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Vasudevan SS, Zulli A, Olinde L, Pang J, Nathan CAO, Asarkar AA. Survival Outcomes of Transoral Microsurgery in T3/T4a Laryngeal Tumors: Systematic Review and Meta-Analysis. Laryngoscope 2024. [PMID: 39140205 DOI: 10.1002/lary.31695] [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: 05/13/2024] [Revised: 07/17/2024] [Accepted: 07/30/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE To critically evaluate oncological and functional outcomes following transoral laser microsurgery (TLM) in patients with T3/T4a glottic and supraglottic squamous cell carcinoma (SCC). DATA SOURCES A comprehensive search of five major databases-PubMed, Embase, Scopus, ScienceDirect, and Web of Science-was conducted using a combination of relevant keywords and MeSH terms. REVIEW METHODS Systematic review and meta-analysis of odds ratio (OR), hazards ratio (HR), and proportion, focusing on oncological and functional outcomes of TLM in advanced T3/T4a glottic and supraglottic tumors. A random-effects meta-analysis model was employed. RESULTS The review incorporated 29 cohort studies, representing a total of 1,897 patients undergoing TLM for T3/T4a glottic and supraglottic SCC. The cumulative 5-year disease-free survival (DFS) rate for T3 glottic and supraglottic tumors was 44.4% (95% CI: 47-66%) and 62.8% (95% CI: 63-81%), while the 5-year DFS for T4 glottic and supraglottic tumors was 41.1% (95% CI: 33.4-49.2%) and 32.9% (95% CI: 19.3-50.1%), respectively. T3 glottic tumors exhibited a 2.5-fold significantly higher odds of local recurrence post-TLM compared to their T3 supraglottic tumors (95% CI: 1.6-3.9, p < 0.0001). Laryngeal preservation rates for T3glottic and supraglottic tumors were 68.9% (95% CI: 48.7-83.8%) and 88.4% (95% CI: 79.4-93.8%), respectively. Both groups showed comparable rates of tracheostomy (p = 0.48) and gastrostomy performed (p = 0.17). CONCLUSIONS This meta-analysis suggests that TLM is a viable larynx preservation approach in select patients with T3/T4a glottic and supraglottic tumors. However, glottic tumors may have less favorable outcomes after TLM compared to those with advanced supraglottic tumors. LEVEL OF EVIDENCE N/A Laryngoscope, 2024 Laryngoscope, 2024.
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Affiliation(s)
- Srivatsa Surya Vasudevan
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Adam Zulli
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Lindsay Olinde
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - John Pang
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Cherie-Ann O Nathan
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Surgery, Overton Brooks Veterans Administration Medical Center, Shreveport, Louisiana, USA
| | - Ameya A Asarkar
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Müderris T, Sevil E, Gül F. Transoral robotic supraglottic laryngectomy: Long-term functional and oncologic outcomes. Am J Otolaryngol 2024; 45:104105. [PMID: 37977058 DOI: 10.1016/j.amjoto.2023.104105] [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: 07/23/2023] [Revised: 10/17/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES Minimally invasive transoral organ preservation surgeries are being increasingly used for supraglottic tumors. This study investigates the long-term functional and oncologic outcomes of transoral robotic supraglottic laryngectomy (TORS-SGL). MATERIALS AND METHODS Twenty-three patients with supraglottic laryngeal cancer who underwent TORS-SGL between 2012 and 2015 at a tertiary referral hospital were retrospectively analyzed with at least 5 years of follow-up. The head and neck tumor council and the multidisciplinary oncological board decided whether the patients were suitable for robotic surgery, and the necessity of adjuvant radiotherapy or chemotherapy. Inclusion criteria was histopathological diagnosis of squamous cell carcinoma of the larynx. RESULTS Twenty-one patients with T1-T3 supraglottic squamous cell carcinoma were included in this study. Mean follow-up was 48.8 months. Local control was 94.4 % at 2 years and 85.9 % at 5 years. Disease-free survival and overall survival were 85.7 % and 81 % at 2 years and 69.3 % and 57.1 % at 5 years, respectively. There was no permanent tracheostomy or prolonged swallowing dysfunction among patients. Age, perineural and lymphovascular invasion were found to be risk factors affecting overall survival. CONCLUSION TORS-SGL is a feasible, safe and reliable approach with excellent functional results for T1, T2, and selected T3 supraglottic tumors, providing acceptable long-term oncologic results when compared to alternative treatment modalities.
