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Evangelista L, Nativ-Zeltzer N, Bewley A, Birkeland AC, Abouyared M, Kuhn M, Cates DJ, Farwell DG, Belafsky P. Functional Laryngectomy and Quality of Life in Survivors of Head and Neck Cancer With Intractable Aspiration. JAMA Otolaryngol Head Neck Surg 2024; 150:335-341. [PMID: 38451502 PMCID: PMC10921343 DOI: 10.1001/jamaoto.2024.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/15/2024] [Indexed: 03/08/2024]
Abstract
Importance Late effects of head and neck cancer (HNC) treatment include profound dysphagia, chronic aspiration, and death. Functional laryngectomy (FL) can improve patient survival and quality of life (QoL); however, removing a failing larynx for a noncancer reason is a difficult decision. Data regarding the ability of FL to improve self-perceptions of voice, swallowing, and QOL in survivors of HNC with intractable aspiration are inconclusive. Objective To investigate the association of FL with changes in self-reported perceptions of voice, swallowing, oral intake, QoL, and mood in survivors of HNC experiencing profound dysphagia and intractable aspiration. Design, Settings, and Participants This cohort study was conducted at a single academic institution and included survivors of HNC with profound swallowing dysfunction and intractable aspiration who underwent FL from July 2016 through March 2022. Of the initial 22 patients enrolled, 2 patients (15%) died of aspiration pneumonia before receiving FL. Data analyses were performed from July 2016 through March 2023. Main Outcomes and Measures Self-reported measures of voice using the VHI (30-item Voice Handicap Index), swallowing using the EAT-10 (10-item Eating Assessment Tool), functional oral intake scale using the FOIS (Functional Oral Intake Scale), and quality of life using the FACT-H&N (Functional Assessment of Cancer Therapy-Head & Neck) were assessed before FL and at 1, 3, and 6 months after FL. Mood states were evaluated using the POMS (Profile of Mood States, second edition), before FL and at 6 months after FL. Results The study analyses included 20 patients (mean [SD] age, 72.4 (7.0) years; 19 [95%] males and 1 [5%] female) who underwent FL and had complete data across all time points. Among these, 12 patients (60%) had received chemoradiation for oropharyngeal, 7 (35%) for laryngeal, or 1 (5%) for nasopharyngeal cancer. The mean (SD) time from completion of oncologic treatment to FL was 15.5 (5.5) years. Mean (SD) score on the EAT-10 improved from 33.2 (7.4) to 23.1 (10.8) at 1 month; 12.1 (9.1) at 3 months; and 8.3 (7.4) at 6 months, with a large effect size (η2 = 0.72; 95% CI, 0.54-0.80). Mean (SD) score on the FOIS improved from 2.0 (1.5) to 2.9 (1.7) at 1 month; 4.8 (2.5) at 3 months; and 5.2 (1.7) at 6 months, with a large effect size (η2 = 0.6; 95% CI, 0.38-0.71). Improvement in oral intake was achieved in 19 patients (95%), and feeding tubes were removed in 10 of 16 patients (63%) who were feeding tube-dependent; 6 patients (27%) continued to require supplemental tube feedings. Mean (SD) score on the VHI improved from 63.6 (34.0) to 86.9 (33.7) at 1 month; 71.3 (36.1) at 3 months; and 39.7 (26.9) at 6 months, with a large effect size (η2 = 0.42; 95% CI, 0.19-0.56). Seventeen patients (85%) were able to use a tracheoesophageal voice prosthesis for alaryngeal communication. Mean (SD) score on the FACT-H&N improved from 86.2 (17.8) to 93.6 (18.4) at 1 month; 109.0 (18.4) at 3 months; and 121.0 (16.8) at 6 months, with a large effect size (η2 = 0.64; 95% CI, 0.42-0.74). Mean (SD) score on the POMS improved from 58.9 (13.2) at baseline to 44.5 (9.9) at 6 months, with a large effect size (Cohen d = 1.04; 95% CI, 0.48-1.57). None of the patients experienced major complications of FL; 1 patient (5%) had a postoperative pharyngocutaneous fistula. Conclusions and Relevance The findings of this cohort study indicate that FL was associated with marked improvements in self-perception of voice and swallowing, functional oral intake, QoL, and mood state among survivors of HNC. These findings can serve as a framework for FL counseling among HNC survivors experiencing profound dysphagia and intractable aspiration.
