Analysis of swallowing after partial frontolateral laryngectomy with epiglottic reconstruction for glottic cancer

Closure without epiglottoplasty or tracheotomy after reconstructive frontal anterior laryngectomy

Reconstructive frontal anterior laryngectomy (RFAL) is a partial laryngeal surgery technique for resecting early-stage (T1-T2) glottic squamous cell carcinoma. Indications comprise a lesion of the anterior commissure of the larynx that cannot be adequately exposed by endoscopy, and cases in which radiotherapy is refused or contraindicated. The initial RFAL technique included epiglottoplasty. Here we propose a technique without epiglottoplasty, with the advantage of avoiding need for tracheotomy in most cases. After the first stage of surgical excision, reconstruction consists in placing a vertical brace transepiglottically and below the cricoid. The epiglottis is thus left at its original height and secured in place to prevent flapping in the pharyngolaryngeal lumen. Transverse bracing is then performed through the thyroid wings: one of the key points of this surgery is to control tension to avoid risk of stenosis. The subhyoid muscles are sutured together to achieve satisfactory sealing. This technique offers satisfying functional results and oncological control. The most frequent complications are (1) secondary tracheotomy, which can be avoided by selecting patients who require a primary tracheotomy and optimizing the seal, and (2) stenosis, which can be limited by not bringing the cartilaginous structures too close together during bracing.

Investigation of swallowing function and swallowing-related quality of life after partial laryngectomy in Chinese patients with laryngeal carcinoma

Background

Swallowing function and swallowing-related quality of life (QoL) can be adversely affected in patients after partial laryngectomy, but are often neglected by patients and clinical workers. This study aimed to investigate the degree of swallowing function and swallowing-related QoL after partial laryngectomy in patients with laryngeal carcinoma.

Methods

Sixty-eight hospitalized patients undergoing partial laryngectomy due to laryngeal carcinoma at the Second Affiliated Hospital of Xi’an Jiao Tong University were included in this prospective study. A general information questionnaire was used to collect baseline characteristics. The water swallow test and swallowing quality of life questionnaire (SWAL-QOL) were carried out the day before surgery and at 2, 4, 12, 24 and 48 weeks after surgery.

Results

Swallowing dysfunction occurred in 1 case (1.5%) the day before surgery and in 49 (72.1%), 44 (64.7%), 33 (49.3%), 19 (28.4%) and 8 (11.9%) cases at 2, 4, 12, 24 and 48 weeks after surgery, respectively. Mean SWAL-QOL total scores were 4266.3 ± 232.0 the day before surgery, and 1992.9 ± 1062.4, 2473.9 ± 962.9, 3169.2 ± 753.6, 3696.7 ± 718.3 and 3910.8 ± 1510.4 at 2, 4, 12, 24 and 48 weeks, respectively. SWAL-QOL total scores increased gradually after operation, and the differences were statistically significant (P < 0.05). There was no statistical difference between postoperative 24 and 48 weeks (P = 0.379).

Conclusions

Partial laryngectomy affects swallowing function and swallowing-related QoL in patients with laryngeal carcinoma. While swallowing function and swallowing-related QoL increase gradually over time, in some patients, nearly a year after surgery they are not fully restored. Therefore, attention should be paid during postoperative nursing to improve swallowing function.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

A pilot study about speech changes after partial Tucker's laryngectomy: the reduction of regressive voicing assimilation

Partial frontolateral laryngectomy (PL) is performed to remove larynx tumor while preserving its main functions. So far, the speech changes induced by difficulties of voicing and the alterations to the vocal tract due to PL have been seldom addressed. The goal of our study was to make an acoustic analysis of regressive voicing assimilation (RVA) among patients after PL and to study the relationship with rates of speech. A retrospective study was conducted from January to April 2013. 11 subjects treated by partial frontolateral laryngectomy, and ten healthy subjects were included. Functional recordings of voice were analyzed and compared. For assimilation sequences we found a significant modification of voicing ratio in healthy subjects (p < 0.05) and PL patient at accelerated speaking rate only (p < 0.05). The vowel duration is significantly modified only for healthy subjects. For all subjects (PL patients and healthy) the duration of C1 consonant was not significantly modified. Our results highlight the presence of RVA in healthy subjects, but also in PL patients in the rapid speaking mode.

