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Kinkhabwala CM, Amin J, Rist T, Vaitaitis VJ, Skoner JM. Latissimus dorsi myocutaneous free flap for the laryngopharyngectomy defect. Head Neck 2024; 46:2048-2055. [PMID: 38391089 DOI: 10.1002/hed.27682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Partial or total laryngopharyngectomy defects have traditionally been reconstructed using the radial forearm, anterolateral thigh, or jejunal free flaps. The latissimus dorsi myocutaneous free flap (LDMFF) is an option for high-risk patients with complex laryngopharyngeal ± cutaneous neck defects. METHODS Retrospective single-surgeon case series from 2017 to 2022. Outcomes were assessed at both the back donor site and head and neck. RESULTS Twenty-four patients were identified. Flap survival was 100%. There was 1 (4.2%) pharyngocutaneous fistula and 2 (8.3%) tracheo-esophageal peristomal fistulas. At last follow-up, 17 (71%) were sustaining weight on oral intake, and 7 (29%) were G-tube dependent with 4 of these able to do some type of oral intake. Seven (29.2%) had post-operative stricture/stenosis requiring dilation. There were only minor donor site complications, all managed conservatively. CONCLUSIONS The LDMFF can be a robust reconstructive option, particularly for radiated high-risk patients with complex pharyngeal defects, including skin.
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Affiliation(s)
- Corin M Kinkhabwala
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Julian Amin
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tyler Rist
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vilija J Vaitaitis
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Judith M Skoner
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Giotakis AI, Potamianos S, Zachou Z, Giotakis EI, Kyrodimos E. Horizontal pharyngeal closure during total laryngectomy reduces rates of pharyngocutaneous fistula. Eur Arch Otorhinolaryngol 2024; 281:3179-3187. [PMID: 38551697 DOI: 10.1007/s00405-024-08593-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/29/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE Pharyngocutaneous fistula (PCF) is a possible complication following total laryngectomy (TL), with a mean incidence of 17%. We intended to investigate the effect of pharyngeal closure type during TL on the prevention of PCF. METHODS We retrospectively reviewed patients that underwent TL with a horizontal pharyngeal closure over a 10-year period. The frequency of PCF clinically, dysphagia, total oral diet, postoperative dilatation of the neopharynx and voice problems were tabulated. RESULTS Seventy-seven subjects underwent TL due to laryngeal tumor without pharyngeal extension. Of them, 45 underwent a salvage TL. PCF occurred in 1/77 subjects. The rest of the subjects (76/77) did not develop a PCF, neither in the early nor in the late postoperative phase. All subjects (15/77) that underwent implantation of a voice prosthesis were satisfied with their voice. No subject complained about dysphagia. Every subject achieved total oral diet. CONCLUSION The horizontal pharyngeal closure is a safe pharyngeal closure technique during TL, reduces PCF rates (< 2%), results in excellent voice rehabilitation and swallowing function, and can also be used during salvage TL instead of a major pectoral flap. This type of closure should be used only in selected patients with laryngeal disease without pharyngeal extension.
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Affiliation(s)
- Aris I Giotakis
- First Department of Otorhinolaryngology, Head and Neck Surgery, Hippocrateion General Hospital Athens, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527, Athens, Greece.
| | - Spyridon Potamianos
- First Department of Otorhinolaryngology, Head and Neck Surgery, Hippocrateion General Hospital Athens, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527, Athens, Greece
| | - Zoi Zachou
- First Department of Otorhinolaryngology, Head and Neck Surgery, Hippocrateion General Hospital Athens, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527, Athens, Greece
| | - Evangelos I Giotakis
- First Department of Otorhinolaryngology, Head and Neck Surgery, Hippocrateion General Hospital Athens, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527, Athens, Greece
| | - Efthymios Kyrodimos
- First Department of Otorhinolaryngology, Head and Neck Surgery, Hippocrateion General Hospital Athens, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527, Athens, Greece
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Tumlin P, Dugan B, Hassid S, Lawson G, Turner M. Robotic and endoscopic trans-oral total laryngectomy, a systematic review and meta-analysis. J Robot Surg 2024; 18:214. [PMID: 38758418 DOI: 10.1007/s11701-024-01970-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/03/2024] [Indexed: 05/18/2024]
Abstract
Trans-oral total laryngectomy (TOTL) is a novel minimally invasive approach to narrow-field laryngectomy. The objective of this study was to review published data on robotic and endoscopic-assisted TOTL to examine oncologic, functional, and adverse outcomes. MEDLINE, Web of Science, and Cochrane databases were searched between January 2009 and December 2023. PRISMA guidelines were used for data abstraction independently by two reviewers. Proportional meta-analysis (random effects model) was used for analysis. Main outcomes included oncologic outcomes (margin status, recurrence rate) and surgical complications (fistula, hemorrhage, need for second operation). Eight studies were included (total of 37 patients). Cases included 31 robotic-assisted, 3 endoscopic-assisted, and 3 robotic cases which required conversion to open approach. Most cases were performed for laryngeal SCC (22 patients, 59.5%). Primary closure was achieved in all patients. Negative margins were achieved in 20 of 21 patients with LSCC. Recurrence data was reported in 20 LSCC patients with disease recurrence in 4 patients (20%). Follow-up was described for 15 patients (mean of 3.5 years, range 1.6-5.8 years). Eleven complications occurred including fistula, bleed, and stomal stenosis with a pooled rate of 33.7% (95% CI: 16.4-53.0%, I2 = 0). Six fistulas occurred with a pooled rate of 23.2% (95% CI: 5.8-45.4%, I2 = 0). TOTL is an emerging treatment modality appropriate for select patients requiring TL and offers a minimally invasive approach with less tissue disruption. This is the first systematic review and meta-analysis to examine its oncologic outcomes and complications. Larger case series with adequate follow-up are needed to better characterize TOTL outcomes.
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Affiliation(s)
- Parker Tumlin
- Department of Otolaryngology, West Virginia University, One Medical Center Dr, Morgantown, WV, 26508, USA.
| | - Bradford Dugan
- Department of Otolaryngology, West Virginia University, One Medical Center Dr, Morgantown, WV, 26508, USA
| | - Samantha Hassid
- Université Catholique de Louvain, Centre Hospitalier Universitaire de Mont-Godinne, Yvoir, Belgium
| | - Georges Lawson
- Université Catholique de Louvain, Centre Hospitalier Universitaire de Mont-Godinne, Yvoir, Belgium
| | - Meghan Turner
- Department of Otolaryngology, West Virginia University, One Medical Center Dr, Morgantown, WV, 26508, USA
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Dong YB, Yuan LN, Luo JK, Liu YH, Liu LF, Lu C, Li WX. Delayed oral feeding reduces pharyngocutaneous fistula formation after open surgical treatment of primary hypopharyngeal cancer: A case-control study. EAR, NOSE & THROAT JOURNAL 2024; 103:110-116. [PMID: 36345057 DOI: 10.1177/01455613221136359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
OBJECTIVES Pharyngocutaneous fistula (PCF) formation following open surgical treatment of hypopharyngeal cancer (HPC) is a common and troublesome complication. To date, the postoperative protocol of restarting oral intake is not clear, and vast discrepancies exist in the literature and among institutions. This study aimed to explore the impact of a postoperative protocol of restarting oral intake on PCF formation after open surgical treatment of primary HPC, and its impact on overall survival (OS) and swallowing function based on the functional outcome swallowing scale (FOSS). MATERIALS AND METHODS This was a prospective observational study of 42 patients who received open surgical treatment for primary HPC at Beijing Friendship Hospital between April 2019 and August 2021. This cohort included two groups: patients who restarted oral intake on the 10th postoperative day (Group 1), and those who started on the 20th (Group 2). The Chi-square test and Fisher's exact chi-squared test were used for comparing qualitative data among the groups. RESULTS Group 1 (n = 27) and Group 2 (n = 15) were comparable in clinical characteristics. PCF occurred in 7 (25.9%) patients in Group 1, while none occurred in Group 2 (P = 0.038). The 2-year OS of all 42 patients was 75.6%; 65.8% and 93.3% for Groups 1 and 2, respectively (P = 0.07). The swallowing function was satisfactory (FOSS Grades 0-III) for 19 (70.4%) patients in Group 1 and 15 (100%) patients in Group 2 (P = 0.035). Laryngeal preservation was achieved in 25 (59.5%) patients, while decannulation was successful in 22 (88.0%) patients. CONCLUSIONS Delayed oral feeding significantly reduces PCF after open surgical treatment of primary HPC, and improves the swallowing function outcome without jeopardizing the OS.
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Affiliation(s)
- Yan-Bo Dong
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Li-Na Yuan
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jin-Kai Luo
- Department of Nursing, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yu-He Liu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liang-Fa Liu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Cheng Lu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wan-Xin Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Penêda JF, Fernandes J, Monteiro E. Pharyngocutaneous Fistula Following Total Laryngectomy: a High-Volume Tertiary Centre Series. Indian J Surg Oncol 2023; 14:742-748. [PMID: 37900634 PMCID: PMC10611653 DOI: 10.1007/s13193-023-01765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/29/2023] [Indexed: 10/31/2023] Open
Abstract
Pharyngocutaneous fistula is the leading complication following total laryngectomy. It delays complementary treatments, speech rehabilitation and oral feeding. Despite evolving medical care, fistula incidence remains high. There is no consensus regarding risk factors for fistula development. A standard score for fistula prediction is lacking. Study population included all patients submitted to total laryngectomy (with or without pharyngectomy) due to laryngeal or hypopharyngeal tumours, occurring between January 1st, 2012, and December 31st, 2016. Patient demographics were recorded as well as disease and treatment variables. Statistical analysis was performed using the IBM SPSS Statistics 25®. A previously described predictive model for fistula occurrence was applied. A total of 212 patients were included, the vast majority with advanced local disease (97.5%). Only 10% were submitted to rescue surgery. Fistula incidence was 39.9%. Our rates of locally advanced tumours, with extensive hypopharyngeal involvement, were higher than in most series. Age, tumour location, diabetes, previous chemoradiotherapy, advanced local and regional disease, extensive pharyngectomy, flap reconstruction, manual suture and low post-operative albumin level were associated to fistula occurrence on univariate analysis. Only salvage surgery and advanced local disease remained significant on multivariate analysis. An adapted Cecatto score correlated with fistula occurrence but has not achieved statistical significance. Predictive models for fistula occurrence are lacking. Cecatto score showed promising results in our population but large multicentric studies are necessary for cut-off adjustments.