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Affiliation(s)
- Lisa Evangelista
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Nogah Nativ-Zeltzer
- Department of Communication Disorders, Tel Aviv University, Tel Aviv, Israel
| | - Arnaud Bewley
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Andrew C. Birkeland
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Marianne Abouyared
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Maggie Kuhn
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Daniel J. Cates
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - D. Gregory Farwell
- Department of Otolaryngology–Head & Neck Surgery, Hospital of the University of Pennsylvania
| | - Peter Belafsky
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
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Reale M, Bardon ML, Ciavarro G, Pedrazzi G, Santoro GP. Value and role of surgical margins in transoral laser microsurgery of the larynx, literature review and clinical considerations. Eur Arch Otorhinolaryngol 2024; 281:23-30. [PMID: 37740744 DOI: 10.1007/s00405-023-08238-9] [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: 06/29/2023] [Accepted: 09/10/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE There is no agreement on the most appropriate post-operative pathway for the management of positive margins after laser cordectomy for early stage glottic tumours (T1-2N0M0). This literature review and meta-analysis aim to evaluate the post-operative treatment with the best oncological results among follow-up, radiotherapy (RT) and surgical second look. The parameters utilized were incidence of recurrence, overall (OS), disease-specific (DSS) and disease-free (DFS) survival and larynx preservation (LP). METHODS The articles were found through a string typed into PubMed from 2007 to 2022. The studies with detailed oncological results were selected according to inclusion criteria, and then the meta-analysis was carried out. RESULTS Sixteen studies met the inclusion criteria for 2808 patients. The positive margin was found in 748 patients (26.6%), of which 416 were referred to follow-up, 89 to RT and 242 to a surgical second look. A false positive margin was found in 58/104 patients (56%). The recurrence rate in patients with positive margins was significantly higher (p = 0.003). In OS, DSS, DFS and LP, the odds ratio (OR) value was always greater than 1, assessing the role of the positive margin as a risk factor. CONCLUSIONS Prospective studies will be necessary to establish the role of positive margin as a prognostic factor. A surgical second look in case of positive margin seems to be the best option for the patient in terms of lower risk of recurrence and better oncological results. Better collaboration between surgeon and pathologist would be desirable to limit the real and false positive margins.
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Affiliation(s)
- M Reale
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - M L Bardon
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - G Ciavarro
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - G Pedrazzi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - G P Santoro
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
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Hsieh Y, Chen I, Lin C, Yang K, Liu W, Chiu C, Lee S, Chen L. Comparison of the outcomes of anterolateral thigh flap and peroneal flap in total laryngectomy reconstruction. Laryngoscope Investig Otolaryngol 2023; 8:645-650. [PMID: 37342117 PMCID: PMC10278101 DOI: 10.1002/lio2.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/09/2023] [Indexed: 06/22/2023] Open
Abstract
Background We usually use an ALT or peroneal flap in total laryngectomy reconstruction, depending on the surgeons' preference. No direct comparison of the outcomes of the ALT flap and peroneal flap exists. Methods From 2014 to 2022, we reviewed patients who had total laryngectomy and were reconstructed with an ALT flap and peroneal flap. Patient characteristics and surgical outcomes were collected and compared. Results The peroneal group had a significantly higher risk of neopharynx leakage (40% vs. 13.2%, p = .020) and late pharyngocutaneous fistula formation (30% vs. 5.3%, p = .009) than the ALT group. Peroneal flap was found to be the only independent risk factor for neopharynx leakage (p = .025, odds ratio [OR] = 5.5) and late pharyngocutaneous fistula formation (p = .02, OR = 7.7) in multivariate logistic regression. Conclusion In the reconstruction of total laryngectomy, the ALT flap is preferable over the peroneal flap.
