Quality of life in patients after resection of pT3 lateral tongue carcinoma: Microvascular reconstruction versus primary closure

Tongue reconstruction after oncological resection: Analysis of the functional outcomes

The curative management of oral squamous cell carcinoma can be responsible for swallowing and/or speech impairments. In this study, we analyzed the functional outcomes in patients who underwent an oncological resection and a primary reconstruction of the tongue and/or of the floor of the mouth (TFM). We also investigated the predictive factors for poor functional outcomes. This retrospective study included operated patients from October 2013 to May 2021 at the TOURS University Hospital. We assessed the functional results two years after the completion of the cancer treatment with self-administered questionnaires quantifying swallowing and speech disorders. Thirty-three patients were included and reconstructed with antebrachial free flap (N = 16), local flap (N = 8) or Biodesign ® membrane (N = 9). A higher proportion of pT1 tumor was observed in patient who had a Biodesign-based reconstruction (p = 0.001). There was no significant difference between the groups in terms of postoperative complications or for the duration of enteral feeding. The 21 patients who had an adjuvant radiation therapy had no significant more altered functions. Functional scores were significantly higher in the free flap reconstruction group (DHI =24 and SHI=21) (p = 0.008). No predictive factors for poor outcomes were observed. The repair of TFM defects must be adapted to the resection size. The reconstruction techniques allow to get acceptable functional outcomes even for the greater tumors or in case of radiation therapy. Further research would be required to better identify the predictive factors for poor outcomes.

Depression and anxiety in patients with head and neck cancer undergoing free flap reconstruction

PURPOSE

To determine the prevalence and severity of depression and anxiety in patients with head and neck cancer (HNC) undergoing treatment with free-flap (FF) reconstruction.

METHODS

Participants with HNC undergoing FF reconstruction were given the validated 9-item Patient Health Questionnaire (PHQ-9) and a 7-item Generalized Anxiety Disorder (GAD-7) questionnaire prior to surgery. Patient factors and responses were analyzed.

RESULTS

Seventy-one patients were included. Mean (SD) pre-operative PHQ-9 was 7.6 (7.04) with 34 % (n = 24) having moderate to severe depression. Mean (SD) pre-operative GAD-7 was 6.5 (6.86) with 30 % (n = 21) having moderate to severe anxiety.

CONCLUSION

Prevalence of depression and anxiety is high in this cohort and undiagnosed in 22 % and 18 % of patients, respectively. Due to the findings, it is prudent to screen HNC patients at initial diagnosis and offer mental health services.

Functional considerations between flap and non-flap reconstruction in oral tongue cancer: A systematic review

This systematic review aims to provide insight into the ideal reconstructive approach of the oral tongue in oral tongue cancer (OTC) by investigating the relationship between functional outcomes and the extent of tongue resection. A structured search was performed in Ovid MEDLINE, EMBASE, and Web of Science. Studies comparing patient-reported and objective measurements of the oral tongue function between flap vs. non-flap reconstruction were included. Functional outcomes of interest were speech production, deglutition efficiency, tongue mobility, overall quality of life, and postoperative complications. A total of nine studies were retrieved and critically appraised. Patients with 20 % or less of oral tongue resected had superior swallowing efficiency and speech intelligibility with a non-flap reconstruction while patients with a tongue defect of 40-50 % self-reported or demonstrated better swallowing function with a flap repair. The data in intermediate tongue defects (20-40 % tongue resected) was inconclusive, with several studies reporting comparable functional outcomes between approaches. A longitudinal multi-institutional prospective study that rigidly controls the extent of tongue resected and subsites involved is needed to determine the percentage of tongue resected at which a flap reconstruction yields a superior functional result in OTC.

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

Comparison of T1/2 Tongue Carcinoma with or without Radial Forearm Flap Reconstruction Regarding Post-Therapeutic Function, Survival, and Gender

BACKGROUND

Flap reconstruction is commonly used in advanced tongue carcinoma in order to compensate for the loss of tongue tissue and function. Surprisingly, a large number of reconstructed early-stage tongue cancer can be found. Survival or functional benefits in these cases remain unclear.

METHODS

A retrospective data analysis of 384 surgically treated tongue carcinoma patients was conducted aiming to find epidemiologic and survival differences between patients with (n = 158) or without flap reconstruction (n = 226). A prospective functional analysis was performed on 55 early-stage tongue cancer patients, 33 without and 22 with radial-forearm flap reconstruction, focusing on post-therapeutic swallowing function as the primary endpoint, speech as the secondary endpoint, xerostomia, quality of life, and mouth opening.

