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

Analysis of swallowing and voice-related quality of life in patients after supracricoid partial laryngectomy

OBJECTIVE

This study evaluated the swallowing and voice function of laryngeal cancer patients after Supracricoid Partial Laryngectomy(SCPL), and its influence on quality of life to provide a reference for the selection of surgical methods for laryngeal cancer patients.

METHODS

Twenty-one patients who received SCPL between April 2015 and November 2021 were included. Each patient's swallowing function and quality of life were assessed through fiberoptic endoscopic examination of swallowing (FEES) and the M.D. Anderson Dysphagia Inventory (MDADI). Fundamental, jitter, shimmer, maximum phonation time (MPT), and voice handicap index-10 (VHI-10) were performed to assess voice function and voice-related quality of life.

RESULTS

The results of the FEES of the 21 patients were as follows: the rates of pharyngeal residue after swallowing solid, semiliquid, and liquid food were 0%, 28.57%, and 38.09%, respectively; the rates of laryngeal infiltration after swallowing solid, semiliquid, and liquid food were 0%, 28.57%, and 4.76%, respectively; and aspiration did not occur in any of the patients. In the evaluation of swallowing quality of life, the mean total MDADI score was 92.6 ± 6.32. The voice function evaluation showed that the mean F0, jitter, shimmer, and MPT values were 156.01 ± 120.87 (HZ), 11.57 ± 6.21 (%), 35.37 ± 14.16 (%) and 7.85 ± 6.08 (s), respectively. The mean total VHI-10 score was 7.14 ± 4.84.

CONCLUSION

SCPL provides patients with satisfactory swallowing and voice function. The patients in this study were satisfied with their quality of life in terms of swallowing and voice. SCPL can be used as a surgical method to preserve laryngeal function in patients with laryngeal cancer.

Multicentric Study on Oncological Outcomes and Prognostic Factors of Open Partial Horizontal Laryngectomies

Objective: In recent years, the number of open preservation surgeries for the treatment of laryngeal Cancer has increased. This surgery aims to maintain laryngeal function and ensure oncological radicality, thereby avoiding a total laryngectomy (TL) that could significantly impact the patient's quality of life. The purpose of this study was to assess the oncologic results of OPHL I and II and to identify prognostic factors that could impact patient survival and local failure rates. Methods: This study was conducted on 182 patients with laryngeal squamous cell carcinoma treated with OPHLs between 2005 and 2015. The survival rates of a group of patients treated with TL between 2004 and 2014 were taken into consideration to compare survival outcomes. Results: The disease-specific survival in pT2 and pT3 tumors in relation to the type of surgery showed no statistically significant difference between OPHLs and TL (P = .54 and P = .63, respectively). The 5-year T-recurrence-free survival showed that pT4 tumors, perineural/vascular positive invasion, and OPHL IIb + ARY-treated tumors were associated with a higher risk of tumor recurrence (P < .0001, P = .0005 and P = .016 respectively). Conclusions: OPHLs represent an excellent alternative to TL considering the characteristics of the tumor and the general conditions of the patient.

Longitudinal Voice Outcomes and Neoglottic Function After Supracricoid Partial Laryngectomy: The Development of a New Scale

OBJECTIVES

Supracricoid partial laryngectomy (SCPL) is an oncologically sound alternative to total laryngectomy that results in long-term alterations in vocal function. Little is known about long-term improvements in dysphonia and the mechanism of vocal recovery is unclear due to the lack of a standardized rating tool: The Pattern, Degree, and Vibration (PDV) Scale.

METHODS

Data from 24 individuals were compared over 3 post-operative timepoints after SCPL: 3 to 11, 12 to 35, and over 35 months. Voice outcomes were assessed using the Voice Handicap Index (VHI) and the GRBAS scale. Laryngeal exams were deidentified and rated using a novel rating scheme developed using literature review and consensus panel discussions.

RESULTS

There were significant improvements in VHI scores, Grade, and Strain over time. There was an increase in the Degree of Closure and a decline in Mucosal Vibration across timepoints. Pattern of Movement (P) was associated with dysphonia Grade. Better Degree of Closure (D) was associated with lower VHI scores and better Grade and Roughness. Mucosal Vibration (V) was associated with reduced Breathiness and Strain but variable Roughness. Age, T-stage, radiation treatment, surgery type, and time to feeding-tube removal were also associated with voicing characteristics.

CONCLUSIONS

There is evidence of improvement in several voice parameters over time after the first post-operative year. Various subcomponents of the new PDV rating scale were associated with voice outcomes. Its utility for research and clinical practice merits further investigation.

Validation and Cross-Cultural Adaptation of Croatian Self-Evaluation of Communication Experiences after Laryngectomy Questionnaire

INTRODUCTION

The Self-Evaluation of Communication Experiences after Laryngectomy (SECEL) is a 35-item patient-reported questionnaire developed to address the communication needs of patients with laryngectomies. The aim was to translate, cross-culturally adapt, and validate the Croatian version.

METHODS

The SECEL was translated from English by two independent translators and back-translated by a native speaker, after which it was approved by an expert committee. The Croatian version of the Self-Evaluation of Communication Experiences after Laryngectomy questionnaire (SECEL:HR) was filled in by 50 laryngectomised patients who had completed their oncological treatment a year prior to inclusion in the study. Patients also filled in the Voice Handicap Index (VHI) and the Short Form Health Survey (SF-36) on the same day. All patients completed the SECEL:HR twice, the second time being 2 weeks after the initial test. Maximum phonation time and diadochokinesis of articulation organs were used for objective assessment.