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Affiliation(s)
- Yu‐Hsuan Hsieh
- Division of Plastic and Reconstructive Surgery, Department of SurgeryKaohsiung Veterans General HospitalKaohsiung CityTaiwan
- School of MedicineCollege of Medicine, National Yang Ming Chiao Tung UniversityTaipeiTaiwan
- School of MedicineCollege of Medicine, National Sun Yat‐sen UniversityKaohsiung CityTaiwan
| | - I‐Wen Chen
- Department of PediatricsKaohsiung Veterans General HospitalKaohsiung CityTaiwan
| | - Cheng‐Ta Lin
- Division of Plastic SurgeryChi Mei Medical CenterLiouyingTaiwan
- School of Dentistry and Institute of Oral MedicineCollege of Medicine, National Cheng Kung UniversityTainanTaiwan
| | - Kuo‐Chung Yang
- Division of Plastic and Reconstructive Surgery, Department of SurgeryKaohsiung Veterans General HospitalKaohsiung CityTaiwan
- School of MedicineCollege of Medicine, National Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Wen‐Chung Liu
- Division of Plastic and Reconstructive Surgery, Department of SurgeryKaohsiung Veterans General HospitalKaohsiung CityTaiwan
- School of MedicineCollege of Medicine, National Yang Ming Chiao Tung UniversityTaipeiTaiwan
- School of MedicineCollege of Medicine, National Sun Yat‐sen UniversityKaohsiung CityTaiwan
| | - Ching‐Ching Chiu
- Department of OtolaryngologyKaohsiung Veterans General HospitalKaohsiung CityTaiwan
| | - Shih‐Yu Lee
- Division of Plastic and Reconstructive Surgery, Department of SurgeryKaohsiung Veterans General HospitalKaohsiung CityTaiwan
| | - Lee‐Wei Chen
- Division of Plastic and Reconstructive Surgery, Department of SurgeryKaohsiung Veterans General HospitalKaohsiung CityTaiwan
- School of MedicineCollege of Medicine, National Yang Ming Chiao Tung UniversityTaipeiTaiwan
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Kuhn MA, Gillespie MB, Ishman SL, Ishii LE, Brody R, Cohen E, Dhar SI, Hutcheson K, Jefferson G, Johnson F, Rameau A, Sher D, Starmer H, Strohl M, Ulmer K, Vaitaitis V, Begum S, Batjargal M, Dhepyasuwan N. Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients. Otolaryngol Head Neck Surg 2023; 168:571-592. [PMID: 36965195 DOI: 10.1002/ohn.302] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/16/2023] [Accepted: 02/01/2023] [Indexed: 03/27/2023]
Abstract
OBJECTIVE To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx. METHODS Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible. RESULTS The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus. CONCLUSION Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.
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Affiliation(s)
- Maggie A Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, USA
| | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stacey L Ishman
- Department of Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa E Ishii
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University Medical Institute, Cockeysville, Maryland, USA
| | - Rebecca Brody
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, West Linn, Oregon, USA
| | - Ezra Cohen
- Moores Cancer Center at UC San Diego Health, La Jolla, California, USA
| | | | - Kate Hutcheson
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Center, Houston, Texas, USA
| | - Gina Jefferson
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Surgical Oncology/Microvascular Reconstruction, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Anais Rameau
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - David Sher
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Heather Starmer
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Madeleine Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Karen Ulmer
- Milton J Dance, Jr Head and Neck Cancer at GBMC, Baltimore, Maryland, USA
| | - Vilija Vaitaitis
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center, New Orleans, Charleston, South Carolina, USA
| | - Sultana Begum
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Misheelt Batjargal
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Layton T, Thomas R, Harris C, Holmes S, Fraser L, Silva P, Winter SC. Functional Outcomes Following Total Laryngectomy and Pharyngolaryngectomy: A 20-Year Single Center Study. Ann Otol Rhinol Laryngol 2022; 131:1301-1309. [PMID: 35081778 DOI: 10.1177/00034894211072987] [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: 11/15/2022]
Abstract
BACKGROUND Laryngeal cancer accounts for 1% of all cancers in men and 0.3% of all cancers in women. Pharyngolaryngectomy (TPL) and total laryngectomy (TL) are central surgical techniques in the management of advanced laryngeal malignancies but are associated with significant morbidity. In addition, optimal reconstruction following TPL remains an area of active research. METHODS Here, we compared speech and swallowing outcomes following circumferential and partial pharyngeal resection alongside total laryngectomy in patients with laryngeal and hypolaryngeal tumors. We performed a systemic analysis of patient demographics, tumor characteristics, treatment modality, and pharyngeal reconstruction technique following TPL and TL, leveraging data collected over a 20-year period at a large tertiary referral center. RESULTS Analyzing 155 patients the results show circumferential pharyngeal defects and prior radiotherapy have a significant impact on surgical complications. CONCLUSION Pharyngeal resection carries a substantial risk of incurring impaired speech and swallowing in patients. Moreover, our results support poorer functional outcomes with more radical pharyngeal resections and show a clear trend toward worse swallowing outcomes in salvage surgery.