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Affiliation(s)
- Togay Müderris
- Izmir Bakırçay University Faculty of Medicine, Department of Otorhinolaryngology, Head and Neck Surgery, Izmir, Turkey.
| | - Ergün Sevil
- Alaaddin Keykubat University Faculty of Medicine, Department of Otorhinolaryngology, Head and Neck Surgery, Antalya, Turkey
| | - Fatih Gül
- Ankara Yıldırım Beyazıt University Faculty of Medicine, Department of Otorhinolaryngology, Head and Neck Surgery, Ankara, Turkey
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Kim BH, Ryu HG, Mun SJ, Lim YS, Shin JW, Jung YH. Prediction of anterior commissure exposure of vocal folds prior to laryngeal microscopic surgery: Parameters reflecting occipito-atlanto-axial complex extension capacity. Auris Nasus Larynx 2020; 47:458-463. [PMID: 32044181 DOI: 10.1016/j.anl.2020.01.006] [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: 09/15/2019] [Revised: 12/28/2019] [Accepted: 01/21/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this prospective study was to identify preoperative predictors of unstable exposure of vocal folds with focus on the anterior commissure (AC) prior to Laryngeal Microscopic Surgery. METHODS AND MATERIALS Patients were classified into four groups based on the degree of AC exposure during Laryngeal Microscopic Surgery, and for the analysis, these groups were subdivided into unstable exposure and stable exposure subgroups depending on whether external manipulation was required to achieve AC exposure. Correlation of the degree of AC exposure with demographics, physical measurements, and anatomical measurements taken using landmarks in simple radiograph were evaluated. Receiver operating characteristic curve analysis was used to determine optimal cutoff values to predict unstable AC exposure. RESULTS Fifty-nine patients were included in the analyses. Thyroid-mandible angle (TMA) in the extended position, thyroid-mental distance (TMD) ratio, and TMA difference in the neutral and extended positions were significantly correlated with the degree of AC exposure. However, only a TMD ratio of <1.25 reliably predicted unstable AC exposure. CONCLUSIONS TMD ratio of <1.25 reliably predicted unstable AC exposure. If there is no increase of the distance between the thyroid notch and the mental prominence (TMD) more than 25% on neck extension, the probability of getting stable exposure of the anterior commissure is low.
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Affiliation(s)
- Bo Hae Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sue Jean Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Yun-Sung Lim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Jung Woo Shin
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Young Ho Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
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Upregulation of microRNA-141 suppresses epithelial-mesenchymal transition and lymph node metastasis in laryngeal cancer through HOXC6-dependent TGF-β signaling pathway. Cell Signal 2019; 66:109444. [PMID: 31629025 DOI: 10.1016/j.cellsig.2019.109444] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/14/2019] [Accepted: 10/14/2019] [Indexed: 11/23/2022]
Abstract
Laryngeal cancer is one of the most malignant cancers among the head and neck malignant tumors. Abnormal expression of microRNAs (miRNAs) contributes to cancer development through regulating proliferation and apoptosis of cancer cells. In this study, we aim to explore the roles of microRNA-141 (miR-141), Homeobox C6 (HOXC6) and TGF-β signaling pathway in epithelial-mesenchymal transition (EMT) and lymph node metastasis in laryngeal cancer. Initially, we identified differentially expressed genes in laryngeal cancer, among which HOXC6 was identified. Then the target miRNA of HOXC6 was predicted and verified. Next, expression of miR-141, HOXC6, TGF-β1, Smad3, Vimentin and Snail in cancer tissues was detected. Then, AMC-HN-8 cells were transfected with miR-141 mimic, miR-141 inhibitor and HOXC6-siRNA to investigate specific role of miR-141, HOXC6 and TGF-β signaling pathway in laryngeal cancer in vivo and in vitro. Our results showed that HOXC6 was a target gene of miR-141, which was downregulated in laryngeal cancer. Besides, overexpression of miR-141 could downregulate HOXC6 and inhibit the TGF-β signaling pathway. Upregulation of miR-141 or silencing of HOXC6 can repress EMT, viability, migration and invasion abilities of laryngeal cancer cells. In addition, upregulation of miR-141 inhibited the tumor growth and lymph node metastasis in vivo. In summary, our findings demonstrated that upregulated miR-141 decreased HOXC6 expression, and inhibited the TGF-β signaling pathway, EMT and lymph node metastasis in laryngeal cancer, which is of clinical significance in the treatment of laryngeal cancer.
