Effects of Laryngeal Cancer on Voice and Swallowing

Integration of Dysphagia Therapy Techniques into Voice Rehabilitation: Design and Content Validation of a Cross-Therapy Protocol

BACKGROUND

The intricate relationship between swallowing and phonation, sharing anatomical and physiological substrates, underscores a clinical demand for integrated therapeutic approaches. Existing interventions often address these functions in isolation, overlooking their interconnected dynamics.

OBJECTIVE

To design and validate a cross-therapy protocol incorporating dysphagia therapy techniques (maneuvers/exercises) into voice rehabilitation. This protocol aims to exploit the shared biomechanical components of swallowing and phonation to improve both functions simultaneously in patients with underlying hypofunctional laryngeal pathology.

METHODS

A descriptive research design was employed, consisting of three phases: a comprehensive literature review and expert discussions in a German seminar format to conceptualize the protocol; detailed analysis and categorization of swallowing maneuvers/exercises; and content validation by a panel of seven experts through a structured evaluation instrument. The process integrated motor learning and exercise physiology principles to ensure the protocol's clinical applicability and theoretical coherence.

RESULTS

The developed cross-therapy protocol incorporates four core swallowing therapy techniques to voice therapy procedures. Selected swallowing therapy techniques target laryngeal excursion and vocal fold closure because they are critical components of swallowing and phonation. Expert validation yielded a Content Validity Coefficient exceeding 0.90 for most items, indicating high consensus on the protocol's relevance, clarity, and applicability. Adjustments were made based on feedback, enhancing the protocol's precision and user-friendliness.

CONCLUSION

We present a novel, evidence-based therapy protocol for voice and swallowing difficulties resulting from hypofunctional laryngeal pathology. Its development marks a significant step toward bridging the gap between swallowing and voice therapy. Future empirical studies are needed to assess its effectiveness in clinical settings.

Effects on Voice Quality of Thyroidectomy: A Qualitative and Quantitative Study Using Voice Maps

OBJECTIVES

This study aims to explore the effects of thyroidectomy-a surgical intervention involving the removal of the thyroid gland-on voice quality, as represented by acoustic and electroglottographic measures. Given the thyroid gland's proximity to the inferior and superior laryngeal nerves, thyroidectomy carries a potential risk of affecting vocal function. While earlier studies have documented effects on the voice range, few studies have looked at voice quality after thyroidectomy. Since voice quality effects could manifest in many ways, that a priori are unknown, we wish to apply an exploratory approach that collects many data points from several metrics.

METHODS

A voice-mapping analysis paradigm was applied retrospectively on a corpus of spoken and sung sentences produced by patients who had thyroid surgery. Voice quality changes were assessed objectively for 57 patients prior to surgery and 2months after surgery, by making comparative voice maps, pre- and post-intervention, of six acoustic and electroglottographic (EGG) metrics.

RESULTS

After thyroidectomy, statistically significant changes consistent with a worsening of voice quality were observed in most metrics. For all individual metrics, however, the effect sizes were too small to be clinically relevant. Statistical clustering of the metrics helped to clarify the nature of these changes. While partial thyroidectomy demonstrated greater uniformity than did total thyroidectomy, the type of perioperative damage had no discernible impact on voice quality.

CONCLUSIONS

Changes in voice quality after thyroidectomy were related mostly to increased phonatory instability in both the acoustic and EGG metrics. Clustered voice metrics exhibited a higher correlation to voice complaints than did individual voice metrics.

Do Effects of Voice Rehabilitation in Patients Irradiated for Laryngeal Cancer Remain 5 Years Postradiotherapy?

PURPOSE

Laryngeal cancer treated by radiotherapy results in many patients being left with an abnormal voice long-term. This prospective study aims to report efficacy of voice rehabilitation 5years postradiotherapy completion.

METHODS

Seventy-seven patients were randomized into an intervention group (n = 37) or a control group (n = 40). Voice rehabilitation was administered postradiotherapy. Patients were followed at baseline, 12- and 60-month postradiotherapy with voice recordings assessed using GRBAS protocol (Grade, Roughness, Breathiness, Asthenia, Strain). Patients filled in the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Head and Neck 35 (EORTC QLQ-HN35) and the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer (S-SECEL).

RESULTS

There were no statistically significant differences between the intervention and control group in scores reported on EORTC QLQ-HN35, S-SECEL or in perceptual evaluation at study end-point. The intervention group reported an improvement in EORTC QLQ-HN35 Speech between baseline-60months postradiotherapy. No significant changes between 12-60months were observed. The control group demonstrated significant improvement in domains Pain, Senses, Speech, Social eating and Sexuality from baseline-60months postradiotherapy, of which only Speech showed a statistically significant change between 12-60months postradiotherapy (P = 0.02). Both groups reported improved S-SECEL scores from baseline-60months, with no significant dynamic between the 12- and 60-month follow-up.