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Affiliation(s)
- José Ferreira Penêda
- Otorhinolaryngology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho (CHVNG/E), Rua Conceição Fernandes S/N, 4434-502 Vila Nova de Gaia, Portugal
| | - João Fernandes
- Otorhinolaryngology Department, Instituto Português de Oncologia do Porto–Francisco Gentil (IPOP FG), Porto, Portugal
| | - Eurico Monteiro
- Otorhinolaryngology Department, Instituto Português de Oncologia do Porto–Francisco Gentil (IPOP FG), Porto, Portugal
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Salzano G, Maglitto F, Calvanese C, Apolito M, Buono S, Franco P, Perri F, Vaira LA, De Luca R, Salzano FA, Califano L, Ionna F. Pharyngocutaneous Fistula in Salvage Laryngectomy: Use of the Stapler Versus Manual Suturing Technique. Indian J Otolaryngol Head Neck Surg 2023; 75:1441-1446. [PMID: 37636788 PMCID: PMC10447661 DOI: 10.1007/s12070-023-03587-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 02/16/2023] [Indexed: 02/27/2023] Open
Abstract
A pharyngocutaneous fistula (PCF) is the most common complication after salvage total laryngectomy (STL) with an incidence ranging from 5 to 73%, causing an increase in morbidity and delaying the patient's recovery. A surgical technique to prevent PCF formation is the use of the stapler to suture the pharyngeal mucosa. We have reviewed the medical files of 91 patients who had undergone STL, dividing the patients into two groups (manual suture vs. stapler), based on the type of pharyngeal suture performed during the STL. We found 12/49 (24.5%) cases of a PCF in group A (manual) and 5/42 (11.9%) cases of a PCF in group B (stapler). There is a statistically significant difference between the two groups with the patients in group B presenting better results in terms of the reduction of the surgical time, the length of the hospital stay and also in the restarting of oral feeding. The advantages of mechanical suturing with the stapler are reduced surgical times, a lower PCF formation rate, which involves an early removal of the nasogastric tube, and reduced hospitalization times. Further studies with a larger case series will be necessary to confirm the results obtained and to standardize the surgical technique.
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Affiliation(s)
- Giovanni Salzano
- Maxillo-Facial and ENT Surgery Unit, INT- IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Fabio Maglitto
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Carlo Calvanese
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Michela Apolito
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Sarah Buono
- Ear Nose and Throat Unit, Department of Neuroscience, Reproductive and Odontostomatological Science , University of Naples ‘Federico II’, Naples, Italy
| | - Pierluigi Franco
- Maxillo-Facial and ENT Surgery Unit, INT- IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Francesco Perri
- Medical and Experimental Head and Neck Oncology Unit, INT- IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Luigi Angelo Vaira
- Maxillofacial Surgery Operative Unit, University Hospital of Sassari, Sassari, Italy
| | - Rolando De Luca
- Division of Anesthesia and Pain Medicine, INT- IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Francesco Antonio Salzano
- Otolaryngology Operative Unit, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana”, University of Salerno, Salerno, Italy
| | - Luigi Califano
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Franco Ionna
- Maxillo-Facial and ENT Surgery Unit, INT- IRCCS “Fondazione G. Pascale”, Naples, Italy
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Penêda JF, Fernandes J, Monteiro E. Risk Factors for Pharyngocutaneous Fistula Following Total Laryngectomy. Indian J Otolaryngol Head Neck Surg 2023; 75:485-491. [PMID: 37274999 PMCID: PMC10235409 DOI: 10.1007/s12070-022-03311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Pharyngocutaneous fistula is the leading complication following total laryngectomy. It delays complementary treatments, speech rehabilitation and oral feeding. Despite evolving medical care, fistula incidence remains high. There is no consensus regarding which patients are at higher risk for fistula development. This article comprised a literature review about risk factors for fistula development. All articles published on an on-line database (PUBMED™) using MESH terms "larynx cancer" and "fistula" in a 5-year period (January 1st, 2014 to January 27th, 2019) were included. Further articles were selected due to expert suggestion by one of the senior surgeons. Only articles written in Portuguese or English were included. Animal studies were excluded. 151 articles were selected and abstracts analysed. 82 articles were selected for full text revision. 32 were later excluded because they described single clinical cases, experimental surgical technics, irrelevant data or poor methodology. Final selection comprised 50 studies: 9 systematic reviews, one non-systematic review, 34 unicentric and 4 multicentric retrospective analysis and two prospective studies. There is no consensus regarding risk factors for fistula development. Patients submitted to salvage surgery for advanced disease seem to be at greater risk. Bad nutritional status is a logical contributor, but the ideal surrogate marker is still missing. Several variables are inconsistently pointed as risk factors and should be abandoned unless proved otherwise. There are no standard scores for fistula occurrence despite being a common complication following surgery.
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Affiliation(s)
- José Ferreira Penêda
- Otorhinolaryngology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho (CHVNG/E), Vila Nova de Gaia, Portugal
| | - João Fernandes
- Otorhinolaryngology Department, Instituto Português de Oncologia do Porto–Francisco Gentil (IPOP FG), Porto, Portugal
| | - Eurico Monteiro
- Otorhinolaryngology Department, Instituto Português de Oncologia do Porto–Francisco Gentil (IPOP FG), Porto, Portugal
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Sussman S, Philips R, Renslo B, Givens A, Swendseid B, Tassone P, Goldman RA, Curry JM, Cognetti DM, Luginbuhl AJ. Effects of Prior Tracheostomy on Total Laryngectomy Outcomes. Otolaryngol Head Neck Surg 2023; 168:782-789. [PMID: 35943815 DOI: 10.1177/01945998221116761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess whether preoperative tracheostomy (PreOT) increases risk of complications after total laryngectomy (TL) and to determine if timing of tracheostomy creation is associated with an increased risk. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care hospital between 2007 and 2020. METHODS Inclusion criteria were patients who underwent primary or salvage TL for oncologic treatment. Dependent variables of interest included surgical complications, such as wound dehiscence, infection, hematoma, complete flap failure, fistula formation, and stoma stenosis, as well as medical complications. Categorical variables were compared with chi-square test or Fisher exact test, and continuous variables were compared with an independent t test. Multivariable regression was conducted to assess predictors of complications after laryngectomy. RESULTS A total of 306 patients were included. Primary TL was performed in 161 (53%) patients and salvage in 145 (47%) patients. Of the patients undergoing primary laryngectomy, 105 (65%) received a PreOT. Of the patients undergoing salvage laryngectomy, 86 (59%) received a PreOT. In both primary and salvage cases, there was no association between PreOT and surgical or medical complications. Additionally, there was no significant association between timing of tracheostomy and surgical complications. On multivariable analysis, the presence of a PreOT was not associated with surgical complications. In salvage cases, those with a PreOT had a significantly longer average length of stay than those without a PreOT (12 vs 9 days, P = .008). CONCLUSION PreOT in patients undergoing primary and salvage laryngectomies was not associated with surgical or medical complications postlaryngectomy. Timing of tracheostomy in relation to laryngectomy was not found to adversely affect clinical outcomes.
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Affiliation(s)
- Sarah Sussman
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Bryan Renslo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alyssa Givens
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian Swendseid
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Patrick Tassone
- Department of Otolaryngology, University of Missouri, Columbia, Missouri, USA
| | - Richard A Goldman
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Kim DH, Kim SW, Hwang SH. Predictive Value of Risk Factors for Pharyngocutaneous Fistula After Total Laryngectomy. Laryngoscope 2023; 133:742-754. [PMID: 35769042 DOI: 10.1002/lary.30278] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/02/2022] [Accepted: 06/11/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To assess the predictive value of various risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy. METHODS The characteristics of each study were collected from six databases up to January of 2022. Risk for bias was assessed using the QUADAS-2 tool. RESULTS A total of 58 studies in 9845 patients were included in the analysis. The incidence of PCF was 21.69%, 95% confidence intervals (CI) [0.20; 0.24] in the included studies. Age (OR = 1.33, 95% CI [1.12; 1.58]), postoperative anemia (OR = 2.29, 95% CI [1.47; 3.57]), diabetes mellitus (OR = 1.81, 95% CI [1.20; 2.71]), tumor site (above or below the glottis) (OR = 1.47, 95% CI [1.15; 1.88]), previous radiation therapy (OR = 2.06, 95% CI [1.56; 2.72]), previous tracheostomy (OR = 1.26, 95% CI [1.04; 1.53]), surgery timing (salvage vs. primary) (OR = 2.08, 95% CI [1.46; 2.97]), extended total laryngectomy (including pharyngectomy) (OR = 1.96, 95% CI [1.28; 3.00]), primary tracheoesophageal puncture (OR = 0.61, 95% CI [0.40; 0.93]), and postoperative hypoproteinemia (OR = 9.98, 95% CI [3.68; 27.03]) were significantly associated with the occurrence of PCF. In view of predictive ability, postoperative hypoproteinemia showed the highest accuracy (sensitivity = 51%, specificity = 90%, area under the curve = 0.84). CONCLUSION Multiple patient-, disease-, and surgery-related factors are risk factors for PCF. In particular, postoperative hypoproteinemia could be a good predictive factor for PCF in patients undergoing total laryngectomy. Laryngoscope, 133:742-754, 2023.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul Saint Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul Saint Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon Saint Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Cîrstea AI, Berteșteanu ȘVG, Scăunașu RV, Popescu B, Bejenaru PL, Simion-Antonie CB, Berteșteanu GS, Diaconu TE, Taher PB, Rujan SA, Oașă ID, Grigore R. Management of Locally Advanced Laryngeal Cancer-From Risk Factors to Treatment, the Experience of a Tertiary Hospital from Eastern Europe. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20064737. [PMID: 36981644 PMCID: PMC10048780 DOI: 10.3390/ijerph20064737] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 05/28/2023]
Abstract
Laryngeal cancer is an important oncological entity in which prognosis depends on the establishment of appropriate preventive and diagnostic measures, especially in high-risk populations. We present a retrospective two-year study (January 2021 to December 2022) with 152 patients diagnosed with laryngeal cancer from a tertiary hospital in Romania. The average age of the patients was 62 years old for both sexes, with a range from 44 to 83 years. The most frequent symptom was dysphonia with or without dyspnea in 142 cases (93.42%), followed by dyspnea alone in nine patients (5.92%) and dysphagia in one case (0.66%). Surgical treatment in this study consisted of partial laryngectomy (CO2 laser transoral tumor ablation, supraglottic horizontal laryngectomy or hemilaryngectomy), or total laryngectomy. The main treatment was total laryngectomy (63%). For the eight patients with initial organ preservation treatment, the average time of recurrence was about two-and-a-half years. For the four patients who underwent a total circular pharyngo-laryngectomy, the upper digestive tract needed to be rebuilt with a salivary bypass tube or with a tubed myocutaneous flap from the major pectoralis muscle. One strong point is characteristic of the study group in gathering patients with advanced stages of laryngeal carcinoma candidates for salvage surgery and extended reconstruction methods. The development of new prevention protocols is mandatory in Eastern European countries.
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Affiliation(s)
- Anca-Ionela Cîrstea
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Șerban Vifor Gabriel Berteșteanu
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Răzvan-Valentin Scăunașu
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of General Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Bogdan Popescu
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Paula Luiza Bejenaru
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
| | - Catrinel Beatrice Simion-Antonie
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
| | - Gloria Simona Berteșteanu
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, “Carol Davila” Emergency Central Military Hospital, 010825 Bucharest, Romania
| | - Teodora Elena Diaconu
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Petra Bianca Taher
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Simona-Andreea Rujan
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Irina-Doinița Oașă
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
| | - Raluca Grigore
- Department 12-Otorhynolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-I.C.)