Post-surgical and oncologic outcomes of frontal anterior laryngectomy with epiglottic reconstruction: a review of 68 cases

OBJECTIVE

To report post-surgical and oncological outcomes of 68 patients treated with frontal anterior laryngectomy with epiglottic reconstruction.

STUDY DESIGN

Demographic data and all information regarding histopathological grade, initial tumor stage and neck status, follow up time, postoperative complications, nasogastric tube removal time, decannulation time and recurrences were collected from the database and follow-up forms.

SETTING

All patients between 1994 and 2014 who were treated with frontal anterior laryngectomy with epiglottic reconstruction for early glottic carcinoma at Ege University Otolaryngology Clinic were included in the study.

SUBJECTS AND METHODS

Sixty-six of the patients were male and 2 were female with a median age of 57.5 years (IQR 53-63.75, range 44-75). Four patients had a tumor stage of T1a, 43 had T1b and 21 had T2. Median nasogastric tube removal time, decannulation time, overall and disease free survival rates were calculated.

RESULTS

Median nasogastric tube removal time was 10 days. Median decannulation time was 12 days. Median N/G tube removal and decannulation times were higher in T2 patients but this did not reach statistical significance (p>0.05). Median follow-up time was 68.5 months (6-222 months). Five year disease free survival was 93.5%. There were 6 oncologic failures which were salvaged with total laryngectomy, neck dissection and adjuvant radiotherapy.

CONCLUSION

According to our results, which is one of the largest reported FAL with epiglottic reconstruction series in the English literature, this procedure's local control and survival rates are high with good functional results.

[Re-evaluation of 191 larynx cancer surgeries according to the Open Partial Horizontal Laryngectomies classification proposed by European Laryngological Society working committee in 2014]

AIM

of study was to present material of open partial horizontal laryngectomies (OPHL) in T1b, T2 and T3 larynx cancer treatment in single tertiary referral institution.

MATERIAL AND METHODS

Retrospective analysis of operating protocols in patients treated in Poznań ENT University Department between 2000-2012 with glottis (T1b - 185, T2 - 185, T3 - 231) and supraglottis tumors (T1 - 80, T2 - 104, T3 - 206), potentially available for organ preservation treatment. Transoral laser microsurgery, OPHL, radiotherapy and total laryngectomy were treatment options in 210, 191, 271 and 326 patients respectively. OPHL was applied in glottic tumors: 21 - T1b, 103 - T2, 27 - T3 and in supraglottic tumors: 4 - T1, 29 - T2. All procedures were re-evaluated acc. to European Laryngogical Society working committee on nomenclature new classification presented in 2014.

RESULTS

There was no discrepancies in supraglottic laryngectomies (4 cases), classified as OPHL Typ I. All the rest: 84 transglottic, 96 supracricoid with CHEP and 7 supracricoid with CHP laryngectomies were re-classified into Typ II (172) and Type III (15) OPHL. Thus, revision of inferior incision changed classification of procedure into supratracheal laryngectomy in 15 cases. Transglottic laryngectomies, in which upper part of thyroid cartilage was preserved and crito-thyreo-pexy was performed (84 pts), have not been distinguished any more. In 7 cases superior incision included epiglottis; thus 165 patients were distinguished as Typ II a and 7 patients as Typ IIb OPHL. The most pronounced difference was stated in description of structures additionally included into surgical specimen: arytenoid (+ARY) in 24, crico-arytenoid-unit (+CAU) in 5 and piriform sinus (+PIR) in 17 cases; none had the base of tongue (+BOT) resected.

CONCLUSIONS

In 36/191 additional structures and in 15/191 the cricoid ring resection was re-evaluated and pointed out. All these data were available retrospectively in the operating protocols but not pronounced in surgery headlines. Thanks to the univocal, simple new classification all operation details can be included into operation title.