BACKGROUND: We aimed to determine predictors of morbidity in patients undergoing microvascular free flap reconstruction of the head and neck. METHODS: We prospectively evaluated 796 cases between 1999 and 2007 using univariate and multivariate analysis to determine predictors of morbidity and prolonged hospital stay. RESULTS: Two hundred thirty-nine patients (30%) developed major complications. Age, body mass index (BMI), American Society of Anesthesiology (ASA) score, Kaplan Feinstein comorbidity index (KFI) score, preoperative hemoglobin, and tracheostomy were independent predictors of major complication. Predictors of prolonged hospital stay included age, recent weight loss, alcohol excess, ASA, KFI, preoperative hemoglobin, mucosal surgery, anesthesia duration, and crystalloid replacement volume. CONCLUSION: Several variables are associated with an increased risk of development of major complications following free flap reconstruction of the head and neck. Although many of these variables are irreversible, they aid risk stratification of patients undergoing free flap reconstruction, and assist clinicians in making treatment decisions, consenting, and providing patients with realistic expectations regarding their perioperative course.(c) 2010 Wiley Periodicals, Inc. Head Neck, 2010.

The role of open surgery for management of laryngeal cancer has been greatly diminished during the past decade. The development of transoral endoscopic laser microsurgery (TLS), improvements in delivery of radiation therapy (RT) and the advent of multimodality protocols, particularly concomitant chemoradiotherapy (CCRT) have supplanted the previously standard techniques of open partial laryngectomy for early cancer and total laryngectomy followed by adjuvant RT for advanced cancer. A review of the recent literature revealed virtually no new reports of conventional conservation surgery as initial treatment for early stage glottic and supraglottic cancer. TLS and RT, with or without laser surgery or CCRT, have become the standard initial treatments for T1, T2 and selected T3 laryngeal cancer. Photodynamic therapy (PDT) may have an emerging role in the treatment of early laryngeal cancer. Anterior commissure involvement presents particular difficulties in application of TLS, although no definitive conclusions have been reached with regard to optimal treatment of these lesions. Results of TLS are equivalent to those obtained by conventional conservation surgery, with considerably less morbidity, less hospital time and better postoperative function. Oncologic results of TLS and RT are equivalent for glottic cancer, but with better voice results for RT in patients who require more extensive cordectomy. The preferred treatment for early supraglottic cancer, particularly for bulkier or T3 lesions is TLS, with or without postoperative RT. The Veterans Administration Study published in 1991 established the fact that the response to neoadjuvant CT predicts the response of a tumor to RT. Patients with advanced tumors that responded either partially or completely to CT were treated with RT, and total laryngectomy was reserved for non-responders. This resulted in the ability to preserve the larynx in a significant number of patients with locally advanced laryngeal cancer, while achieving local control and overall survival results equivalent to those achieved with initial total laryngectomy. Following this report, similar "organ preservation" protocols were employed in many centers. By 2003, results of the RTOG 93-11 trial, utilizing CCRT as initial treatment, were published, demonstrating a higher rate of laryngeal preservation with this protocol. Surgery was reserved for treatment failures. This concept changed the paradigm for management of advanced laryngeal cancer, greatly reducing the number of laryngectomies performed. While supracricoid laryngectomy has been employed for selected patients, total laryngectomy is the usual procedure for salvage of failure after non-surgical treatment.

OPINION STATEMENT: The incidence of cancer among older patients continues to rise. The use of combined modality therapy has improved survival in a variety of malignancies, including rectal, head and neck, and lung cancer; however, the addition of chemotherapy increases substantially the toxicities of treatment. Elderly patients have generally been excluded from prospective clinical trials and as such, there is a lack of evidence-based data with regards to the most appropriate treatment. Age itself should not be used as a criterion for foregoing combined modality therapy in elderly patients. Due to the increased toxicity of therapy, patients must be carefully selected. Any medical intervention should account for life expectancy, performance status, tolerance to therapy, and presence of medical or social conditions that may impact therapy. We encourage a comprehensive geriatric assessment to evaluate functional status, comorbidities, mental status, psychological state, social support, nutritional status, polypharmacy, and geriatric conditions in order to improve a patient's overall functional status during the course of therapy. Fit elderly patients should be considered candidates for combined modality therapy, however, because they are potentially more vulnerable to therapy, careful attention should be paid to hydration and nutritional status with early intervention when necessary. Investigators should be encouraged to expand eligibility to include elderly patients on non age-related clinical trials. Additionally, therapy-related clinical trials directed at the elderly should be developed.