- Department of ENT, Head and Neck Surgery, Colţea Clinical Hospital, 030167 Bucharest, Romania
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11
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Fitzgerald CWR, Davies JC, de Almeida JR, Rich JT, Orsini M, Eskander A, Monteiro E, Mimica X, Mclean T, Cracchiolo JR, Ganly I, Hessel A, Tam S, Wei D, Goepfert R, Su J, Xu W, Zafereo M, Goldstein DP, Cohen MA. Factors predicting pharyngocutaneous fistula in patients after salvage laryngectomy for laryngeal malignancy - A multicenter collaborative cohort study. Oral Oncol 2022; 134:106089. [PMID: 36057225 PMCID: PMC10190204 DOI: 10.1016/j.oraloncology.2022.106089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/10/2022] [Accepted: 08/15/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Pharyngocutaneous fistula (PCF) is a major morbidity of salvage total laryngectomy (TL). Understanding the factors predicting PCF is fundamental to managing laryngeal cancer. We aim to assess factors associated with PCF following salvage TL in a multicenter, international retrospective cohort study of academic centers in the US and Canada. RESULTS In total, 550 patients post-salvage TL were identified (mean [SD; range] age, 64 [10.4; 32-90] years; 465 [85 %] male and 84 [15 %] female) between 2000 and 2014. Rate of PCF was 23 % (n = 127) with median time to PCF of 2.9 weeks. Surgical management of PCF was required in 43 % (n = 54) while 57 % (n = 73) required wound care alone. Rates of PCF differed by primary treatment modality [radiation, 20 % (n = 76); chemoradiation, 27 % (n = 40); not available (n = 6)] and use of vascularized tissue in pharyngeal closure [free/regional flap, 18 % (n = 25); no vascularized tissue/primary closure, 24 % (n = 98); not available (n = 4)]. There was no statistically significant association between PCF and treatment with chemoradiation (HR, 1.32; 95 % CI, 0.91-1.93, p = 0.14) or lack of vascularized tissue reconstruction (HR, 1.41, 95 % CI 0.91-2.18, p = 0.12). Significant association between PCF and advanced stage (T3 or T4), positive margin, close margin (<5mm), lymphovascular invasion and pre-operative tracheostomy were identified on univariable analysis. Positive surgical margin (HR, 1.91; 95 % CI, 1.11 to 3.29) was the only significant association on multivariable analysis. CONCLUSION We highlight positive surgical margin as the only variable significantly associated with increased risk of PCF following salvage TL on multivariable analysis in a large cohort across several major head and neck oncology centers.
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Affiliation(s)
| | - Joel C Davies
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jason T Rich
- Department of Otolaryngology-Head & Neck Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Mario Orsini
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eric Monteiro
- Department of Otolaryngology-Head & Neck Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ximena Mimica
- Head & Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tim Mclean
- Head & Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Ian Ganly
- Head & Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amy Hessel
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Samantha Tam
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Dongmin Wei
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan Goepfert
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Jie Su
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Mark Zafereo
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - David P Goldstein
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Marc A Cohen
- Head & Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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12
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Michael RC, Das S, Mani S, Arunagiri S, Thomas R, Vediappan RS, Philip DM. Pharyngocutaneous Fistula Following Primary and Salvage Laryngectomy: Aetiology and Predictive Factors. Indian J Otolaryngol Head Neck Surg 2022; 74:2139-2148. [PMID: 36452720 PMCID: PMC9701951 DOI: 10.1007/s12070-020-02046-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022] Open
Abstract
Laryngeal cancer treatment is often wrought with challenges, pharyngocutaneous fistula formation (PCF) in patients undergoing either primary or salvage laryngectomy for laryngeal and hypopharyngeal for squamous cell carcinoma is an important one. We aimed to study the factors before and at the surgery that are associated with PCF formation in a South Indian tertiary care hospital. A retrospective chart review of 127 patients who underwent total laryngectomy (TL) between May 2014 and April 2019 at our centre were done. Data was collected, including patient age and gender, comorbidities (Diabetes mellitus, COPD and hypothyroidism), smoking, tumor stage and site, prior tracheostomy, prior radiation, concurrent neck dissection and type of pharyngoplasty, Preoperative hemoglobin and albumin levels, surgical margin status and development of a PCF was also done. Further details specific to the development of a PCF were recorded for that subset of patients including the length of time to fistula, mode of closure, time of closure and modality of management. The overall incidence of PCF was 16.5% (21 of 127 patients), and the median time from TL to the diagnosis of PCF was 6 days (range, 3-20 days). The analysis was done separately for laryngectomies without any pharyngeal reconstruction (112/127 patients). In patients treated with a primary TL, the incidence of PCF was 12.20% (10 of 82) and 26.66% (8 of 30) after salvage TL. Subset analysis for type of pharyngoplasty repair showed 12% (15/127) underwent different types of vascularised/muscular flap for smaller residual pharyngeal mucosa, of which 20% (3/15) developed PCF and one patient developed haematoma needing exploration and re-suturing. The predictive factors for PCF were hypopharynx cancer (P < 0.05), surgical margin positivity (P < 0.0001), female gender (P < 0.05), absence of prior tracheostomy (P < 0.05) and tumor extension into pyriform sinus mucosa (P < 0.05). Preoperative patient factors of gender and site of primary along with histological margin positivity and extension of tumor to the pyriform sinus mucosa were significant risk factors for PCF formation. Pre-Op radiotherapy remains a strong clinical suspicion but not statistically significant.
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Affiliation(s)
- Rajiv C. Michael
- Department of Head and Neck Surgery, Christian Medical College, Vellore, 6320004 India
| | - Sukamal Das
- Department of Head and Neck Surgery, Christian Medical College, Vellore, 6320004 India
| | - Suresh Mani
- Department of Head and Neck Surgery, Christian Medical College, Vellore, 6320004 India
| | | | - Regi Thomas
- Department of ENT, Christian Medical College, Vellore, India
| | | | - Dona Maria Philip
- Department of Biostatistics, Christian Medical College, Vellore, India
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13
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Galli J, Di Cintio G, Settimi S, Salvati A, Parrilla C, Almadori G, Paludetti G. Elective Neck Dissection during Salvage Total Laryngectomy: Personal Experience. J Clin Med 2022; 11:jcm11051438. [PMID: 35268528 PMCID: PMC8911131 DOI: 10.3390/jcm11051438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/14/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022] Open
Abstract
The role of elective neck dissection during salvage surgery in patients with a clinically negative neck (cN0) is still discussed. The main objective of this work was to estimate the prevalence and predictive factors of occult neck nodes metastasis; we therefore aimed to evaluate the survival rate and the main oncologic outcomes of cN0 patients who underwent salvage total laryngectomy and elective bilateral neck dissection. In this retrospective observational study, we enrolled 80 cN0 patients affected by recurrent laryngeal cancer and who underwent salvage total laryngectomy and bilateral selective elective neck dissection. Several parameters were collected in order to find prognostic factors; finally, postoperative complications were reviewed and survival analysis was performed. Occult lymph node metastases were reported in 18 out of 80 patients (22.5%). Significant statistical correlation between lymphovascular invasion (p = 0.007), perineural invasion (p = 0.025) and occult nodal metastasis was found. Other variables (glottic subsite of recurrence, clinical T, pathological T, previous chemotherapy) were not significantly predictive of occult nodal metastasis. The 5-year OS, DSS, and RFS were 50.4%, 64.7%, and 63.4%, respectively. In conclusion, our single-institution data on a large cohort of patients, suggest performing routinely elective selective bilateral neck dissection during salvage total laryngectomy in cN0 patients due to the biological attitude of the tumor to spread to cervical nodes, considering an acceptable complications rate.
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Affiliation(s)
- Jacopo Galli
- Unit of Otolaryngology—Head and Neck Surgery, “A. Gemelli” Hospital Foundation IRCCS, 00168 Rome, Italy; (J.G.); (C.P.); (G.A.); (G.P.)
- Department of Head and Neck and Sensory Organs, Catholic University of the Sacred Hearth, 00168 Rome, Italy
| | - Giovanni Di Cintio
- Unit of Otolaryngology, “Nuovo Ospedale Degli Infermi”, 13875 Ponderano, Italy;
| | - Stefano Settimi
- Unit of Otolaryngology—Head and Neck Surgery, “A. Gemelli” Hospital Foundation IRCCS, 00168 Rome, Italy; (J.G.); (C.P.); (G.A.); (G.P.)
- Department of Head and Neck and Sensory Organs, Catholic University of the Sacred Hearth, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-06-30154149
| | - Antonio Salvati
- Airway Surgery Unit, Pediatric Surgery Department, “Bambino Gesù” Children Hospital, 00165 Rome, Italy;
| | - Claudio Parrilla
- Unit of Otolaryngology—Head and Neck Surgery, “A. Gemelli” Hospital Foundation IRCCS, 00168 Rome, Italy; (J.G.); (C.P.); (G.A.); (G.P.)
| | - Giovanni Almadori
- Unit of Otolaryngology—Head and Neck Surgery, “A. Gemelli” Hospital Foundation IRCCS, 00168 Rome, Italy; (J.G.); (C.P.); (G.A.); (G.P.)
- Department of Head and Neck and Sensory Organs, Catholic University of the Sacred Hearth, 00168 Rome, Italy
| | - Gaetano Paludetti
- Unit of Otolaryngology—Head and Neck Surgery, “A. Gemelli” Hospital Foundation IRCCS, 00168 Rome, Italy; (J.G.); (C.P.); (G.A.); (G.P.)
- Department of Head and Neck and Sensory Organs, Catholic University of the Sacred Hearth, 00168 Rome, Italy
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14
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Pharyngocutaneous fistula in irradiated patients: systematic review and our experience. The Journal of Laryngology & Otology 2022; 136:1027-1033. [DOI: 10.1017/s0022215121004370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective
Radiotherapy is considered a risk factor for pharyngocutaneous fistula after a total laryngectomy. This study aimed to analyse the impact of exclusive radiotherapy versus chemoradiotherapy and the time interval between radiotherapy and surgery on the risk of pharyngocutaneous fistula.
Method
This study was a retrospective revision of 171 patients treated with a total laryngectomy after radiotherapy or chemoradiotherapy.
Results
Pharyngocutaneous fistula occurred in 33 patients (19.3 per cent). Patients previously treated with chemoradiotherapy showed a non-significant higher pharyngocutaneous fistula rate compared with patients treated with radiotherapy (25.0 per cent vs 18.0 per cent; p = 0.455). Patients with a pharyngocutaneous fistula after chemoradiotherapy treatment required a surgical repair more frequently than patients treated with radiotherapy (p = 0.005). There were no significant differences in the pharyngocutaneous fistula rate depending on the time interval between radiotherapy and surgery (p = 0.580).