RESULTS

Consistent with the current literature, we demonstrated the significantly more frequent use of flap grafts in advanced tongue carcinomas. For the first time, we depicted a higher female ratio in the reconstructed group (p = 0.02). There were no significant differences in survival or functional outcomes between the groups. The none-reconstructed group showed more frequent use of adjuvant C/RT despite presenting fewer N+ stages.

CONCLUSIONS

The higher female ratio in the reconstruction group is plausible due to the anatomically smaller oral cavity and relatively larger carcinoma in women. A higher presence of close margins in the none-reconstruction group may explain the more frequent use of adjuvant C/RT. Since we found no survival or functional differences between the groups, we propose a critical approach toward flap reconstruction in T1/2 tongue carcinoma. At the same time, proportional aspects and adequate resection margins should be taken into account.

Health-Related Quality of Life in Oral Cancer Patients: Scoping Review and Critical Appraisal of Investigated Determinants

Simple Summary

Oral cancer may strongly impair patients’ quality of life. Huge efforts have been made during recent decades in trying to improve the treatment outcomes in terms of patients’ survival, self-perception, and satisfaction. Consequently, the investigation into health-related quality of life (HRQOL) became an established and worldwide practice. Hundreds of studies tried to clarify which could be the most important variables that impact HRQOL in head and neck cancer patients. However, such a complex topic may be influenced by a multitude of interconnected aspects and several controversies were reported. In this study the current literature was reviewed to identify all those possible sources of bias that may be encountered in trying to correlate HRQOL to patient-specific or disease/treatment-specific aspects. As a result, a list of recommendations was reported to enhance the evidence of future studies.

Abstract

Background: health-related quality of life (HRQOL) represents a secondary endpoint of medical interventions in oncological patients. Our aim was to highlight potential sources of bias that could be encountered when evaluating HRQOL in oral cancer patients. Methods: this review followed PRISMA-ScR recommendations. Participants: patients treated for oral cancer. Concept: HRQOL assessed by EORTC QLQ-C30 and QLQ-H&N35/QLQ-H&N43. A critical appraisal of included studies was performed to evaluate the accuracy of data stratification with respect to HRQOL determinants. Results: overall, 30 studies met the inclusion criteria, totaling 1833 patients. In total, 8 sociodemographic (SDG) and 15 disease/treatment-specific (DT) HRQOL determinants (independent variables) were identified. The mean number of the independent variables was 6.1 (SD, 4.3)—5.0 (SD, 4.0) DT-related and 1.1 (SD, 1.8) SDG-related variables per article. None of the included papers considered all the identified determinants simultaneously. Conclusions: a substantial lack of evidence regarding HRQOL determinants was demonstrated. This strongly weakens the reliability of the reported findings due to the challenging presence of baseline confounding, selection, and omitted variable biases. The proposed approach recommends the use of further evaluation tools that gather more variables in a single score together with a selection of more homogeneous, reproducible, and comparable cohorts based on the identified baseline confounding.

Preliminary Functional Outcomes and Quality of Life after Tongue Reconstruction with the Vastus Lateralis Myofascial Free Flap

The aim of the present study is to report our preliminary experience with the vastus lateralis myofascial free flap (VLMFF) for tongue reconstruction according to tongue and donor site functional outcomes. Twelve consecutive patients (F: 5; median age: 54.0 years, interquartile range or IQR 42.75-69.0) were included. The validated European Organization for Research and Treatment of Cancer of the Head and Neck 35 Quality of Life Questionnaire (EORTC QLQ-H&N35) and the performance status scale for head and neck cancer (PSS-HN) questionnaires were used to assess the health-related quality of life (HRQOL). The lower extremity functional scale (LEFS) was used to self-report the donor area function. All patients were successfully treated, and no VLMFF failure was detected during a median follow-up period of 10.5 months (IQR: 6.5-33.0). The HRQOL showed a median EORTC QLQ-H&N35 score of 56.0 (IQR: 50.0-72.5). The median PSS-HN score was 80.0 (IQR: 45.0-95.0), 75.0 (IQR: 62.5-100.0), 75.0 (IQR: 62.5-100.0) for "Normalcy of Diet," "Public Eating," and "Understandability of Speech," respectively. The self-reported function of the lower extremities (donor area) showed a median LEFS of 59.0 (IQR: 32.5-74.0). This study reports optimistic data regarding the functional and quality of life outcomes after tongue reconstruction using VLMFF. Prospective controlled studies are needed to demonstrate advantages and disadvantages when compared with other reconstructive techniques.

