Recovery of postoperative swallowing in patients undergoing partial laryngectomy

Swallowing Function After Treatment of Laryngeal Cancer

Dysphagia is a common functional outcome following treatment of laryngeal cancer. Despite curative advances in both nonsurgical and surgical approaches, preserving and optimizing swallowing function is critical. Understanding the nature and severity of dysphagia depending on initial tumor staging and treatment modality and intensity is crucial. This chapter explores current evidence on the acute and chronic impacts of treatments for laryngeal cancer on swallow function, as well as the medical and nonmedical management of dysphagia in this population.

Oncological and functional impact of adjuvant treatments after open partial laryngeal surgery: a systematic review of the literature and a meta-analysis

BACKGROUND

The oncological and functional role of postoperative radiotherapy (PORT) after open partial laryngeal surgery (OPLS) remains debatable.

METHODS

A systematic review and a meta-analysis of the literature were conducted according to the PRISMA guidelines. Outcomes of patients receiving OPLS with and without PORT for laryngeal cancer were summarized.

RESULTS

In the 10 studies that were included in the meta-analysis, no significant difference emerged in terms of pooled overall survival between OPLS patients who did and who did not receive PORT (- 0.3%, 95% CI - 5.4 to 4.9%, p = 0.922). Only one study showed a significantly higher incidence of complications in the PORT cohort.

CONCLUSIONS

PORT may apparently be performed after OPLS in face of adverse postoperative features without an increased risk of toxicities affecting the neolarynx. Because of the limitations in the available literature, the oncological and functional effects of PORT in this setting needs to be prospectively assessed to strengthen the evidence of this treatment strategy for laryngeal cancer.

Correlating muscle resection with functional swallow outcomes: An anatomic framework informed systematic review of the literature

OBJECTIVE

To perform a systematic review of studies reporting swallow-associated outcomes in patients who received surgery for head and neck cancer (HNC), informed by an anatomic and physiologic framework of pharyngeal phase of swallowing (Pearson's dual-sling model).

METHODS

PUBMED and Google Scholar databases were searched for peer-reviewed papers published between 1990 and 2019 using relevant MeSH terms. Exclusion criteria were 1) discussions comparing reconstruction techniques, 2) case-report/series (n < 10), 3) perspective articles, 4) papers comparing objective instrumental methods of swallowing evaluation, 5) animal/cadaver studies, 6) no instrumental or validated swallow assessment tools used, 7) papers that discuss/include radiotherapy treatment, 8) systematic reviews, 9) papers that discuss swallow training or rehabilitation methods. Two investigators reviewed papers meeting inclusion/exclusions criteria. Muscles resected, anatomic resection site, swallow outcomes, and patient treatment variables were collected.

RESULTS

A total of 115,020 peer-reviewed papers were identified. 74 papers were relevant to this review, 18 met inclusion and exclusion criteria, and none discussed surgical impact on the pharyngeal phase of swallowing using Pearson's dual-sling model. Most papers discussed the effect of tongue-base, supraglottic, or regional anatomic resection. Post-surgical resection Follow-up times ranged from 1 to 13 months. 67% of studies used objective instrumental swallow studies; 22% used patient reported outcome measures. Follow up time since surgical resection, time to feeding tube removal, feeding tube present/absent, aspiration severity were used to define dysphagia endpoints.

CONCLUSIONS

To date, no surgical HNC studies have used the dual-sling mechanism to guide study design, and dysphagia assessment has been inconsistent. To counsel patients on the effects of surgery on pharyngeal phase of swallow function, specialists need physiologically grounded research that correlates muscles resected with consistent measures of swallow function.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Preservation of Internal Branch of Superior Laryngeal Nerve during Surgery for Hypopharyngeal Cancer

OBJECTIVES

This study was performed to evaluate the significance of intraoperative preservation of the internal branch of the superior laryngeal nerve (ibSLN) during surgery for hypopharyngeal squamous cell carcinoma (HSCC).

METHODS

Twelve patients with HSCC underwent surgery between January 2017 and December 2018. Sensation in the hypopharyngeal mucosa was tested using a flexible laryngeal endoscope on postoperative day 5.

RESULTS

Surgeries were successfully performed in 10 patients with HSCC arising from the internal wall of the pyriform fossa and in 2 patients with HSCC arising from the posterior wall of the hypopharynx. The main trunk of the ibSLN was preserved in all patients. Testing of sensation in the hypopharyngeal mucosa revealed the presence of the cough reflex in all patients. All patients achieved a full normal oral diet at a median of 8.5 days (range, 6-11 days) and removal of the tracheal tube at a median of 10 days (range, 7-12 days).

CONCLUSIONS

Our results showed that preservation of the ibSLN during surgery for HSCC is feasible and important in the recovery of sensation in the hypopharyngeal mucosa.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Practice variations in voice treatment selection following vocal fold mucosal resection

OBJECTIVES/HYPOTHESIS

To characterize initial voice treatment selection following vocal fold mucosal resection in a Medicare population.

STUDY DESIGN

Retrospective analysis of a large, nationally representative Medicare claims database.

