Overcoming wound complications in head and neck salvage surgery

[Therapy of tumor recurrences or secondary carcinomas in pretreated area is not compatible with the primary therapy in non-previously treated tissue - an overview]

There are different initial situations in the treatment of local or locoregional recurrences, secondary carcinomas or residual squamous cell carcinomas of the head and neck region after primary therapy. The majority of patients with locoregional recurrences have had prior treatment consisting of surgery and/or postoperative radiotherapy or radiochemotherapy or primary radiotherapy or radiochemotherapy. In any case, it is a matter of new tumor growth in a previously treated area, which must be taken into account for the therapy decision. The biological backgrounds are diverse and are described in more detail and clinically classified in the present work.

Reducing Risks for Poor Surgical Wound Healing

This review summarizes common risk factors for poor surgical healing on the face and neck and a generalized approach to treating a delayed healing wound. During the preoperative evaluation patients should be screened for prior irradiation, cigarette or e-cigarette use, chronic steroid use, alcoholism, diabetes, malnutrition, and other chronic medical conditions and medications. Despite the surgeon's best efforts to prevent poor surgical healing, some wounds may display signs of persistent inflammation. The facial plastic surgeon should be astute in recognizing delayed healing and identifying intrinsic and extrinsic risk factors so that timely intervention can be performed.

Post-irradiation sarcoma after definitive radiation therapy for nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

Postirradiation sarcoma (PIS) is a rare radiation-induced malignancy after nasopharyngeal carcinoma (NPC) treatment.

MATERIALS AND METHODS

We retrospectively screened 9,185 NPC patients between 2000 and 2020 and identified 41 patients with PIS according to the modified Cahan's criteria: (1) the PIS must have arisen within a previous radiation field; (2) a latent period must have existed; (3) histologically proved sarcoma; (4) the tissue in which the PIS arose must have been healthy prior to the radiation. The initial radiation therapy techniques used were 2D (25; 61.0%), 3D (7; 17.1%), and IMRT (9; 22%).

RESULTS

The time (year) from radiotherapy (RT) to PIS was longer when using 2D or 3D irradiation techniques (median, 14.2; range, 3.4-28.1; Q1-Q3, 8.6-19.7) than when using IMRT (median, 6.6; range, 3.8-15.7; Q1-Q3, 4.5-11.7; P =.026). The time (year) from RT to PIS diagnosis was significantly longer when using lower radiation energy from cobalt-60 (median, 15.8; range, 10.4-28.4; Q1-Q3, 12.5-23.8) than when using a higher radiation energy of 6 or 10 MV (median, 10.2; range, 3.4-23.3; Q1-Q3, 6.5-16.1; P =.006). The 2-year overall survival rates for patients who underwent surgery, radical radiotherapy, systemic therapy alone and no treatment were 60.7 %, 42.9 %, 0 % and 0 %, respectively (P =.000). Of the 3 retrievable initial RT dosimetry plans for NPC, the D95 values (dose that covers 95 % of the PIS volume) for PIS were 6267, 6344 and 5820 cGy, respectively.

CONCLUSION

High radiation energy and modern techniques may shorten NPC PIS latency. Surgery may be associated with improved survival if feasible.

Effect of Citrate- and Gold-Stabilized Superparamagnetic Iron Oxide Nanoparticles on Head and Neck Tumor Cell Lines during Combination Therapy with Ionizing Radiation

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide. They are associated with alcohol and tobacco consumption, as well as infection with human papillomaviruses (HPV). Therapeutic options include radiochemotherapy, surgery or chemotherapy. Nanoparticles are becoming more and more important in medicine. They can be used diagnostically, but also therapeutically. In order to provide therapeutic alternatives in the treatment of HNSCC, the effect of citrate-coated superparamagnetic iron oxide nanoparticles (Citrate-SPIONs) and gold-coated superparamagnetic iron oxide nanoparticles (Au-SPIONs) in combination with ionizing irradiation (IR) on two HPV positive and two HPV negative HNSCC and healthy fibroblasts and keratinocytes cell lines were tested. Effects on apoptosis and necrosis were analyzed by using flow cytometry. Cell survival studies were performed with a colony formation assay. To better understand where the SPIONs interact, light microscopy images and immunofluorescence studies were performed. The HNSCC and healthy cell lines showed different responses to the investigated SPIONs. The cytotoxic effects of SPIONs, in combination with IR, are dependent on the type of SPIONs, the dose administered and the cell type treated. They are independent of HPV status. Reasons for the different cytotoxic effect are probably the different compositions of the SPIONs and the related different interaction of the SPIONs intracellularly and paramembranously, which lead to different strong formations of double strand breaks.