Conclusion
There were no differences in the pharyngocutaneous fistula rate after total laryngectomy depending on the previous treatment with radiotherapy or chemoradiotherapy, or depending on the interval between radiotherapy treatment and surgery.
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15
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Liu JC, James M, Al-Basheer MA, Al Agha R, Sabra O. Pharyngo-carotid fistula and Acute Carotid Blowout Syndrome after “salvage” total laryngectomy: A Case Report. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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The potential role of imaging techniques in avoiding neck dissection during salvage surgery after head and neck carcinoma treated with bioradiotherapy. The Journal of Laryngology & Otology 2021; 135:970-975. [PMID: 34482849 DOI: 10.1017/s0022215121001900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of computed tomography and positron emission tomography-computed tomography prior to salvage surgery after head and neck carcinoma treated with bioradiotherapy and to look at the role of neck dissection in this setting. METHOD This study was a retrospective chart review of a series of consecutive patients with locally advanced head and neck squamous cell carcinoma treated with bioradiotherapy. Radiological and pathological stages were compared to evaluate the accuracy of computed tomography and positron emission tomography-computed tomography in detecting occult neck metastasis in the context of recurrence of primary tumour. In order to assess the impact of neck dissection on survival, Kaplan-Meier survival curves after salvage surgery with and without neck dissection were derived. RESULTS A total of 268 patients were identified, of which 22 underwent salvage surgery. The negative predictive value of computed tomography and positron emission tomography-computed tomography was excellent. Neck dissection did not represent an improvement on overall, disease specific and regional recurrence free survival (p = 0.67, p = 0.91 and p = 0.62, respectively) amongst clinically and radiologically negative necks. CONCLUSION Conservative treatment of the neck should be considered when dealing with patients with primary site recurrence or persistent disease after bioradiotherapy without evidence of neck disease.
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Do Salivary Bypass Tubes Reduce the Risk of Pharyngocutaneous Fistula after Laryngopharyngectomy-A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13112827. [PMID: 34204054 PMCID: PMC8201015 DOI: 10.3390/cancers13112827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/30/2021] [Accepted: 06/02/2021] [Indexed: 01/12/2023] Open
Abstract
Simple Summary Salivary bypass tubes (SBT) have been introduced in order to reduce the risk of pharyngocutaneous fistula (PCF) after laryngectomy with pharynx reconstruction. Although the current literature is rather heterogenous, our meta-analysis demonstrates a favorable effect of SBT insertion on PCF formation in patients after laryngopharyngectomies. Abstract To evaluate the effect of salivary bypass tube (SBT) usage on the occurrence of pharyngocutaneous fistula (PCF) in patients after a laryngopharyngectomy, a total of 20 studies, published between 1988 and 2021, were identified including 2946 patients. We performed a meta-analysis assessing the risk of PCF occurrence in patients after SBT application compared to those without. PCF occurred in 26.8% of cases (669/2496) and SBT was applied in 33.0% of patients (820/2483). There was an overall trend towards lower PCF rates when using SBTs (22.2% vs. 35.3%; p = 0.057). We further selected five studies, comprising 580 patients who underwent laryngopharyngectomies, for meta-analysis showing that application of SBT reduced the risk of PCF formation (OR 0.46; 95% CI 0.18–1.18; p = 0.11). The meta-analysis demonstrates a beneficial effect of SBT insertion on PCF formation in patients after laryngopharyngectomy.
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18
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Choi N, Kim Z, Song BH, Park W, Chung MJ, Cho BH, Son YI. Prediction of risk factors for pharyngo-cutaneous fistula after total laryngectomy using artificial intelligence. Oral Oncol 2021; 119:105357. [PMID: 34044316 DOI: 10.1016/j.oraloncology.2021.105357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Pharyngocutaneous fistula (PCF) is one of the major complications following total laryngectomy (TL). Previous studies about PCF risk factors showed inconsistent results, and artificial intelligence (AI) has not been used. We identified the clinical risk factors for PCF using multiple AI models. MATERIALS & METHODS Patients who received TL in the authors' institution during the last 20 years were enrolled (N = 313) in this study. They consisted of no PCF (n = 247) and PCF groups (n = 66). We compared 29 clinical variables between the two groups and performed logistic regression and AI analysis including random forest, gradient boosting, and neural network to predict PCF after TL. RESULTS The best prediction performance for AI was achieved when age, smoking, body mass index, hypertension, chronic kidney disease, hemoglobin level, operation time, transfusion, nodal staging, surgical margin, extent of neck dissection, type of flap reconstruction, hematoma after TL, and concurrent chemoradiation were included in the analysis. Among logistic regression and AI models, the neural network showed the highest area under the curve (0.667 ± 0.332). CONCLUSION Diverse clinical factors were identified as PCF risk factors using AI models and the neural network demonstrated highest predictive power. This first study about prediction of PCF using AI could be used to select high risk patients for PCF when performing TL.
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Affiliation(s)
- Nayeon Choi
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Zero Kim
- Medical AI Research Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Bok Hyun Song
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Woori Park
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myung Jin Chung
- Medical AI Research Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea; Department of Radiology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 135-710, Republic of Korea
| | - Baek Hwan Cho
- Medical AI Research Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea; Department of Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Young-Ik Son
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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19
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Sanchez A, Frank E, Inman J, Wang W, Namin A, Ducic Y. Fistula Management in Head and Neck Cancer. Semin Plast Surg 2020; 34:299-304. [PMID: 33380917 PMCID: PMC7759424 DOI: 10.1055/s-0040-1721825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fistulas in head and neck cancer patients are a common and challenging issue. Despite their commonality, there is little consensus regarding optimal treatment strategies or in preventative measures that might be taken preoperatively. A general knowledge and understanding of what factors correlate with fistula formation can assist a surgeon in optimizing a patient for surgery, thus decreasing prevalence. In addition, surgical techniques can aid in both the prevention and treatment of fistulas once they form. This review details risk factors for fistula formation, the use of vascularized tissue as a preventative measure, conservative and nonconservative treatment of fistulas, and possible strategies to decrease the likelihood of their formation.
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Affiliation(s)
- Anthony Sanchez
- Department of Otolaryngology – Head & Neck Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Ethan Frank
- Department of Otolaryngology – Head & Neck Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Jared Inman
- Department of Otolaryngology – Head & Neck Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Weitao Wang
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Arya Namin
- Department of Otolaryngology – Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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20
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A Novel Laryngoscope-assisted Method for Sealing Pharyngocutaneous Fistula. J Craniofac Surg 2020; 32:e351-e353. [PMID: 33027172 DOI: 10.1097/scs.0000000000007127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Pharyngocutaneous fistula (PCF) is one of the most common but stranded complications for salvage laryngectomy. As for localized fistula, there is no convincing standard and method to cure. This paper described a patient who was submitted to extensive resection of mass in right lingual root, total laryngectomy, and pharyngoesophageal reconstruction with an anterolateral thigh flap (ALTF), because of recurred carcinoma of right lingual root which invaded bilateral epiglottis. 2 weeks after surgery, subsequent pharyngocutaneous fistula developed at the junction of the tracheostomy, and maintained over 2 months under conservative treatment. With the assistance of laryngoscope, inner and outer orificiums of fistula were found and sealed by bundled iodoform strip. 9 days after sealing, fistula had been already filled with fresh granulation tissue. During 2 years after surgery, the fistula area dose not recur. This technique provides a safe and effective way for sealing the inner and outer orificiums of fistula.
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21
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Pézier TF, Rijken JA, Tijink BM, Braunius WW, de Bree R. Time interval between (chemo)radiotherapy and subsequent laryngectomy is not prognostic for post operative complications and survival. Eur Arch Otorhinolaryngol 2020; 278:2511-2516. [PMID: 32995913 PMCID: PMC8165068 DOI: 10.1007/s00405-020-06384-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022]
Abstract
Purpose Pharyngocutaneous fistula (PCF) formation and swallowing difficulties are common and troublesome complications following total laryngectomy (TL). Prior (chemo)radiotherapy ((C)RT) is thought to be a risk factor for these complications, but there is conflicting evidence as to whether the time interval between (C)RT and TL is important. The impact of time interval on these complications and also its impact on overall survival are investigated. Methods This is a retrospective case note review of all patients undergoing TL at the University Medical Center, Utrecht, The Netherlands over the 10-year period from January 2008 to December 2017. The cohort was split into those who underwent TL within a year of finishing (C)RT and those longer than 1 year. Results One hundred and twenty-six patients (108 males, 18 females), with a mean age of 66 underwent total laryngectomy after prior (C)RT in the study period. Overall 5-year survival was 35% with a median follow-up of 30 months. Fifty-four patients underwent laryngectomy within a year of their (C)RT versus 72 patients who had a time interval of more than one year. No differences in PCF rate, risk of dilatation or overall survival could be found between the two groups. Conclusions In this modern cohort, time interval between (C)RT and surgery did not impact PCF rate, risk of dilatation or overall survival.
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Affiliation(s)
- Thomas F Pézier
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Johannes A Rijken
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bernard M Tijink
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Weibel Braunius
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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22
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Cabrera CI, Joseph Jones A, Philleo Parker N, Emily Lynn Blevins A, Weidenbecher MS. Pectoralis Major Onlay vs Interpositional Reconstruction Fistulation After Salvage Total Laryngectomy: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 164:972-983. [PMID: 32988281 DOI: 10.1177/0194599820957962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the difference in pharygocutaneous fistula (PCF) development between pectoralis major flap onlay and interpositional reconstructions after salvage total laryngectomy (STL). DATA SOURCES Medline, Cochrane, Embase, Web of Science, CINAHL, and ClinicalTrials.gov. REVIEW METHODS A systematic review was performed during January 2020. English articles were included that described minor and major PCF rates after STL reconstructed with pectoralis major onlay or interposition. PCFs were classified as major when conservative therapy was unsuccessful and/or revision surgery was needed. Articles describing total laryngopharyngectomies were excluded. Meta-analyses of the resulting data were performed. RESULTS Twenty-four articles met final criteria amassing 1304 patients. Three articles compared onlay with interposition, and 18 compared onlay with primary closure. Pectoralis interposition demonstrated elevated odds ratio (OR) of PCF formation as compared with onlay (OR, 2.34; P < .001). Onlay reconstruction reduced overall (OR, 0.32; P < .001) and major (OR, 0.21; P < .001) PCF development as compared with primary pharyngeal closure alone. Data were insufficient to compare interposition against primary closure. CONCLUSIONS This research shows evidence that pectoralis onlay after STL diminishes the odds of total and major PCF development. Pectoralis interposition reconstruction showed elevated odds of PCF formation as compared with pectoralis onlay.
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Affiliation(s)
- Claudia I Cabrera
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Alexander Joseph Jones
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Noah Philleo Parker
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Amy Emily Lynn Blevins
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Mark S Weidenbecher
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
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Piazza C, Paderno A, Del Bon F, Grammatica A, Montalto N, Bresciani L, Giannini L, Incandela F, Fontanella W, Nicolai P. Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy. Eur Arch Otorhinolaryngol 2020; 278:219-226. [PMID: 32583182 DOI: 10.1007/s00405-020-06137-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/16/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol. METHODS Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent. RESULTS Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%). CONCLUSION The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature.