METHODS

Patients with > 12 months of continuous Medicare coverage who underwent a leukoplakia- or cancer-related vocal fold mucosal resection (index) procedure during calendar years 2004 to 2009 were studied. The primary outcome of interest was receipt of initial voice treatment (thyroplasty, vocal fold injection, or speech therapy) following the index procedure. We evaluated the cumulative incidence of each postindex treatment type, treating the other treatment types as competing risks, and further evaluated postindex treatment utilization using the proportional hazards model for the subdistribution of a competing risk. Patient age, sex, and Medicaid eligibility were used as predictors.

RESULTS

A total of 2,041 patients underwent 2,427 index procedures during the study period. In 14% of cases, an initial voice treatment event was identified. Women were significantly less likely to receive surgical or behavioral treatment compared to men. From age 65 to 75 years, the likelihood of undergoing surgical treatment increased significantly with each 5-year age increase; after age 75 years, the likelihood of undergoing either surgical or behavioral treatment decreased significantly every 5 years. Patients with low socioeconomic status were significantly less likely to undergo speech therapy.

CONCLUSION

The majority of Medicare patients do not undergo voice treatment following vocal fold mucosal resection. Further, the treatments analyzed here appear disproportionally utilized based on patient sex, age, and socioeconomic status. Additional research is needed to determine whether these observations reflect clinically explainable differences or disparities in care.

LEVEL OF EVIDENCE

2c. Laryngoscope, 126:2505-2512, 2016.

Early Oral Feeds in Laryngectomized Patients

Objectives:

It is a common practice to start oral feeding after 7 to 10 days in patients who have undergone laryngeal surgeries. It was our observation that when oral feeds were initiated earlier than this period, there was no increase in the incidence of pharyngocutaneous fistulas. This prospective study is about our experience in initiating early oral feeds in the postoperative period (on the 2nd day) in laryngectomized patients.

Methods:

Seventy-eight patients underwent laryngectomy with or without partial pharyngectomy over a period of 38 months between October 2001 and December 2004. The oral feeds were initiated on the 2nd postoperative day in 40 patients. Thirty-eight patients served as controls in whom feeds were initiated after the 10th postoperative day.

Results:

Only 1 patient in the study group and 2 patients in the control group developed pharyngocutaneous fistulas. Most patients in the control group wished to avoid nasogastric intubation in the recovery period because of discomfort, gastric symptoms, and the need to taste food.

Conclusions:

With this study we can assume that in a select group of patients, it is possible to initiate oral feeding much earlier in the postoperative period than was formerly thought.

Effect of induction chemotherapy on swallow physiology and saliva production in patients with head and neck cancer: a pilot study

BACKGROUND

No objective data are available to assess the potential damage induction chemotherapy alone contributes to swallowing physiology and salivary production in patients with locally and regionally confined head and neck cancer.

METHODS

Thirteen patients with head and neck cancer were evaluated preinduction and postinduction chemotherapy. Assessment included: (1) percentage of nutrition taken orally and food consistencies in diet; (2) videofluorographic swallow evaluation; (3) whole mouth saliva collection; (4) quality-of-life questionnaire; and (5) pain and oral mucositis scores.

RESULTS

All patients were able to consume most foods and took 100% of their nutrition orally both preinduction and postinduction chemotherapy. Although a number of swallow measures worsened, no statistically significant differences were observed in diet, quality of life measures, pain, or saliva weight, or in most temporal swallow measures. Pharyngeal residue decreased significantly after chemotherapy.

CONCLUSION

Induction chemotherapy alone did not significantly negatively alter swallowing physiology and salivary secretion, although the trend was toward worsening in function.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Voice after supracricoid laryngectomy: Subjective, objective and self-assessment data

Supracricoid laryngectomy (SCL) is an efficient surgical procedure for the treatment of selected laryngeal carcinoma, presently being performed not only in Europe but also in North America. The functional goals of the technique are voice and swallowing without a permanent tracheostoma. Perceptual and acoustic voice characteristics after SCL have been reported by different authors, but self-assessment data together with subjective and objective data have only been reported for a small number of subjects. Twenty male subjects, with a mean age of 71 years (range: 51-82 years) who underwent a SCL at least one year before our observation, were included in the study. Each subject underwent a flexible laryngoscopy and his voice was perceptually rated using the GRBAS scale. Objective examination included: maximum phonation time (MPT), voice spectrograms and syllable diadochokinesis on a single breath. Finally, each subject assessed his own voice using the Voice Handicap Index (VHI). The mean values of the GRBAS scale were respectively 2.4, 2.6, 2.4, 0.8, 0.5, 0.8. Mean MPT was 7.5 s, while for voice spectrograms the mean value of the Yanagihara scale was 3.7. Mean syllable diadochokinesis appeared as 3.3 syllables/s. Mean value of the VHI was 29.9. Subjective and objective data show a severely dysphonic voice after SCL; self-assessment data, on the contrary, reveal only moderate functional and emotional consequences. While perceptual, aerodynamic and acoustic data are in line with previous reports, self-assessment data were less severe in our subjects compared to what appears in the literature. It is concluded that self-assessment explores a different dimension of the patient's voice and that even if a severe dysphonia is present the consequences on everyday oral communication are only moderate.

