Outcomes of carotid-sparing IMRT for T1 glottic cancer: Comparison with conventional radiation

OBJECTIVES

We aim to report oncologic outcomes after conventional radiotherapy (ConRT) using opposed lateral beams and intensity-modulated radiation therapy (IMRT) for tumor (T)1 nodal (N)0 T1 N0 glottic squamous cell carcinoma.

STUDY DESIGN

Retrospective case-control study.

METHODS

We retrospectively reviewed demographic, disease, and treatment characteristics for patients treated at our institution during 2000 to 2013.

RESULTS

One hundred fifty-three patients (71%) were treated using ConRT and 62 (29%) using IMRT. The median follow-up for all patients was 68 months. There was no statistically significant difference in 5-year local control between patients with T1a versus T1b disease (94% vs. 89%, respectively, P = 0.5). Three-year locoregional control for patients treated with ConRT was 94% compared to 97% with IMRT (P = 0.4). Three-year overall survival (OS) for patients treated with ConRT was 92.5% compared with 100% with IMRT (P = 0.1). Twelve of 14 patients with local recurrence underwent salvage surgery with 5-year ultimate locoregional control of 98.5% and 97.1% in the ConRT and IMRT cohorts, respectively (P = 0.7). Multivariate analysis showed age < 60 years (P < 0.0001) and pretreatment Eastern Cooperative Oncology Group performance status <2 (P = 0.0022) to be independent correlates of improved OS. Postradiation cerebrovascular events were in four patients in the ConRT cohort (3%), whereas no patients in the IMRT cohort suffered any events.

CONCLUSION

Because the oncologic outcomes for patients treated with IMRT were excellent and IMRT allows for carotid sparing, we have transitioned to IMRT as our standard for most patients with T1 glottic cancer.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:146-153, 2020.

Experimental and Computational Modeling of the Effects of Voice Therapy Using Tubes

Purpose Phonations into a tube with the distal end either in the air or submerged in water are used for voice therapy. This study explores the effective mechanisms of these therapy methods. Method The study applied a physical model complemented by calculations from a computational model, and the results were compared to those that have been reported for humans. The effects of tube phonation on vocal tract resonances and oral pressure variation were studied. The relationships of transglottic pressure variation in time P_trans ( t) versus glottal area variation in time GA( t) were constructed. Results The physical model revealed that, for the phonation on [u:] vowel through a glass resonance tube ending in the air, the 1st formant frequency ( F₁ ) decreased by 67%, from 315 Hz to 105 Hz, thus slightly above the fundamental frequency ( F₀ ) that was set to 90-94 Hz . For phonation through the tube into water, F₁ decreased by 91%-92%, reaching 26-28 Hz, and the water bubbling frequency F_b ≅ 19-24 Hz was just below F₁ . The relationships of P_trans ( t) versus GA( t) clearly differentiate vowel phonation from both therapy methods, and show a physical background for voice therapy with tubes. It is shown that comparable results have been measured in humans during tube therapy. For the tube in air, F₁ descends closer to F₀ , whereas for the tube in water, the frequency F_b occurs close to the acoustic-mechanical resonance of the human vocal tract. Conclusion In both therapy methods, part of the airflow energy required for phonation is substituted by the acoustic energy utilizing the 1st acoustic resonance. Thus, less flow energy is needed for vocal fold vibration, which results in improved vocal efficiency. The effect can be stronger in water resistance therapy if the frequency F_b approaches the acoustic-mechanical resonance of the vocal tract, while simultaneously F₀ is voluntarily changed close to F_1.

Effect of Dynamic Versus Stylet-Guided Intubation on First-Attempt Success in Difficult Airways Undergoing Glidescope Laryngoscopy: A Randomized Controlled Trial

BACKGROUND

Tracheal intubation failure in patients with difficult airway is still not uncommon. While videolaryngoscopes such as the Glidescope offer better glottic vision due to an acute-angled blade, this advantage does not always lead to an increased success rate because successful insertion of the tube through the vocal cords may be the limiting factor. We hypothesize that combined use of Glidescope and fiberscope used only as a dynamic guide facilitates tracheal intubation compared to a conventional Glidescope technique with a preshaped nondynamic stylet.

