{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,5]],"date-time":"2026-09-05T02:54:21Z","timestamp":1788576861791,"version":"build-2803163510"},"reference-count":32,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,27]],"date-time":"2026-01-27T00:00:00Z","timestamp":1769472000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001659","name":"Deutsche Forschungsgemeinschaft","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100001659","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Baden-Wuerttemberg Ministry of Science, Research, and the Arts"},{"DOI":"10.13039\/501100001661","name":"Ruprecht-Karls-Universit\u00e4t Heidelberg","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100001661","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background: Osteoradionecrosis (ORN) following head and neck radiotherapy has been demonstrated to induce structural and functional alterations of the upper airway, with the potential to complicate the process of tracheal intubation. Despite its clinical relevance, there is a paucity of systematic evidence on airway characteristics in ORN and reliable predictors of difficult tracheal intubation. This study compares preoperative airway parameters and tracheal intubation outcomes in irradiated patients with and without ORN and introduces a novel preoperative ORN-Difficult-Airway Score for risk stratification. Methods: In this retrospective cohort study, airway assessments, tracheal intubation methods, and perioperative visualization parameters were evaluated in 105 patients following head and neck radiotherapy. Group differences between non-ORN and ORN were analyzed using chi-square tests. A preoperative ORN-Difficult-Airway Score was constructed using exclusively bedside parameters, based on statistically and clinically relevant predictors. Results: Patients with ORN showed significantly restricted mouth opening (p &lt; 0.001), higher Mallampati classes, particularly Mallampati IV, and a greater need for fiberoptic tracheal intubation (p &lt; 0.01). Direct laryngoscopy (DL) was significantly less feasible in ORN, while hyperangulated videolaryngoscopy (VL) yielded consistently positive visualization (first-pass success (FPS) 100% in both groups). Under DL, FPS was lower in ORN (54.2% vs. 79.5%), resulting in an odds ratio of 0.305. Based on observed predictors, ORN status, mouth opening &lt;3 cm, Mallampati class, restricted neck reclination, and history of difficult intubation, a preoperative ORN-Difficult-Airway Score was developed. Conclusions: ORN has been associated with distinct alterations in airway anatomy and visualization, resulting in increased tracheal intubation complexity after head and neck radiotherapy. The proposed ORN-Difficult-Airway Score presents a clinically practical, bedside-applicable approach to stratifying the risk of tracheal intubation in this population. Prior to clinical implementation, prospective validation in larger cohorts is warranted.<\/jats:p>","DOI":"10.3390\/medsci14010059","type":"journal-article","created":{"date-parts":[[2026,1,27]],"date-time":"2026-01-27T11:35:42Z","timestamp":1769513742000},"page":"59","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Predicting Difficult Tracheal Intubation in Head and Neck Cancer Patients with Osteoradionecrosis: Development of the ORN-Difficult-Airway-Score"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0559-8684","authenticated-orcid":false,"given":"Davut Deniz","family":"Uzun","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2621-961X","authenticated-orcid":false,"given":"Tobias","family":"Gruebl","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Philipps University of Marburg, 35043 Marburg, Germany"},{"name":"Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Bundeswehr Central Hospital, 56072 Koblenz, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Moritz","family":"Bleymehl","sequence":"additional","affiliation":[{"name":"Department of Oral and Cranio-Maxillofacial Surgery, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oliver","family":"Ristow","sequence":"additional","affiliation":[{"name":"Department of Oral and Cranio-Maxillofacial Surgery, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"N2|MKG N\u00fcrnberg-Noerdlingen, 90443 Nuernberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1731-7090","authenticated-orcid":false,"given":"Fabian","family":"Weykamp","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany"},{"name":"Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3913-4693","authenticated-orcid":false,"given":"Thomas","family":"Held","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany"},{"name":"Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4292-663X","authenticated-orcid":false,"given":"Stefan","family":"Mohr","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6464-6191","authenticated-orcid":false,"given":"Felix C. F.","family":"Schmitt","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Philipps University of Marburg, 35043 Marburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Markus A.","family":"Weigand","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6411-4811","authenticated-orcid":false,"given":"Juergen","family":"Debus","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany"},{"name":"Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany"},{"name":"National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany"},{"name":"German Cancer Consortium (DKTK), Partner Site Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5355-3173","authenticated-orcid":false,"given":"Kristin","family":"Uzun-Lang","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"},{"name":"Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany"},{"name":"Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Medical Faculty Heidelberg, University Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2289","DOI":"10.1016\/S0140-6736(21)01550-6","article-title":"Head and neck cancer","volume":"398","author":"Mody","year":"2021","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/j.ijom.2010.10.005","article-title":"Incidence and prevention of osteoradionecrosis after dental extraction in irradiated patients: A systematic review","volume":"40","author":"Nabil","year":"2011","journal-title":"Int. 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