Hospital stays constitute the main component of costs of cancer treatment. We conducted a prospective study to identify the determinants of the length of stay (LOS) after head and neck cancer surgery (HNCS). Patients who underwent major HNCS with opening of mucosa and with curative intent were enrolled. Data were collected for patient characteristics, type of tumour, surgical procedures and postoperative outcome. LOS defined as the interval between the day of admission for surgery until hospital discharge or death was determined by the Kaplan-Meier method. Independent determinants of LOS were identified using a Cox model. All 260 patients were included. Median LOS was 26 days (range, 3-178). In the multivariate model, four variables remained associated with increased LOS: American Society of Anaesthesiologist's score equal to 3 (hazard ratio 1.62 [1.23-1.99]), duration of surgical procedure >220min.,(HR=1.37 [1.22-1.56]), SSI (HR=2.09 [2.02-2.54]), occurrence of SSI caused by multi-resistant pathogen (HR=2.92 [2.78-3.77]) and occurrence of PP (HR=2.09 [1.78-2.81]). The present results highlighted the long duration of LOS after head and neck cancer surgery. Two variables (duration of surgical procedure and occurrence of nosocomial infections) were associated with LOS and might be improved by appropriate strategies.

Since the original data from the Department of Veterans Affairs Laryngeal Cancer Study Group demonstrated that nonsurgical therapy could achieve survival rates comparable to total laryngectomy in selected cases, there has been a progressive increase in employment of nonsurgical therapy for the management of advanced laryngeal cancer. Both neoadjuvant chemotherapy followed by conventionally fractionated or hyperfractioned radiotherapy for chemotherapy responders, or simultaneously administered chemoradiation has resulted in a significant number of patients who achieved cure while preserving their larynges. Nevertheless, combined chemotherapy and external beam radiation is associated with a variety of acute and chronic sequelae that can have a debilitating impact on function and quality of life. Although no therapeutic option is without risk, the decision regarding the modality of therapy for a patient with advanced laryngeal cancer should prompt a careful review of the current surgical techniques available for treatment. Data on quality of life and aging, as well as advances in minimally invasive surgical techniques, are available today that were not available at the time of the Veterans study. Selection of optimal therapy is often complex and raises the question whether the pendulum may have swung too far in the direction of nonsurgical therapy for advanced laryngeal cancer. This article reviews the current options available for a patient with advanced laryngeal cancer and discusses the impact of therapy.(c) 2007 Wiley Periodicals, Inc. Head Neck, 2007.

BACKGROUND.: Postoperative complications are relevant outcomes in patients with head and neck tumor who have undergone surgery. Few trials have assessed predictive factors in older patients. We assessed the predictive effect of preoperative clinical factors on postoperative complications. METHODS.: We conducted a cohort study with 242 patients older than 70 years with head and neck cancer who underwent surgery. Logistic regression identified predictive factors for postoperative complications. Significant variables were used to build a predictive index. RESULTS.: Comorbidities were present in 87.6% of patients, and 56.6% had some type of complication (44.6% local and 28.5% systemic). Male sex, bilateral neck dissection, presence of 2 or more comorbidities, reconstruction, and clinical stage IV were associated with postoperative complications. The predictive index showed a receiver operating characteristics curve (ROC) area of 0.69. CONCLUSION.: It is possible to predict postoperative complications in older patients with head and neck tumors who underwent oncologic surgery using clinical preoperative variables.(c) 2007 Wiley Periodicals, Inc. Head Neck, 2007.

BACKGROUND: Aggressive surgical treatment of oral and oropharyngeal cancers may be compromised by significant surgical complications. Early identification of patients at risk for postoperative complications may assist in clinical decision-making. The objective of this study was to assess the value of the Acute Physiology and Chronic Health Evaluation (APACHE II) score in predicting early postoperative surgical complications. METHODS: There were 510 cases of free tissue transfer surgery identified on the Liverpool Oncology Head and Neck Database for 1995 to 2002. APACHE II data were collected independently from critical care records and by case note retrieval. The authors' main a priori outcomes were total flap failure and any immediate complication requiring further surgery (including any from hemorrhage, hematoma, partial flap failure, airways, and anastomosis exploration). RESULTS: Overall total flap loss and immediate complication rates were 6.2 percent (30 of 485) and 13.6 percent (66 of 485), respectively. APACHE II data were known for 399 operations (82 percent) and, of these, 90 percent (360 of 399) were managed postoperatively in the critical care unit. There were clear correlations between APACHE II scores with total flap loss and with other immediate complications. CONCLUSIONS: The APACHE II score is associated with immediate postoperative surgical complications involving flap compromise and thus may be a useful tool in postoperative decision-making.