METHODS

One hundred sixty adult patients with predicted difficult airway were randomly assigned to a conventional Glidescope (standard Glidescope group) or a combined Glidescope + fiberscope group intubation. In the Glidescope + fiberscope group under direct vision from the Glidescope, tracheal intubation was performed using the fiberscope as a guide without using fiberoptic vision, while in the standard Glidescope group, a conventional stylet-guided intubation technique was performed. We evaluated the rate of tracheal intubation success at first attempt as the primary end point (Fisher exact test). The difference between groups in airway injury, time to successful intubation, and the need for an alternative technique was also evaluated.

RESULTS

First-attempt intubation success was higher in the Glidescope + fiberscope group than in the standard Glidescope group (91% vs 67%; P = .0012; fragility index, 8; absolute risk reduction, 24% [95% CI, 12%-36%]). Median time to successful tracheal intubation was shorter in the Glidescope + fiberscope group (50 vs 64 seconds; P = .035). Airway injury rate was lower in the Glidescope + fiberscope group than in the standard Glidescope group (1% vs 11%; P = .035; fragility index, 1; absolute risk reduction, 10% [95% CI, 3%-18%]). Alternative rescue technique requirements to achieve tracheal intubation were higher in the standard Glidescope group (24% vs 4%; P < .001; fragility index, 7).

CONCLUSIONS

The use of a dynamic, flexible guide during a Glidescope laryngoscopy in patients with a predicted difficult airway compared to a standard intubation technique improves first-attempt intubation success, decreases the incidence of airway injury and time to successful intubation, as well as the need of an alternative technique to succeed.

Office-based retrograde transtracheal application of mitomycin C

OBJECTIVES

The utility of topical mitomycin C (MMC) as an adjuvant treatment in the management of laryngeal and tracheal stenosis has been studied; however, the ideal timing of MMC application has not been fully elucidated. There is a paucity of studies evaluating the timing of MMC application after surgical airway intervention for stenosis. The purpose of this study is to describe a novel technique for MMC application that allows for delayed application in the unsedated, office-based setting, approximately one week following endoscopic airway dilation.

METHODS

A technique for retrograde transtracheal application of MMC was developed and utilized in 3 tracheostomy-dependent patients with subglottic stenosis and glottic stenosis with bilateral vocal fold immobility. After administration of topical anesthesia, a MMC (0.4 mg/ml) coated pledget was advanced via a transtracheal approach and directed to the area of stenosis in retrograde fashion using endoscopic frontal sinus instruments. Appropriate positioning of the pledget was confirmed via transnasal flexible fiberoptic laryngoscopy.

RESULTS

All 3 patients underwent successful in-office retrograde application of MMC onto the area of laryngeal stenosis 7-9 days after their preceding surgery. There were no complications. Two patients achieved decannulation while the third patient's management was interrupted due to cancer treatment.

CONCLUSIONS

We present a novel and well tolerated technique for delayed in-office application of MMC in tracheostomy-dependent patients with laryngeal stenosis. This approach can facilitate the study of the ideal timing of topical MMC use in airway stenosis.

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial

IMPORTANCE

The optimal approach to airway management during out-of-hospital cardiac arrest is unknown.

OBJECTIVE

To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018.

INTERVENTIONS

Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy.

MAIN OUTCOMES AND MEASURES

The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration.

RESULTS

A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women [36.3%]), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], -0.6% [95% CI, -1.6% to 0.4%]). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% [95% CI, 6.3% to 10.2%]). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients [77.6%] vs 4161 of 4883 patients [85.2%] in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients [26.1%] in the SGA group vs 1072 of 4372 patients [24.5%] in the TI group; adjusted RD, 1.4% [95% CI, -0.6% to 3.4%]; aspiration: 729 of 4824 patients [15.1%] vs 647 of 4337 patients [14.9%], respectively; adjusted RD, 0.1% [95% CI, -1.5% to 1.8%]).