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Affiliation(s)
- Cesare Piazza
- Department of Otorhinolaryngology, Maxillofacial, and Thyroid Surgery, Fondazione IRCCS National Cancer Institute of Milan, Milan, Italy.,Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Alberto Paderno
- Department of Otorhinolaryngology - Head and Neck Surgery, Spedali Civili of Brescia, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
| | - Francesca Del Bon
- Department of Otorhinolaryngology - Head and Neck Surgery, Spedali Civili of Brescia, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Alberto Grammatica
- Department of Otorhinolaryngology - Head and Neck Surgery, Spedali Civili of Brescia, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Nausica Montalto
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Padua, Padua, Italy
| | - Lorenzo Bresciani
- Department of Otorhinolaryngology, Maxillofacial, and Thyroid Surgery, Fondazione IRCCS National Cancer Institute of Milan, Milan, Italy
| | - Lorenzo Giannini
- Department of Otorhinolaryngology, Maxillofacial, and Thyroid Surgery, Fondazione IRCCS National Cancer Institute of Milan, Milan, Italy
| | - Fabiola Incandela
- Department of Otorhinolaryngology, Maxillofacial, and Thyroid Surgery, Fondazione IRCCS National Cancer Institute of Milan, Milan, Italy
| | - Walter Fontanella
- Department of Otorhinolaryngology, Maxillofacial, and Thyroid Surgery, Fondazione IRCCS National Cancer Institute of Milan, Milan, Italy
| | - Piero Nicolai
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Padua, Padua, Italy
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Galli J, Salvati A, Di Cintio G, Mastrapasqua RF, Parrilla C, Paludetti G, Almadori G. Stapler Use in Salvage Total Laryngectomy: A Useful Tool? Laryngoscope 2020; 131:E473-E478. [PMID: 32415791 DOI: 10.1002/lary.28737] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/09/2020] [Accepted: 04/21/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS To analyze stapler benefits in salvage total laryngectomy in terms of surgical time, hospitalization length, oral feeding time, and occurrence of pharyngocutaneous fistula, and to evaluate risk factors for its onset. STUDY DESIGN Retrospective analysis. METHODS One hundred fourteen patients affected by endolaryngeal squamous cell carcinoma who underwent salvage total laryngectomy following primary treatment failure were reviewed. We divided patients into two groups based on type of pharyngeal suture performed: mechanical suture with stapler (group A) and manual suture (group B). These two groups were compared for surgical time, start of oral feeding, hospitalization length, surgical margins and pharyngocutaneous fistula incidence considering its relationship with diabetes mellitus, nutritional status, primary treatment, and neck dissection. RESULTS In group A and group B, oral feeding restarting time was 15 ± 9.33 versus 20.03 ± 13.81 days, hospitalization was 17.63 ± 10.08 versus 23.72 ± 14.29 days, and surgery lasted 268.39 ± 76.93 versus 294.26 ± 140.58 minutes, respectively (P < .05). Surgical margins resulted infiltrated in two patients (4.3%) in group A and 12 patients in group B (17.6%) (P = .03). Twenty-one patients (18.4%) presented with pharyngocutanoeus fistula. In group A and group B the incidence of fistula was 15.2% and 20.6%, respectively (P = .468). Fistula occurred in 7 of 18 diabetic patients (38.9%) and 14 of 96 (14.6%) nondiabetic patients (P = .015). Nineteen fistulas (90.5%) occurred in patients who had undergone previous radiation treatment (P = .013). CONCLUSIONS Using a stapler shortened operative time and hospitalization, while also providing a faster restart of oral feeding. Moreover, mechanical pharyngeal suture seems to decrease fistula rate even though its prevention role in salvage laryngectomy should be confirmed by further studies. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E473-E478, 2021.
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Affiliation(s)
- Jacopo Galli
- Department of Otorhinolaryngology-Head and Neck Surgery, "A. Gemelli" Hospital Foundation Scientific Institute for Research, Hospitalization and Healthcare, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Salvati
- Department of Otorhinolaryngology-Head and Neck Surgery, "A. Gemelli" Hospital Foundation Scientific Institute for Research, Hospitalization and Healthcare, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Di Cintio
- Department of Otorhinolaryngology-Head and Neck Surgery, "A. Gemelli" Hospital Foundation Scientific Institute for Research, Hospitalization and Healthcare, Catholic University of the Sacred Heart, Rome, Italy
| | - Rodolfo F Mastrapasqua
- Department of Otorhinolaryngology-Head and Neck Surgery, "A. Gemelli" Hospital Foundation Scientific Institute for Research, Hospitalization and Healthcare, Catholic University of the Sacred Heart, Rome, Italy
| | - Claudio Parrilla
- Department of Otorhinolaryngology-Head and Neck Surgery, "A. Gemelli" Hospital Foundation Scientific Institute for Research, Hospitalization and Healthcare, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Department of Otorhinolaryngology-Head and Neck Surgery, "A. Gemelli" Hospital Foundation Scientific Institute for Research, Hospitalization and Healthcare, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Almadori
- Department of Otorhinolaryngology-Head and Neck Surgery, "A. Gemelli" Hospital Foundation Scientific Institute for Research, Hospitalization and Healthcare, Catholic University of the Sacred Heart, Rome, Italy
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Gross JH, Vila PM, Simon L, Rizvi ZH, Zenga J, Jackson RS, Pipkorn P. Elective neck dissection during salvage laryngectomy: A systematic review and meta‐analysis. Laryngoscope 2020; 130:899-906. [DOI: 10.1002/lary.28323] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/14/2019] [Accepted: 09/06/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Jennifer H. Gross
- Department of Otolaryngology–Head and Neck SurgeryWashington University St. Louis Missouri
| | - Peter M. Vila
- Department of Otolaryngology–Head and Neck SurgeryWashington University St. Louis Missouri
| | - Laura Simon
- Bernard Becker Medical LibraryWashington University St. Louis Missouri
| | - Zain H. Rizvi
- Department of Otolaryngology–Head and Neck SurgeryWashington University St. Louis Missouri
| | - Joseph Zenga
- Department of Otolaryngology and Communication SciencesMedical College of Wisconsin Milwaukee Wisconsin U.S.A
| | - Ryan S. Jackson
- Department of Otolaryngology–Head and Neck SurgeryWashington University St. Louis Missouri
| | - Patrik Pipkorn
- Department of Otolaryngology–Head and Neck SurgeryWashington University St. Louis Missouri
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Gonzalez-Orús Álvarez-Morujo R, Martinez Pascual P, Tucciarone M, Fernández Fernández M, Souviron Encabo R, Martinez Guirado T. Salvage total laryngectomy: is a flap necessary? Braz J Otorhinolaryngol 2020; 86:228-236. [PMID: 30683565 PMCID: PMC9422674 DOI: 10.1016/j.bjorl.2018.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/06/2018] [Accepted: 11/26/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with or without chemotherapy. Objective Our purpose is to review the fistula rate in radiated patients undergoing salvage total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors. Methods We made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed. Results We identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p = 0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p = 0.03) and large pharyngostomes (64.3% versus 0%, p = 0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p = 0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p = 0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes. Conclusions Prophylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy.
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Management of the irradiated N0-neck during salvage pharyngo-laryngeal surgery. Eur J Surg Oncol 2020; 46:1059-1065. [PMID: 31952930 DOI: 10.1016/j.ejso.2020.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/06/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Salvage surgeries are challenging procedures, with an associated poor prognosis. Management of the N0 neck in those situations remains controversial. We aim to compare oncologic outcomes regarding neck management after surgery for N0 pharyngo-laryngeal carcinoma occurring after loco-regional radiotherapy. METHODS We conducted a multicentric retrospective study, including all patients undergoing surgery for persistent, recurrent or new primary N0 carcinoma of the oropharynx, hypopharynx or larynx between 2005 and 2015, following loco-regional radiotherapy. RESULTS A total of 239 patients were included, concerning respectively 44%, 34% and 22% oropharyngeal, laryngeal and hypopharyngeal tumors operated. A neck dissection was performed in 143 patients (60%), with an occult nodal metastasis rate of 9%. This rate was higher for hypopharyngeal carcinomas (18%, p = 0.16) and tumors with initial nodal involvement (16%, p = 0.05). With a median follow-up of 60 months, the median overall survival (OS) and progression-free survival rates (PFS) were 34 months and 25 months. We identified negative margin excision status, age at the time of surgery (under 60) and delay between RT and surgery over 2 years as the only variables associated with better OS (p < 0.0001 and p = 0.004) and PFS (p < 0.0001 and p = 0.010) in multivariable analysis, with no difference regarding neck management. Regional progression (alone or with distant metastasis) was noted in 10 cases: 4 in the neck observation group (4%) versus 6 in the neck dissection group (4%). CONCLUSION Elective lymph node dissection of irradiated neck should not be routinely performed in patients undergoing surgery for persistent, recurrent or new primary pharyngo-laryngeal carcinomas.
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Wang M, Xun Y, Wang K, Lu L, Yu A, Guan B, Yu C. Risk factors of pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2019; 277:585-599. [PMID: 31712878 DOI: 10.1007/s00405-019-05718-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/31/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this study was to systematically evaluate the risk factors of pharyngocutaneous fistula (PCF) after total laryngectomy. METHODS We systematically searched Pubmed, Web of Science, Cochrane Library, and Embase databases and included the literature according to the inclusion and exclusion criteria. RESULTS A total of 52 studies with 8605 patients were included in the meta-analysis. The total incidence of PCF was 21% (1808/8605). Meta-analysis results indicated that age (OR = 1.29, 95% CI 1.06-1.58, P = 0.01), smoking (OR = 1.62, 95% CI 1.27-2.07, P < 0.01), COPD (chronic obstructive pulmonary disease) (OR = 1.62, 95% CI 1.19-2.22, P < 0.01), CAD (coronary atherosclerotic heart disease) (OR = 1.82, 95% CI 1.36-2.45, P < 0.01), T-stage (OR = 0.81, 95% CI 0.67-0.98, P = 0.03), previous radiotherapy (OR = 2.41, 95% CI 2.00-2.90, P < 0.01), preoperative albumin (OR = 2.95, 95% CI 1.47-5.91, P < 0.01), preoperative hemoglobin (OR = 1.97, 95% CI 1.28-3.03, P < 0.01), tumor site (OR = 0.28, 95% CI 0.22-0.36, P < 0.01), and treatment method (OR = 1.85, 95% CI 1.44-2.38, P < 0.01) were risk factors associated with PCF. CONCLUSIONS In our study, age, smoking, COPD, CAD, T-stage, previous radiotherapy, preoperative albumin, preoperative hemoglobin, tumor site, and treatment method were risk factors of PCF.