Mapping the Risk Factors of Pharyngocutaneous Fistula After Salvage Laryngectomies

To evaluate the postoperative surgical wound infection prevalence rates of patients undergoing SL, identify the causative organism and determine predisposing factors leading to infection. A retrospective study of all consecutive patients who underwent salvage total laryngectomy at our unit between 2015 and 2020 was performed. The following parameters were also analyzed: age, smoking history, pre and postoperative albumin level, history of radio and chemo-radiotherapy, reconstruction with pectoralis flap, intraoperative tracheoesophageal puncture, and tumor stage. A total of 12 of the 21 patients (57%) experienced a postoperative infection after SL during the study period. 82% of those patients whose preoperative albumin level below 3gm/dl developed postoperative infection. There is a significant increase (p < 0.01) in infection in patients with N1 and 2 stage tumor (68%) compared with the N0 stage tumors (40%). Multivariate analysis showed that preoperative albumin and nodal stage were significant risk factors for postoperative infection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02603-y.

Salvage Surgery in Recurrent Oral Squamous Cell Carcinoma

More than half of patients with oral cancer recur even after multimodality treatment and recurrent oral cancers carry a poorer prognosis when compared to other sites of head and neck. The best survival outcome in a recurrent setting is achieved by salvage surgery; however, objective criteria to select an ideal candidate for salvage surgery is difficult to frame, as the outcome depends on various treatment-, tumor-, and patient-related factors. The following is summarizes various tumor- and treatment-related factors that guide our decision-making to optimize oncologic and functional outcomes in surgical salvage for recurrent oral cancers. Short disease-free interval, advanced tumor stage (recurrent and primary), extracapsular spread and positive tumor margins in a recurrent tumor, regional recurrence, and multimodality treatment of primary tumor all portend worse outcomes after surgical salvage. Quality of life after surgical intervention has shown improvement over 1 year with a drastic drop in pain scores. Various trials are underway evaluating the combination of immunotherapy and surgical salvage in recurrent head and neck tumors, including oral cavity, which may widen our indications for salvage surgery with improved survival and preserved organ function.

Prognostic factors in salvage surgery for recurrent head and neck cancer: A systematic review and meta-analysis

INTRODUCTION

Although salvage surgery (SS) is considered the best curative choice in recurrent head and neck cancer, the identification of patients who can benefit the most from this treatment is challenging.

METHODS

We systematically reviewed the prognostic role of pre- and post-surgery factors in patients undergoing SS for recurrent head and neck cancer (oral cavity, oropharynx, hypopharynx, and larynx).

RESULTS

Twenty-five studies met the inclusion criteria out of 1280 screened citations. Pre-surgery factors significantly associated with worse overall survival were age>60 years, advanced initial stage, early recurrence, and regional recurrence; no heterogeneity between study emerged. Among post- surgery factors, worse survival emerged for positive surgical margins, extracapsular extension and perineural invasion.

CONCLUSION

The identification of pre-surgery factors associated with poor outcomes may help the selection of the best candidate to SS; alternative treatments should be considered for high-risk patients. Post-surgery predictors of worse prognosis may guide clinicians in tailoring patients' surveillance.

Postoperative Pharynx and Larynx

Cancers of the pharynx and larynx are treated using a combination of chemotherapeutic, radiation, and surgical techniques, depending on the cancer type, biology, location, and stage, as well as patient and other factors. When imaging in the postsurgical setting, the knowledge of the type of tumor, preoperative appearance, and type of surgery performed is essential for accurate interpretation. Surgical anatomic changes, surgical implants/devices, and potential postsurgical complications must be differentiated from suspected recurrent tumors.