CONCLUSIONS AND RELEVANCE

Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.

TRIAL REGISTRATION

ISRCTN Identifier: 08256118.

[EVALUATION OF THE EFFICACY OF THE EXTENDED-COMBINED OPERATIONS ON THE ZONES OF PRE- AND PARATRACHEAL METASTASIS IN SUBGLOTTIC CANCER OF THE LARYNX]

After a retrospective study of the history of patients with a diagnosis of laryngeal cancer (2151 people), as well as the analysis of their own clinical materials, subglottic cancer was found in 103 patients, which was 4.8% of the total number of patients admitted to the hospital. One group of patients (n=39) underwent laryngectomy with subsequent irradiation, another group (n=64) was carried out by us developed and introduced into practice the method of the extended-combined laryngectomy. This method involves the mobilization and excision of the cervical tissue with lymph nodes located within it at the level VI level, the mobilization of the larynx and its removal at the level of the V-th or VI-th tracheal rings, as well as the dissection or thyroid share from the side of lesion in the unilateral localization, or complete dissection in the circular localization of the tumor. The comparative analysis was carried out on the frequency of metastasis in the pre- and paratracheal zones during the subglottic cancer of the larynx. A statistically significant (p<0.001) decrease in the incidence of metastases was observed in the advanced-combined laryngectomy (14.5%) compared with the traditional treatment (66.5%). If we consider that the main cause of death of patients with a tumor, both in subglottic cancer of the larynx and any other localization is metastasis, the development and introduction of new surgical methods that reduce the incidence of metastasis is a major breakthrough in practical oncology.

Radiotherapy for T1 Carcinoma of the Glottis

Aims and background

The management of patients with T1 carcinoma of the glottic larynx is controversial, because surgery and radiation therapy are reported to be effective treatments. Several studies have shown radiotherapy to be safe and effective, with a high percentage of voice preservation and minimal complications, but most Italian physicians prefer to surgically treat such patients.

Methods

From 1980 to 1990, 36 patients with stage I squamous cell glottic carcinoma were treated with radiotherapy alone at the Institute of Radiology of University of Rome “La Sapienza”. In all patients the irradiation fields were limited to the larynx, with field size ranging from 4 × 4 cm to 7 × 7 cm. Total tumor doses ranged between 51 and 70 Gy (median 60 Gy) with a mean number of 30 fractions of 2 to 3 Gy per fraction (3 or 5 fractions per week).

Results

After a median follow-up of 98 months, we observed an overall survival rate at 5 years of 91.4% and actuarial 10-year survival of 85.7%. Local control was achieved in 97.1% of cases, with an event-free survival of 94.2% at 5 and 10 years. No major complications like necrosis or persistent edema of the larynx were observed. Minor complications like dysphonia (8%) and dysphagia (5.5%) were temporary; laryngeal function was completely preserved at the end of therapy. Final voice quality ranged from good to excellent.

Conclusions

Our series confirms that radiation therapy has a major role in the management of early glottic cancer, with results comparable to surgical approaches and with better voice preservation.

Hyperfractionated Radiotherapy for T2N0 Glottic Carcinoma: A Retrospective Analysis at 10 Years Follow-up in a Series of 60 Consecutive Patients

Aims and background

To report results of hyperfractionated radiotherapy for T2N0 glottic carcinoma at a single institution after extended follow-up.

Methods

Between 1980 and 1988 at Varese University Hospital, 60 consecutive patients with T2N0 glottic carcinoma received exclusive radiotherapy consisting of 1.5 Gy/fraction twice a day. Treatment gaps during the radiotherapy course were allowed according to individual tolerance. This policy resulted in a wide range of elapsed treatment time: median, 5.7 weeks; range, 3.7-8.9. Median follow-up is 9.8 years.