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Affiliation(s)
- Thomas Layton
- The Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Bleinheim Head and Neck Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachel Thomas
- Bleinheim Head and Neck Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Carol Harris
- Bleinheim Head and Neck Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sam Holmes
- Bleinheim Head and Neck Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lisa Fraser
- Bleinheim Head and Neck Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Priy Silva
- Bleinheim Head and Neck Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Stuart C Winter
- Bleinheim Head and Neck Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Olinde L, Evangelista L, Bewley AF. Functional laryngectomy for the dysfunctional larynx: indications and outcomes in setting of prior chemoradiotherapy. Curr Opin Otolaryngol Head Neck Surg 2021; 29:473-478. [PMID: 34535008 DOI: 10.1097/moo.0000000000000757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To review the recent literature on indications for and functional outcomes following laryngectomy for severe laryngeal dysfunction. RECENT FINDINGS The use of functional laryngectomy as a definitive treatment for severe laryngeal dysfunction is increasing as more patients with head and neck cancer are treated with definitive chemoradiotherapy. Data are emerging on the efficacy of this technique as measured by aspiration, recurrent pneumonias, enteral tube feeding dependence, and surgical complication rates. Though most patients have marked improvement in aspiration and oral intake, difficulties in swallowing and voicing functions may persist. SUMMARY Functional laryngectomy is an effective treatment for end-stage laryngeal dysfunction. There is a clear benefit with regard to prevention of aspiration and alleviation of nothing by mouth status. However, qualitative speech and swallowing outcomes are less well studied, though available data suggest that many patients still suffer some degree of continued chronic impairment. More research is needed on these outcomes in order to appropriately counsel patients regarding long-term functional outcomes.
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Affiliation(s)
- Lindsay Olinde
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis Medical Center, Sacramento, California, USA
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Gheorghe DC, Ilie A, Niculescu AG, Grumezescu AM. Preventing Biofilm Formation and Development on Ear, Nose and Throat Medical Devices. Biomedicines 2021; 9:1025. [PMID: 34440229 PMCID: PMC8394763 DOI: 10.3390/biomedicines9081025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/10/2021] [Accepted: 08/14/2021] [Indexed: 12/17/2022] Open
Abstract
Otorhinolaryngology is a vast domain that requires the aid of many resources for optimal performance. The medical devices utilized in this branch share common problems, such as the formation of biofilms. These structured communities of microbes encased in a 3D matrix can develop antimicrobial resistance (AMR), thus making it a problem with challenging solutions. Therefore, it is of concern the introduction in the medical practice involving biomaterials for ear, nose and throat (ENT) devices, such as implants for the trachea (stents), ear (cochlear implants), and voice recovery (voice prosthetics). The surface of these materials must be biocompatible and limit the development of biofilm while still promoting regeneration. In this respect, several surface modification techniques and functionalization procedures can be utilized to facilitate the success of the implants and ensure a long time of use. On this note, this review provides information on the intricate underlying mechanisms of biofilm formation, the large specter of implants and prosthetics that are susceptible to microbial colonization and subsequently related infections. Specifically, the discussion is particularized on biofilm development on ENT devices, ways to reduce it, and recent approaches that have emerged in this field.