RESULTS

Among the Croatian patients, the questionnaire was well-accepted and demonstrated good test-retest reliability and internal consistency for two out of three subscales. The correlations between VHI, SF-36, and SECEL:HR were moderate to strong. There were no significant differences between patients who are using oesophageal speech, tracheoesophageal speech, or the electrolarynx based on the SECEL:HR.

CONCLUSION

Preliminary findings of the research indicate that the Croatian version of the SECEL has sufficient psychometric qualities, high reliability, and good internal consistency, with a Cronbach's alpha of 0.89 for the total score. The Croatian version of SECEL can be recommended as a reliable and clinically valid measure for the assessment of substitution voices in Croatian-speaking patients.

Voice and communication after open partial horizontal laryngectomies: A cross-sectional outcome study

OBJECTIVE

The present study evaluates voice and communication after open partial horizontal laryngectomies (OPHLs), according to surgery and patient-related variables.

METHODS

Fifty-eight patients were included: 18 type I OPHL, 20 type II OPHL and 20 type III OPHL. Acoustic, aerodynamic, endoscopic, perceptual and self-assessment analyses were carried out. Surgery-related variables and patient-related variables were considered for the analysis.

RESULTS

Type I OPHL revealed the best phonatory outcomes. Type II and type III OPHL showed similar and poor results, with a highly deteriorated voice quality. A significant difference in MTP was found for patients who had both arytenoids/cricoarytenoid units preserved. Age and time from surgery showed significant correlations with voice quality after OPHLs.

CONCLUSIONS

Voice and communication outcomes after OPHLs are heterogeneous and might be influenced by several factors. Knowing variables with a substantial impact on phonatory outcomes may help clinicians in the preoperative decision-making process and the postoperative rehabilitative program.

Supracricoid partial laryngectomy with cricohyoidoepiglottopexy for patients with laryngeal cicatricial stenosis: Safety and efficacy

BACKGROUND

We assessed the safety and efficacy of supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCL-CHEP) in patients with laryngeal cicatricial stenosis.

METHODS

Sixteen patients receiving SCL-CHEP for severe laryngeal cicatricial stenosis between 2017 and 2018 were reviewed. Decannulation rate and tracheostomy closure time were used to evaluate efficacy. The Voice Handicap Index-10 (VHI-10), Voice-related Quality of Life (V-RQOL) scale and Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) scale were used to assess vocal function. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed and the Penetration-Aspiration Scale (PAS), Eating Assessment Tool-10 (EAT-10), and Swallow Quality of Life Questionnaire (SWAL-QOL) were used to assess swallowing function.

RESULTS

Thirteen patients (81.25%) were decannulated successfully. The average tracheostomy closure time was 45.15 days. There was no observed postoperative complications or recurrence of stenosis. VHI-10 and V-RQOL scores showed significantly improved V-RQOL (p < 0.05). FEES-PAS, EAT-10, and SWAL-QOL showed no swallowing function damage.

CONCLUSIONS

SCL-CHEP is effective and safe for patients with severe laryngeal cicatricial stenosis. Accurate pre-procedure evaluation is especially important for patient selection and surgical success.

The Penetration-Aspiration Scale: Adaptation to Open Partial Laryngectomy and Reliability Analysis

A standard for assessing swallowing function after open partial horizontal laryngectomy (OPHL) is still not established. The variability in the measures used to investigate swallowing functional outcomes after OPHL limits the communication among clinicians and the possibility to compare and combine results from different studies. The study aims to adapt the PAS to the altered anatomy after OPHLs using fiberoptic endoscopic evaluation of swallowing (FEES) and to test its reliability. To adapt the PAS, two landmarks were identified: the entry of the laryngeal vestibule and the neoglottis. Ninety patients who underwent an OPHL were recruited (27 type I, 31 type II and 32 type III). FEES was performed and video-recorded. Two speech and language therapists (SLTs) independently rated each FEES using the PAS adapted for OPHL (OPHL-PAS). FEES recordings were rated for a second time by both SLTs at least 15 days from the first video analysis. Inter- and intra-rater agreement was assessed using unweighted Cohen's kappa. Overall, inter-rater agreement of the OPHL-PAS was k = 0.863, while intra-rater agreement was k = 0.854. Concerning different OPHL types, inter- and intra-rater agreement were k = 0.924 and k = 0.914 for type I, k = 0.865 and k = 0.790 for type II, and k = 0.808 and k = 0.858 for type III, respectively. The OPHL-PAS is a reliable scale to assess the invasion of lower airway during swallowing in patients with OPHL using FEES. The study represents the first attempt to define standard tools to assess swallowing functional outcome in this population.

Limitations and Opportunities in Open Laryngeal Organ Preservation Surgery: Current Role of OPHLs

The current trend for treatment of intermediate-early advanced laryngeal cancer is essentially oriented toward preservation of organ and laryngeal function, and with a good potential for treating the disease. This goal can be achieved by adopting open laryngeal organ preservation surgery (OLOPS), at present mainly represented by open partial horizontal laryngectomies (OPHLs). An approach using rigorous selection criteria based on both the general condition of the patient and the local and regional extent of the disease gives excellent oncological and functional results in untreated patients. Similar outcomes, albeit slightly worse, are also obtainable in radio-recurrent and laser-recurrent patients. Troublesome postoperative management and the inconsistency of functional recovery are the main limitations for extensive application of this therapeutic strategy. The future direction is represented by simplification of the indications identifying iso-prognostic sub-categories within the T-stage, wider consensus on rehabilitation protocols, hybrid approaches to the larynx, and open minimally invasive access.