Reconstructive methods to resolve intractable fistulas that develop after radiation therapy in patients with head and neck cancer

Background

Radiation therapy (RT) is frequently used for supportive treatment and management of advanced head and neck cancers. This study performed a retrospective review of the treatment methods that were used for intractable draining fistulas in seven patients who had received RT for head and neck cancers. Treatment methods used for two of the seven patients are presented in detail.

Methods

From 2009 to 2020, seven patients underwent reconstructive surgery for intractable fistulas which occurred after RT for head and neck cancers. Patient characteristics, medical history, treatment method, and treatment outcome were reviewed for each case. The type of surgery performed, failure rate, and treatment period were also analyzed.

Results

In this study, a total of seven patients received additional management for radiation-induced fistulas. Patients underwent a mean of 3.3± 1.4 surgeries (maximum: six surgeries) to resolve their fistulas. The mean time interval from the first surgery to the last surgery for the patients to achieve resolution of the fistula was 8.7 months. Loco-regional flaps have performed an average of 1.9± 1.5 times. However, all loco-regional flaps failed. Instead, the patients’ intractable fistulas were resolved with the use of distant flaps or free tissue transfers.

Conclusion

Fistulas that develop after head and neck cancer treatment following RT are difficult to treat with simple loco-regional flap procedures. Therefore, more aggressive treatment techniques, such as distant flap or free tissue transfer, may be needed to shorten patients’ treatment periods and avoid unnecessary surgeries.

A closer look at 30 day hospital readmissions after head and neck cancer surgery

PURPOSE

30-day hospital readmissions after head and neck cancer surgery continue to be a significant source of patient harm and healthcare expenditure. While there is substantial data in the literature assessing predictive factors for readmissions after head and neck cancer surgery, there are a paucity of studies which attempt to understand if such readmissions are preventable. The goal of this paper is to determine factors associated with 30-day hospital readmissions after head and neck cancer surgery and to understand if these readmissions were preventable.

MATERIALS AND METHODS

Retrospective review from a single academic tertiary care center. Patients readmitted within 30 days after undergoing surgery for cancers of the head and neck between 2015 and 2018 were identified.

RESULTS

Over a 3-year period, 26 patients undergoing resection with or without reconstruction of head and neck cancers were readmitted to the hospital within 30 days of discharge. There were 15 (58%) men and 11 (42%) women with a mean age of 68 years (SD 14 years). Twenty-one (81%) patients had squamous cell carcinoma and 13 (50%) had a primary site in the oral cavity. Thirteen (50%) had undergone free or regional flap reconstruction. The indication for readmission was related to the surgical wound in 19 (73%) and to medical complications in 7 (27%). Each case was categorized as "possibly preventable" versus "uncertain if preventable" based on whether a reasonable and feasible change in management may have prevented readmission. Six (23%) readmissions were deemed possibly preventable. Four were related to the surgical wound where initial free or regional flaps may have prevented complication. Two were medical complications that may have benefited from longer inpatient observation.

CONCLUSIONS

For a subset of patients readmitted within 30 days of head and neck cancer surgery, a reasonable and feasible change in management may have prevented their hospital readmission. The significance of better understanding this patient population is underscored by the high mortality rate.

Salvage surgery for recurrent carcinoma of the oral cavity: assessment of prognostic factors

Salvage surgery is the most acceptable therapeutic option for disease control of loco-regional recurrences in oral cancers. Prognostic factors need to be assessed to select patients for salvage surgery who would benefit the most. This was a single-centre retrospective observational study conducted between 2015 and 2018. A total of 168 patients with recurrent oral cavity carcinoma who underwent salvage surgery were included for analysis. The primary endpoints of the study were to evaluate overall survival (rOS) after salvage surgery and prognostic factors affecting survival. In this study, the median rOS was 18 months and the median disease-free survival (rDFS) was 14 months. Advanced stage (hazard ratio (HR) 2.387, 95% confidence interval (CI) 1.496-3.808; P = 0.001) and multimodality treatment (HR 1.642, 95% CI 1.139-2.367; P = 0.008) in the initial disease, as well as nodal spread (HR 3.794, 95% CI 1.580-9.111; P = 0.008) and perineural invasion (HR 2.167, 95% CI 1.358-3.455; P = 0.001) in the recurrent disease, were found to adversely affect survival after salvage surgery. With thorough assessment of the prognostic factors and appropriate patient selection, survival may be favourable after salvage surgery for recurrent oral cavity carcinoma.