Rehabilitation of dysphagia following head and neck cancer

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.

[Phoniatrics in the rehabilitation for head and neck cancer]

The aim of treating head and neck cancer is to eliminate the tumor and save functions as much as possible. Despite all efforts the vital (swallowing) and communicative (phonation, articulation) functions can be injured. The treatment of dysphagia is the most important in the rehabilitation, because it can lead to fatal complications: aspiration pneumonia (for example aspiration of saliva), dehydration, malnutrition. According to the localization of the lesion we distinguish oropharyngeal and esophageal dysphagia. The aspiration may be pre-, intra- and post-deglutition. The aspiration without coughing is called silent aspiration which is mainly seen in neurogenic dysphagia, but can also happen in head and neck cancer patients. There are different possibilities to compensate the failing functions in the phoniatric rehabilitation. The swallowing therapy includes causal, compensatory and dietary strategies. In addition to the swallowing therapy the treatment of communicative dysfunctions with articulation exercises will also improve the quality of life of the patients.

Long-term voice and swallowing modifications after supracricoid laryngectomy: objective, subjective, and self-assessment data

PURPOSE

The supracricoid laryngectomies (SCLs) are conservative surgical techniques for the treatment of selected laryngeal carcinomas. The advantage of SCL is that a permanent tracheostoma is not required, thus, maintaining the principal laryngeal functions. The aim of the study is to report objective, subjective, and self-assessment long-term results of voice and swallowing in a large group of patients who underwent SCL at least 2 years before this study was undertaken.

METHODS

Twenty male subjects who underwent SCL with a mean age of 71 years (range, 51-82) were involved in a retrospective study on swallowing and vocal function. Videoendoscopic ratings were taken of neoglottic vibration patterns and bolus transit. The maximum phonation time and the syllable diadochokinesis were measured. Spectrograms were recorded. Voices were perceptually rated using the Grade, Instability, Roughness, Breathiness, Asthenicity, Strain (GIRBAS) scale. All of the subjects completed a self-assessment questionnaire for both voice and swallowing.

RESULTS

Videoendoscopic ratings showed moderate to severe impairment of neoglottal vibration, whereas bolus transit appeared only mildly impaired. The mean values of the GIRBAS scale were 2.4, 2.6, 2.4, 0.8, 0.5, and 0.8. The mean maximum phonation time was 7.5 seconds, whereas the mean value of the Yanagihara scale was 3.7 for voice spectrograms. Mean syllable diadochokinesis appeared as 3.3 syllables per second. Voice and swallowing quality of life questionnaires revealed satisfied patients.

CONCLUSIONS

Swallowing after SCL was satisfactory; on the contrary, endoscopic, aerodynamic, perceptual, and acoustic data showed a highly dysphonic voice after SCL. However, self-assessment results revealed relatively satisfied speakers on the emotional, physical, and functional levels.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

Purpose

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials.

Methods

A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors.

Results

Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated.

Recommendations

All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Extended and standard supraglottic laryngectomies: a review of 110 patients

The purpose of this study was to compare functional and oncological results of extended and standard supraglottic laryngectomies. One hundred ten patients with supraglottic carcinoma were treated. A standard supraglottic laryngectomy (SSL), a laterally extended supraglottic laryngectomy (LESL) and an anteriorly extended supraglottic laryngectomy (AESL) were performed on 32, 47 and 31 patients, respectively. Indications for postoperative radiotherapy included positive surgical margins (23% of patients) and/or node metastasis (63% of patients). Local recurrence occurred in 13% of SSL, 15% of LESL and 17% of AESL patients. Pulmonary complications due to aspiration were observed in 6% of SSL, 15% of LESL and 19% of AESL. The overall 5-year cure rates were 63% for SSL, 45% for LESL and 47% for the AESL procedures. Extended supraglottic laryngectomies provided as good a local tumor control as SSL. Extension to the hypopharynx (LESL) and to the vallecula (AESL) showed more frequent pulmonary complications and reduced cure rates.

Dysphagia

Dysphagia is a common complaint that always warrants investigation. The patient's history and preliminary testing can help differentiate between the two types of dysphagia: oropharyngeal or esophageal. Specific treatments for either of these types of dysphagia depend on the underlying etiology. Oropharyngeal dysphagia is often associated with a neuromuscular disorder and is treated with swallowing rehabilitation. Esophageal dysphagia is usually due to an anatomic defect or a motility disorder. Anatomic defects can often be corrected with endoscopic or surgical procedures. Motility disorders often benefit from pharmacologic treatment. Achalasia may be corrected with an endoscopic procedure with pneumatic dilation or, more recently, with injection of botulinum toxin.

Predictive values for aspiration after endoscopic laser resections of malignant tumors of the hypopharynx and larynx

BACKGROUND

CO2-laser surgery is a relatively new treatment for selected carcinomas of the upper aerodigestive tract. The purpose of our study was to evaluate prospectively the functional results for swallowing after CO2-laser resections.