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Affiliation(s)
- Maohua Wang
- Department of Otolaryngology, Head and Neck Surgery, XiangYa School of Medicine, Central South University, Changsha, 410000, People's Republic of China
| | - Youfang Xun
- Department of Otolaryngology, Head and Neck Surgery, XiangYa School of Medicine, Central South University, Changsha, 410000, People's Republic of China
| | - Kaijian Wang
- Department of Otolaryngology, Head and Neck Surgery, Drum Tower Clinical Medical College, Nanjing Medical University, Nanjing, 210008, People's Republic of China
| | - Ling Lu
- Department of Otolaryngology, Head and Neck Surgery, Drum Tower Clinical Medical College, Nanjing Medical University, Nanjing, 210008, People's Republic of China.,Department of Otolaryngology, Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory), Nanjing, 210008, People's Republic of China
| | - Aimin Yu
- Department of Otolaryngology, Head and Neck Surgery, Clinical Medical College of Yangzhou University, Yangzhou, 225001, People's Republic of China
| | - Bing Guan
- Department of Otolaryngology, Head and Neck Surgery, Clinical Medical College of Yangzhou University, Yangzhou, 225001, People's Republic of China.
| | - Chenjie Yu
- Department of Otolaryngology, Head and Neck Surgery, Drum Tower Clinical Medical College, Nanjing Medical University, Nanjing, 210008, People's Republic of China. .,Department of Otolaryngology, Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory), Nanjing, 210008, People's Republic of China. .,Research Institute of Otolaryngology, Nanjing, 210008, People's Republic of China.
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Sumarroca A, Rodríguez-Bauzà E, Lop-Gros J, García J, López M, Quer M, León X. Repair of post-laryngectomy pharyngocutaneous fistulas using a pectoralis major flap. Braz J Otorhinolaryngol 2019; 85:351-356. [PMID: 29650373 PMCID: PMC9442886 DOI: 10.1016/j.bjorl.2018.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 01/21/2018] [Accepted: 03/01/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The pectoralis major flap is a reconstructive option to consider in the treatment of pharyngocutaneous fistula after a total laryngectomy. There are not large studies assessing variables related to pharyngocutaneous fistula recurrence after removal of the larynx. Our objectives were to review the results obtained with this type of treatment when pharyngocutaneous fistula appears in laryngectomized patients, and to evaluate variables related to the results. METHODS We retrospectively reviewed our results using either a myocutaneous or fasciomuscular pectoralis major flap to repair pharyngocutaneous fistula in 50 patients. RESULTS There were no cases of flap necrosis. Oral intake after fistula repair with a pectoralis major flap was restored in 94% of cases. Fistula recurrence occurred in 22 cases (44%), and it was associated with a lengthening of the hospital stay. Performing the flap as an emergency procedure was associated with a significantly higher risk of fistula recurrence. Hospital stay was significantly shorter when a salivary tube was placed. CONCLUSIONS The pectoralis major flap is a useful approach to repair pharyngocutaneous fistula. Placing salivary tubes during fistula repair significantly reduces hospital stay and complication severity in case of pharyngocutaneous fistula recurrence.
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Affiliation(s)
- Anna Sumarroca
- Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Otorhinolaryngology Department, Barcelona, Spain.
| | - Elena Rodríguez-Bauzà
- Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Plastic Surgery Department, Barcelona, Spain
| | - Joan Lop-Gros
- Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Otorhinolaryngology Department, Barcelona, Spain
| | - Jacinto García
- Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Otorhinolaryngology Department, Barcelona, Spain
| | - Montserrat López
- Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Otorhinolaryngology Department, Barcelona, Spain
| | - Miquel Quer
- Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Otorhinolaryngology Department, Barcelona, Spain
| | - Xavier León
- Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Otorhinolaryngology Department, Barcelona, Spain
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Kim YH, Roh J, Choi S, Nam SY, Kim SY. Prediction of pharyngocutaneous fistula and survival after salvage laryngectomy for laryngohypopharyngeal carcinoma. Head Neck 2019; 41:3002-3008. [DOI: 10.1002/hed.25786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 03/14/2019] [Accepted: 04/09/2019] [Indexed: 12/17/2022] Open
Affiliation(s)
- Yong Han Kim
- Department of Otolaryngology, Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
| | - Jong‐Lyel Roh
- Department of Otolaryngology, Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
| | - Seung‐Ho Choi
- Department of Otolaryngology, Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
| | - Soon Yuhl Nam
- Department of Otolaryngology, Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
| | - Sang Yoon Kim
- Department of Otolaryngology, Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
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Haidar YM, Kuan EC, Verma SP, Goddard JA, Armstrong WB, Tjoa T. Free Flap Versus Pedicled Flap Reconstruction of Laryngopharyngeal Defects: A 10-Year National Surgical Quality Improvement Program Analysis. Laryngoscope 2018; 129:105-112. [PMID: 30151829 DOI: 10.1002/lary.27455] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 06/03/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS Large defects after total laryngectomy (TL) and total laryngopharyngectomy (TLP) often benefit from free flap (FF) or pedicled flap (PF) reconstruction to maintain continuity of the aerodigestive tract, protect great vessels, or reinforce pharyngeal closure. Although both techniques are commonly used, no consensus exists as to which results in fewer complications. The goal of this study was to determine if 30-day morbidity/mortality outcomes differ between PF and FF reconstruction in patients undergoing TL/TLP. STUDY DESIGN Retrospective cohort study. METHODS Patients were analyzed who underwent TL/TLP with reconstruction using records from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015). RESULTS A total of 347 patients were included; 204 received FF reconstruction, whereas 143 received PF reconstruction. FF reconstruction was more commonly used with TLP defects (P = .001). The total operative time in the FF (590 ± 140 minutes) was longer than the PF (441 ± 125 minutes) group (P < .0001). There was a higher rate of postoperative transfusions in those undergoing FF reconstruction (P = .022). There was no significant difference in complication rates among TLP patients. Among TL patients only, FF reconstruction had a higher association with wound infections than PFs (P = .040). On multivariate analysis, low hematocrit was associated with complications (P = .031). Age (P = .031) and congestive heart failure exacerbation (P < .001) were associated with increased hospital stay. Overall, there were no differences in readmissions, reoperations, or deaths between the groups. CONCLUSIONS Reported complication rates after TL/TLP remain high, despite widespread usage of vascularized flaps in reconstruction. This comparison reveals no significant difference in postoperative complications between patients who received PF and FF laryngopharyngeal reconstruction. LEVEL OF EVIDENCE 4 Laryngoscope, 129:105-112, 2019.
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Affiliation(s)
- Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California
| | - Sunil P Verma
- Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California
| | - Julie A Goddard
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Colorado, Denver, Colorado, U.S.A
| | - William B Armstrong
- Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California
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Vasani SS, Youssef D, Lin C, Wellham A, Hodge R. Defining the low-risk salvage laryngectomy-A single-center retrospective analysis of pharyngocutaneous fistula. Laryngoscope Investig Otolaryngol 2018; 3:115-120. [PMID: 29721544 PMCID: PMC5915824 DOI: 10.1002/lio2.144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/03/2018] [Indexed: 11/07/2022] Open
Abstract
Objectives Salvage total laryngectomies (STL) are not a homogeneous group. Most will fall into two groups: i) Patients with previous AJCC stage I/II larynx cancer who have had radiotherapy to the larynx only (STL‐LOR), or ii) Patients who have had previous AJCC stage III/IV larynx cancer and subsequent radiotherapy to the larynx and draining nodal basins with concurrent cisplatin chemotherapy (STL‐CRT). We aimed to compare PCF rates following STL in these two groups. Methods A retrospective review of the department's cohort between January 2010 and August 2015 was conducted. Results Seventy‐seven patients underwent total laryngectomy for larynx cancer between January 2010 and August 2015. There were 10 post‐laryngectomy fistulas (13.0%). Three of these occurred in the 38 patients undergoing primary total laryngectomy (PTL), and seven in the 39 patients undergoing STL, rates of 7.9% and 17.9%, respectively. Twenty‐two patients had received radiation to the larynx alone without chemotherapy (STL‐LOR) for initial Stage I/II disease. Eleven patients had received laryngeal and neck irradiation plus cisplatin chemotherapy (STL‐CRT) for initial stage III/IV disease. Of the 22 STL‐LOR patients, two developed PCF (9.1%). Of the 11 STL‐CRT patients, five developed PCF. There was no difference in the rate of PCF between PTL and STL‐LOR. There was a statistically significant increase in PCF in STL‐CRT versus PTL (p = .009) and in PCF in STL‐CRT versus STL‐LOR (p = .027). Conclusion Salvage laryngectomies are often treated as a homogenous group. We demonstrate that PCF rates vary significantly depending on preoperative radiation fields and the use of chemotherapy. Level of Evidence 2b.
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Affiliation(s)
- Sarju S. Vasani
- Department of Otolaryngology, Royal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Daniel Youssef
- Department of Otolaryngology, Royal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Charles Lin
- Department of Oncology, Royal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Annabelle Wellham
- Department of Otolaryngology, Royal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Robert Hodge
- Department of Otolaryngology, Royal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
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Partington EJ, Moore LS, Kahmke R, Warram JM, Carroll W, Rosenthal EL, Greene BJ. Laser-Assisted Indocyanine Green Dye Angiography for Postoperative Fistulas After Salvage Laryngectomy. JAMA Otolaryngol Head Neck Surg 2017; 143:775-781. [PMID: 28520896 DOI: 10.1001/jamaoto.2017.0187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Pharyngocutaneous fistula formation is an unfortunate complication after salvage laryngectomy for head and neck cancer that is difficult to anticipate and related to a variety of factors, including the viability of native pharyngeal mucosa. Objective To examine whether noninvasive angiography with indocyanine green (ICG) dye can be used to evaluate native pharyngeal vascularity to anticipate pharyngocutaneous fistula development. Design, Setting, and Participants This cohort study included 37 patients enrolled from June 1, 2013, to June 1, 2016, and follow-up was for at least 1 month postoperatively. The study was performed at the University of Alabama at Birmingham, a tertiary care center. Included patients were those undergoing salvage total laryngectomy who were previously treated with chemoradiotherapy or radiotherapy alone. Exposures The ICG dye was injected intraoperatively, and laser-assisted vascular imaging was used to evaluate the native pharyngeal mucosa after the ablative procedure. The center of the native pharyngeal mucosa was used as the reference to compare with the peripheral mucosa, and the lowest mean ICG dye percentage of mucosal perfusion was recorded for each patient. Main Outcomes and Measures The primary outcome was the formation of a postoperative fistula, which was assessed by clinical and radiographic assessment to test the hypothesis formulated before data collection. Results A total of 37 patients were included (mean [SD] age, 62.3 [8.5] years; 32 [87%] male and 5 [14%] female); 20 had a history of chemoradiotherapy, and 17 had history of radiotherapy alone. Thirty-four patients (92%) had free flap reconstruction, and 3 had primary closure (8%). Ten patients (27%) developed a postoperative fistula. No significant difference was found in fistula rate between patients who underwent neck dissection and those who did not and patients previously treated with chemoradiotherapy and those treated with radiotherapy alone. A receiver operator characteristic curve was generated to determine the diagnostic performance of the lowest mean ICG dye percentage of mucosal perfusion determined by fluorescence imaging, which was found to be a threshold value of 26%. The area under the curve was 0.85 (95% CI, 0.73-0.97), which was significantly greater than the chance diagonal. The overall mean lowest ICG dye percentage of mucosal perfusion was 31.3%. The mean lowest ICG dye percentage of mucosal perfusion was 22.0% in the fistula group vs 34.9% in the nonfistula group (absolute difference, 12.9%; 95% CI, 5.1%-21.7%). Conclusions and Relevance Patients who developed postoperative fistulas had lower mucosal perfusion as detected by ICG dye angiography when compared with patients who did not develop fistulas.