Long-term Swallowing Function, Pulmonary Complications, and Quality of Life after Supracricoid Laryngectomy

Objectives

Long-term effects of supracricoid laryngectomies are nowadays under discussion. The purpose of this study was to detect the prevalence of chronic aspiration and incidence of pulmonary complications, to investigate possible influencing factors, and to analyze dysphagia-related quality of life in a cohort of patients who recovered swallowing function after undergoing supracricoid laryngectomies.

Study Design

Retrospective observational study.

Setting

San Raffaele Hospital, Vita-Salute University, Milan, Italy.

Methods

A cohort of 39 patients who recovered swallowing function free of disease after a minimum 3-year follow-up period was retrospectively investigated between October and December 2017—clinically with the Pearson’s Scale and M. D. Anderson Dysphagia Inventory and instrumentally with fiberoptic endoscopic evaluation of swallowing.

Results

Chronic aspiration was demonstrated in a significant portion of patients (clinically in 33.3% and instrumentally in 35.9%). Aspiration was influenced by advanced age at surgery ( P = .020). Type of surgical procedure, resection of 1 arytenoid cartilage, postoperative rehabilitation with a speech-language therapist, radiotherapy, age at consultation, and length of follow-up did not influence the prevalence of aspiration. Pulmonary complications affected 5 patients; incidence of pulmonary complications was related to aspiration and was favored by poor laryngeal sensation/cough reflex. Aspiration significantly affected quality of life.

Conclusions

Chronic aspiration is frequent and affects patients’ quality of life. However, incidence of pulmonary complications is low; therefore, oral feeding should not be contraindicated for aspirating patients. Preservation of laryngeal sensation and cough reflex is mandatory to prevent pulmonary complications.

Impact of the anterior commissure involvement on the survival of early glottic cancer treated with cricohyoidoepiglottopexy: a retrospective study

Background

Laryngeal early glottic tumors can benefit from different treatment modalities, including transoral laser microsurgery, open partial horizontal laryngectomy (OPHL), and radiotherapy. However, the treatment of early glottic tumors with the involvement of the anterior commissure remains controversial. The studies about the role of anterior commissure involvement in oncologic outcomes in patients with early glottic cancer treated with supracricoid laryngectomy (SCL) are very few. For this reason, we conducted a retrospective study to evaluate local recurrence-free survival and specific survival in patients with and without involvement of the anterior commissure who underwent SCL with cricohyoidoepiglottopexy.

Methods

This retrospective study has been carried out on patients with T1b–T2 glottic squamous cell carcinoma submitted to SCL with cricohyoidoepiglottopexy. The patients’ demographic and clinical data were collected, and the histological findings of the surgical specimens were reviewed to identify patients who had involvement of the anterior commissure.

Results

A total of 72 patients were included in the study; two of them were female and 70 were male. The mean age at diagnosis was 61.5±8.0 SD years. In 26 of the 72 (36.2%) patients, anterior commissure was not pathologically involved (group A), while in 46 (63.8%) patients, it was involved (group B). The 5-year local recurrence-free survival rate was 96.1% and 93.48% in groups A and B, respectively, P=0.09. The 5-year disease-specific survival rate was 92.31% and 95.65% in groups A and B, respectively, P=0.057.

Conclusion

SCL with cricohyoidoepiglottopexy seems to be an adequate treatment modality, even for T1b–T2 glottic tumors with anterior commissure involvement.

Comparison of long-term functional results between standard supracricoid laryngectomy and modified technique with sternohyoid muscle

Introduction

Laryngeal cancer is the most common cancer of the upper respiratory tract. The main methods of treatment included surgery (partial laryngectomy and total laryngectomy) and radiation therapy. Laryngeal dysfunction is seen after both treatment modalities.

Objective

The aim of the study is to compare postoperative functional results of the standard supracricoid partial laryngectomy technique and a modified supracricoid partial laryngectomy technique using the sternohyoid muscle.

Methods

In total, 29 male patients (average years 58.20 ± 9.00 years; range 41–79 years) with laryngeal squamous cell carcinoma who underwent supra cricoid partial laryngectomy were included. The patients were divided into two groups in terms of the surgical techniques. In Group A, all patients underwent standard supracricoid partial laryngectomy technique between January 2007 and November 2011. In Group B, all patients underwent modified supracricoid partial laryngectomy between August 2010 and November 2011. Fiberoptic endoscopic evaluation of swallowing test, short version of the voice handicap index scores, and the MD Anderson dysphagia inventory, the time of oral feeding and the decanulation of the patients after surgery of each groups were compared.