Little is known about long-term treatment outcome of elderly head and neck cancer patients and their quality of life (QOL). One hundred and eighteen older (>/=70 years) and 148 younger (45-60 years) patients with head and neck cancer were followed up for 3-6 years. In the long-term follow-up 33 younger and 24 older patients completed the EORTC QLQ-C30 and H&N35 and a questionnaire about depression. The survival rate after 3-6 years for younger patients was 36%, as compared to 31% in the older patient group. Higher tumour stages, more co-morbidity and non-standard treatment showed to be independent prognostic factors for mortality. No independent prognostic value of age could be found. The global QOL score remains roughly comparable. Even up to 6 years after treatment, we found no significant differences in survival or overall QOL between older and younger head and neck cancer patients.

BACKGROUND: Craniofacial resection (CFR) for patients over 70 years of age is uncommon. This study examines a cohort of 36 patients who had CFR at a single institution with the aim of reporting mortality, complications, and outcome. METHODS: Thirty-six patients 70 years of age and older were identified from a prospective database of 234 patients who had CFR at a single institution. The median age was 72 years (range, 70-87). Seventeen (47%) patients had had prior single-modality or combined treatment, which included surgery in 14 (40%), radiation in 13 (36%), and chemotherapy in 2 (6%). Thirty-five patients had a malignant tumor and 1 patient a benign tumor; 15 (42%) had high-grade, 17 (47%) intermediate-grade, and 4 (11%) low-grade pathology. The margins of resection were close or microscopically positive in 18 (50%). Adjuvant radiotherapy was given in 15 (42%) and chemotherapy in 1 (3%). Complications were classified into overall, local, central nervous system (CNS), systemic, and orbital. Overall survival (OS) and disease-specific survival (DSS) were determined using the Kaplan-Meier method. Outcomes were compared with patients less than 70 years of age. RESULTS: Postoperative mortality occurred in 6 (17%) patients and postoperative complications occurred in 23 (64%) patients. Local wound complications occurred in 11 (30%), CNS in 12 (33%), systemic in 6 (17%), and orbital in 1 (3%). Postoperative mortality and complications were significantly higher in patients 70 years of age and older compared with patients less than 70 years of age (17% versus 1.5%, p =.0005; 64% versus 36%, p =.003, respectively). With a median follow-up of 27 months (range, 1-237), the 3 year OS and DSS were significantly poorer than patients less than 70 years of age (OS: 53% versus 69%, p =.0004; DSS: 61% versus 70%, p =.01) due to increased medical comorbidity (53% versus 24%, p =.001) and poorer histology (high-, intermediate-, low-grade histology: 42%, 47%, 11% versus 26%, 47%, 27%, p =.05, respectively) in patients over 70 years of age. CONCLUSION: CFR in patients 70 years of age and older is associated with increased mortality, increased incidence of complications, and a poorer overall and disease-specific 3-year survival, compared with patients less than 70 years of age. The survival was likely due to increased medical comorbidity and adverse histology. These factors must be taken into account when considering an elderly patient for craniofacial resection.(c) 2006 Wiley Periodicals, Inc. Head Neck, 2006.

The aim of this study was to determine the risk factors for the mortality during the first 30days after a major head and neck cancer surgery. Two hundred and sixty one consecutive surgical procedure were prospectively studied at Oscar Lambret Cancer Centre within a 36-months period. Twenty variables were recorded for each patient. The significant risk factors for postoperative mortality were assessed by univariate and multivariate analysis. Overall 30-days mortality rate was 3.83%[95% CI 3.13-4.53]. In univariate analysis identified four risk factors: female gender (odd ratio 4.25 [95% CI 1.03-17.56]), age equal or superior than 70 (odd ratio 5.06 [95% CI 1.35-18.36]), current alcohol addiction (odd ratio 3.65 [1.02-13.06]) and laryngeal location (odd ratio 4.23 [CI 95% 1.18-3.38]). In multivariate analysis only female gender and laryngeal location remained significant. The incidence of postoperative mortality was 1.63% for patients without risk factor and was 6.41% for those with one or two risk factors. This model identifies easily high-risk patients for major head and neck cancer surgery. A multicenter validation is necessary.