METHODS

The sample was composed of 210 consecutive patients with malignancies of the larynx and hypopharynx treated with CO2 laser between February 1998 and January 2002. Endoscopic resections included all T1 and T2 tumors and selected T3 and T4 tumors. T1 glottic tumors were not included in the analysis. We assessed the need for a feeding tube and the period the tube remained in place, aspiration pneumonia, tracheotomy secondary to aspiration, the need for a permanent or temporary gastrostomy, and total laryngectomy secondary to aspiration.

RESULTS

The nasogastric feeding tube was used in 23.2% of small tumors (2.5 +/- 8.04 days) and in 63% of locally advanced tumors (13.95 +/- 22.55 days). Frequency and period of storage of the feeding tube were higher in locally advanced tumors (p=.0001). Twelve patients (5.7%) had postoperative pneumonia and 59 (28.1%) had temporary postoperative cough during oral intake. Aspiration symptoms correlated with location (p=.001) and locally advanced tumors (p=.016). Eight patients (3.8%) needed a postoperative tracheotomy for severe swallowing difficulties; six (2.9%) of them were definitive and two (0.95%) temporary. Thirteen gastrostomies (6.2%) were performed to avoid severe aspirations; five of them were definitive. The need for gastrostomy correlated significantly with location (p=.002), pT3 and pT4 tumors (p=.002), age (p=.02), and postoperative radiotherapy (p=.04). No correlation was found with the period of feeding tube (p=.38), or aspiration pneumonia (p=.24).

CONCLUSIONS

Endoscopic resection of laryngeal and hypopharyngeal tumors is associated with good recovery of deglutition. Many tracheotomies are avoided, the need for a feeding tube is usually reduced, and organ preservation is often feasible even in locally advanced tumors.

Partial laryngectomy after irradiation failure

INTRODUCTION

Radiation therapy is often the first method of treating patients with early cancer of the glottis. There is a substantial failure rate among these patients. Total laryngectomy has usually been the means of treating patients with failure after radiation. In recent decades, partial laryngectomy has been used for salvage in such patients. This article will discuss the use of partial laryngectomy for radiation failure both from the oncologic result as well as the morbidity.

PATIENTS AND METHODS

Between 1984 and 1995, 27 patients with early-stage laryngeal carcinoma underwent salvage partial laryngectomy after irradiation failure. Vertical laryngectomy was performed in 18 patients (13 with T1 N0 and 5 with T2 N0) and horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 with T2 N0, and 5 with T2 N1). The mean follow-up was 4.1 years.

RESULTS

Local control was obtained in 77.7% of patients with glottic lesions (T1: 84.6%; T2: 60%, P = NS) and in 55.5% of patients with supraglottic lesions (T1: 66.6%; T2: 50%; P = NS). There was no regional recurrence in the vertical laryngectomy group, whereas the regional control rate in the horizontal-supraglottic laryngectomy group was 77.7%. Distant control was achieved in 94.4% of patients with glottic disease and in 77.7% of patients with supraglottic disease. The overall survival rate for glottic lesions was 88.8% (T1: 92.3%; T2: 80%; P = NS) versus 66.6% for supraglottic lesions (T1: 100%; T2: 50%; P = NS).

CONCLUSION AND SIGNIFICANCE

Vertical laryngectomy was not associated with an increased complication rate. Morbidity in the horizontal-supraglottic laryngectomy group was higher, but a satisfactory functional outcome was obtained in all cases. Therefore, in early laryngeal cancer (glottic T1-T2, supraglottic T1) partial laryngectomy can be performed with good expectation of cure and satisfactory laryngeal function. In T2 supraglottic lesions, the oncologic results are less satisfactory; further research is required for developing more efficient complimentary or alternative treatments modalities.

Organ preservation surgery for laryngeal cancer

The open organ preservation surgical procedures are an important part of the head and neck surgeon's armamentarium for treating laryngeal cancer. The principles of organ preservation surgery as they apply to laryngeal cancer must be thoroughly appreciated and strictly applied for oncologic and functional success. The selection of eligible patients for these procedures is an art and requires a keen clinical acumen. The vertical partial laryngectomy and supraglottic laryngectomy have defined clinical applications that are relatively well accepted. The supracricoid laryngectomy continues gaining acceptance as a means of treating more extensive glottic and transglottic lesions while maintaining physiologic speech and swallowing without the need for a permanent tracheostoma. The inability to include and use the open surgical organ preservation approaches in the organ preservation paradigm for larynx cancer severely limits the patient's treatment options. Total laryngectomy and medical organ preservation protocols may not be acceptable to the patient from a quality-of-life standpoint. Therefore, it is incumbent upon the head and neck surgeon to have a thorough understanding of all the options available for treatment in the organ preservation paradigm for laryngeal cancer. These options must be skillfully evaluated as they relate to the patient's disease process and confidently used to provide the best oncologic and functional outcome.

Swallow function and perception of dysphagia in patients with head and neck cancer

BACKGROUND

The relationship between subjective complaints of dysphagia and objective measures of swallow function in patients with cancers of the oral cavity, pharynx, or larynx, treated with radiotherapy +/- chemotherapy has not been well documented in the literature.