Results

The mean maximum phonation time was 8.68 ± 4.21 s in Group A and 15.24 ± 6.16 s in Group B (p > 0.05). The S/Z (s/s) ratio was 1.23 ± 0.35 in Group A and 1.08 ± 0.26 in Group B (p > 0.05); the voice handicap index averages were 9.86 ± 4.77 in Group A and 12.42 ± 12.54 in Group B (p > 0.05); the fiberoptic endoscopic evaluation of swallowing test averages were calculated as 12.73 ± 3.08 in Group A and 13.64 ± 1.49 in Group B (p > 0.05). In the MD Anderson dysphagia inventory, evaluation of swallowing, the emotional, physical, and functional scores were 29.21 ± 4.11, 32.21 ± 6.85, and 20.14 ± 2.17 in the Group B, and 29.20 ± 2.54, 32.4 ± 4.79, and 19 ± 1.92 in Group A, respectively.

Conclusion

Although there is no statistical difference in functional outcome comparisons, if rules are adhered to in preoperative patient selection, modified supracricoid partial laryngectomy can be applied safely and meaningful gains can be achieved in functional outcomes.

Supracricoid Laryngectomy: The Function of the Remaining Arytenoid in Voice and Swallowing

Introduction  Supracricoid laryngectomy still has selected indications; there are few studies in the literature, and the case series are limited, a fact that stimulates the development of new studies to further elucidate the structural and functional aspects of the procedure.

Objective  To assess voice and deglutition parameters according to the number of preserved arytenoids.

Methods  Eleven patients who underwent subtotal laryngectomy with cricohyoidoepiglottopexy were evaluated by laryngeal nasofibroscopy, videofluoroscopy, and auditory-perceptual, acoustic, and voice pleasantness analyses, after resuming oral feeding.

Results  Functional abnormalities were detected in two out of the three patients who underwent arytenoidectomy, and in six patients from the remainder of the sample. Almost half of the sample presented silent laryngeal penetration and/or vallecular/hypopharyngeal stasis on the videofluoroscopy. The mean voice analysis scores indicated moderate vocal deviation, roughness and breathiness; severe strain and loudness deviation; shorter maximum phonation time; the presence of noise; and high third and fourth formant values. The voices were rated as unpleasant. There was no difference in the number and functionality of the remaining arytenoids as prognostic factors for deglutition; however, in the qualitative analysis, favorable voice and deglutition outcomes were more common among patients who did not undergo arytenoidectomy and had normal functional conditions.

Conclusion  The number and functionality of the preserved arytenoids were not found to be prognostic factors for favorable deglutition efficiency outcomes. However, the qualitative analysis showed that the preservation of both arytenoids and the absence of functional abnormalities were associated with more satisfactory voice and deglutition patterns.

Long-term functional results after open partial horizontal laryngectomy type IIa and type IIIa: A comparison study

BACKGROUND

The purpose of this study was to compare long-term swallowing, voice results, and quality of life (QOL) after open partial horizontal laryngectomy (OPHL) type IIa and type IIIa.

METHODS

Twenty-three patients after OPHL type IIa and 18 patients after OPHL type IIIa were involved. Swallowing skills and neoglottis' motility and vibrations were videoendoscopically assessed. Aerodynamic measures, spectrogram analysis, aspiration pneumonia, body weight variations, and voice perceptual assessment were performed. Generic voice-related and swallowing-related QOL were assessed. Data were statistically compared using Mann-Whitney U test or Fisher exact tests, as appropriate.

RESULTS

Significant differences were found only for the residue with solids and for the intelligibility (I) parameter of the overall quality impression and intelligibility, additive and unnecessary noise, speech fluency, and presence of voiced segments scale with patients of the OPHL type IIIa group showing worse performances than the OPHL type IIa group.

CONCLUSION

Patients who underwent OPHL type IIa and type IIIa show comparable long-term functional outcomes. OPHL type IIIa represents a valid surgical alternative to OPHL type IIa. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1427-E1435, 2016.

Evaluation of swallowing function after supracricoid laryngectomy as a primary or salvage procedure

The primary functional issues following conservative therapy for advanced laryngeal cancer concern swallowing. Here, we evaluated the recovery of swallowing after supracricoid partial laryngectomy (SCL) in patients with primary or recurrent laryngeal cancer. We evaluated the swallowing recovery in 27 SCL patients through oropharyngoesophageal scintigraphy, and we evaluated their quality of life using EORTC questionnaires. Four patients underwent total laryngectomy during follow-up. Patients who retained their larynges were able to feed without nutritional support and without tracheostoma. The only significantly different parameter between the primary and salvage cases was the time elapsed to the removal of nasogastric/PEG tubes, which was longer in salvage cases. SCL has been demonstrated as a valuable option for primary and recurrent laryngeal cancer patients. The present data demonstrate good functional results, particularly in terms of swallowing after previous treatments and in primary settings. The combination of oropharyngoesophageal scintigraphy and questionnaires appears to be an adequate, standardizable approach to assessing swallowing function after SCL.

Quality of Life After Conservation Surgery for Laryngeal Cancer

Quality of life preservation has become an essential goal of treatment in the management of laryngeal carcinoma. Although established treatments of reference such as total laryngectomy and chemoradiation protocols have focused on survival and anatomic preservation of the larynx, they still generate considerable functional morbidity with detrimental effects on quality of life. Transoral and transcervical partial laryngectomy techniques can offer significant advantages when used prudently after proper patient selection. The growing relevance of those techniques in the management of advanced and recurrent laryngeal carcinoma deserves particular attention, with potential for improved quality of life without compromising oncologic outcomes.