PURPOSE OF REVIEW: This review will discuss the mortality after major ear, nose and throat surgery, particularly sudden death. It will also discuss the postoperative follow-up of patients. RECENT FINDINGS: Sudden death is a rare event after major ear, nose and throat surgery, and occurs mainly during the first three postoperative days. SUMMARY: In more recent studies, the mortality rate after neck dissection was below 4%, which is at a lower value than reported in previous studies. Sudden deaths have been described, however, mainly during the first three postoperative days. Alcoholism and perioperative hypotension are two predictive factors for cardiac complications. Careful follow-up of these patients during the early postoperative period should be performed to reduce the mortality by shortening the delay of care.

INTRODUCTION: In the industrialized nations of the Western hemisphere the age group beyond 75 years will grow steadily, requiring special attention by medical professionals in the future. With regard to these expectations 40 patients, beyond the age of 75 and who were first diagnosed to suffer from squamous cell carcinoma of the upper aerodigestive tract, were analysed. MATERIAL AND METHODS: Forty patients diagnosed and treated between 1998 and 2003 for head and neck squamous cell carcinoma (HNSCC) were analysed. RESULTS: Laryngeal carcinoma was noted in 80% of the patients. All types of treatment were tolerated well. Patient compliance was generally good and the rate of complications was low. CONCLUSION: The results of the present study show that HNSCC in elderly patients should be treated with curative intention. Age itself should never be a sole factor in deciding which curative therapy should be undertaken. Exceptions could be made in patients with severe general comorbidity.

As life expectancy increases, surgeons can expect an increasing number of geriatric patients. In turn, the number of elderly patients presenting with head and neck cancer is likely to increase. Management of this subpopulation has become a source of debate because there is a paucity of randomized data regarding the effect of age on treatment response and morbidity associated with the treatment of head and neck cancer. The management of head and neck cancer in the elderly depends on the patient's age and general condition, the stage of disease, the effects of treatment on quality of life (such as speech and swallowing), patient and family wishes, and active physician participation in continued care. Elderly patient's comorbid conditions need appropriate attention especially if surgery is to be undertaken. The aim of this review is to examine the current literature in an attempt to develop an approach to the treatment of the elderly patient with head and neck cancer and to define the pertinent issues that require further study.

Although the majority of head and neck cancers occur between the fifth and sixth decade, their onset in patients older than 60 years is not a rare event. A peculiar characteristic of almost all case series is the lower prevalence of radical treatments among elderly as compared to younger patients, in particular surgery and combined treatment of surgery plus radiation therapy or chemotherapy and radiation therapy. Radiotherapy is a feasible treatment in elderly patients, also in very advanced age groups and, in the era of organ preservation, chemotherapy combined with RT has a paramount importance. Therapeutical planning must be based not only on tumor characteristics, but also on the physiological, rather than the chronological age the patient. The main clinical problem is, therefore, the selection of patients to be administered anticancer treatment. In patients aged 70 or older, complete geriatric assessment and a multidisciplinary approach are the crucial points.

OBJECT: The elderly population is increasing in number and is healthier now than in the past. The purpose of this study was to examine complications and outcomes following craniofacial resection (CFR) in elderly patients and to compare findings with those of a matched younger cohort. METHODS: All patients 70 years of age or older undergoing CFR at the M.D. Anderson Cancer Center (elderly group) between December 1992 and July 2003 were identified by examining the Department of Neurosurgery database. A random cohort of 28 patients younger than 70 years of age (control group) was selected from the overall population of patients who underwent CFR. There were 28 patients ranging in age from 70 to 84 years (median 74 years). Major local complications occurred in seven elderly patients (25%) and in six control patients (21%)(p = 0.75), and major systemic complications occurred in nine elderly patients (32%) and in three control patients (11%)(p = 0.05). There was one perioperative death in both groups of patients. The median duration of disease-specific survival for the elderly patients was not reached (mean 6.8 years); however, it was 8.3 years for control patients (p = 0.24). Predictors of poorer overall survival from a multivariate analysis of the elderly group included presence of cardiac disease (p = 0.005), a major systemic perioperative complication (p = 0.03), and a preoperative Karnofsky Performance Scale score less than 100 (p = 0.04). CONCLUSIONS: In this study of elderly patients who underwent CFR, there was no difference in disease-specific survival when compared with a matched cohort of younger patients. There was, however, an increased incidence of perioperative major systemic complications in the elderly group.