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Affiliation(s)
- Dan Cristian Gheorghe
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- “M.S. Curie” Clinical Emergency Hospital for Children, 077120 Bucharest, Romania
| | - Andrei Ilie
- Faculty of Engineering in Foreign Languages, University Politehnica of Bucharest, 060042 Bucharest, Romania; (A.I.); (A.-G.N.)
| | - Adelina-Gabriela Niculescu
- Faculty of Engineering in Foreign Languages, University Politehnica of Bucharest, 060042 Bucharest, Romania; (A.I.); (A.-G.N.)
- Faculty of Applied Chemistry and Materials Science, University Politehnica of Bucharest, 060042 Bucharest, Romania
| | - Alexandru Mihai Grumezescu
- Faculty of Applied Chemistry and Materials Science, University Politehnica of Bucharest, 060042 Bucharest, Romania
- Research Institute of the University of Bucharest—ICUB, University of Bucharest, 050657 Bucharest, Romania
- Academy of Romanian Scientists, 3 Ilfov Street, 50044 Bucharest, Romania
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Grasl S, Schmid E, Heiduschka G, Brunner M, Marijić B, Grasl MC, Faisal M, Erovic BM, Janik S. A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy. Cancers (Basel) 2021; 13:cancers13061474. [PMID: 33806944 PMCID: PMC8004622 DOI: 10.3390/cancers13061474] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 12/27/2022] Open
Abstract
Simple Summary Evaluation of the long-term functional outcome after primary or salvage laryngopharyngectomy. Long term functional outcome mainly depends on extent of pharyngectomy and salvage situation, which is reflected by our new classification system. Abstract (1) Objective: To evaluate long-term functional outcome in patients who underwent primary or salvage total laryngectomy (TL), TL with partial (TLPP), or total pharyngectomy (TLTP), and to establish a new scoring system to predict complication rate and long-term functional outcome; (2) Material and Methods: Between 1993 and 2019, 258 patients underwent TL (n = 85), TLPP (n = 101), or TLTP (n = 72). Based on the extent of tumor resection, all patients were stratified to (i) localization I: TL; II: TLPP; III: TLTP and (ii) surgical treatment (A: primary resection; B: salvage surgery). Type and rate of complication and functional outcome, including oral nutrition, G-tube dependence, pharyngeal stenosis, and voice rehabilitation were evaluated in 163 patients with a follow-up ≥ 12 months and absence of recurrent disease; (3) Results: We found 61 IA, 24 IB, 63 IIA, 38 IIB, 37 IIIA, and 35 IIIA patients. Complications and subsequently revision surgeries occurred most frequently in IIIB cases but rarely in IA patients (57.1% vs. 18%; p = 0.001 and 51.4% vs. 14.8%; p = 0.002), respectively. Pharyngocutaneous fistula (PCF) was the most common complication (33%), although it did not significantly differ among cohorts (p = 0.345). Pharyngeal stenosis was found in 27% of cases, with the highest incidence in IIIA (45.5%) and IIIB (72.7%) patients (p < 0.001). Most (91.1%) IA patients achieved complete oral nutrition compared to only 41.7% in class IIIB patients (p < 0.001). Absence of PCF (odds ratio (OR) 3.29; p = 0.003), presence of complications (OR 3.47; p = 0.004), and no need for pharyngeal reconstruction (OR 4.44; p = 0.042) represented independent favorable factors for oral nutrition. Verbal communication was achieved in 69.3% of patients and was accomplished by the insertion of voice prosthesis in 37.4%. Acquisition of esophageal speech was reached in 31.9% of cases. Based on these data, we stratified patients regarding the extent of surgery and previous treatment into subgroups reflecting risk profiles and expectable functional outcome; (4) Conclusions: The extent of resection accompanied by the need for reconstruction and salvage surgery both carry a higher risk of complications and subsequently worse functional outcome. Both factors are reflected in our classification system that can be helpful to better predict patients’ functional outcome.
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Affiliation(s)
- Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (E.S.); (G.H.); (M.B.); (M.C.G.)
| | - Elisabeth Schmid
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (E.S.); (G.H.); (M.B.); (M.C.G.)
| | - Gregor Heiduschka
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (E.S.); (G.H.); (M.B.); (M.C.G.)
| | - Markus Brunner
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (E.S.); (G.H.); (M.B.); (M.C.G.)
| | - Blažen Marijić
- Institute of Head and Neck Diseases, Evangelical Hospital, 1180 Vienna, Austria; (B.M.); (B.M.E.)