Results

As a result of dose/time distribution, 16, 20 and 24 patients received an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week or >10 Gy/week, respectively. Mean total dose for each group was 62.8 Gy, 63.7 Gy and 63.8 Gy, respectively. Five-year local-regional control was 69 ± 6% (95% Cl); ultimate local-regional control, including salvage surgery, was 78 ± 5%. All failures were at the primary site, and no patient developed neck recurrence as first site of failure. The actuarial incidence of grade 2-3 late reactions at 5 years was 42 ± 6%. Most late toxicity events were grade 2: only 2 patients developed grade 3 reactions and none grade 4. None of the several clinical and treatment-related variables showed any statistically significant impact on local-regional control or late toxicity at univariate and multivariate analysis. In particular, 3-year local-regional control rates were 73 ± 11%, 84 ± 8% and 69 ± 10% for an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week and >10 Gy/week, respectively (not significantly different).

Conclusions

At a very long follow-up, the hyperfractionated regimen tested in the study was shown to be effective and devoid of major complications, provided individual patient acute tolerance is carefully taken into account. Also, time factor did not affect outcome in this series.

An Evaluation of Elective Irradiation of Neck Nodes in Patients with Cancer of the Supraglottic Larynx

Between 1964 and 1973, 152 patients with supraglottic cancer limited to the larynx with clinically negative neck were included in the controlled randomized study designed to evaluate elective irradiation of the neck. The patients were randomized to one of the 2 treatment groups: 1) « T + N »: irradiation of the larynx and all neck nodes, tumor dose 5130 rad/6-7 weeks, 2) « T »: irradiation of the laryngeal portals only, tumor dose 5130 rad/5 weeks. All patients received 250 kV orthovoltage irradiation. The biologic dose delivered to the larynx was greater in group « T » because of faster fractionation and shorter overall time of therapy. The calculated NSD value for the patients in group « T + N » varied from 1620 to 1690 ret, and in group « T » it was 1800 ret. Five-year survival rates with a preserved larynx and without cancer were 45.3 % for group « T + N » and 66.2 % for group « T ». Seven patients of group « T » developed metastatic cancer in the neck, and 4 of them were cured by neck dissection. It is concluded that patients with early supraglottic cancer can be successfully irradiated through laryngeal portals only, including the larynx, and possibly midjugular and digastric nodes. The tumor dose should be at least equivalent to the NSD of 1800 ret in the condition of megavoltage therapy.

Early Glottic Cancer: Surgery or Radiation Therapy?

From 1970 to 1979 at the University Otorhinolaryngological Clinic, at the Radiology Institute of the University and at the Radiation Therapy Department of the Hospital of Florence, 385 early glottic cancers were treated: 300 by surgery and 85 with radiation therapy as the primary therapy. The policy of treatment in this period was in most cases surgery; those patients who could not be operated were treated with radiation therapy. The local control actuarial rates at 5 years were 85 %, 70 % and 65 % for the T1a, T1b and T2 patients treated by surgery, and 86 %, 83 % and 57 % for those treated with radiation therapy. Considering the surgical salvage, the actuarial results at 5 years were 95 %, 86 % and 71 % for the group treated by surgery, and 86 %, 90 % and 69 % for the one treated with radiotherapy. The crude results at 3 and 5 years with an analysis of failures according to treatment modalities are also reported. In our experience, cordectomy can be the treatment of choice in T1a glottic cancer, whereas radiation therapy offers better results in the T1b forms. Tratment policy is more questionable in the T2 cases.

Treatment of Cancer of the Base of the Tongue and Glosso-Epiglottic Region: A Multicenter Italian Survey

BACKGROUND

The current treatment options for cancer of the base of the tongue and glosso-epiglottic region are surgery, radiotherapy, or a combination of both modalities. Comparisons between different modalities are not common in the literature, and a real standard of treatment has not yet been established. The purpose of our study was to evaluate the results of treatment in a large series of patients from 18 Italian institutions in relation to the main treatment adopted.