METHODS

Swallowing function in 132 patients with various lesions was evaluated using videofluoroscopy and analyzed by patient complaint of dysphagia grouping.

RESULTS

Patients with complaints of dysphagia demonstrated significantly worse swallow function as indicated by lower oropharyngeal swallow efficiency (OPSE), longer transit times, larger residues, and more swallows with aspiration. Patients with complaints of dysphagia also tended to take less of their nutrition by mouth and less variety of food consistencies in their diet compared with those without complaint.

CONCLUSIONS

Patients were able to perceive decrements in their swallowing function as dysphagia and may have limited their oral intake in response to that perception. The ability to accurately perceive swallowing function may be useful for self-monitoring changes in dysphagia status during a course of swallow therapy.

Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection

PURPOSE

To present the results of radiotherapy with or without neck dissection for squamous cell carcinoma of the supraglottic larynx treated at the University of Florida and to compare these data with those obtained after conservation surgery.

METHODS AND MATERIALS

Continuous-course radiotherapy alone or combined with a planned neck dissection was used to treat 274 patients with squamous cell carcinoma of the supraglottic larynx between 1964 and 1998. All patients had follow-up for a minimum of 2 years, and 250 (91%) had follow-up for 5 years or more.

RESULTS

At 5 years, the actuarial probability of local control after radiotherapy according to T stage was as follows: T1, 100%; T2, 86%; T3, 62%; and T4, 62%. The probability of cause-specific survival at 5 years by AJCC stage was as follows: stage I, 100%; II, 93%; III, 81% IVA, 50%; and IVB, 13%. The risk of severe late complications was 4%. Of 57 patients undergoing planned postradiotherapy neck dissection, 7% experienced a severe complication.

CONCLUSIONS

On the basis of our data and the literature, early or moderately advanced supraglottic carcinomas may be treated successfully with either supraglottic laryngectomy or radiotherapy. Supraglottic laryngectomy probably produces a higher initial local control rate but, based on anatomic and coexisting medical constraints, is suitable for a smaller subset of patients and has a higher risk of complications compared with radiotherapy.

Avaliação dos resultados da cirurgia conservadora do câncer da laringe

OBJETIVO: Avaliar retrospectivamente os resultados de pacientes submetidos a laringectomias parciais por carcinoma epidermóide de laringe no serviço do HMCP. MÉTODOS: Dos doentes estudados, 28 eram do sexo masculino (93,5%) e dois do feminino (6,5%) com idade variável de 42 a 66 anos, com média de 58 anos. Em relação ao procedimento cirúrgico, este foi variável, dependendo do local da extensão tumoral e do estádio. A técnica mais utilizada foi a laringectomia frontolateral em 12 pacientes (40%), seguido pela laringectomia vertical em oito (26,6%), laringectomia supraglótica em quatro (13,3%), laringectomia supracricóidea em quatro (13,3%), laringectomia near-total em um (3,3%) e cordectomia em um (3,3%). RESULTADOS: Na avaliação pós-operatória precoce, três pacientes (10%) apresentaram complicações evidenciadas por fístula faringocutâneas em dois, com boa evolução após tratamento conservador, e pneumotórax no paciente restante com boa evolução após drenagem do tórax. No que se refere à avaliação da deglutição, cinco pacientes (16,6%) apresentaram dificuldade de ingestão oral devido a aspirações recorrentes com tempo variável de 45 a 180 dias (média - 65 dias), o que obrigou a um paciente ser submetido à totalização da laringectomia devido a pneumonias recorrentes. Na avaliação tardia, de seis a 125 meses e média de 29 meses, quatro pacientes (13,3%) apresentaram recidiva locorregional, sendo dois submetidos à laringectomia vertical, um à frontolateral e o restante à supracricóidea. Em todos foram realizadas totalização e/ou radioterapia, e dois evoluíram a óbito pela doença. Vinte e quatro pacientes (84%) apresentaram preservação da voz. CONCLUSÃO: Assim, os autores concluem que a cirurgia conservadora da laringe proporciona bom controle da doença e com sobrevida aceitável, já que 90% dos pacientes estudados estão vivos e sem doença até o final da avaliação. Além disso, apresentam melhor qualidade de vida já que a maioria dos pacientes demonstrou voz e ingestão oral bem satisfatórias.

Management of swallowing in supraglottic and extended supraglottic laryngectomy patients

BACKGROUND

Aspiration of food and liquid following supraglottic and supracricoid laryngectomy has been documented and found to be the most frequent major postoperative complication that extends hospitalization. The advantages as well as disadvantages of discharging a patient with percutaneous endoscopic gastrostomy (PEG) placement and home therapy versus an aggressive in-hospital dysphagia management program remain controversial. The present investigation examines an aggressive in-patient postoperative dysphagia management program following decannulation.

METHODS

Twenty-one patients participated in a four-part dysphagia management program following decannulation: patient education, indirect therapy, swallowing evaluation, and nutrition education.