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Retraction. Am J Physiol Cell Physiol 2019; 317:C627. [PMID: 38894492 DOI: 10.1152/ajpcell.00291.2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Chang BA, Lott DG, Nagel TH, Howard BE, Hayden RE, Hinni ML. Outcomes Following Transoral Laser Microsurgery With Resection of Cartilage for Laryngeal Cancer. Ann Otol Rhinol Laryngol 2019; 128:978-982. [DOI: 10.1177/0003489419851521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction:The ability to treat more advanced laryngeal cancers by transoral approaches has expanded significantly in the past several decades. Transoral management of laryngeal cancers that require removal of the laryngeal framework is controversial. Resecting cartilage through endoscopic means carries inherent technical challenges and the question of oncologic safety.Methods:We describe a retrospective review of patients undergoing resection of the thyroid cartilage during transoral laser microsurgery (TLM) for laryngeal cancer over a 10-year period. Only patients with 5-year follow-up were included.Results:Fourteen patients were identified that underwent attempted endoscopic resection of the thyroid cartilage. Preoperative staging ranged from T1 to T4 laryngeal cancers. Most patients underwent resection of the thyroid cartilage either for close proximity of the tumor to cartilage or microscopic involvement of the inner perichondrium, although 6 patients had gross invasion of the cartilage. Twelve patients underwent successful endoscopic clearance. Two patients were converted to total laryngectomy either at the time of surgery or shortly after due to extent of disease that was deemed not amenable to endoscopic resection. Overall 5-year survival was 71%. Disease-free survival was 62% at 5 years. The majority of patients avoided gastrostomy and tracheostomy tube dependence. One patient underwent total laryngectomy following initial TLM for chronic aspiration.Conclusion:We conclude that TLM for laryngeal cancer performed with removal of thyroid cartilage is feasible. Both oncologic and functional outcomes are reasonable in a select group of patients. This paper describes that cartilage can be resected endoscopically in the appropriate setting and not necessarily that cartilage invasion should routinely be treated with TLM.
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Affiliation(s)
- Brent A. Chang
- Department of Otolaryngology/Head & Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - David G. Lott
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Thomas H. Nagel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Brittany E. Howard
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Richard E. Hayden
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Michael L. Hinni
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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Meta-analytic comparison of robotic and transoral laser surgical procedures in supraglottic carcinoma. J Laryngol Otol 2019; 133:404-412. [DOI: 10.1017/s0022215119000707] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveTo assess published reports of oncological surgical success rates in patients who underwent transoral laser supraglottic surgery and robotic surgery for supraglottic cancer.MethodsA systematic review of the literature was conducted and a meta-analysis of published data was performed. PubMed, Sage, Medline and Cochrane data sources were investigated. Overall survival rates, disease-specific survival rates, additional treatments and recurrence rates were investigated to determine the success of the surgical procedures.ResultsThe meta-analysis included 24 studies; 1617 studies were excluded. There were no statistically significant differences between the transoral laser supraglottic surgery and transoral robotic supraglottic surgery groups in terms of overall survival (77.0 per cent and 82.4 per cent respectively) and disease-specific survival (75.8 per cent and 87.0 per cent respectively). There was recurrence in 164 out of 832 patients (19.7 per cent) in the transoral laser supraglottic surgery group and in only 6 out of 66 patients (9 per cent) in the transoral robotic supraglottic surgery group.ConclusionTransoral laser surgery and robotic surgery appear to have comparable and acceptable oncological success rates.
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Vilaseca I, Nogués-Sabaté A, Avilés-Jurado FX, Berenguer J, Grau JJ, Verger E, Nadal A, Muxí A, Bernal-Sprekelsen M, Blanch JL. Factors of local recurrence and organ preservation with transoral laser microsurgery in laryngeal carcinomas; CHAID decision-tree analysis. Head Neck 2018; 41:756-764. [DOI: 10.1002/hed.25422] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/09/2018] [Accepted: 09/24/2018] [Indexed: 12/27/2022] Open
