Tracheostomy Dependence in Hypopharyngeal Cancer: Comparative Prognostic Impact of CRT Versus Surgery

Objectives: Organ preservation strategies are increasingly adopted for hypopharyngeal carcinoma, but functional outcomes may be suboptimal. Posttreatment tracheostomy dependence significantly increases morbidity and reduces quality of life. This study evaluated airway outcomes and oncologic results in patients treated with primary chemoradiotherapy (CRT) or upfront surgery. Methods: This retrospective study included 165 patients, with data collected on demographics, treatment type, tracheostomy status, and oncologic outcomes. The primary endpoint was long-term tracheostomy dependence. Oncologic outcomes, including local control, disease-free survival (DFS), and overall survival (OS), were analyzed. Results: Among the 165 patients included, 139 had advanced-stage disease; 54 received CRT and 85 underwent upfront surgery. The 5-year OS rate was significantly higher with surgery (40.0%) than CRT (18.4%). Patients who underwent total laryngectomy (TL) had higher 5-year OS (35.5% vs. 28.6%) and 3-year DFS (41.9% vs. 27.3%) compared to those managed with organ preservation. When stratified by airway status, 5-year OS was 58.8% in patients with preserved airways, 29.3% after TL, and 6.7% in those with long-term tracheostomy dependence. Notably, emergency tracheostomy (n = 41) was associated with significantly poorer OS (12.2%), and none of these patients retained their native airway. Overall, 75.54% (105/139) of advanced-stage patients ultimately lost their native airway, including 55.84% (43/77) of those who initially pursued an organ preservation strategy. Conclusions: Patients with long-term tracheostomy dependence exhibited the poorest prognosis and highest recurrence rates. Emergency tracheostomy was a strong predictor of long-term dependence. Upfront surgery may be more appropriate for patients with impaired baseline laryngeal function. Level of Evidence: 3.