RESULTS

Eleven patients achieved functional swallowing goals prior to discharge with no reports of pneumonia or rehospitalization over a 3-month follow-up period. Six patients were discharged with a tracheostomy and duo tube; five of these patients were started on an oral diet the same day of decannulation. Four patients decannulated prior to discharge did not achieve functional swallowing.

CONCLUSION

Certain patients can achieve functional swallowing goals prior to discharge and avoid the cost and surgical placement of a PEG. This group required an additional 2 to 3 days of hospitalization; however, the usual and customary charges for aggressive dysphagia management in this group were exceeded by charges for PEG placement and in-home therapy according to pricing guidelines for the hospital where these patients were treated. Specific patient profiles of those who were unsuccessful relate to extent of surgery, ie, supraglottic + base of tongue (SUPRA + BOT) and supraglottic + vocal fold (SUPRA + VF) resection, and non-compliance. Complicated patients often require longer rehabilitation and may benefit from a PEG at the time of surgery.

Pretreatment swallowing function in patients with head and neck cancer

BACKGROUND

Few objective data characterizing the pretreatment swallow function of patients with head and neck cancer are available.

METHODS

Pretreatment swallowing function in 352 patients with various lesions was evaluated with videofluoroscopy and compared with control subjects.

RESULTS

Patients had significantly longer oral and pharyngeal transit times, greater amounts of oral and pharyngeal residue, shorter cricopharyngeal opening durations, and lower swallow efficiencies. Swallow function worsened significantly with increased tumor stage, and patients with oral or pharyngeal lesions had worse swallow function than patients with laryngeal lesions. Frequency of complaint of swallow difficulty before treatment was 59%. Patients with lower stage tumors had fewer complaints of swallowing, as did patients with oral cavity lesions.

CONCLUSIONS

Despite demonstrating significant differences from control subjects, patients had highly functional swallows before treatment. The tendency for patients not to perceive a swallowing problem is consistent with the highly functional nature of their pretreatment swallow.

How Do head and neck cancer patients prioritize treatment outcomes before initiating treatment?

PURPOSE

To determine, pretreatment, how head and neck cancer (HNC) patients prioritize potential treatment effects in relationship to each other and to survival and to ascertain whether patients' preferences are related to demographic or disease characteristics, performance status, or quality of life (QOL).

PATIENTS AND METHODS

One hundred thirty-one patients were assessed pretreatment using standardized measures of QOL (Functional Assessment of Cancer Therapy-Head and Neck) and performance (Performance Status Scale for Head and Neck Cancer). Patients were also asked to rank a series of 12 potential HNC treatment effects.

RESULTS

Being cured was ranked top priority by 75% of patients; another 18% ranked it second or third. Living as long as possible and having no pain were placed in the top three by 56% and 35% of patients, respectively. Items that were ranked in the top three by 10% to 24% of patients included those related to energy, swallowing, voice, and appearance. Items related to chewing, being understood, tasting, and dry mouth were placed in the top three by less than 10% of patients. Excluding the top three rankings, there was considerable variability in ratings. Rankings were generally unrelated to patient or disease characteristics, with the exception that cure and living were of slightly lower priority and pain of higher priority to older patients compared with younger patients.

CONCLUSION

The data suggest that, at least pretreatment, survival is of primary importance to patients, supporting the development of aggressive treatment strategies. In addition, results highlight individual variability and warn against making assumptions about patients' attitudes vis-à-vis potential outcomes. Whether patients' priorities will change as they experience late effects is currently under investigation.

Patients' priorities among treatment effects in head and neck cancer: evaluation of a new assessment tool

BACKGROUND

Patients with head and neck cancer may face decisions between surgery or radiation (with or without chemotherapy) which involve significant trade-offs in functional outcomes. This preliminary investigation is designed to examine patients' priorities among the effects of treatments for head and neck cancer.

METHODS

A new instrument designed to allow patients to rank personal priorities among 12 treatment effects was developed and tested. A cross section of patients (19) from pretreatment and posttreatment time periods and 23 controls participated.

RESULTS

Preliminary findings indicate high individual variability, with some differences between groups according to treatment time. Differences between patients and controls are evident. We report test-retest reliability and the limitations of this new tool.

CONCLUSIONS

The data suggest that measures of health state values should be conducted with patients rather than healthy volunteers. Patients' priorities may be influenced by treatment and some values may be more susceptible to change with experience of treatment effects. This new tool may provide insight into how patients' prioritize the anticipated and experienced effects of treatment for head and neck cancers.

Carbon dioxide laser microsurgery for early supraglottic carcinoma

Forty-eight untreated patients with early supraglottic carcinoma (12 patients stage I and 36 patients stage II) had primary carbon dioxide laser microsurgery between 1979 and 1994 with the intent of complete tumor removal with preservation of functionally important structures of the larynx. Ninety-six percent of the patients were treated exclusively by surgery; 4% had laser microsurgery and postoperative radiotherapy. With a median follow-up of 55 months, the 5-year local control rate with the first treatment was 100% for pT1 cases and 89% for pT2 cases. The ultimate local control rate with voice preservation, including patients successfully salvaged after a local recurrence, was 97% for pT2 carcinomas. Five (10%) patients died of tumor (TNM)-related deaths. The 3-year recurrence-free rate and 3-year overall survival rate (Kaplan-Meier) were 87% and 85%; the 5-year recurrence-free rate and 5-year overall survival rate were 83% and 76%, respectively. The results achieved with transoral laser microsurgery in early supraglottic carcinoma are comparable to those of open supraglottic laryngectomy with respect to local control and survival. The functional results are superior, since clinically relevant aspiration did not occur.