Attempt to improve functional outcomes in supracricoid laryngectomy in T2b and T3 glottic cancers

The goal of this study was to compare the survival rate and functional outcome of an open partial horizontal laryngectomies, Type IIa and modified Type IIa (OPHL Type IIa and OPHL mType IIa), in treatment of moderately advanced glottic carcinoma. Retrospective analysis. 80 Patients underwent OPHL Type IIa and 27, OPHL modified Type IIa (OPHL mType IIa) between the years 2001 and 2009. Clinical staging was performed according to the UICC criteria (2002). Primary endpoints of study were recurrence rate, and 3- and 5-year survival time. Secondary endpoints were laryngeal functions: respiration, swallowing and voice. There were no significant differences within local and regional recurrence rates, organ preservation rate, 3- and 5-year specific disease survival rates between OPHL Type II and OPHL modified Type IIa. Significantly lower need for temporary (OPHL mType IIa 4/27, OPHL Type IIa 30/80) and permanent tracheostomy (OPHL mType IIa 2/27, OPHL Type IIa 16/80) was found. All but one patient (OPHL Type IIa) achieved unrestricted diet. Significantly differed social eating, this ability gained 25/27 OPHL mType IIa and 54/80 OPHL Type IIa (p < 0.05). Voice handicap index revealed a decrease in quality of life in all areas; OPHL Type IIa and OPHL mType IIa differed significantly (31 and 46 points respectively, p < 0.005). The MPT value (longest pitch) for OPHL Type IIa and OPHL mType IIa lasted 8 s and 10, respectively (p < 0.005). There was no significant difference in oncological outcomes between the two types of OPHL succeeded in the earlier extubation, thus significantly lowering the need for temporary and permanent tracheotomy and providing better long-term swallowing. Although the voice was altered in all observed OPHL patients, modified Type IIa technique proved to be superior to the Type IIa in terms of voice quality. Thus, OPHL modified Type IIa is worth promoting, as long as indications were strictly conformed.

Swallowing, voice, and quality of life after supratracheal laryngectomy: preliminary long-term results

BACKGROUND

The purpose of this study was to report preliminary long-term outcomes after supratracheal laryngectomy (STL).

METHODS

Twenty-two male patients who underwent STL were involved in this study. Swallowing skills, neoglottis motility, and vibrations were videoendoscopically assessed. Aerodynamic measures, spectrogram analysis, aspiration pneumonia, body weight variations, and voice perceptual assessment were performed. Generic, voice-related, and swallowing-related quality of life (QOL) were assessed.

RESULTS

Aspiration was found in 10, 2, and 5 patients, respectively, for liquids, semisolids, and solids. Neoglottis motility was generally preserved, whereas vibration was impaired. Aerodynamic measures showed a poor performance. Perceptual assessment revealed highly dysphonic voices. In only 8 patients, a harmonic structure was visible in the spectrograms. Aspiration pneumonia occurred in 2 patients. Preoperative weight was maintained in 16 patients. Generic, voice-related, and swallowing-related QOL revealed satisfied patients.

CONCLUSION

After STL, swallowing was sufficiently restored and QOL was satisfactory, whereas the voice was severely impaired even if oral communication was well preserved.

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

The aim of the study was to evaluate swallowing using a reproducible objective methodology and to seek preoperative factors that could influence swallowing outcomes in patients operated on for partial laryngectomy. Twenty-four patients who underwent partial frontolateral laryngectomy with epiglottic reconstruction for T1bN0 or T2N0 glottic carcinoma between 2008 and 2012 were retrospectively evaluated. Using fiberoptic endoscopic and videofluoroscopic evaluation, early (15 days postoperatively) and late (2 months postoperatively) scores were obtained for all patients to quantify their swallowing skills. Eighty-three percent of patients achieved at least partial oral feeding at time of hospital discharge and 87.5% achieved exclusive oral feeding within 2 months postoperatively. Early score was good or excellent in 50%, average in 4.2% and poor in 41.8%. Regarding late scores, 63% were classified as having a good or excellent late score, 7 patients (29%) were classified as "middle result" because their time to recover was longer (i.e. between 1 and 2 months postoperatively), and two patients had a poor late score. Finally, at last follow-up, only one patient was partially fed by gastrostomy (180 days after surgery). T stage (p = 0.04) was the only factor influencing early swallowing outcomes and length of hospital stay was longer for poor scores than for good late results (p = 0.02). Our findings show good outcomes in terms of postoperative swallowing. Objective assessment of deglutition is essential for a better understanding of the mechanisms of postoperative swallowing disorders and for patient selection.

Análise da qualidade de vida dos pacientes com câncer de laringe em hospital de referência na região Sudeste do Brasil

