Importance:
: Due to substantial rates of contralateral nodal disease in patients with base of tongue (BOT) squamous cell carcinoma (SCC), bilateral neck dissections (BND) are commonly performed, particularly for tumors that approach midline. Conventionally, these neck dissections were staged in order to limit risk of circumferential airway edema and compromise, thereby obviating the need for prolonged intubation and/or tracheostomy. With the rise of less invasive transoral approaches, concurrent bilateral neck dissections may be safely done, which would reduce total surgical and anesthesia time, hospitalizations, and resource utilization. However, there are no studies to date assessing airway and other postoperative outcomes between staged and concurrent ND in transoral BOT patients.

Objectives: To assess airway and resource utility outcomes between patients with BOT SCC who underwent staged BND and those who underwent concurrent BND with their transoral surgery.

Design, Setting, Participants: A retrospective cohort study of consecutive patients with BOT SCC who underwent transoral robotic surgery or transoral laser microsurgery along with BND from January 1, 2015 through October 1, 2021 at our tertiary care center was conducted. Both HPV-related and HPV-unrelated cases were included. Patients who underwent free flap reconstruction were excluded.

Main Outcomes and Measures: The primary outcomes were postoperative intubation, tracheostomy, and intensive care unit admission. Secondary outcomes were progressive care unit admission, total operative time, total length of stay, urgent operative intervention, gastrostomy tube placement, 30-day readmission, and time from surgery to initiation of adjuvant treatment.

Results: In total, 113 patients (mean age 60.8 [SD 8.4] years, 8 [7.1%] females) were included, of whom 44 (39%) underwent staged BND and 69 (61%) underwent concurrent BND with their transoral surgery. The overwhelming majority of patients had HPV-related disease (109/113, 96%) and pathologic T1-T2 disease (106/113, 94%). Demographics and TNM stage distribution were similar between the two cohorts. 

There were no significant or clinically meaningful differences in airway events, including postoperative intubation (difference -3.5% [95% CI -10.6% to 3.6%]), re-intubation (difference -1.4% [-4.2% to 1.4%]), and tracheostomy (difference -0.6% [-6.5% to 5.3%]) between the two cohorts. The rates of ICU (difference -1.3% [-9.5% to 6.9%]) and PCU admission (difference -7.9% [-23.3% to 7.5%]), urgent operative intervention, gastrostomy, 30-day readmission, and additional surgery for margin re-resection were also not significantly different. Total operative time (median difference 1.3 [95% CI 0.8 to 1.8] hours) and total length of stay (median difference 1.0 [95% CI 1.0 to 2.0] days) were lower in the concurrent BND cohort. The duration between initial surgery and adjuvant therapy initiation was also lower in the concurrent BND cohort (median difference 4.0 [0.0 to 8.0] days).

Conclusions and Relevance: Concurrent BND with transoral BOT resection appears to be safe with similar airway outcomes compared to ipsilateral neck dissection with transoral BOT resection followed by a staged contralateral neck dissection. Concurrent BND was associated with lower total operative times and total length of stay, which presumably reduce resource utilization and costs.