Impact of Previous Irradiation on Wound Healing after Negative Pressure Wound Therapy in Head and Neck Cancer Patients-A Systematic Review

(1) Background: Negative pressure wound therapy (NPWT) has been effectively used for wound management in comparison to traditional dressings. The purpose of this study was to provide an evidence-based review of NPWT in head and neck cancer patients, as well as the impact of previous irradiation and other risk factors on wound healing. (2) Material and Methods: We conducted a comprehensive search in PubMed, Medline, Embase, Web of Science, and Cochrane Library databases for relevant literature. (3) Results: 15 studies fulfilled the inclusion criteria. The most common etiologies requiring NPWT were defects post tumor resection and flap reconstruction and oro/pharyngo-cutaneous fistulas. The neck was found to be the most common site of involvement (47.3%). The overall wound healing response rate was 87.5%. The median negative pressure recorded was 125 mm of Hg, with a median dressing change time of three days. Previous irradiation (p = 0.01; OR = 4.07) and diabetes mellitus (DM) (p = 0.001; OR = 5.62) were found to be significantly associated with delayed wound healing after NPWT. (4) Conclusion: NPWT treats complex wounds in head and neck cancer patients and should represent a significant armamentarium in head and neck cancers. Previous irradiation and DM have detrimental effects on wound healing after NPWT.

A pre-operative prognostic score for the selection of patients for salvage surgery after recurrent head and neck squamous cell carcinomas

Salvage surgery in recurrent head and neck squamous cell carcinoma has a poor outcome, both in terms of survival and quality of life. Therefore, the identification of pre-operative prognostic factors to improve the selection of patients who could benefit the most from salvage surgery is clinically relevant. The present study is a single-center retrospective analysis of 164 patients treated with salvage surgery after recurrence of head and neck cancer. Progression free survival and overall survival were calculated through Kaplan–Meier method. Hazard risk (HR) and corresponding confidence intervals (CI) were estimated through Cox proportional hazard model, adjusting for potential confounders. Significant predictors were combined into a prognostic score, attributing one point to each factor. Progression-free survival and overall survival were respectively 50.3% and 56.5% at 2 years, and 36.6% and 44.2% at 5 years. Four pre-operative factors were independently associated with poor prognosis: age > 70 years (HR = 2.18; 95% CI 1.27–3.73), initial stage IV (HR = 2.37; 95% CI 1.18–4.76), disease free interval < 12 months (HR = 1.72; 95% CI 1.01–2.94), and loco-regional recurrence (HR = 2.22; 95% CI 1.22–4.04). No post operative factor was associated with oncologic outcomes. Patients with 3–4 unfavorable factors showed a 5-year overall survival of 0.0% compared to 65.7% in those with 0–1 unfavorable factors (HR = 5.61; 95% CI 2.89–10.92). Despite the low number of patients, 3–4 unfavorable factors were associated to worse prognosis in all sub-sites. In conclusion, age > 70 years, initial stage IV, disease-free interval < 12 months, and loco-regional recurrence are strong independent pre-operative predictors of poor outcome in patients undergoing salvage surgery. Patients with two or more of these factors should be informed about the low success rate after salvage surgery and alternative treatments should be considered.

Regional Salvage Flap Options in Head and Neck Reconstruction

Microvascular free tissue transfer is the standard in the complex head and neck reconstruction with success rates greater than 95%. Free tissue transfer allows for more versatility in reconstructing complex defects with better tissue match. Failures, however, do occur and subsequent free tissue transfer might not be an option due to either the patients' health or in a vessel depleted neck. In these challenging salvage scenarios, the head and neck reconstructive surgeon must turn to regional flaps for reconstruction. Here, we review multiple regional flap options for salvage head and neck reconstruction.