Prediction of Speech, Swallowing, and Quality of Life in Oral Cavity Cancer Patients: A Pilot Study

OBJECTIVES/HYPOTHESIS

To investigate the impact of specific treatment-related variables on functional and quality of life outcomes in oral cavity cancer (OCC) patients.

STUDY DESIGN

Retrospective Cohort.

METHODS

Patients with primary OCC at least 6 months after resection and adjuvant therapy were included. Patients completed surveys including the Speech Handicap Index (SHI), M.D. Anderson Dysphagia Inventory (MDADI), and Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN). Performance Status Scale (PSS) and tongue mobility scale were completed to allow provider-rated assessment of speech and tongue mobility, respectively. Additional details regarding treatment were also collected. These data were used to generate a predictive model using linear regression.

RESULTS

Fifty-three patients with oral tongue and/or floor of mouth (FOM) resection were included in our study. In multivariable analysis, greater postoperative tongue range of motion (ROM) and time since treatment improved SHI. Flap reconstruction and greater postoperative tongue ROM increased MDADI and PSS (eating and speech). A larger volume of resected tissue was inversely correlated with PSS (diet and speech). Tumor site was an important predictor of PSS (all sections). There were no statistically significant predictors of FACT-HN.

CONCLUSIONS

In this pilot study, we propose a battery of tools to assess function in OCC patients treated with surgery. Using the battery of tools we propose, our results show that a surgical endpoint that preserves tongue mobility and employs flap reconstruction resulted in better outcomes, whereas those with greater volume of tissue resected and FOM involvement resulted in poorer outcomes. Larger prospective studies are needed to validate our findings.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Factors impacting successful salvage of the failing free flap

BACKGROUND

Understanding factors impacting successful salvage of a compromised free flap.

METHODS

Multi-institutional review of free flap reconstructions for head and neck defects (n = 1764).

RESULTS

Free flap compromise rate: 9% (n = 162); 46% salvaged (n = 74). Higher salvage rates in initial 48 hours (64%) vs after (30%; P < .001). Greater compromise (14%) and failure (8%) if inset challenging vs straightforward (6% compromise, 4% failure; P = .035). Greater compromise (23%) and failure (17%) following intraoperative anastomosis revision vs no revision (7% compromise, 4% failure; P < .0001). Success following arterial insufficiency was lower (60% failed, 40% salvaged) vs venous congestion (23% failed, 77% salvaged) (P < .0001). Greater flap salvage following thrombectomy (66%) vs no thrombectomy (34%; P < .0001). Greater flap salvage if operative duration ≤8 hours (57%), vs >8 hours (40%) (P = .04).

CONCLUSIONS

There were higher rates of free flap salvage if the vascular compromise occurred within 48 hours, if due to venous congestion, if operative duration ≤8 hours, and if the anastomosis did not require intraoperative revision.

"Sushi roll" technique for precise total tongue functional reconstruction using a pre-sutured femoral anterolateral myocutaneous flap

OBJECTIVES

Reconstruction of the total tongue after cancer resection remains one of the challenges in head and neck surgery. Inadequate reconstruction after subtotal or total glossectomy defects leads to poor quality of life. The aim of this study was to explore an economical, practical and effective flap design for functional tongue reconstruction.

MATERIAL AND METHODS

Sixty patients were randomly divided into two groups, namely, a "Sushi roll" technique group (30 patients) and a conventional surgery group (30 patients). Then, the patients underwent total or subtotal tongue reconstruction. Swallowing function, speech intelligibility, cosmetic results, and quality of life were assessed with the appropriate scales. Outcomes were analysed, and a p-value <0.05 was considered significant.

RESULTS

The perioperative recovery of the "Sushi roll" group was superior to that of the conventional group. Relative to patients in the conventional group, patients in the "Sushi roll" group showed significantly improved speech intelligibility (p = 0.025), cosmetic results (p < 0.001) and swallowing function (p < 0.001).

CONCLUSION

The innovative "Sushi roll" anterolateral thigh myocutaneous flap approach for total tongue reconstruction creates a free neotongue tip with adequate volume and protuberance and causes minimal damage to the donor site, producing acceptable swallowing function and speech intelligibility.