METHODS

The present study is a retrospective survey. The series was divided into a combined surgery group and a radiotherapy group. The Kaplan-Meier method and the log-rank test were used for survival calculations and comparisons.

RESULTS

Eight hundred patients were registered (25.7% stage III and 62% stage IV), 336 in the surgery and 372 in the radiotherapy group. Conventional fractionation was adopted in almost all cases. The five-year overall and disease free survival of the whole series was 32% and 38%, respectively. Survival was slightly better for patients with tumors of the glosso-epiglottic region than for those with a tumor of the base of the tongue. Five-year disease-free survival was 55% for patients treated with surgery +/- radiochemotherapy and 26% for those submitted to radiotherapy alone or in combination with chemotherapy. As far as the total dose and the treatment duration were concerned, only 26% of the patients of the radiotherapy group met the established criteria of adequacy, but in patients with adequate radiation the control rate was better only for small tumors (T1-T2).

CONCLUSIONS

The results in patients treated with surgery +/- postoperative radiotherapy were similar to or better than those reported in the best series in the literature. By contrast, the survival rate of irradiated patients was lower than those reported by other centers.

[Development of Portable Anesthesia Video Laryngoscope Based on ARM]

In the process of tracheal intubation, the anesthesia video laryngoscope is used to lift up the patient's epiglottis to expose the glottis, and thus guiding the medical staff to perform anesthesia intubation accurately. This paper describes the method and significance of video laryngoscope in the process of guiding anesthesia intubation, introduces the overall structure and function of portable anesthesia video laryngoscope, the design is mainly focused on image acquisition module, core board circuit, video decoding circuit, lithium battery charging circuit and external storage circuit, at last briefly introduces work process of the video laryngoscope.

Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: the randomised multicentre EMMA trial study protocol

INTRODUCTION

The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients.

METHODS AND ANALYSIS

The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications.

ETHICS AND DISSEMINATION

The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT 02611986; pre-results.

Patterns of Care for Patients With Early-Stage Glottic Cancer Undergoing Definitive Radiation Therapy: A National Cancer Database Analysis

PURPOSE

To characterize practice patterns, including temporal trends, in fractionation schedules among patients in the United States undergoing definitive radiation therapy for early-stage glottic cancer and to compare overall survival outcomes between fractionation schedules.

METHODS AND MATERIALS

We queried the National Cancer Database for patients with TisN0M0, T1N0M0, or T2N0M0 squamous cell carcinoma of the glottic larynx diagnosed between 2004 and 2012 and undergoing definitive radiation therapy. Dose per fraction was calculated to define cohorts undergoing conventional fractionation (CFxn) and hypofractionation (HFxn). Logistic regression was performed to identify predictors of receiving HFxn, and Cox regression was used to determine predictors of death. One-to-one propensity score matching was then used to compare survival between fractionation schedules.

RESULTS

The study included 10,539 patients, with 6576 undergoing CFxn and 3963 undergoing HFxn. Patients with T1 disease comprised a majority of each cohort. Use of HFxn increased significantly over the period studied (P<.001), but even in the final year, nearly one-half of patients continued to receive CFxn. Receipt of HFxn was also independently associated with higher income and facility types other than community cancer programs on logistic regression. On multivariate Cox regression, HFxn was associated with improved survival (hazard ratio [HR] for death, 0.90; 95% confidence interval [CI], 0.83-0.97; P=.008), a finding redemonstrated on univariate Cox regression among a well-matched cohort after propensity score matching (HR, 0.88; 95% CI, 0.80-0.96; P=.003). Subgroup Cox multivariate analysis demonstrated a significant survival advantage with HFxn among patients with T1 disease (HR, 0.90; 95% CI, 0.81-0.99; P=.042) but a nonsignificant benefit among those with Tis (HR, 0.86; 95% CI, 0.57-1.30; P=.472) or T2 (HR, 0.88; 95% CI, 0.76-1.02; P=.099) disease.