Thyroid Gland Flap for Minimally Invasive Reconstructive Head and Neck Surgery

Head and neck surgery sometimes causes small defects, and salvage surgery after chemoradiotherapy poses some risk because of damage to the surgical site from the previous treatment. We have developed a novel thyroid gland flap for head and neck surgical reconstruction and here we describe elevating the flap, including arc rotation, size, and suture technique, and our outcomes to date.

Methods

Thyroid gland flap reconstruction was performed in 13 cases (11 patients) between July 2009 and May 2020. The clinical importance and adverse effects of the procedure were examined. Thyroid function and blood flow of the flap were assessed, and the status of the flap and irradiated recipient tissue was examined histopathologically.

Results

Median age at surgery was 64.6 years (range 49-77 years). Two of the patients underwent reconstruction with a thyroid gland flap twice. There were 4 cases of primary head and neck cancer resection with neck dissection in which the flap was harvested from the thyroid gland as reinforcement. In 1 case, surgery was performed for cervical esophageal diverticulum. In all cases, the arc was limited to 6 cm and suturing was basic. There were no complications of the surgical procedure, and the postoperative course was uneventful. Contrast-enhanced computed tomography revealed adequate enhancement of the flap. Postoperative thyroid function was normal. The thyroid gland flap was firmly adapted and fused with the irradiated recipient tissue.

Conclusion

The thyroid gland flap could be an effective tissue flap fed by the superior thyroid arteriovenous pedicle for head and neck reconstruction.

Use of fibrin adhesive for preventing pharyngocutaneous fistula in total laryngectomy

BACKGROUND

Minimizing pharyngocutaneous fistula after total laryngectomy is a perpetual focus for head and neck surgeons. Multiple intrinsic and extrinsic factors have been implicated in the wound healing process. Activated fibrin glue uniquely promotes healing as a tissue adhesive as well as a biochemical growth factor.

METHODS

We present a pilot case series of total laryngectomy with simple pharyngeal closure with a single surgeon. Fibrin tissue adhesive was incorporated in all patients along with standardized pre-operative, operative, and post-operative care. Outcomes measured included pharyngocutaneous fistula rate, perioperative complications, and other wound complications as well as long term swallowing function and voice rehab outcomes. We also present a review of the literature for the theoretical basis of using fibrin glue as well as other similar applications.

RESULTS

Fibrin tissue adhesive was successfully used in 18 consecutive patients undergoing total laryngectomy and pharyngoplasty. Despite the presence of a variety of wound healing risk factors including prior radiation and tobacco use, there were no pharyngocutaneous fistulas or other significant wound problems. No locoregional or free tissue overlay flap was done.

CONCLUSION

Fibrin tissue glue is a readily available, easily applied, and cost-effective adjunct that may reduce pharyngocutaneous fistula.

Fistula Management in Head and Neck Cancer

Fistulas in head and neck cancer patients are a common and challenging issue. Despite their commonality, there is little consensus regarding optimal treatment strategies or in preventative measures that might be taken preoperatively. A general knowledge and understanding of what factors correlate with fistula formation can assist a surgeon in optimizing a patient for surgery, thus decreasing prevalence. In addition, surgical techniques can aid in both the prevention and treatment of fistulas once they form. This review details risk factors for fistula formation, the use of vascularized tissue as a preventative measure, conservative and nonconservative treatment of fistulas, and possible strategies to decrease the likelihood of their formation.

Predictors of Complications Occurrence Associated With Emergency Surgical Tracheotomy

OBJECTIVE

In emergency airway management, the occurrence of surgical tracheotomy complications is increased and may be fatal for the patient. However, the factors that play a role in complication occurrence and lead to lethal outcome are not known. The objective of this study was to determine predictors associated with the occurrence of complications and mortality after emergency surgical tracheostomy.

STUDY DESIGN

Retrospective study with a systematic review of the literature.

SETTING

Tertiary medical academic center.

SUBJECTS AND METHODS

We included 402 adult patients who underwent emergency surgical tracheostomy under local anesthesia due to upper airway obstruction. Demographic, clinical, complication occurrence, and mortality data were collected. For statistical analysis, univariable and multivariable logistic regression methods were used.