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Affiliation(s)
- Erin J Partington
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham
| | - Lindsay S Moore
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham
| | - Russel Kahmke
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham
| | - Jason M Warram
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham
| | - William Carroll
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham
| | - Eben L Rosenthal
- Department of Otolaryngology, Stanford University, Stanford, California
| | - Benjamin J Greene
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham
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Curative treatment of head and neck squamous cell carcinoma : Organ preservation strategies in clinical routine in German-speaking countries. HNO 2017; 64:501-7. [PMID: 27357174 DOI: 10.1007/s00106-016-0191-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION For the treatment of head and neck squamous cell carcinoma (HNSCC), there are currently no official standard of care guidelines in German-speaking countries, with the exception of oral cavity cancer. In order to learn about the applied treatment modalities in the clinical routine, we conducted a web-based survey to evaluate the local standards of palliative and curative treatment of HNSCC. This article focuses on the curative treatment options and organ preservation strategies. MATERIALS AND METHODS The survey consisted of a web-based questionnaire that was performed between November 2013 and July 2014. The questionnaire included ten multiple-choice questions and four open questions in the section about curative treatment. RESULTS Altogether, 62 of the 204 addressed centers participated in the survey. For primary chemoradiation (CRT), most centers used a platinum-based chemotherapy (52/54, 96.3 %). Induction chemotherapy (ICT) was offered in 37 of the 62 centers (60 %). In oral cavity cancer, CRT and ICT were used in 37.5 and 4.3 % of the cases, respectively. In oropharyngeal cancer, CRT and ICT were applied in 44.5 and 10.3 % of cases, respectively. For hypopharyngeal cancer, 44.8 % of the patients received CRT and 11.8 % received ICT, while for laryngeal cancer 35.9 % received CRT and 9.4 % underwent ICT. CONCLUSION Our data showed that a variety of treatments are used for HNSCC within German-speaking countries. Many centers offer ICT. The majority of the hospitals uses platinum-based therapy as a conservative first-line option in their organ preservation protocols.
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Sternocleidomastoid flap augmentation of the pharyngeal closure after total laryngectomy. Eur Arch Otorhinolaryngol 2017; 274:3197-3202. [DOI: 10.1007/s00405-017-4582-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
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Lewis CM, Aloia TA, Shi W, Martin I, Lai SY, Selber JC, Hessel AC, Hanasono MM, Hutcheson KA, Robb GL, Weber RS. Development and Feasibility of a Specialty-Specific National Surgical Quality Improvement Program (NSQIP): The Head and Neck-Reconstructive Surgery NSQIP. JAMA Otolaryngol Head Neck Surg 2016; 142:321-7. [PMID: 26892756 DOI: 10.1001/jamaoto.2015.3608] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) serves the need for continual quality assessment in general surgery. Previously, no parallel mechanism specific to head and neck oncologic surgery existed. OBJECTIVE To address the need for continual quality assessment in subspecialty surgery by adapting the ACS NSQIP platform for complex head and neck oncologic surgical procedures. DESIGN, SETTING, AND PARTICIPANTS With an institutional ACS NSQIP team's guidance, surgeons from the departments of head and neck surgery and plastic and reconstructive surgery developed disease- and procedure-specific preoperative, intraoperative, and postoperative variables specific to head and neck surgery requiring reconstruction. Collection occurred with 100% sampling and standard ACS NSQIP 30-day follow-up. After a pilot period, long-term functional outcomes were added to this platform. A total of 312 patients underwent head and neck surgery requiring reconstruction at an academic medical center between August 1, 2012, and June 30, 2013. EXPOSURES Development of a specialty-specific head and neck surgery ACS NSQIP platform. MAIN OUTCOMES AND MEASURES The feasibility of adapting the ACS NSQIP platform to capture complex head and neck surgery metrics in all patients. RESULTS Head and neck surgery-specific preoperative, intraoperative, and postoperative variables were added to the ACS NSQIP platform and evaluated in 312 patients (201 [64.4%] male). Only 42 patients (13.5%) had no preoperative risk factors, and 136 (43.6%) had 3 or more risk factors. The mean (SD) duration of operation was 9.4 (3.0) hours (range, 1.7-19.3 hours). The mean (SD) postoperative length of stay was 7.9 (4.7) days (range, 1-40 days), 58 patients (18.6%) had an unplanned return to the operating room, 23 patients (7.4%) were readmitted within 30 days, and 3 patients (1.0%) died within 30 days. More than half of the patients (160 [51.3%]) did not experience a postoperative occurrence. CONCLUSIONS AND RELEVANCE To our knowledge, this is the first comprehensive complex oncologic surgery outcomes platform derived from ACS NSQIP methods. The initial pilot demonstrates the ability to systematically capture head and neck surgery-specific variables with complete sampling. With multi-institutional expansion, increased accrual, and long-term patient-reported outcomes, we hope to set risk-adjusted benchmarks that may underpin quality improvement efforts in complex head and neck surgery.
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Affiliation(s)
- Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Weiming Shi
- Office of Performance Improvement, The University of Texas MD Anderson Cancer Center, Houston
| | - Ira Martin
- Office of Performance Improvement, The University of Texas MD Anderson Cancer Center, Houston
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Jesse C Selber
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Amy C Hessel
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew M Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Geoffrey L Robb
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
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Aslıer NGY, Doğan E, Aslıer M, İkiz AÖ. Pharyngocutaneous Fistula after Total Laryngectomy: Risk Factors with Emphasis on Previous Radiotherapy and Heavy Smoking. Turk Arch Otorhinolaryngol 2016; 54:91-98. [PMID: 29392026 DOI: 10.5152/tao.2016.1878] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 08/31/2016] [Indexed: 11/22/2022] Open
Abstract
Objective In this retrospective cohort study, we aimed to determine the incidence of pharyngocutaneous fistula (PCF) after total laryngectomy (TL) and to define the possible predictors for PCF formation. Methods The medical records of 198 patients with laryngeal squamous cell carcinoma who underwent TL were reviewed. After the exclusion of patients with history of free flap reconstruction, previous laryngeal surgery, and previous radiotherapy (RT) for other primary cancers, the risk factors for PCF were analyzed in 183 patients who were included in the study. Results The overall incidence of PCF was 20.2%. A history of heavy smoking and previous RT were detected as independent risk factors in both univariate (p=0.004 and p=0.007, respectively) and multivariate (p=0.005) analyses. Preoperative tracheotomy (PT) longer than 14 days was a risk factor for PCF among patients with PT in the univariate analysis (p=0.031). Overall three- and five-year survival rates were statistically indifferent between the PCF and non-PCF groups (p>0.05). However, the overall five-year survival rate was lesser in the persistent PCF group (47%) than in the non-persistent PCF group (83%) (p=0.038). Conclusion Heavy smoking and previous RT are independent risk factors for PCF, and the persistence of PCF decreases survival rates. Preventable measures should be taken to decrease the incidence and persistence of this complication of TL in the management of patients with possible risk factors.
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Affiliation(s)
- Nesibe Gül Yüksel Aslıer
- Department of Otorhinolaryngology-Head and Neck Surgery, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Ersoy Doğan
- Department of Otorhinolaryngology-Head and Neck Surgery, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Mustafa Aslıer
- Department of Otorhinolaryngology-Head and Neck Surgery, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Ahmet Ömer İkiz
- Department of Otorhinolaryngology-Head and Neck Surgery, Dokuz Eylül University School of Medicine, İzmir, Turkey
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Rovira A, Tornero J, Oliva M, Taberna M, Montal R, Nogues J, Farre A, Lares H, Navarro V, Mari A, Vinals JM, Lozano A, Mesia R, Manos M. Salvage surgery after head and neck squamous cell carcinoma treated with bioradiotherapy. Head Neck 2016; 39:116-121. [PMID: 27459296 DOI: 10.1002/hed.24549] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 02/23/2016] [Accepted: 06/22/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study was to describe the results and complications of primary site salvage surgery after head and neck squamous cell carcinoma (HNSCC) treated with bioradiotherapy. METHODS We conducted a retrospective chart review of 268 patients treated with bioradiotherapy between March 2006 and December 2013 at the Hospital Universitari de Bellvitge-ICO. RESULTS Fifty-nine patients developed local recurrence or had residual disease with a 1-year and 3-year overall survival of 47% and 15.4%, respectively. Salvage surgery was feasible in 22 patients (37.3%). There were 16 complications in these 22 patients (72.7%), 11 (50%) of which were major. Bilateral neck dissection was identified as a risk factor for complications. CONCLUSION Salvage surgery after bioradiotherapy is associated with a high rate of complications. Neck dissection seems to be related to an increased rate of complications with no survival improvement. © 2016 Wiley Periodicals, Inc. Head Neck 39: 116-121, 2017.
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Affiliation(s)
- Aleix Rovira
- Department of Otorhinolaryngology, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Tornero
- Department of Otorhinolaryngology, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Marc Oliva
- Department of Medical Oncology, Catalan Institute of Oncology, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Miren Taberna
- Department of Medical Oncology, Catalan Institute of Oncology, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Robert Montal
- Department of Medical Oncology, Catalan Institute of Oncology, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Julio Nogues
- Department of Otorhinolaryngology, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Farre
- Department of Otorhinolaryngology, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Henry Lares
- Department of Otorhinolaryngology, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Valenti Navarro
- Statistics Unit, Hospital Duran I Reynalds, Catalan Institute of Oncology, Hospitalet de Llobregat, Barcelona, Spain
| | - Antoni Mari
- Department of Maxillofacial Surgery, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Maria Vinals
- Department of Plastic and Reconstructive Surgery, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Alicia Lozano
- Department of Radiotherapy, Hospital Duran I Reynalds, Catalan Institute of Oncology, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Ricard Mesia
- Department of Medical Oncology, Catalan Institute of Oncology, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Manel Manos
- Department of Otorhinolaryngology, Bellvitge University Hospital, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain
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Bearelly S, Heaton CM, Seth R, Daniel Knott P. Laryngopharyngeal Repair in Salvage Laryngectomy. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0125-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Freiser ME, Ojo RB, Lo K, Saint-Victor S, Bollig C, Nayak CS, Sargi ZB. Complications and oncologic outcomes following elective neck dissection with salvage laryngectomy for the N0 neck. Am J Otolaryngol 2016; 37:186-94. [PMID: 27178505 DOI: 10.1016/j.amjoto.2016.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/17/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the difference in survival and complication outcomes between patients with a clinically and radiologically N0 neck who received an elective neck dissection at the time of salvage total laryngectomy compared to those who had salvage total laryngectomy alone. MATERIALS AND METHODS A retrospective chart review was performed on 125 salvage total laryngectomy patients who were clinically and radiologically N0 preoperatively. Performance of an elective neck dissection and other factors were tested for associations with various postoperative complications, disease-free survival, and overall survival. RESULTS Ninety-eight patients underwent elective neck dissection, of which ten had positive nodal pathology. Elective neck dissection was not significantly associated with complications or survival outcomes. Positive nodal disease was associated with worse disease-free and overall survival on multivariate analysis. CONCLUSIONS In patients with clinically and radiologically N0 necks undergoing salvage total laryngectomy, an elective neck dissection can provide prognostic information but does not appear to be significantly associated with increased complications or improved survival.