CONCLUSIONS

Use of HFxn is increasing and is associated with improved survival over CFxn. Our findings support the broadened use of HFxn for patients with early-stage glottic cancer undergoing definitive radiation therapy.

[Replacement of a Tracheal Tube by Concomitant Use of an Aintree Intubation Catheter? and a Tube Exchanger]

A tracheal tube can be safely replaced by using a tube exchanger (TE). However, only a thin TE can be used to replace a double-lumen tracheal tube (DLT) with a standard single-lumen tracheal tube (SLT). We successfully replaced a DLT to a SLT by inserting an Aintree Intubation Catheter® (AIC) over a TE in two cases. The AIC (diameter : 19 Fr, overall length : 56 cm) is mainly used for the replacement of various supra- glottic apparatuses using a SLT. In our cases, an AIC with an internal diameter of 4.7 mm was placed over a thin TE with an external diameter of 3.7 mm (11 Fr) to increase the support, and the difference between the SLT with an internal diameter of 7.5 mm and an AIC with an external diameter of 6.3 mm (19 Fr) was decreased, resulting in smooth replacement of the tubes. Even for those cases in which tube replacement might be difficult, acute administration of oxygen could be provided using an AIC with a larger internal lumenthan TE. In conclusion, replacement of a DLT with a SLT i safe and useful through the concomitant use of an AI( and a TE.

[A Case of Aglossia for which the Airway Could Not be Managed with a Laryngoscope]

We encountered a case of congenital aglossia accom- panied by upper airway obstruction and faucal con- striction, for which mask ventilation was straightfor- ward and nasal intubation under bronchofiberscopic guidance was effective. The faucal constriction was easily alleviated under anesthesia, facilitating the pas- sage of a laryngoscope blade. The absence of the tongue base, a target site for laryngoscope manipulation, prevented visualization of the glottis. Airway Scope® AWS-SIOOL (Nihon Kohden Corporation, Tokyo) equipped with PBLADE® (ITL-NL-NEO- NATE) for newborns facilitated detection of the glottis, suggesting its usefulness as an intubator.

Effect of the type of maternal pushing during the second stage of labour on obstetric and neonatal outcome: a multicentre randomised trial-the EOLE study protocol

INTRODUCTION

The scientific data currently available do not allow any definitive conclusion to be reached about what type of pushing should be recommended to women during the second stage of labour. The objective of this trial is to assess and compare the effectiveness of directed open-glottis pushing versus directed closed-glottis pushing. Secondary objectives are to assess, according to the type of pushing: immediate maternal and neonatal morbidity, intermediate-term maternal pelvic floor morbidity, uncomplicated birth, and women's satisfaction at 4 weeks post partum.

METHODS AND ANALYSIS

This multicentre randomised clinical trial compares directed closed-glottis pushing (Valsalva) versus directed open-glottis pushing during the second stage of labour in 4 hospitals of France. The study population includes pregnant women who received instruction in both types of pushing, have no previous caesarean delivery, are at term and have a vaginal delivery planned. Randomisation takes place during labour once cervical dilation ≥7 cm. The principal end point is assessed by a composite criterion: spontaneous delivery without perineal lesion (no episiotomy or spontaneous second-degree, third-degree or fourth-degree lacerations). We will need to recruit 125 women per group. The primary analysis will be by intention-to-treat analysis, with the principal results reported as crude relative risks (RRs) with their 95% CIs. A multivariate analysis will be performed to take prognostic and confounding factors into account to obtain adjusted RRs.

ETHICS AND DISSEMINATION

This study was approved by a French Institutional Review Board (Comité de Protection des Personnes Sud Est 6:N°AU1168). Results will be reported in peer-reviewed journals and at scientific meetings. This study will make it possible to assess the effectiveness of 2 types of directed pushing used in French practice and to assess their potential maternal, fetal and neonatal effects. Findings from the study will be useful for counselling pregnant women before and during labour.