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia
| | - Matthaeus Ch. Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (E.S.); (G.H.); (M.B.); (M.C.G.)
| | - Muhammad Faisal
- Shaukat Khanum Memorial Cancer Hospital, Lahore 54000, Pakistan;
| | - Boban M. Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital, 1180 Vienna, Austria; (B.M.); (B.M.E.)
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (E.S.); (G.H.); (M.B.); (M.C.G.)
- Correspondence:
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Baijens LWJ, Walshe M, Aaltonen LM, Arens C, Cordier R, Cras P, Crevier-Buchman L, Curtis C, Golusinski W, Govender R, Eriksen JG, Hansen K, Heathcote K, Hess MM, Hosal S, Klussmann JP, Leemans CR, MacCarthy D, Manduchi B, Marie JP, Nouraei R, Parkes C, Pflug C, Pilz W, Regan J, Rommel N, Schindler A, Schols AMWJ, Speyer R, Succo G, Wessel I, Willemsen ACH, Yilmaz T, Clavé P. European white paper: oropharyngeal dysphagia in head and neck cancer. Eur Arch Otorhinolaryngol 2021; 278:577-616. [PMID: 33341909 PMCID: PMC7826315 DOI: 10.1007/s00405-020-06507-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Laura W J Baijens
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Christoph Arens
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Magdeburg, Otto-von-Guericke University, Magdeburg, Germany
| | - Reinie Cordier
- Department of Special Needs Education, University of Oslo, Oslo, Norway
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| | - Patrick Cras
- Department of Neurology, Born Bunge Institute, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Lise Crevier-Buchman
- Voice, Speech, Swallowing Lab, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital UVSQ and Research lab CNRS-UMR7018, Hôpital Foch, Suresnes, France
| | - Chris Curtis
- Swallows Head and Neck Cancer Charity, Blackpool, UK
| | - Wojciech Golusinski
- Department of Head and Neck Surgery, The Greater Poland Cancer Centre, Poznan University of Medical Sciences, Poznan, Poland
| | - Roganie Govender
- Head and Neck Cancer Centre, University College London Hospital, London, UK
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kevin Hansen
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Kate Heathcote
- Robert White Centre for Airway, Voice and Swallow, Poole Hospital NHS Foundation Trust, Dorset, UK
| | - Markus M Hess
- Deutsche Stimmklinik, Hamburg, Germany
- Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sefik Hosal
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Atılım University, Medicana International Ankara, Ankara, Turkey
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - C René Leemans
- Department of Otolaryngology, Head and Neck Surgery, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands
| | - Denise MacCarthy
- Division of Restorative Dentistry and Periodontology, Faculty of Health Sciences, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
| | - Beatrice Manduchi
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Jean-Paul Marie
- Department of Otorhinolaryngology, Head and Neck Surgery, Rouen University Hospital, Rouen, France
| | - Reza Nouraei
- Department of Ear Nose and Throat Surgery, The Robert White Centre for Airway Voice and Swallowing, Poole Hospital NHS Foundation Trust, University of Southampton, Southampton, UK
| | - Claire Parkes
- Department of Speech and Language Therapy, St. James's Hospital, Dublin, Ireland
| | - Christina Pflug
- Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Walmari Pilz
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- MHeNs School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Nathalie Rommel
- Department Neurosciences, Experimental Otorhinolaryngology, Deglutology, University of Leuven, Leuven, Belgium
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Renee Speyer
- Department of Special Needs Education, University of Oslo, Oslo, Norway
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Faculty of Health, School of Health and Social Development, Victoria, Australia
| | - Giovanni Succo
- Head and Neck Oncology Service, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy
- Department of Oncology, University of Turin, Orbassano, TO, Italy
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anna C H Willemsen
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Taner Yilmaz
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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10
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Escalante D, Vincent AG, Wang W, Shokri T, Ducic Y. Reconstructive Options During Nonfunctional Laryngectomy. Laryngoscope 2020; 131:E1510-E1513. [PMID: 33037821 PMCID: PMC8247398 DOI: 10.1002/lary.29154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/14/2020] [Accepted: 09/16/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE A paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability. METHOD We performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed. RESULTS A total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty-four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube-dependent (P = < .0001). CONCLUSION Herein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long-term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1510-E1513, 2021.