Affiliation(s)
- Isabel Vilaseca
- Otolaryngology Department; Hospital Clínic; Barcelona Spain
- Head Neck Clínic; Agència de Gestió d'Ajuts Universitaris i de Recerca; Barcelona Catalunya Spain
- Institutd'Investigacions Biomèdiques Agusti Pi Sunyer (IDIBAPS); Barcelona Spain
- Faculty of Medicine; University of Barcelona; Barcelona Spain
| | - Anna Nogués-Sabaté
- Otolaryngology Department; Hospital Clínic; Barcelona Spain
- Head Neck Clínic; Agència de Gestió d'Ajuts Universitaris i de Recerca; Barcelona Catalunya Spain
| | - Francesc Xavier Avilés-Jurado
- Otolaryngology Department; Hospital Clínic; Barcelona Spain
- Head Neck Clínic; Agència de Gestió d'Ajuts Universitaris i de Recerca; Barcelona Catalunya Spain
- Institutd'Investigacions Biomèdiques Agusti Pi Sunyer (IDIBAPS); Barcelona Spain
- Faculty of Medicine; University of Barcelona; Barcelona Spain
| | - Joan Berenguer
- Institutd'Investigacions Biomèdiques Agusti Pi Sunyer (IDIBAPS); Barcelona Spain
- Faculty of Medicine; University of Barcelona; Barcelona Spain
- Radiology Department; Hospital Clínic; Barcelona Spain
| | - Juan José Grau
- Head Neck Clínic; Agència de Gestió d'Ajuts Universitaris i de Recerca; Barcelona Catalunya Spain
- Institutd'Investigacions Biomèdiques Agusti Pi Sunyer (IDIBAPS); Barcelona Spain
- Faculty of Medicine; University of Barcelona; Barcelona Spain
- Oncology Department; Hospital Clínic; Barcelona Spain
| | - Eugenia Verger
- Faculty of Medicine; University of Barcelona; Barcelona Spain
- Radiotherapy Department; Hospital Clínic; Barcelona Spain
| | - Alfons Nadal
- Faculty of Medicine; University of Barcelona; Barcelona Spain
- Pathology Department; Hospital Clínic; Barcelona Spain
| | - Africa Muxí
- Faculty of Medicine; University of Barcelona; Barcelona Spain
- Nuclear Medicine Department; Hospital Clínic; Barcelona Spain
| | - Manuel Bernal-Sprekelsen
- Otolaryngology Department; Hospital Clínic; Barcelona Spain
- Faculty of Medicine; University of Valencia; Valencia Spain
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Piazza C, Filauro M, Paderno A, Marchi F, Perotti P, Morello R, Taboni S, Parrinello G, Incandela F, Iandelli A, Missale F, Peretti G. Three-Dimensional Map of Isoprognostic Zones in Glottic Cancer Treated by Transoral Laser Microsurgery as a Unimodal Treatment Strategy. Front Oncol 2018; 8:175. [PMID: 29872643 PMCID: PMC5972218 DOI: 10.3389/fonc.2018.00175] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/04/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction The Union for International Cancer Control–American Joint Committee on Cancer TNM staging system for glottic squamous cell carcinoma (SCC) includes different types of lesions defined by the involvement of specific subsites in each T category. Our study aims to identify different subcategories according to tumor local extension and determine oncologic outcomes after treatment by transoral laser microsurgery (TLM) alone. Methods We retrospectively evaluated 410 patients affected by previously untreated pT1-pT3 glottic SCC treated by TLM alone from January 2005 to December 2015 at the Departments of Otorhinolaryngology—Head and Neck Surgery, Universities of Genoa and Brescia, Italy. All patients had at least 2 years of follow-up. Clinical, radiological, surgical, and histopathological data were reviewed and tumors divided into six subcategories: I, pT1a not involving the anterior commissure (AC); II, pT1b involving the AC; III, pT2 extending superficially to the supraglottis or the subglottis; IV, pT2 infiltrating the vocal muscle; V, pT3 involving the anterior paraglottic space; VI, pT2 or pT3 with vertical extension across the AC with/without involvement of the pre-epiglottic space. Recurrence-free survival (RFS), local control with laser alone (LCL), and organ preservation (OP) were defined as the primary oncologic outcomes. Results The 2, 5, and 10-year RFS for the entire series were 85.7, 80.3, and 73.8%, LCL rates 93.8, 92.1, and 89.6%, and OP rates 96.8, 95.9, and 93.5%, respectively. However, when comparing the rates of RFS, LCL, and OP for each subcategory, important differences emerged. In particular, subcategories V and VI showed a significantly increased risk of local recurrence [hazard ratio (HR) = 9.2 and 13.3, respectively]. These subcategories also had a significantly reduced probability to achieve LCL (HR: 73.6 and 93.5, respectively) and OP (HR: 6.4 and 8.1, respectively). Conclusion The present classification in subcategories allows introducing the concept of a three-dimensional map of isoprognostic zones in glottic SCC treated by TLM alone as a useful tool in its management by a multidisciplinary tumor board.