TRIAL REGISTRATION NUMBER

Agence national de sécurité du médicament et des produits de santé (ANSM): 150099B-22 and IDRCB: 2014-A01920-47. ClinicalTrials.gov: NCT02474745. Pre-result stage.

[Airway Management for Partial Lung Lobectomy in a Patient with Subglottic Stenosis: A Case Report]

We report a case of sub-glottis stenosis encountered during anesthetic induction. A 79 year-old male was scheduled for a right partial lung lobectomy with video assisted thoracic surgery. Significant history includes percutaneous coronary intervention and pacemaker insertion for myocardial infarction, tuberculosis, trache- ostomy and radiation therapy for vocal cord cancer. Difficulty in tracheal intubation was predicted, but chest X-ray and CT scan did not show tracheal steno- sis. General anesthesia was induced smoothly and mask ventilation was easy. The vocal cord was fully exposed by McGRATH® MAC laryngoscope. However, inser- tion of double lumen tube (37 Fr) was impossible because of resistance just under the vocal cords. A membranous subglottic stenosis was found using a flexible bronchoscope. Then we inserted ID 7.0 mm single lumen tube and accomplished differential lung ventilation using a bronchial blocker. Surgery was done smoothly. In spite of recent advances in radiographic imaging, some cases of tracheal stenosis are difficult to diagnose.

Dosimetric comparison of helical tomotherapy, intensity-modulated radiation therapy, volumetric-modulated arc therapy, and 3-dimensional conformal therapy for the treatment of T1N0 glottic cancer

Various radiotherapy planning methods for T1N0 laryngeal cancer have been proposed to decrease normal tissue toxicity. We compare helical tomotherapy (HT), linac-based intensity-modulated radiation therapy (IMRT), volumetric-modulated arc therapy (VMAT), and 3-D conformal radiotherapy (3D-CRT) techniques for T1N0 laryngeal cancer. Overall, 10 patients with T1N0 laryngeal cancer were selected and evaluated. Furthermore, 10 radiotherapy treatment plans have been created for all 10 patients, including HT, IMRT, VMAT, and 3D-CRT. IMRT, VMAT, and HT plans vs 3D-CRT plans consistently provided superior planning target volume (PTV) coverage. Similar target coverage was observed between the 3 IMRT modalities. Compared with 3D-CRT, IMRT, HT, and VMAT significantly reduced the mean dose to the carotid arteries. VMAT resulted in the lowest mean dose to the submandibular and thyroid glands. Compared with 3D-CRT, IMRT, HT, and VMAT significantly increased the maximum dose to the spinal cord It was observed that the 3 IMRT modalities studied showed superior target coverage with less variation between each plan in comparison with 3D-CRT. The 3D-CRT plans performed better at the D_max of the spinal cord. Clinical investigation is warranted to determine if these treatment approaches would translate into a reduction in radiation therapy-induced toxicities.

The effect of vocal fold vertical stiffness variation on voice production

A parametric study was conducted using the numerical technique that coupled a three-dimensional continuum vocal fold model with a one-dimensional Bernoulli flow model to investigate the effect of vocal fold vertical stiffness variation on voice production. Vertical stiffness gradient was defined as the ratio of the inferior-superior stiffness difference to the mean stiffness and was introduced in the cover layer. The results showed that increasing the vertical stiffness gradient would increase the peak flow rate and sound intensity and decrease the open quotient and threshold pressure. The effect was found to be more prominent at low subglottal pressures. The underlying mechanism might be that the reduced stiffness at the superior aspect of the vocal fold would allow a larger lateral displacement and result in a larger vibration. Increasing the vertical stiffness gradient was also found to increase the vertical phase difference and glottal divergent angle during the vocal fold vibration. Meanwhile, increasing the vertical stiffness variation only slightly increased the mean flow rate, which is important to maintaining the speech time between breaths.