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Affiliation(s)
- Monika E Freiser
- Department of Otolaryngology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 650D, Miami, FL.
| | - Rosemary B Ojo
- Department of Otolaryngology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 650D, Miami, FL.
| | - Kaming Lo
- Biostatistics Collaboration and Consulting Core, Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 N.W. 14th Street, Suite 1049, Miami, FL.
| | - Sandra Saint-Victor
- Department of Otolaryngology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 650D, Miami, FL.
| | - Craig Bollig
- Department of Otolaryngology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 650D, Miami, FL.
| | - Chetan S Nayak
- Department of Otolaryngology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 650D, Miami, FL.
| | - Zoukaa B Sargi
- Department of Otolaryngology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 650D, Miami, FL.
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Pectoralis major myofascial interposition flap prevents postoperative pharyngocutaneous fistula in salvage total laryngectomy. Eur Arch Otorhinolaryngol 2016; 273:3943-3949. [DOI: 10.1007/s00405-016-4049-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
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ZHANG XIANGMIN, LIU FOLIN, LAN XIAOLIN, LUO KEQING, XIAO FUFU, LI SHAOJIN. Continuous negative pressure-flush through a dual tube for the treatment of a complicated pharyngeal fistula: A case report. Oncol Lett 2016; 11:1815-1818. [PMID: 26998082 PMCID: PMC4774409 DOI: 10.3892/ol.2016.4152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 12/10/2015] [Indexed: 11/06/2022] Open
Abstract
The treatment of pharyngeal fistulas is complicated. It is more difficult to deal with pharyngeal fistula following surgical treatment for hypopharynx carcinoma, particularly in cases of pectoralis major muscle flap repair. The present study describes the case of a 56-year-old man who presented with a highly-differentiated pharyngeal squamous cell carcinoma located at the right side of the hypopharynx. The patient underwent a total laryngectomy and a right functional carotid dissection and tracheostomy; this was followed by post-operative radiotherapy. A pharyngeal fistula subsequently developed, but an attempt to repair this with a pectoralis major muscle flap failed. The complicated pharyngeal fistula was treated via continuous negative pressure-flush through a dual tube, without the requirement for incision, daily dressing or antibiotics. The favorable patient outcome represented a positive result, which was also able to reduce the psychological burden of the patient and improve their quality of life.
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Affiliation(s)
- XIANGMIN ZHANG
- Department of Head and Neck Surgery, Ganzhou Tumor Hospital, Ganzhou, Jiangxi 341000, P.R. China
| | - FOLIN LIU
- Institute of Cancer Research, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi 341000, P.R. China
| | - XIAOLIN LAN
- Department of Head and Neck Surgery, Ganzhou Tumor Hospital, Ganzhou, Jiangxi 341000, P.R. China
| | - KEQING LUO
- Department of Head and Neck Surgery, Ganzhou Tumor Hospital, Ganzhou, Jiangxi 341000, P.R. China
| | - FUFU XIAO
- Department of Head and Neck Surgery, Ganzhou Tumor Hospital, Ganzhou, Jiangxi 341000, P.R. China
| | - SHAOJIN LI
- Institute of Cancer Research, Ganzhou Institute of Cancer Research, Ganzhou, Jiangxi 341000, P.R. China
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Guimarães AV, Aires FT, Dedivitis RA, Kulcsar MAV, Ramos DM, Cernea CR, Brandão LG. Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: A systematic review. Head Neck 2015; 38 Suppl 1:E2317-21. [DOI: 10.1002/hed.24248] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- André Vicente Guimarães
- Department of Head and Neck Surgery, Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - Felipe Toyama Aires
- Department of Head and Neck Surgery, Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - Rogério Aparecido Dedivitis
- Department of Head and Neck Surgery, Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | | | - Daniel Marin Ramos
- Department of Head and Neck Surgery; Cancer Institute of São Paulo ICESP; São Paulo Brazil
| | - Claudio Roberto Cernea
- Department of Head and Neck Surgery, Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - Lenine Garcia Brandão
- Department of Head and Neck Surgery, Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
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Pharyngocutaneous fistula after total laryngectomy: a single-institution experience, 2001-2012. Am J Otolaryngol 2015; 36:24-31. [PMID: 25245411 DOI: 10.1016/j.amjoto.2014.08.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/27/2014] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this study was to determine the incidence of and risk factors for pharyngocutaneous fistula in patients undergoing total laryngectomy at a single institution. MATERIALS AND METHODS The records of 59 patients undergoing primary or salvage total laryngectomy at our institution from 2001 to 2012 were retrospectively reviewed. Data collected included patient, tumor and treatment characteristics, and surgical technique. Risk factors were analyzed for association with pharyngocutaneous fistula formation. RESULTS Twenty patients (34%) developed fistulas. Preoperative tracheostomy (OR 4.1; 95% CI 1.3-13 [p=0.02]) and low postoperative hemoglobin (OR 9.1; 95% CI 1.1-78 [p=0.04]) were associated with fistula development. Regarding surgical technique, primary sutured closure of the total laryngectomy defect had the lowest fistula rate (11%). In comparison, primary stapled closure and pectoralis onlay flap over primary closure had nonsignificantly increased fistula rates (43%, OR 6.0; 95% CI 1.0-37.3 [p=0.06] and 25%, OR 2.7; 95% CI 0.4-23.9 [p=0.38], respectively). Pectoralis flap incorporated into the suture line had a significantly increased fistula rate (50%, OR 7.1; 95% CI 1.4-46 [p=0.02]). After stratification for salvage status, patient comorbidities were associated with fistula in non-salvage cases whereas disease-related characteristics were associated with fistula in salvage cases. Fistula development was associated with increased length of hospital stay (p<0.001) and increased time before oral diet initiation (p<0.001). CONCLUSIONS Pharyngocutaneous fistula is a common complication of total laryngectomy. Preoperative tracheostomy, postoperative hemoglobin, and surgical technique are important in determining the risk of fistula.
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Neubauer P, Cañadas K, Sasaki CT. Delayed platysma myocutaneous turnover flap for repair of pharyngocutaneous fistula. Am J Otolaryngol 2015; 36:93-6. [PMID: 25241029 DOI: 10.1016/j.amjoto.2014.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 08/27/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Pharyngocutaneous fistula (PCF) is a common and serious complication after total laryngectomy. Numerous surgical and non-surgical treatment approaches have been described. Here we describe a platysma myocutaneous turnover flap for repair of PCF. MATERIALS AND METHODS Platysma myocutaneous turnover flap is described and two patients are used as examples. RESULTS Repair was initially successful in both patients; however, one patient had recurrence of fistula after her cancer recurred at the stoma. DISCUSSION Numerous surgical techniques have been described for repair of PCF. Here a turnover flap was used, a technique not previously described for this problem. The delay technique enhances the viability of the flap thought to be through numerous mechanisms. CONCLUSION The platysma myocutaneous turnover flap is useful for closure of pharyngocutaneous fistula when non-operative measures have failed.
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Gilbert MR, Sturm JJ, Gooding WE, Johnson JT, Kim S. Pectoralis major myofascial onlay and myocutaneous flaps and pharyngocutaneous fistula in salvage laryngectomy. Laryngoscope 2014; 124:2680-6. [PMID: 25132580 DOI: 10.1002/lary.24796] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 05/10/2014] [Accepted: 06/02/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To review the fistula rate in irradiated patients undergoing salvage laryngectomy, compare the effect of closure type on fistula rate, and examine possible perioperative risk factors that might contribute to an increased fistula rate. STUDY DESIGN Case series with chart review. METHODS We conducted a retrospective review of the University of Pittsburgh head and neck tumor registry and identified 73 patients from 1998 to 2011 who had received prior radiation before total laryngectomy or salvage laryngectomy and who had either primary closure, pectoralis major myofascial (PMMF) flap onlay, or pectoralis major myocutaneous (PMMC) flap. RESULTS Fistula was more common in patients who underwent initial primary closure (45%) than in patients who had immediate PMMF onlay (10.5%). The fistula rate for patients who underwent immediate PMMC flap was 28.6%, intermediate to primary closure and PMMF flap. Several factors were evaluated for relationship to fistula, but no significant associations were identified. However, patients with fistula tended to have longer inpatient stays and may have been more likely to have a history of cardiovascular or hypoxic disease. CONCLUSION Pharyngocutaneous fistula is a well-established complication of total laryngectomy and is especially a concern in patients with a previous history of radiation. Our retrospective review demonstrates that PMMF onlay flap appears to be more effective in reducing the rate of fistula compared to primary closure in these patients. Myocutaneous augmentation flaps, in contrast, have a fairly high fistula rate and may be better replaced with alternative closures such as free flaps. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Mark R Gilbert
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
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Abstract
Squamous cell carcinoma of the larynx continues to be the commonest head and neck cancer in many Western countries. The larynx plays a key role for many essential functions, including breathing, voice production, airway protection, and swallowing. The goals of laryngeal cancer treatment are thus to provide best possible oncologic control, while optimizing functional outcomes. In recent decades, the treatment paradigm for advanced laryngeal cancer has shifted from one of primary surgery (total laryngectomy) as gold standard, toward non-surgical organ-preserving treatment using radiotherapy or chemoradiotherapy. However, concerns have emerged regarding functional outcomes after chemoradiotherapy, as well as possible decreased overall survival in patients with laryngeal cancer. The purpose of the present review is to review surgical and non-surgical options for treatment of advanced laryngeal cancer, as well as the evidence supporting each of these.
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Affiliation(s)
- Carlos Takahiro Chone
- Department of Otolaryngology Head and Neck, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
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Scotton WJ, Nixon IJ, Pezier TF, Cobb R, Joshi A, Urbano TG, Oakley R, Jeannon JP, Simo RS. Time interval between primary radiotherapy and salvage laryngectomy: a predictor of pharyngocutaneous fistula formation. Eur Arch Otorhinolaryngol 2013; 271:2277-83. [DOI: 10.1007/s00405-013-2726-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 09/20/2013] [Indexed: 11/28/2022]
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