OBJETIVO: estimar a qualidade de vida e fatores a ela associados de uma amostra de pacientes portadores de tumor laríngeo, na região Sudeste do Brasil. MÉTODO: amostra constituída por 60 pacientes em tratamento para o câncer de laringe em 2 Hospitais do município de Juiz de Fora, estado de Minas Gerais (Brasil), cidade polo regional e referência para tratamento de cânceres de cabeça e pescoço na região sudeste do Brasil. Com a aplicação do questionário Functional Assessment Cancer Therapy- Head & Neck , foram coletados os dados e submetidos à análises bivariada e multivariada, para atestar a implicação das variáveis na qualidade de vida dos pacientes de instituições de atenção terciária para tratamento de câncer. RESULTADOS: na análise bivariada, foram significantes as variáveis: sexo; anos de escolaridade; análise do tratamento recebido; acompanhamento fonoaudiológico e nutricional. Após a análise multivariada, ainda demonstraram associação independente: análise do tratamento recebido, tratamento fonoaudiológico e nutricional. CONCLUSÕES: a qualidade de vida dos pacientes envolvidos no estudo pode ser avaliada como satisfatória, sendo influenciada pelo bem-estar físico e funcional. O questionário Functional Assessment Cancer Therapy- Head & Neck, específico para cabeça e pescoço, mostrou que além dos fatores socioeconômicos e clínico-funcionais, os sociodemográficos também estão ligados à qualidade de vida dos portadores de câncer de laringe. Foi demonstrada também a importância do tratamento reabilitador fonoaudiológico e nutricional no ganho da qualidade de vida dos pacientes.

Buccal fat augmentation for insufficient neoglottal closure after supracricoid laryngectomy with cricohyoidoepiglottopexy

OBJECTIVE

Supracricoid laryngectomy with Cricohyoidoepiglottopexy (SCL-CHEP) is a functional organ preservation surgery for laryngeal cancers. Post-operative laryngeal function is generally promising. Some patients, however, cannot attain satisfactory functional results because of an excessively wide neoglottis resulting in an insufficient neoglottal closure. Autologous buccal fat augmentation was conducted to correct the insufficiency.

PATIENTS AND METHODS

Two patients underwent intervention. Under general anesthesia, autologous fat was harvested from the buccal fat pad. Fat tissue was injected into the widest plane of the neoglottis under direct laryngoscopy; a navigation system was incorporated to identify the responsible site. Acoustic, aerodynamic, and perceptual analyses along with videofluoroscopic swallowing study and screening questionnaires were used for functional evaluation.

RESULTS

A total of 0.8ml (Case 1) and 0.7ml (Case 2) of fat tissues were injected into the submucosal space of the responsible sites. Both patients experienced functional improvement subjectively after augmentation; psychological parameters for voice and swallowing also improved.

CONCLUSIONS

Buccal fat augmentation to correct insufficient neoglottal closure after SCL-CHEP was technically feasible. A navigation system was helpful for confirmation. Fat absorption occurred and one third of the volume remained at 3 and 6 months. Although, vocal measurements remained unchanged, psychological parameters for voice and swallowing improved.

Multidimensional evaluation of vocal function after supracricoid laryngectomy with cricohyoidopexy

OBJECTIVES

The aim of this study was to assess the vocal outcome and the impact of arytenoid resection on vocal function following supracricoid laryngectomy with cricohyoidopexy.

METHODS

Twenty-eight male patients who had undergone supracricoid laryngectomy with cricohyoidopexy were included in the study. In 7 patients, one arytenoid cartilage had been totally resected; in 11, both arytenoid cartilages had been preserved; and in 10, one arytenoid cartilage had been partially resected. The maximum phonation time, fundamental frequency, jitter, shimmer, and noise-to-harmonics ratio were assessed and analyzed. Perceptual analysis was performed with the grade, roughness, breathiness, asthenia, and strain (GRBAS) scale. Abduction-adduction and anteroposterior squeezing actions were analyzed from videoendoscopic records. The Voice Handicap Index-10 (VHI-10) was used for self-assessment.

RESULTS

The acoustic and aerodynamic parameters and GRBAS score showed severe impairment. The self-assessment revealed that patients were relatively satisfied with their voice quality. There were no statistically significant differences in the acoustic and aerodynamic parameters, the GRBAS score, or the VHI-10 score according to the level of arytenoid resection.

CONCLUSIONS

Supracricoid laryngectomy with cricohyoidopexy caused deterioration of acoustic and aerodynamic voice parameters and the GRBAS score. Statistically, the level of arytenoid resection had no apparent effect on the objective, perceptual, or subjective voice parameters.

Morphological changes of the vocal fold mucosa in hyperfunctional dysphonia diagnosed by psychoacoustic and videostroboscopic methods

PURPOSE

The aim of the study was to provide a morphological assessment of the laryngeal mucosa in patients with hyperfunctional dysphonia diagnosed by psychoacoustic and videostroboscopic methods.

MATERIAL AND METHODS

Forty patients with voice quality disorders of hyperfunctional dysphonia were recruited for participation in the study. The diagnosis of dysphonia was based on the Voice Rating Scale GRBAS, and endoscopic and stroboscopic assessment of the vocal folds. Acoustic assessment was carried out using following parameters: fundamental frequency, Jitter, Shimmer, Noise to Harmonic Rate and Yanagihara (YG) scale. In order to evaluate the morphology of the vocal fold mucosa transmission electron microscopy was performed using postoperative material obtained from the larynx. Results of clinical and morphological analysis were compared with the reference group. The morphological material was obtained from patients with hypopharyngeal cancer without pathological changes of the vocal folds.

RESULTS

The psychoacoustic assessment using the perceptual GRBAS scale enables the appropriate diagnostics of hyperfunctional dysphonia, which was confirmed by evaluation of acoustic parameters and YG scale analysis. In 40 patients with voice quality disorders causing by hyperfunctional dysphonia, in morphological assessment of the laryngeal mucosa, 4 (10%) patients demonstrated the presence of oedema and signs of intensive dysphonia in psychoacoustic and stroboscopic examination.