Synthetic multi-line kymographic analysis: A spatiotemporal data reduction technique for high-speed videoendoscopy

High-speed videoendoscopy (HSV) enables observation of the true vibratory behavior of the vocal folds. To quantify the vocal fold vibration captured by the HSV, lateral movement features (e.g., glottal width and vocal fold edge displacements) have been extracted as functions of time. The most common analysis method is to extract the features on a lateral strip used to form digital kymogram. The weakness of this method is that it can only capture the vibrational behavior local to the strip location. While the multi-line kymographic approach has been utilized to capture the spatial diversity, the observation points are either fixed or manually positioned. Behaviors of pathological vocal folds, especially those with lesions, are expected to be spatially diverse and also diverse among speakers, making fixed observation points ineffective. This paper proposes a technique to synthesize kymographic waveforms from full spatiotemporal HSV feature data to extract distinctive behaviors automatically. Each synthesized waveform represents a non-overlapping section of the glottis, where vocal folds are locally behaving homogeneously. The efficacy of the algorithm is demonstrated with four HSV recordings (three pathological) and discussed, including mitigation of the known drawbacks.

Surgical vs Nonsurgical Treatment Modalities for T3 Glottic Squamous Cell Carcinoma

Importance

Further investigation is needed in the outcomes of currently available treatment for T3 glottic squamous cell carcinoma (SCC), a unique type of laryngeal cancer.

Objective

To compare overall survival (OS) and functional outcomes among patients with T3 glottic SCC receiving nonsurgical and surgical management.

Design, Setting, and Participants

This secondary analysis used data from the Surveillance, Epidemiology, and End Results (SEER) registry and Medicare databases. All patients with T3 glottic SCC who received a diagnosis from January 1, 1992, to December 31, 2010, were included. Data were analyzed from April 2014 to August 2015.

Interventions

Surgery with or without adjuvant radiotherapy and/or chemotherapy.

Main Outcomes and Measures

Five-year OS and functional outcomes.

Results

Among the 487 patients identified with T3 glottic SCC (418 men [85.8%]; 69 women [14.2%]; median age, 74.3 [interquartile range, 70.4-80.6] years), the 5-year OS for nonsurgical management, surgery alone, and surgery plus adjuvant treatment were 36% (95% CI, 30%-42%), 41% (95% CI, 30%-53%), and 41% (95% CI, 32%-51%), respectively. Multivariable analyses revealed an adjusted hazard ratio for OS of 0.68 (95% CI, 0.49-0.94) for patients receiving surgery alone vs nonsurgical management and 0.75 (95% CI, 0.57-0.98) for patients receiving surgery plus adjuvant treatment vs nonsurgical management. Gastrostomy tube dependence was highest in patients receiving surgery plus adjuvant treatment (30 of 98 patients [30.6%]). Tracheostomy dependence was highest in patients receiving chemoradiotherapy (34 of 92 patients [37.0%]).

Conclusions and Relevance

Overall survival showed a statistically significant and clinically meaningful improvement in patients with T3 glottic SCC who underwent surgery compared with a nonsurgical treatment. Furthermore, the data suggest that adjuvant and nonsurgical treatment result in a dysfunctional larynx; however, this association needs further study.

Mechanics of human voice production and control

As the primary means of communication, voice plays an important role in daily life. Voice also conveys personal information such as social status, personal traits, and the emotional state of the speaker. Mechanically, voice production involves complex fluid-structure interaction within the glottis and its control by laryngeal muscle activation. An important goal of voice research is to establish a causal theory linking voice physiology and biomechanics to how speakers use and control voice to communicate meaning and personal information. Establishing such a causal theory has important implications for clinical voice management, voice training, and many speech technology applications. This paper provides a review of voice physiology and biomechanics, the physics of vocal fold vibration and sound production, and laryngeal muscular control of the fundamental frequency of voice, vocal intensity, and voice quality. Current efforts to develop mechanical and computational models of voice production are also critically reviewed. Finally, issues and future challenges in developing a causal theory of voice production and perception are discussed.