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Affiliation(s)
- Cesare Piazza
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Marta Filauro
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Alberto Paderno
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy.,Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Filippo Marchi
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Pietro Perotti
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Riccardo Morello
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Stefano Taboni
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Giampiero Parrinello
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Fabiola Incandela
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy.,Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Andrea Iandelli
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Francesco Missale
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Giorgio Peretti
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
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Succo G, Crosetti E, Bertolin A, Piazza C, Molteni G, Cirillo S, Petracchini M, Tascone M, Sprio AE, Berta GN, Peretti G, Presutti L, Rizzotto G. Treatment for T3 to T4a laryngeal cancer by open partial horizontal laryngectomies: Prognostic impact of different pathologic tumor subcategories. Head Neck 2018; 40:1897-1908. [DOI: 10.1002/hed.25176] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 11/27/2017] [Accepted: 02/15/2018] [Indexed: 11/07/2022] Open
Affiliation(s)
- Giovanni Succo
- Head and Neck Oncology Service, Oncology Department; University of Turin, Candiolo Cancer Institute - FPO; IRCCS Candiolo (To) Italy
| | - Erika Crosetti
- Head and Neck Oncology Service, Oncology Department; University of Turin, Candiolo Cancer Institute - FPO; IRCCS Candiolo (To) Italy
| | - Andy Bertolin
- Otolaryngology Service, Vittorio Veneto Hospital; Vittorio Veneto; Treviso Italy
| | - Cesare Piazza
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Brescia; Brescia Italy
| | - Gabriele Molteni
- Otolaryngology Service, Head and Neck Department, Policlinico Hospital; University of Modena; Italy
| | - Stefano Cirillo
- Radiology Service; Mauriziano Umberto I Hospital; Turin Italy
| | | | - Martina Tascone
- Head and Neck Oncology Service, Oncology Department; University of Turin, Candiolo Cancer Institute - FPO; IRCCS Candiolo (To) Italy
| | - Andrea Elio Sprio
- Department of Clinical and Biological Sciences; University of Turin; Italy
| | | | - Giorgio Peretti
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Genoa; Genoa Italy
| | - Livio Presutti
- Otolaryngology Service, Head and Neck Department, Policlinico Hospital; University of Modena; Italy
| | - Giuseppe Rizzotto
- Otolaryngology Service, Vittorio Veneto Hospital; Vittorio Veneto; Treviso Italy
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Ambrosch P, Gonzalez-Donate M, Fazel A, Schmalz C, Hedderich J. Transoral Laser Microsurgery for Supraglottic Cancer. Front Oncol 2018; 8:158. [PMID: 29868479 PMCID: PMC5954241 DOI: 10.3389/fonc.2018.00158] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/25/2018] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Transoral laser microsurgery (TLM) is an accepted and effective treatment strategy for supraglottic carcinomas. Early supraglottic carcinoma has excellent outcomes independently of the treatment approach. The role of TLM for the treatment of locally advanced tumors is debated. Particularly, the functional outcomes after TLM have to be proven by functional assessment of large cohorts of patients. This study analyzes the oncologic and functional outcomes after TLM for supraglottic carcinomas. PATIENTS AND METHODS Ninety-one patients with pT1-pT4a supraglottic carcinomas treated between January 2002 and December 2012 were analyzed. Distribution of tumors (UICC 2010) was 11 patients with pT1, 31 patients with pT2, 36 patients with pT3, and 13 patients with pT4a tumors. Node status was positive in 40 (43.6%) patients; 61 (67.1%) patients had stage III or IVa disease. Local control and survival were estimated using the Kaplan-Meier method. For the assessment of functional outcomes, the MD Anderson Dysphagia Inventory (MDADI), the Voice Handicap Index-10 (VHI-10), and the performance status scale for head and neck cancer [Performance Status Scale for Head and Neck (PSS-HN)] were used. RESULTS The median age was 62 years (range, 33-88 years). Fourteen (15.4%) patients developed a local or locoregional recurrence. The 5-year local control rate and 5-year ultimate local control rate were 72 and 92%, respectively. The 5-year overall survival rate was 63%. Twelve (13.2%) patients needed temporary tracheostomy. Sixty-eight (74.0%) patients had a nasogastric feeding tube post-operatively. At 1-year post-operative follow-up, only three patients were PEG dependent. The median VHI-10 score was 35, the median MDADI composite score was 80, and the median score of the domain "normalcy of diet" in the PSS-HN was 91. CONCLUSION The oncologic outcomes are comparable to the results of open surgery for early and advanced supraglottic carcinomas. Functional swallowing outcome is superior to open surgery and to concomitant chemoradiation. Patients treated with TLM perceive low levels of voice- and swallowing-related quality of life impairment.