Compartmental Surgery for Oral Tongue Cancer: Objective and Subjective Functional Evaluation

OBJECTIVE

To assess functional outcomes in patients treated by compartmental tongue surgery (CTS) and reconstruction for advanced oral tongue/floor-of-mouth cancer.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective cohort of patients (n = 48) treated by CTS and free flap reconstruction was prospectively evaluated concerning postoperative functional outcomes at different time points (6 months and 1 year). Swallowing was studied by videonasal endoscopic evaluation (VEES) and videofluoroscopy (VFS), testing various food consistencies and grading the results with the Donzelli scale. Speech articulation, lingual strength, and endurance were studied by phone call and Iowa Oral Performance Instrument (IOPI). Subjective tests (EORTC H&N35 and UWQOL) were administered.

RESULTS

After 1 year, VEES showed a Donzelli scale of 67% level 1, 23% level 2, and 10% level 3. Vallecular pouch was present in 81% of patients. VFS showed levels 1, 2, and 3 in 42%, 25%, and 33%, respectively, with liquids (L); 48%, 19%, and 33%, with semi-liquids (SL); and 54%, 33%, and 13%, with semi-solids (SS). Vallecular pouch residue was present in 69% with L, 73% with SL, and 87% with SS. The mean number of words recognized at phone call was 56 of 75 (range, 27-74). IOPI showed a mean tongue strength of 19.2 kPa (range, 0-40), and a mean endurance of 16.2 seconds (range, 0-60).

CONCLUSION

CTS does not significantly affect speech. Sub-clinical food aspiration and vallecular pouch are present in a significant proportion of patients, especially when adjuvant treatments are administered. Residual tongue strength is not affected when proper reconstruction is performed.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E176-E183, 2021.

Management of early oral cavity squamous cancers

Early oral cavity cancers comprise a favorable entity, amenable to clinical staging and single modality treatment. Surgery typically forms the mainstay of treatment and should ideally address both the primary and the neck in all cases. Careful attention must be paid to reconstruction and rehabilitation of such patients. Radical radiotherapy mainly in the form of brachytherapy can achieve excellent disease related and functional outcomes in a carefully chosen subset of patients. Increasingly, a subset of patients is being recognized, who harbor single or multiple adverse features on histopathology and may therefore benefit from escalation of adjuvant therapy. This review discusses the management of early oral cavity squamous carcinomas (Early OSCCs) in detail and highlights the dilemmas and controversies faced in the management of the same.

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.

Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction

OBJECTIVE

Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction.

STUDY DESIGN

Retrospective multi-institutional review of prospectively collected databases at tertiary care centers.

METHODS

Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history.

RESULTS

Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002).

CONCLUSION

This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:347-353, 2020.

Health-related quality of life: a retrospective study on local vs. microvascular reconstruction in patients with oral cancer

BACKGROUND

New medicinal and surgical oncological treatment strategies not only improve overall survival rates but continually increase the importance of Health-Related Quality of Life (HRQOL). The purpose of this retrospective cross-sectional study was to analyze HRQOL of patients with oral squamous cell carcinoma after ablative surgery and to evaluate predictive factors for HRQOL outcome.

METHODS

The study included 88 patients with histologically confirmed oral squamous cell carcinoma of whom 42 had undergone local reconstruction (LR) and 46 microvascular reconstruction (MVR). During follow-up, all patients completed the University of Washington Quality of Life Questionnaire (UW-QOL) containing 12 targeted questions about the head and neck. Descriptive analyses were made for the tumor site, the T-stage, and adjuvant therapies. HRQOL was compared between the LR and the MVR group with parametric tests. Further analyses were impact of the tumor site, the T-status, and the time from surgery to survey on HRQOL. Statistics also included multivariate correlations and different interaction effects.

RESULTS

HRQOL in the LR group was 'very good' with 84.3 ± 13.7 and 'good' in the MVR group with 73.3 ± 16.5 points. The physical domains swallowing (p = 0.00), chewing (p = 0.00), speech (p = 0.01), taste (p = 0.01), and pain (p = 0.04) were significantly worse in the MVR group. An increase in the T-status had a significant negative effect on swallowing (p = 0.01), chewing (p = 0.01), speech (p = 0.03), recreation (p = 0.05), and shoulder (p = 0.01) in both groups. Regarding the tumor site and subsequent loss of HRQOL, patients with squamous cell carcinoma on the floor of the mouth had significantly worse results in the categories pain (p = 0.002), speech (p = 0.002), swallowing (p = 0.03), activity (p = 0.02), and recreation (p = 0.01) than patients with tumors in the buccal mucosa. Speech (p = 0.03) and pain (p = 0.01) had improved 1 year after surgery.

