In Response to Tracheostomy Dependence in Hypopharyngeal Cancer: Comparative Prognostic Impact of CRT Versus Surgery.

We agree that patient-reported outcomes (PROs), including swallowing function, speech-related outcomes, and psychosocial well-being, are essential for evaluating organ-preservation strategies. Tracheostomy dependence frequently coexists with dysphagia, impaired phonation, reduced social participation, and emotional distress. Incorporating validated instruments such as the EORTC QLQ-C30/QLQ-H&N35 or tracheostomy-specific quality-of-life questionnaires would therefore provide a more comprehensive comparison between chemoradiotherapy (CRT) and surgery. However, in our retrospective cohort (2001–2021), standardized PRO measures were not routinely collected and thus could not be reliably analyzed, which we acknowledge as a limitation. To address this gap, we have implemented routine PRO assessments for all newly diagnosed head and neck cancer patients since 2023, including the EORTC QLQ-C30/QLQ-H&N35 and a tracheostomy-specific functional survey. These data will allow prospective evaluation of functional outcomes, correlations with airway status, and validation of whether organ preservation translates into superior long-term function in contemporary practice. We also acknowledge that our study was not designed to investigate biological mechanisms underlying the strong association between persistent tracheostomy dependence and adverse oncologic outcomes. As a retrospective clinical cohort, our primary objective was to identify prognostic patterns and quantify survival differences. The possible mechanisms—including chronic airway inflammation or infection, dysphagia-associated malnutrition and immune suppression, radiation-induced mucosal or cartilage injury, and tumor-related anatomical compromise—are indeed plausible. Our own observations support several of these hypotheses. In our cohort, 26 of 31 patients with long-term tracheostomy dependence had recurrent disease, suggesting that tumor biology and advanced local invasion likely contribute to both airway obstruction and poor survival. Patients requiring emergency tracheostomy universally lost their native airway and demonstrated extremely poor outcomes, implying that severe pretreatment airway compromise may be a surrogate marker for biologically aggressive disease. Finally, five patients remained tracheostomy-dependent due to chronic aspiration, raising the possibility that malnutrition, recurrent pneumonia, and systemic inflammation may further worsen prognosis. However, our analysis cannot establish causality or exclude reverse causation. We concur that mechanistic and subgroup analyses—such as stratifying by nutritional status, infection burden, pre-treatment laryngeal function, or patterns of cartilage invasion—would strengthen the understanding of whether reducing tracheostomy dependence could improve survival. Future work from our team will incorporate these dimensions. We have begun designing a prospective study integrating nutritional indices, inflammatory markers, swallowing assessments, and imaging-based evaluations of laryngeal framework injury, guided by the UK National Multidisciplinary Guidelines on nutritional management. The authors have nothing to report. The authors have nothing to report. Consent to publish has been obtained from all participants. The authors declare no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.