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Affiliation(s)
- Petra Ambrosch
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Mireia Gonzalez-Donate
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Asita Fazel
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Claudia Schmalz
- Department of Radiation Oncology, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Jürgen Hedderich
- Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, Kiel, Germany
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Kim BH, Park SJ, Jeong WJ, Ahn SH. Comparison of Treatment Outcomes for T3 Glottic Squamous Cell Carcinoma: A Meta-Analysis. Clin Exp Otorhinolaryngol 2018; 11:1-8. [PMID: 29486540 PMCID: PMC5831661 DOI: 10.21053/ceo.2017.00717] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/06/2017] [Accepted: 09/08/2017] [Indexed: 11/22/2022] Open
Abstract
Objectives This study compared the survival outcomes, local control rate, and laryngeal preservation rate of various treatment strategies in the treatment of T3 squamous cell carcinoma of the glottis using proportional meta-analyses. Methods Twenty-five retrospective case-series studies were included in these analyses. Treatment strategies were classified as total laryngectomy (TL), open partial laryngectomy (PL), transoral laser microsurgery (TLM), chemo-radiation therapy (CRT), and radiation therapy (RT) alone. Results The overall survival rate and disease-specific survival rate among laryngeal preservation treatments did not differ from the overall survival rate of TL. However, the local control rate was lower with RT than TL and PL, and laryngeal preservation rates of TLM and CRT were higher than RT alone. Conclusion Consideration of preservation of laryngeal function is necessary when treating T3 glottic squamous cell carcinoma. PL, TLM, and, CRT are considered more appropriate initial laryngeal preservation strategies if available.
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Affiliation(s)
- Bo Hae Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Dongguk University Gyeongju Hospital, Gyeongju, Korea
| | - Sung Joon Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soon-Hyun Ahn
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea
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Bozkurt G, Ünsal Ö, Çelebi İ, Ayhan B, Guliyev U, Akova P, Başak T, Coşkun BU. Does CT help in predicting preepiglottic space invasion in laryngeal carcinoma? Auris Nasus Larynx 2017; 45:546-552. [PMID: 28807527 DOI: 10.1016/j.anl.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/08/2017] [Accepted: 07/06/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Evaluating preepiglottic space involvement in laryngeal cancer by CT may lead misinterpretation. We sought to understand the causes of misinterpretation in evaluating the preepiglottic space by CT and assessed the effects of misinterpretation in treatment plans of patients with laryngeal squamous cell carcinomas. METHODS Specimen histopathology reports of 102 (99 male, 3 female) patients who underwent total or partial laryngectomy due to supraglottic and/or transglottic laryngeal carcinoma were reviewed. Neck CTs were also re-assessed for preepiglottic space involvement by three radiologists. The initial surgical treatment choices were re-examined according to the current radiological evaluation in combination with pathological results of the specimens and physical examination findings in the patients. Interobserver agreement regarding image interpretation was based on a kappa analysis. RESULTS The interclass correlation coefficient in predicting preepiglottic space invasion was 0.74; this was considered 'good.' Among the three radiologists, sensitivity, specificity, accuracy of CT in detecting preepiglottic space involvement were 86-93%, 75-93%, and 77-93%, respectively, while the negative and positive predictive values were 97-98% and 38-50%, respectively. Given the previous treatments applied, false-positive diagnoses for PES involvement resulted in overtreatment in 2.9% of cases. False-negative diagnoses of PES involvement (1.9% of cases) did not result in any undertreatment. CONCLUSIONS Although CT is a practical and inexpensive imaging tool for evaluating laryngeal carcinomas, the PPV of CT in assessing preepiglottic space invasion, especially in advanced tumors, is low and may lead to overtreatment.
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Affiliation(s)
- Gülpembe Bozkurt
- Department of Otolaryngology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey.
| | - Özlem Ünsal
- Department of Otolaryngology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - İrfan Çelebi
- Department of Radiology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Burak Ayhan
- Department of Radiology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Umman Guliyev
- Department of Radiology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Pınar Akova
- Department of Otolaryngology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Tülay Başak
- Department of Pathology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Berna Uslu Coşkun
- Department of Otolaryngology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
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Piazza C, Paderno A. Conservative Surgical and Non-surgical Options in Management of T3 Laryngeal Cancer. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017. [DOI: 10.1007/s40136-017-0155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Reasonable limits for transoral laser microsurgery in laryngeal cancer. Curr Opin Otolaryngol Head Neck Surg 2016; 24:135-9. [PMID: 26963672 DOI: 10.1097/moo.0000000000000240] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Transoral laser microsurgery (TLM) is widely acknowledged to offer several advantages in the treatment of early and selected intermediate-advanced laryngeal cancers. Nevertheless, a number of issues are still under debate. The purpose of this review is to discuss the reasonable limits for TLM in laryngeal cancer to highlight its most appropriate and reproducible indications, putting this therapeutic tool in the right perspective within a comprehensive frame of alternative treatment strategies such as open partial laryngectomies and nonsurgical organ preservation protocols. RECENT FINDINGS Inadequate laryngeal exposure, anterior commissure involvement in the cranio-caudal plane (T2), invasion of the posterior paraglottic space with arytenoid fixation, massive infiltration of the preepiglottic space, and even minor thyroid cartilage erosion (T3) represent the most controversial applications of TLM in management of glottic and supraglottic cancer. SUMMARY Published oncological results appear to be satisfactory when TLM is applied to T1-T2 and accurately selected T3 glottic and supraglottic cancers with favourable exposure. Caution should be used for more advanced tumours.