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Affiliation(s)
| | | | - Weitao Wang
- Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A
| | - Tom Shokri
- Pennsylvania State Hershey Medical Center, Otolaryngology - Head and Neck Surgery, Hershey, Pennsylvania, U.S.A
| | - Yadranko Ducic
- Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A
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11
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Wu MP, Goldsmith T, Holman A, Kammer R, Parikh A, Devore EK, Emerick KS, Lin DT, Deschler DG, Richmon JD, Varvares MA, Naunheim MR. Risk Factors for Laryngectomy for Dysfunctional Larynx After Organ Preservation Protocols: A Case-Control Analysis. Otolaryngol Head Neck Surg 2020; 164:608-615. [DOI: 10.1177/0194599820947702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objective (1) To identify factors associated with severe dysfunctional larynx leading to total laryngectomy after curative treatment of head and neck squamous cell carcinoma and (2) to describe swallowing and voice outcomes. Study Design Retrospective single-institution case-control study. Setting Tertiary care referral center. Methods A 10-year chart review was performed for patients who had previously undergone radiation or chemoradiation for head and neck mucosal squamous cell carcinoma and planned to undergo total laryngectomy for dysfunctional larynx, as well as a control group of matched patients. Controls were patients who had undergone radiation or chemoradiation for mucosal squamous cell carcinoma but did not have severe dysfunction warranting laryngectomy; these were matched to cases by tumor subsite, T stage, and time from last treatment to video swallow study. Main outcomes assessed were postoperative diet, alaryngeal voice, pharyngeal dilations, and complications. Results Twenty-six patients were scheduled for laryngectomy for dysfunctional larynx, of which 23 underwent surgery. Originally treated tumor subsites included the larynx, oropharynx, hypopharynx, oral cavity, and a tumor of unknown origin. The median time from end of cancer treatment to laryngectomy was 11.5 years. All cases were feeding tube or tracheostomy dependent or both prior to laryngectomy. As compared with matched controls, cases were significantly less likely to have undergone IMRT (intensity-modified radiotherapy) and more likely to have pulmonary comorbidities. Eighty-nine percent of cases with follow-up achieved functional alaryngeal voice, and all were able to have oral intake. Conclusion Non-IMRT approaches and pulmonary comorbidities are associated with laryngectomy for dysfunction after radiation or chemoradiation.
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Affiliation(s)
- Michael P. Wu
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Tessa Goldsmith
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Allison Holman
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachael Kammer
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anuraag Parikh
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Elliana K. Devore
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Kevin S. Emerick
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Derrick T. Lin
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Daniel G. Deschler
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Jeremy D. Richmon
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Mark A. Varvares
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Matthew R. Naunheim
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
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12
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Current opinions in otolaryngology and head and neck surgery: functional considerations in reconstruction after laryngectomy. Curr Opin Otolaryngol Head Neck Surg 2020; 28:355-364. [PMID: 32796266 DOI: 10.1097/moo.0000000000000645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW To review reconstruction techniques following total laryngectomy, partial laryngopharyngectomy, and total laryngopharyngectomy with an emphasis on long-term swallow and speech outcomes. RECENT FINDINGS Recent literature has shown that the use of fasciocutaneous free flaps in the reconstruction of laryngectomy defects may lead to improved speech and swallow outcomes as compared with regional or free musculocutaneous flaps. Radial forearm and anterolateral thigh are the most often used fasciocutaneous free flaps, with similar speech and swallow outcomes. Primary closure with myofascial flap onlay yields similar speech and swallow results to fasciocutaneous flaps following laryngectomy that spares sufficient pharyngeal mucosa. SUMMARY Whenever reconstructing a salvage laryngectomy defect or a primary laryngectomy defect with mucosal deficiency, current evidence suggests that a fasciocutaneous free flap used to augment pharyngeal volume both improves fistula rates as well as long-term speech and swallow outcomes. When sufficient pharyngeal mucosa is present, myofascial onlay can be considered as well.
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