CONCLUSIONS

Oedema of the laryngeal mucosa confirmed by stroboscopic and ultramorphological examination may coexist with hyperfunctional dysphonia. The presence of the laryngeal oedema in patients with hyperfunctional dysphonia has the negative impact on voice quality in psychoacoustic assessment with the use of the GRBAS and YG scales.

Analysis of swallowing function after supracricoid laryngectomy with cricohyoidopexy

OBJECTIVE

To evaluate the swallowing function after supracricoid laryngectomy with cricohyoidopexy, focusing on the effects of arytenoid cartilage resection and radiation therapy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Thirty supracricoid laryngectomy-cricohyoidopexy patients, at least 1 year after treatment, were retrospectively analyzed. Fiber-optic endoscopic evaluation of swallowing was performed for each patient. Three blinded judges evaluated the video recordings based on 3 parameters. The M. D. Anderson Dysphagia Inventory was completed by each patient for assessment of disease-specific quality of life.

RESULTS

All patients were decannulated at an average of 23.6 days. Nasogastric feeding tubes were removed at an average of 27.3 days, and all patients could eat orally. Fiber-optic endoscopic evaluation of swallowing showed that patients with total resection of 1 arytenoid had more bolus retention than patients with both arytenoids preserved (P = .008). Compared with patients who did not receive radiotherapy, patients who did receive radiotherapy exhibited increased retention (P = .021) and aspiration (P = .007). The M. D. Anderson Dysphagia Inventory results revealed no differences in quality of life according to the level of arytenoid resection or the administration of radiotherapy.

CONCLUSION

The functional evaluation of swallowing after supracricoid laryngectomy-cricohyoidopexy showed satisfactory results. Patients with total resection of 1 arytenoid had significantly higher bolus retention, and those who received radiotherapy had significantly increased retention and aspiration.

Quality of voice evaluation in patients treated by supracricoid laryngectomy and modified supracricoid laryngectomy

OBJECTIVE

To compare quality of voice in patients treated by supracricoid laryngectomy and patients treated by modified supracricoid laryngectomy using the sternohyoid muscle for neoglottis reconstruction.

STUDY DESIGN

Case series. Setting. Teaching hospital.

SUBJECTS AND METHODS

This study was performed between 2004 and 2008 on 28 consecutive patients affected by T1b-T2 laryngeal carcinoma. Eleven patients were treated by supracricoid laryngectomy, and 17 patients were treated by modified supracricoid laryngectomy. For each patient, postoperative parameters such as decannulation time, nasogastric feeding tube, and length of hospitalization were noted. Vocal function, Voice Handicap Index scores, and perceptual voice analysis scores on intelligibility, noise, fluency, and voice scale were evaluated.

RESULTS

The postoperative course of the patients treated by modified supracricoid laryngectomy was similar to patients treated by supracricoid laryngectomy. No delay in the length of hospitalization was detected in patients undergoing surgery with the new technique. A significant difference was detected in the nasogastric tube removal time and decannulation time. The data from intelligibility, noise, fluency, and voice scale analyses revealed a better quality of voice in patients treated by modified supracricoid partial laryngectomy with a significant difference in intelligibility, fluency, and voicing. The Voice Handicap Index mean value of physical, functional, and emotional subscales confirmed patients' perceptions of a minor voice handicap in patients treated by modified supracricoid laryngectomy, with a significant difference on the physical subscale.

CONCLUSION

Modified supracricoid laryngectomy seems to be a good way to improve quality of voice and quality of life in patients with early laryngeal cancer.

Dysphagia after Nonsurgical Head and Neck Cancer Treatment

Objective. Assess patients’ perspectives on the severity, time course, and relative importance of swallowing deficit before and after (chemo)radiotherapy for head and neck cancer.

Study Design. Before-and-after cohort study.

Setting. Head and neck cancer UK multidisciplinary clinic.

Subjects and Methods. A total of 167 patients with a primary cancer, mostly laryngopharyngeal, completed the MD Anderson Dysphagia Index (MDADI) and the University of Washington Quality of Life Questionnaire (UWQOL) before treatment and at 3, 6, and 12 months. Pretreatment swallowing, age, gender, and tumor site and stage were assessed. Statistical methods used were Mann-Whitney, analysis of variance, and logistic regression.

Results. There was a sharp deterioration in swallowing on average by 18%, from before treatment to 3 months post treatment (mean difference in MDADI score = 14.5; P < .001). Treatment schedule, pretreatment score, and age accounted for 37% of the variance in 3-month posttreatment MDADI scores. There was then little improvement from 3 to 12 months. Patients treated with only 50-Gy radiotherapy reported significantly less dysphagia at 1 year than patients receiving higher doses or combined chemoradiation ( P < .001). Swallowing was the most commonly prioritized of the 12 UWQOL domains both before and after therapy. The MDADI and UWQOL scores were strongly correlated: ρ > 0.69.

Conclusion. Swallowing is a top priority before and after treatment for the vast majority of patients with head and neck cancer. Swallowing deteriorates significantly posttreatment ( P < .001). Treatment intensity, younger age, and lower pretreatment scores predict long-term dysphagia. After chemoradiation, there is little improvement from 3 to 12 months.

Oncologic outcomes after supracricoid partial laryngectomy

OBJECTIVE

To review the oncologic outcomes of a series of supracricoid partial laryngectomy.

DESIGN

Case series with chart review.