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16
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Wiegand S. Evidence and evidence gaps of laryngeal cancer surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 15:Doc03. [PMID: 28025603 PMCID: PMC5169076 DOI: 10.3205/cto000130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Susanne Wiegand
- Department of Otolaryngology, Head & Neck Surgery, University Hospital of Leipzig, Germany
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17
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Kuan EC, Alonso JE, Tajudeen BA, Arshi A, Mallen-St Clair J, St John MA. Small cell carcinoma of the head and neck: A comparative study by primary site based on population data. Laryngoscope 2016; 127:1785-1790. [PMID: 27859290 DOI: 10.1002/lary.26406] [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: 07/31/2016] [Revised: 09/07/2016] [Accepted: 10/07/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Small cell carcinoma (SmCC) of the head and neck is an extremely rare neuroendocrine malignancy. In this study, we describe the incidence and determinants of survival of patients with SmCC of the head and neck between the years of 1973 and 2012 using the Surveillance, Epidemiology, and End Results database as differed by primary site. STUDY DESIGN Retrospective, population-based cohort study. METHODS A total of 237 cases of SmCC of the head and neck were identified, which was divided into sinonasal primaries (n = 82) and all other head and neck primaries (n = 155). Clinicopathologic and epidemiologic variables were analyzed as predictors of overall survival (OS) and disease-specific survival (DSS) based on the Kaplan-Meier method. RESULTS More than half of sinonasal primaries presented with Kadish stage C or D. On multivariate analysis, surgery was the only independent predictor of improved DSS (P = .008) for sinonasal primaries; in contrast, radiation therapy was a favorable prognosticator for OS (P = .007) and DSS (P = .043) in extrasinonasal sites. Comparison of survival between sinonasal primaries and all other sites demonstrated that sinonasal SmCC had uniformly better OS (P = .002) and DSS (P = .006). CONCLUSIONS SmCC in the head and neck remains rare, and sinonasal primaries appear to have improved survival compared to other sites. Based on these results, optimal treatment for sinonasal SmCC appears to be surgical therapy, whereas radiation therapy is the preferred treatment for SmCC of other primary sites, particularly the larynx. LEVEL OF EVIDENCE 4. Laryngoscope, 127:1785-1790, 2017.
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Affiliation(s)
- Edward C Kuan
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Jose E Alonso
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Bobby A Tajudeen
- Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Jon Mallen-St Clair
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco Medical Center, San Francisco, California, U.S.A
| | - Maie A St John
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, U.S.A.,Jonsson Comprehensive Cancer Center, University of California, Los Angeles Medical Center, Los Angeles, California, U.S.A.,University of California, Los Angeles Head and Neck Cancer Program, University of California, Los Angeles Medical Center, Los Angeles, California, U.S.A
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18
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Riga M, Chelis L, Danielides V, Vogiatzaki T, Pantazis TL, Pantazis D. Systematic review on T3 laryngeal squamous cell carcinoma; still far from a consensus on the optimal organ preserving treatment. Eur J Surg Oncol 2016; 43:20-31. [PMID: 27320417 DOI: 10.1016/j.ejso.2016.05.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/12/2016] [Accepted: 05/26/2016] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The optimal treatment of patients with T3 laryngeal carcinoma is controversially challenged by open partial laryngectomies (OPL), transoral laser microsurgery (TLM) and radiation therapy alone (RT) or combined with chemotherapy (ChRT). Treatment guidelines, experts' opinions and clinical studies are highly contradictory. The aim of this study is to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies. METHODS A review of the literature published in the time period 2003-2015 was conducted via the PubMed database (www.pubmed.org) and Scopus database (www.scopus.com) with the search terms "T3 laryngeal squamous cell cancer treatment". Data from clinical studies involving patients with T3 laryngeal cancer (n > 10) subjected to TLM, OPL, ChRT or RT, were pooled. In the absence of controlled studies, prospective and retrospective clinical trials with minimum 5-year follow-up were acceptable, provided that they included a description of patient eligibility criteria, so as to exclude studies with serious selection bias. RESULTS Literature lacks studies with homogenous populations regarding TNM staging, preoperative/postoperative treatment or anatomical subsite. This raises substantial controversies and prohibits the conduction of a meta-analysis. Data for qualitative analysis were pooled from 8 studies (n = 1226). OPL and TLM both offer patients high survival and organ preservation rates. Preoperative induction chemotherapy seems to significantly compromise overall survival. CONCLUSIONS Multicenter studies referring to homogenous populations, at least regarding staging and anatomical subsite, are needed. No safe conclusions can be drawn given the heterogeneity in patient cohorts, study design and evaluation of results in the existing literature.