BACKGROUND.: Little is known about quality of life (QOL) in elderly patients. METHODS.: Seventy-eight older (>/=70 years) and 105 younger patients (45-60 years) with carcinoma of the oral cavity, pharynx (stage >/=II), or larynx (stage >/=III) completed the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire and EORTC Head and Neck Cancer Quality of Life Questionnaire before treatment. Fifty-one older and 70 younger patients completed all follow-up questionnaires at 3, 6, and 12 months. RESULTS.: Before and after treatment, the physical functioning of the older patients was worse than that of younger patients. This difference remained relatively constant during follow-up and is probably related to normal aging. At baseline and 3 months, no other differences were found between both groups. At 6 months, younger patients reported more pain, but at 12 months no relevant differences were found. CONCLUSIONS.: Treatment did not affect QOL differently in older and younger patients. Therefore, standard treatment should always be considered, irrespective of the patient's age.(c) 2004 Wiley Periodicals, Inc. Head Neck 26: 1045-1052, 2004.

OBJECTIVE: Elderly patients with head and neck cancer often receive non-standard treatment for reasons other than comorbidity. In this prospective study we investigated how elderly patients fare 1 year after treatment in comparison with their younger counterparts. MATERIAL AND METHODS: Seventy patients aged 45-60 years and 51 patients aged > or = 70 years with cancer of the oral cavity, pharynx (stage II-IV) or larynx (stage III-IV) participated in the study before treatment and 1 year later. Each patient was interviewed and given a questionnaire concerning physical functioning, social contacts, depressive symptoms, satisfaction with treatment and future expectations. RESULTS: At 12 months, patients in both age groups reported significantly more depressive symptoms and less social support than before treatment, and their Karnofsky Performance Score was lower. However, there were no differences between elderly and younger patients. Approximately 90% of those in both age groups said that they would choose the same treatment again, and there was no age difference regarding the impact of treatment or expectations for the future. CONCLUSION: This study shows that the impact of treatment on quality of life did not differ between elderly and younger patients with head and neck cancer. Therefore, standard treatment should be considered in elderly patients if no severe contraindications exist.

Elderly patients with head and neck cancer are less likely to receive standard treatment. This study assessed the influence that age, tumour characteristics, comorbidity, social support, depressive symptoms and quality of life have on treatment choice. One hundred and five patients between 45 and 60 years of age and 78 patients of > or =70 years of age with carcinoma of the oral cavity (stage > or =II), oro- and hypopharynx (stage > or =II) or larynx (stage > or =III) completed a questionnaire on quality of life (EORTC QLQ-C30 and H&N35), depressive symptoms (CES-D) and social support (RSS12-I). In the 45-60 age group, 89% received standard treatment, compared with 62% of the > or =70 age group. A multivariate logistic regression analysis showed that the following factors predicted non-standard treatment: marital status (widowed), advanced tumour stage, comorbidity, less pain, considering the length of life less important than its quality and old age. This study showed that age itself independently influences treatment choice. However, it should be emphasised that the choice of a treatment should be based on a medical assessment and the patient's preferences, not on chronological age.

OBJECTIVE: To analyze the frequency of and risk factors for postoperative complications after en bloc salvage surgery for head and neck cancer. DESIGN: Retrospective cohort study. SETTING: Patients were evaluated from February 7, 1990, to November 17, 1999, in a tertiary cancer center hospital.Patients Consecutive sample of 124 patients from the hospital database. Only patients with recurrent head and neck squamous cell carcinoma undergoing en bloc salvage resection were eligible for the study. MAIN OUTCOME MEASURES: We analyzed the frequency of and risk factors for complications after salvage surgery. RESULTS: The tumor location was the lip in 6 patients, oral cavity in 55, oropharynx in 31, larynx in 24, and hypopharynx in 8. Previous treatment was surgery alone in 20 patients, radiotherapy alone in 68, surgery and radiotherapy in 21, and radiotherapy and chemotherapy in 14. An additional patient received chemotherapy alone before salvage surgery. The clinical stage of the recurrent tumor was I or II in 23 patients and III or IV in 101 patients. Postoperative complications occurred in 66 patients (53.2%). Fifty-three patients (42.7%) had minor complications, and 23 patients (18.5%) had major ones. There were 4 postoperative deaths (3.2%). The major factor associated with the overall occurrence of postoperative complications was the clinical stage of the recurrent tumor (P =.02). The occurrence of minor complications correlated with the previously treated site, with complications occurring more often in patients undergoing locoregional vs local treatment (P =.04). Major complications were associated with the time between initial treatment and salvage surgery (P =.05). CONCLUSIONS: Salvage surgery can be performed with acceptable rates of postoperative complications. The clinical stage of the recurrent tumor and the previous site treated were the 2 major factors associated with the occurrence of postoperative complications.