Malnutrition as associated with high-risk airway failure phenotypes in hospitalized head and neck cancer: A national, site-specific analysis.

e23172 Background: Malnutrition is common in patients with head and neck cancer (HNC) and is associated with adverse outcomes, yet its role in acute airway failure is poorly characterized. Prior studies focus on mortality or length of stay without isolating airway-specific endpoints or accounting for tumor site heterogeneity. This study evaluated whether malnutrition independently increases the risk of acute airway compromise and defines inpatient airway risk phenotypes across HNC subsites. Methods: A retrospective, survey-weighted analysis of the National Inpatient Sample (NIS), 2016 to 2023, was performed, including adults hospitalized with HNC identified using ICD-10-CM codes C00 to C14 and C30 to C32. Tumors were categorized by first-hit anatomic site. Malnutrition was defined using a narrow definition (E43, E44, E46) and a broad sensitivity definition (E43, E44, E46, R64). Palliative admissions (Z51.5) were excluded. Primary outcomes were airway failure proxies, mechanical ventilation and tracheostomy. Secondary outcomes included shock, in-hospital mortality, length of stay (LOS), and hospitalization cost. Survey-weighted logistic, linear, and gamma-log models adjusted for demographics, payer, socioeconomic status, admission characteristics, hospital factors, tumor site, comorbidity burden, and year. Results: Among 112,495 HNC hospitalizations (weighted national estimate approximately 562,000), 29.0% met the narrow malnutrition definition. Malnutrition was independently associated with mechanical ventilation (OR 1.32, 95% CI 1.13 to 1.53), tracheostomy creation (OR 1.58, 95% CI 1.36 to 1.84), and in-hospital mortality (OR 1.29, 95% CI 1.04 to 1.60). Adjusted absolute risk differences included increases in mechanical ventilation of 2.07% (95% CI 1.64 to 2.49), tracheostomy of 6.21% (95% CI 5.61 to 6.81), mortality of 0.85% (95% CI 0.61 to 1.09), and shock of 0.60% (95% CI 0.40 to 0.81). Mortality varied by airway phenotype, from 1.34% (95% CI 1.26 to 1.42) without airway intervention to 22.18% (95% CI 20.89 to 23.54) with mechanical ventilation alone. LOS increased stepwise from 5.5 days (95% CI 5.46 to 5.55) to 18.7 days (95% CI 18.1 to 19.3) with combined mechanical ventilation and tracheostomy. Malnutrition was associated with approximately 35% higher hospitalization costs (gamma-log coefficient 0.30, 95% CI 0.27 to 0.34), with mean costs ranging from $21,387 to $86,519. Results were consistent using the broad malnutrition definition, with highest baseline airway risk in laryngeal and hypopharyngeal cancers. Conclusions: Malnutrition is an independent determinant of acute airway failure, mortality, and healthcare utilization in hospitalized patients with HNC. Distinct airway failure phenotypes are defined by malnutrition, with large absolute differences in mortality, LOS, and cost, supporting early nutritional risk stratification.