SETTING

La Paz University Hospital, Madrid, Spain.

PATIENTS

Forty-one patients with glottic or supraglottic squamous cell carcinoma who underwent supracricoid partial laryngectomy between 1998 and 2008 at the authors' institution.

MAIN OUTCOME MEASURE

Local control rate, specific-disease survival rate, and overall survival rate.

RESULTS

All patients were male, with a mean age of 56 years (range, 38-71 years). Forty-one percent of tumors were classified as locally advanced carcinomas (T3-T4). Thirty-three patients (80%) underwent supracricoid laryngectomy with cricohyoidoepiglottopexy. Epiglottis was resected in the remaining 8 patients. One patient died in the immediate postoperative period because of cardiac tamponade, 6 developed pneumonia, 2 had a postoperative bleeding that required reintervention, and 2 developed pharyngocutaneous fistula. The median follow-up period was 43 months. More than 85% of the patients completed more than 2 years of follow-up. Five-year actuarial local control rate was 80%, being 92% for T1-T2 tumors and 67% for locally advanced tumors. Thirty-five patients (85%) preserved their larynx. The 6 patients who underwent total laryngectomy had a local recurrence or a regional recurrence that infiltrated the larynx. No laryngectomy was performed for functional reasons.

CONCLUSION

Supracricoid partial laryngectomy is an oncologically safe procedure to preserve laryngeal functions in selected patients with glottic and supraglottic carcinomas.

FEESST in the rehabilitation of dysphagia after partial laryngectomy

OBJECTIVES

We describe the role of the laryngeal adductor reflex (LAR) and fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in the rehabilitation of patients with oropharyngeal dysphagia after partial laryngectomy.

METHODS

Ten patients with a mean age of 64 years (range, 45 to 72 years) were included in the study. Seven patients underwent supraglottic laryngectomy, and 3 had supracricoid laryngectomy. Six patients underwent additional radiotherapy (RT), and 8 had functional neck dissection (ND). FEESST was performed on each patient in order to establish a swallowing rehabilitation program.

RESULTS

In 2 patients, not submitted to either ND or RT, the LAR was preserved; in 6 patients, who underwent both procedures, the LAR was delayed or absent. In 2 patients who underwent ND but not RT, the LAR was preserved in 1 case and delayed in the other. The patients with an absent LAR presented severe aspiration, whereas in those with a preserved LAR, no penetration was found. Moderate aspiration was found in the remaining patients. In the patients with a reduced or absent LAR, tactile and chemical sensory stimulation was added to the rehabilitation program.

CONCLUSIONS

FEESST represents a useful tool in everyday clinical practice for the planning of swallowing rehabilitation after partial laryngectomy.

The Effect of Arytenoid Resection on Functional Results of Cricohyoidopexy

OBJECTIVE: The aim of this study was to evaluate the influence of arytenoid resection on voice and swallowing function in patients who undergo supracricoid laryngectomy with cricohyoidopexy.

STUDY DESIGN: A case series with chart review. According to the arytenoid number, patients were divided into two groups: 11 patients with two arytenoids and 9 patients with one arytenoid. The decannulation, nasogastric tube removal, and hospitalization times were noted. Maximum phonation time, average fundamental frequency, percent jitter, percent shimmer, and noise-to-harmonic ratio were measured. Grade, roughness, breathiness, asthenicity and strain scale (for the perceptual evaluation of vocal quality), Voice Handicap Index (for self-assessment of the voice), and dysphagia score were used.

RESULTS: The mean decannulation, nasogastric tube removal, and hospitalization time was 18.4, 40.2, and 32.7 days in patients with one arytenoid, whereas 8.8, 20.8, and 25.3 days in patients with two arytenoids, respectively. The differences were statistically significant. For all of the parameters that are associated with voice function and dysphagia, there was no statistically significant difference between one arytenoid and two arytenoids.

CONCLUSION: Arytenoid resection may affect the swallowing function in the early postoperative period, but for voice and deglutition functions there was no difference between cricohyoidopexy with one arytenoid and two over the course of time.

Long-term vocal functional results after glottectomy: a multi-dimensional analysis

Horizontal glottectomy (HG) is an efficient surgical procedure for the treatment of selected laryngeal carcinoma. The aim of this study was to verify the long-term voice results in a group of HG subjects. The study involved 16 subjects who had undergone HG at least 1 year before. Each subject underwent laryngoscopy and his/her voice was perceptually rated using the GRBAS (grade, roughness, breathiness, asthenicity, strain) scale; the other objective examinations included maximum phonation time (MPT), spectrography, and perturbation analysis. Finally, all of the subjects assessed their own voice using the voice handicap index (VHI). The endoscopic examinations showed good arytenoid mobility and antero-posterior valving of the arytenoid-epiglottal-ventricular band complex, whereas vibration of the neoglottis was more severely impaired. The mean GRBAS values were, respectively, 2.7, 1.9, 1.9, 0.9 and 0.7; the mean MPT was 8.2 s. The Yanagihara score of the voice spectrograms was 4 in all cases; perturbation analysis revealed the following mean values: fundamental frequency = 147; Jitter% = 6.5; Shimmer% = 13.9; and noise-to-harmonic ratio = 0.76. The mean VHI value was 35.8. Objective and subjective data showed a dysphonic voice after HG, whereas the self-assessment results revealed a low degree of perceived disability, suggesting that oral communication was well preserved.