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Affiliation(s)
- M Riga
- University Otorhinolaryngology Department, Democritus University of Thrace, University Hospital of Evros, Alexandroupolis, Greece.
| | - L Chelis
- Department of Clinical Oncology, University Hospital of Evros, Alexandroupolis, Greece
| | - V Danielides
- University Otorhinolaryngology Department, Democritus University of Thrace, University Hospital of Evros, Alexandroupolis, Greece
| | - T Vogiatzaki
- Department of Anesthesiology, Democritus University of Thrace, University Hospital of Evros, Alexandroupolis, Greece
| | - T-L Pantazis
- Otorhinolaryngology Department, Thriasion General Hospital of Athens, Greece
| | - D Pantazis
- Otorhinolaryngology Department, Thriasion General Hospital of Athens, Greece
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Peretti G, Piazza C, Penco S, Santori G, Del Bon F, Garofolo S, Paderno A, Guastini L, Nicolai P. Transoral laser microsurgery as primary treatment for selected T3 glottic and supraglottic cancers. Head Neck 2016; 38:1107-12. [DOI: 10.1002/hed.24424] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Giorgio Peretti
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Genoa; Genoa Italy
| | - Cesare Piazza
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Brescia; Brescia Italy
| | - Sara Penco
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Genoa; Genoa Italy
| | - Gregorio Santori
- Department of Surgical Sciences and Integrated Diagnostics; University of Genoa; Genoa Italy
| | - Francesca Del Bon
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Brescia; Brescia Italy
| | - Sabrina Garofolo
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Genoa; Genoa Italy
| | - Alberto Paderno
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Brescia; Brescia Italy
| | - Luca Guastini
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Genoa; Genoa Italy
| | - Piero Nicolai
- Department of Otorhinolaryngology - Head and Neck Surgery; University of Brescia; Brescia Italy
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20
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Schindler A, Pizzorni N, Mozzanica F, Fantini M, Ginocchio D, Bertolin A, Crosetti E, Succo G. Functional outcomes after supracricoid laryngectomy: what do we not know and what do we need to know? Eur Arch Otorhinolaryngol 2015; 273:3459-3475. [DOI: 10.1007/s00405-015-3822-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
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21
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Schroeder U, Wollenberg B, Bruchhage KL. [The value of supracricoid partial laryngectomy in moderately advanced laryngeal cancer (T3-T4a)]. HNO 2015; 63:741-6. [PMID: 26452490 DOI: 10.1007/s00106-015-0071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Transoral laser microsurgery (TLM) is the method of choice for partial laryngectomy in Germany. In advanced stages, chemoradiotherapy is increasingly indicated for organ preservation. OBJECTIVE This report considers the indications for and outcomes of supracricoid partial laryngectomy (SPL), also known as crico-hyoido-(epiglotto)-pexy, as an option for surgical organ preservation in moderately advanced laryngeal cancer (T3-T4a), in the well-defined gap between TLM and chemoradiotherapy protocols in Germany. METHODS Retrospective evaluation of functional and oncological outcomes of all SPLs conducted between 2008 and 2014. During this period, 17 SPLs with resection of rpT2 (n = 2), (r)pT3 (n = 11), and (r)pT4a (n = 4) were performed with resection of one arytenoid. Mean age was 58 years (range 47-75 years). In 5 patients, SPL was for a first or second local recurrence after TLM or open partial laryngectomy. Adjuvant radiotherapy was received by 7 patients staged pT4a or pN+. RESULTS Salvage laryngectomy with adjuvant radiotherapy was required by 2 patients. The remaining patients (n = 15) had a mean tumor-free follow-up of 4 years with a functional intact larynx: these patients can eat and drink, have a closed tracheotomy, and a good voice. After 3 years tumor-free follow-up with a functional intact larynx, 2 patients died due to cardiac comorbidity at the age of 76 years. DISCUSSION SPL is a rare but valuable option for surgical larynx preservation in stage pT3-4a laryngeal cancer.
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Affiliation(s)
- U Schroeder
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig Holstein, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - B Wollenberg
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig Holstein, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - K L Bruchhage
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig Holstein, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
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