CONCLUSION

Patients with flap reconstruction because of oral squamous cell carcinoma showed very good overall HRQOL. Outcomes for microvascular reconstruction were good, even in the case of larger defects. The T-status is a predictor for HRQOL. Swallowing, chewing, speaking, taste, and pain were the most important issues in our cohort. Implementing HRQOL questionnaires for the assessment of quality of life could further increase the treatment quality of patients with oral cancer.

Surgical consensus guidelines on sentinel node biopsy (SNB) in patients with oral cancer

BACKGROUND

The eighth international symposium for sentinel node biopsy (SNB) in head and neck cancer was held in 2018. This consensus conference aimed to deliver current multidisciplinary guidelines. This document focuses on the surgical aspects of SNB for oral cancer.

METHOD

Invited expert faculty selected topics requiring guidelines. Topics were reviewed and evidence evaluated where available. Data were presented at the consensus meeting, with live debate from panels comprising expert, nonexpert, and patient representatives followed by voting to assess the level of support for proposed recommendations. Evidence review, debate, and voting results were all considered in constructing these guidelines.

RESULTS/CONCLUSION

A range of topics were considered, from patient selection to surgical technique and follow-up schedule. Consensus was not achieved in all areas, highlighting potential issues that would benefit from prospective studies. Nevertheless these guidelines represent an up-to-date pragmatic recommendation based on current evidence and expert opinion.

Microvascular reconstruction two years after subtotal glossectomy: Is it worth it?

We ought to report an unusual case of a 49-year-old patient who underwent delayed reconstruction of the oral cavity defect, with an anterolateral thigh flap, two years after surgical demolition and adjuvant chemo-radiotherapy. At the end of oncologic treatment, he could not eat through oral route and presented evident speech articulation difficulties. After surgical reconstruction, swallowing assessment showed an improvement of swallowing with no gross signs of airways inhalation. His understandability of speech improved as well. Delayed reconstruction by a microvascular free flap with exclusive functional rehabilitation intent is feasible and may have satisfactory functional outcomes.

Perioperative considerations in free flap surgery: A review of pressors and anticoagulation

Given the high stakes for microvascular reconstruction, the majority of reconstructive surgeons have developed paradigms for pre, intra, and postoperative management that have proven to result in individual high success rates. Much has been done to identify and avoid perioperative factors that could potentially increase flap failure rates. Two example of this practice has been the generalized use of anticoagulation in free tissue transfer and the prohibition against vasopressor use in patients that are undergoing free tissue transfer. This manuscript will discuss these issues.

Patient-reported quality of life outcomes following treatment for oral cancer

Patient-reported quality of life (QoL) outcomes have the potential to assist clinicians in providing individually tailored treatment decisions. QoL assessments were collected prospectively for 168 consecutive patients treated for oral cancer between 1 January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire. Patients were followed up for 18 months post-treatment. Sub-group analyses were performed using paired t-tests and analysis of variance (ANOVA) to compare the effects of adjunctive chemoradiotherapy, type of bone resection, and methods of soft and hard tissue flap reconstruction. The greatest statistically significant reduction in QoL for all oral cavity sub-sites was found following the treatment of floor of mouth tumours (-18.9%, P=0.018). Laser excision for matched patient cohorts resulted in improved resultant QoL compared to other excision techniques (P=0.0002). No significant difference in QoL was found when radial forearm and anterolateral thigh flaps were matched, or when fibula and scapula flaps were matched. These findings support the use of laser excision and the avoidance of postoperative radiotherapy if curative intent and survival outcomes are maintained.

Methods to reduce postoperative surgical site infections after head and neck oncology surgery

Head and neck cancer surgery is often a complex multi-step procedure that includes major resections, vascularised tissue reconstruction, and extensive neck dissection. The upper aerodigestive tract mucosal lining is often disrupted during surgery, which requires the management of a clean-contaminated field and the need to reconstruct the mucosal lining. With bacterial contamination, surgical site infections (SSI) are a serious complication that can result in delayed wound healing, wound breakdown, fistula formation, and compromised tissue reconstruction. Methods to reduce SSI in patients with head and neck cancer have been intensely researched, yielding evolving and varied practice patterns. In this Review, we outline the data supporting perioperative antibiotic prophylaxis for clean-contaminated surgeries, which suggest that clindamycin is an inadequate prophylactic antibiotic therapy in the reduction of SSI, and that prolonged antibiotic courses have no established benefit. For salvage laryngectomy after radiotherapy with or without chemotherapy, reconstruction with vascularised tissue reduces the frequency and severity of pharyngocutaneous fistula formation. These evidence-based recommendations have been shown to reduce the chance of SSI after head and neck surgery.