A prospective quality of life study of patients with laryngeal carcinoma by tumor stage and different radiation therapy schedules

This study was designed to prospectively monitor the quality of life of laryngeal cancer patients, to compare the quality of life of patients with small tumors with that of patients with large tumors, and to test any quality of life difference in patients with small tumors treated with conventional versus hyperfractioned accelerated radiation therapy. Patients having had a laryngectomy within the study year were also analyzed separately. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30), the EORTC Head and Neck Module (H&N-37), and the Hospital Anxiety and Depression (HAD) scale were administered six times during 1 year. These questionnaires were found to be suitable for measuring laryngeal cancer patients' quality of life longitudinally. The questionnaires were sensitive to differences in quality of life for small versus large tumors and showed that hyperfractioned accelerated radiation therapy was advantageous compared with conventional radiation therapy with respect to quality of life at the 1-year follow-up.

Prognostic factors for swallowing rehabilitation following head and neck cancer surgery

Thirty-two head and neck surgical patients with prolonged moderate to severe aspiration were assessed with videoendoscopic and videofluoroscopic swallowing studies to reveal all components of dysphagia and aspiration. All patients received functional swallowing therapy, and 75% of the patients regained full oral intake diet. The duration of non-oral feeding varied widely. The outcome of swallowing rehabilitation (success or failure, duration of non-oral feeding) was statistically correlated with preoperative tumour stage, patients' age, therapy onset, severity of aspiration and the results of the videofluoroscopic measurements of oral and pharyngeal transit time, pharyngeal delay time, duration of laryngeal closure and cricopharyngeal opening, hyoid and laryngeal elevation, presence or absence of a stenosis at the pharyngoesophageal segment. The following factors proved to be statistically significant for the prognostic estimate of swallowing rehabilitation: preoperative tumour stage, therapy onset, and severity of aspiration. For postoperative swallow recovery, an early therapy onset after thorough diagnostics with videoendoscopic and videofluoroscopic swallowing studies is recommended. Videofluoroscopic measurements will yield some prognostic estimate of oropharyngeal dysphagia and aspiration. Videoendoscopy, by it's availability and immediacy, proved to be useful for monitoring the course of rehabilitation.

Conservative management of T1-T2N0 supraglottic cancer: a retrospective study

PURPOSE

Evaluate the results of conservative management of early-stage supraglottic cancer.

PATIENTS AND METHODS

A retrospective analysis of 166 consecutive T1-T2N0 cases of squamous cell carcinoma of the supraglottic larynx, treated conservatively between 1983 and 1992, was performed. Sixty-six patients received conservative surgery (CS), whereas 100 patients received definitive radiation therapy (RT). Surgical procedures included horizontal supraglottic laryngectomy in 38 patients, extended supraglottic laryngectomy in 16 patients, and reconstructive laryngectomy with cricohyoidopexy in 12 patients. Elective bilateral neck dissection was always performed. Radiotherapy was delivered with 60Co or 6 MV photons to the primary laryngeal tumor and the upper and mid neck nodes (level II and III), whereas supraclavicular nodes (level IV) were electively irradiated only in 54 patients with T2N0 tumors. Fifty-two patients received conventional fractionation, whereas 31 patients were irradiated according to a twice-a-day fractionation regimen. The median total tumor dose was 67 Gy (range, 64 to 72 Gy).

RESULTS

The 5-year overall survival of the whole series was 72.7% +/- 4.5. In patients treated with CS, the 5-year disease-free survival was 88.4% +/- 4.5 versus 76.4% +/- 6.1 for patients who received RT. Salvage surgery was effective in rescuing 2 of 3 CS failures and 12 of 25 RT failures. The overall incidence of secondary tumors (11%) and distant metastases (5%) was relatively low, although together they account for 15% of all deaths. Complications of CS were significantly correlated to the extent of surgical procedure. A multivariate analysis performed in the RT group showed that performance status, tumor grade, and fractionation regimen significantly influenced disease-free survival.

CONCLUSION

Conservative management of T1-T2N0 supraglottic cancer, either by CS or RT, can achieve good cure rates with larynx preservation for the majority of the patients (82% overall; 95% in the CS group and 72% in the RT group). The decision between different conservative treatment modalities may be influenced by the patient's conditions, tumor characteristics, treatment modalities, and also economic costs.

