scale (HADS) and the Functional Assessment Cancer Therapy – Nasopharynx (FACT‐NP) score. A stepwise multiple linear regression analysis was conducted to assess factors predicting worse QOL. Results: Eighty‐one patients met inclusion criteria. Twelve (14.8%) patients had a subscale score >11 for anxiety (HADS‐A) or depression (HADS‐D) indicating significant anxiety or depression, at a median of 24 (8–68.5) months post treatment. The median FACT‐NP total score was 136 (110–152). On multivariable analysis, advanced T classification, single status, and worse social support survey score were significant predictors of worse HADS score. Worse social support survey score was a significant predictor of worse total FACT‐NP score. Conclusion: After adjusting for confounders, at a median of 24 months after completion of definitive therapy for SNM, advanced T classification and single relationship status were found to be significant predictors of anxiety and depression (based on HADS). A worse social support survey score was associated with worse anxiety, depression, and QOL (based on HADS and FACT‐NP). Identifying these factors early may help to guide treatment and psychiatric referral to at‐risk individuals after the treatment of SNM. Level of Evidence: 3 Laryngoscope, 131:E2212–E2221, 2021 [ABSTRACT FROM AUTHOR]

Objectives: To determine the impact of lymph node yield (LNY) in patients undergoing neck dissection at the time of total laryngectomy (TL). To determine the impact of radiation therapy (RT) on LNY. Methods: Retrospective review of LNY and clinical outcomes in 232 patients undergoing primary or salvage total laryngectomy (TL) with ND. Results: Preoperative RT significantly decreased mean LNY from 31.7 to 23.9 nodes (P <.001). In primary TL patients, age (P <.001) and positive margins (P =.044) were associated with decreased OS. In salvage TL patients, only positive margins was associated with poorer OS (P =.009). No LNY cutoff provided significant OS or DFS benefit. Conclusions: Radiotherapy significantly reduces LNY in patients undergoing TL and ND. Within a single institution cohort, positive margins, but not LNY, is associated with survival in both primary and salvage TL patients. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]