RESULTS

In multivariable analysis, significant positive predictors of complication occurrence were previously performed tracheotomy (odds ratio [OR] 3.67, 95% confidence interval [CI], 0.75-17.88), neck pathology (OR 2.05, 95% CI 1.1-1.77), and tracheotomy performed outside the operating room (OR 5.88, 95% CI, 1.58-20). General in-hospital mortality was 4%, but lethal outcome as a direct result of tracheotomy complications occurred in only 4 patients (1%) because of intraoperative and postoperative complications.

CONCLUSION

The existence of neck pathology and situations in which tracheotomy was performed outside the operating room in uncontrolled conditions were significant prognostic factors for complication occurrence. Tracheotomy-related mortality was greater in patients with intraoperative and early postoperative complications. Clinicians should be aware of the increased risk in specific cases, to prepare, prevent, or manage unwanted outcomes in further treatment and care.

Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy

INTRODUCTION

Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol.

METHODS

Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent.

RESULTS

Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%).

CONCLUSION

The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature.

Wound monitoring of pH and oxygen in patients after radiation therapy

OBJECTIVES

Postradiogenic wound healing disorders are an important clinical problem. While a variety of treatment modalities are available, there is no strategy to objectively judge treatment success. The aim of this study was to evaluate a 2D luminescence imaging system for pH and oxygen in non-healing wounds after radiotherapy.

METHODS

Luminescence 2D imaging was performed with the VisiSens (Presens, Regensburg, Germany) 2D imaging systems A1 and A2 for oxygen and pH, respectively. Biocompatible planar luminescent sensor foils were applied to non-irradiated and irradiated skin as well as to radiogenic wounds of five patients and the pH and the oxygen saturation was determined.

RESULTS

pH measurements showed significant differences between non-irradiated skin (6.46 ± 0.18) and irradiated skin (6.96 ± 0.26). Radiogenic wounds exhibited the highest pH values (7.53 ± 0.26). Oxygen measurements revealed a mean oxygen saturation of non-irradiated skin of 6.19 ± 0.83 mmHg. The highest value of oxygen saturation (28.4 ± 2.4 mmHg) was found on irradiated skin while irradiated wounds had a poor oxygen saturation (9.4 ± 2.2 mmHg) (mean ± s.e.m.).

CONCLUSION

We found that routine measurement of pH and pO2 in patients could be easily integrated into the clinical routine. The results of the measurements show unfavorable pH and oxygen saturation conditions for wound healing in irradiated wounds. Interestingly, irradiated wounds exhibit a more pronounced hypoxia than irradiated skin which is reflected by an altered pH and pO2 compared to unirradiated skin, which has the potential to serve as a prognostic marker in the future. In addition to the objectification of the treatment success of postradiogenic wound healing disorders, the extent of skin toxicity could already be predicted during radiotherapy with this method.

The Current Role of Salvage Surgery in Recurrent Head and Neck Squamous Cell Carcinoma

Chemoradiotherapy has emerged as a gold standard in advanced squamous cell carcinoma of the head and neck (SCCHN). Because 50% of advanced stage patients relapse after nonsurgical primary treatment, the role of salvage surgery (SS) is critical because surgery is generally regarded as the best treatment option in patients with recurrent resectable SCCHN. Surgeons are increasingly confronted with considering operation among patients with significant effects of failed non-surgical primary treatment. Wide local excision to achieve clear margins must be balanced with the morbidity of the procedure, the functional consequences of organ mutilation, and the likelihood of success. Accurate selection of patients suitable for surgery is a major issue. It is essential to establish objective criteria based on functional and oncologic outcomes to select the best candidates for SS. The authors propose first to understand preoperative prognostic factors influencing survival. Predictive modeling based on preoperative information is now available to better select patients having a good chance to be successfully treated with surgery. Patients with a high comorbidity index, advanced oropharyngeal or hypopharyngeal primary tumors, and both local and regional recurrence have a very limited likelihood of success with salvage surgery and should be strongly considered for other treatments. Following SS, identifying patients with postoperative prognostic factors predicting high risk of recurrence is essential because those patients could benefit of adjuvant treatment or be included in clinical trials. Finally, defining HPV tumor status is needed in future studies including recurrent oropharyngeal SCC patients.