Functional outcome and prognosis factors after supracricoid partial laryngectomy with cricohyoidopexy

A retrospective analysis of the medical records and operative files of 124 patients who consecutively underwent supracricoid partial laryngectomy with cricohyoidopexy (SCPL-CHP) was undertaken. The objective of this study was to analyze the postoperative course and functional results of SCPL-CHP. The mean duration of follow-up was 7 years (range 1 to 20 years). The postoperative mortality was 1.6%. The average times until tracheostomy and nasogastric feeding tube removal were 8 and 22 days, respectively. All patients but 1 were decannulated. The rate of pneumonia from aspiration was 11.5%. Completion total laryngectomy and permanent gastrostomy were required in 2.5% and 2.5% of patients, respectively. Overall normal swallowing without permanent gastrostomy and respiration without tracheostomy were achieved by the first postoperative year in 91% and 99.1% of patients, respectively. Univariate analysis of the potential correlation between various variables and the duration of the tracheostomy and nasogastric feeding tube, the incidence and causes of mortality, the incidence and type of the various complications, the recovery of swallowing, and the length of hospitalization is presented. The report also discusses the management and follow-up care.

Longitudinal assessment of quality of life in laryngeal cancer patients

BACKGROUND

Although quality of life (QL) and performance status are important outcomes in head and neck (HN) cancer, there is little systematic inclusion of these parameters in treatment trials.

METHODS

Rate and recovery of function were evaluated over a 6-month period in 21 laryngeal cancer patients, 7 in each of 3 treatment groups: total laryngectomy (group 1), hemilaryngectomy (group 2), and radiotherapy only (group 3). Assessment included Performance Status Scale for Head and Neck Cancer Patients (PSS-HN: Diet, Speech, and Eating in Public subscales) and the FACT-HN, a multidimensional QL measure.

RESULTS

Groups differed in patterns of performance recovery over time in expected directions. Group 1 recovered most slowly, without achieving normal functioning by 6 months; most of group 2 returned to normal functioning by 3 months; group 3 showed little overall dysfunction. There was no difference in overall QL between groups or over time. Performance status was significantly correlated with the FACT head and neck subscale and somewhat with the Physical subscale. In contrast, ability to eat and/or speak was not associated with overall QL nor with any other specific QL dimension (eg, emotional or social well-being).

CONCLUSIONS

Results support the sensitivity and applicability of two site-specific performance/QL measures: PSS-HN and FACT-HN. Findings also emphasize the need to employ multidimensional tools to adequately evaluate the nonmedical outcomes in head and neck patients.

Radiotherapy for squamous cell carcinoma of the supraglottic larynx: an alternative to surgery

BACKGROUND

The purpose of this article is to present the results of radiotherapy with or without neck dissection for squamous cell carcinoma of the supraglottic larynx at the University of Florida and to compare these data with those obtained after conservation surgery.

METHODS

Continuous-course radiotherapy alone or combined with a planned neck dissection was used to treat 209 patients with 211 supraglottic carcinomas between 1964 and 1992; all patients had follow-up for > or = 2 years.

RESULTS

The 5-year rates of local control after radiotherapy were as follows: T1, 100%; T2, 83%; T3, 68%; and T4, 56%. Tumor volume, as calculated on pretreatment computed tomography (CT) scan, and vocal cord mobility influenced the likelihood of local control.

CONCLUSIONS

Based on our data and the literature, early or moderately advanced supraglottic carcinomas may be treated successfully with either supraglottic laryngectomy or radiotherapy. Supraglottic laryngectomy probably produces a higher initial local control rate but, based on anatomic and coexisting medical constraints, is suitable for a smaller subset of patients and has a higher risk of complications compared with radiotherapy.

Mechanisms of recovery of swallow after supraglottic laryngectomy

This study examines oropharyngeal swallow disorders and measures of pharyngeal and laryngeal movement during deglutition from videofluorographic studies of oropharyngeal swallow in 9 patients who had undergone supraglottic laryngectomy and 9 age-matched normal subjects. The swallows of surgical patients were examined at 2 weeks and 3 months postoperatively. Two critical factors in recovery of swallowing were identified: (a) airway closure at the laryngeal entrance, that is, the space between the arytenoid cartilage and the base of the tongue, and (b) the movement of the tongue base to make complete contact with the posterior pharyngeal wall. When patients achieved these two functions, they returned to normal swallowing. The duration of tongue base contact to the posterior pharyngeal wall and extent of anterior movement of the arytenoid increased significantly from 2 weeks to 3 months in the surgical patients. At 2 weeks postsurgery, patients who had undergone supraglottic laryngectomy exhibited significantly shorter airway closure and tongue base to pharyngeal wall contact, reduced laryngeal elevation, increased width of cricopharyngeal (CP) opening, and later onset of airway closure and tongue base movement than normal subjects. These significant differences remained at 3 months postoperatively, although swallow measures were moving toward normal in the patients who had undergone supraglottic laryngectomy. Comparison of patients not eating at 2 weeks with patients at the time of first eating revealed significantly longer duration of tongue base contact to the pharyngeal wall, longer duration of airway closure, and greater movement of the arytenoid in patients who were eating. Results indicate that the focus of swallowing therapy after supraglottic laryngectomy should be on improvement of posterior movement of the tongue base and anterior tilting of the arytenoid to close the airway entrance and improve bolus propulsion (in the case of the tongue base).