CONCLUSION

Previously observed positive effects of voice rehabilitation on patient communicative skills and perceptual evaluation are no longer noticeable at 5-year post voice therapy completion. Nevertheless, patients receiving voice rehabilitation experience a greater improvement within the first year, which in the control group takes a corresponding 5years.

Revisiting the Concept of Non- and Minimally Invasive Interventions in Early Glottic Cancer – Part II: Single Therapy Should be Favored over the Combination of Transoral Laser Microsurgery and Radiotherapy, Regarding the Postinterventional Voice Quality

Introduction  Early glottic cancer (EGC) is associated with a high cure rate. Hence, patients and physicians also focus on the impact of the proposed treatment on the speaking function of the preserved larynx.

Objectives  The present study assessed the impact of single-modality treatment (transoral laser microsurgery [TLM], or radiotherapy) or combination therapy for EGC on postinterventional voicing and explored factors which might explain the related perceptions.

Methods  A total of 108 patients filled in the voice handicap index 10 questionnaire, 1 and 2 years postinterventionally. Non-parametric tests were used for the respective statistical analyses.

Results  Sixty-four patients were treated with TLM, 15 with radiotherapy, and 29 with both modalities. Transoral microsurgery and radiotherapy were associated with postinterventional dysphonia, which attenuated between the first and second postintervention year ( p  = 0.000). No association between sociodemographic parameters and the attenuation of postinterventional dysphonia was identified for either treatment modality. Transoral microsurgery and radiotherapy resulted in comparable postinterventional voicing, in the first ( p  = 0.940) and second ( p  = 0.196) postintervention years. The addition of TLM to radiotherapy resulted in worse voice quality in the second, compared with the first postintervention year ( p  = 0.000), demonstrating a detrimental effect on speech intelligibility in noise ( p  = 0.000).

Conclusion  Single therapy should be favored over the combination of TLM and radiotherapy for EGC in terms of retaining better postinterventional voice quality. Postinterventional dysphonia should be taken into account, during preinterventional counseling, as it may exert leverage on the quality of patients' lives. Patients and physicians should acknowledge the optimal time of voice function return, which seems to be extending up to two years posttreatment.

Long-term swallowing outcomes of radiotherapy and transoral laser microsurgery for T1 glottic cancer treatment

INTRODUCTION

Both CO2 transoral laser microsurgery (CO2 TOLMS) and radiotherapy (RT) are standard of care in early glottic carcinoma. However, previous studies focus on voice outcomes rather than swallowing outcomes. This study aimed to compare the late post-treatment effects of CO2 TOLMS and RT treatment on swallowing function in T1 glottic carcinoma.

METHODS

Forty patients (20 CO2 TOLMS and 20 RT) with T1 glottic cancer between May 2015 and January 2019 were included. Certain types of foods triggering dysphagia, any difficulties in bolus control, need to clean the throat, the sensation of lumping in the throat, choking, cough and xerostomia were questioned. Also, functional oral intake scale (FOIS), functional outcome swallowing scale (FOSS), Eating Assessment Tool-10 test (EAT-10) and flexible fiberoptic endoscopic examination of swallowing (FEES) findings were assessed.

RESULTS

CO2 TOLMS patients performed significantly better than the RT group regarding penetration and aspiration with 10 and 20 mL water according to the Penetration and Aspiration Scale (P < .05). The mean EAT-10 Score was found 0 in the CO2 TOLMS group, and 3.20 ± 3.24 in the RT group (P < .05) (lower score indicates a better outcome). According to the Yale Pharyngeal Residue Severity Scale for vallecula, there was no statistically significant difference in vallecular residue between the groups (P > .05). A significantly lesser residue in piriform sinus was detected in the CO2 TOLMS group compared to the RT group with 5 mL and 10 mL water, 5 mL and 20 mL honey consistency food and yogurt according to Yale Pharyngeal Residue Severity Scale (P < .05).

CONCLUSION

It is suggested that in the long term, CO2 TOLMS is more advantageous regarding swallowing function in the treatment of T1 glottic cancer.

Comparison of Pharyngoesophageal Segment Biomechanics Between Persons with Total Laryngectomy With and Without Dysphagia Using sEMG: A Multicentric Swallow Study

Total laryngectomy (TL) is the surgical treatment option for advanced stage of laryngeal cancer, involving the removal of larynx along with several muscles attached to it. Several anatomical changes occur following the surgery which will in turn affect the swallowing mechanism. The severing of the cricopharyngeus muscle, which is an important muscle of the pharyngoesophageal segment (PES), may lead to dysphagia. Several other causes have also been explained in the literature. Several invasive instruments have been used to identify dysphagia in this population. The present study aimed to identify the differences in the biomechanics of the PES during dry and wet swallow tasks in persons with TL with and without dysphagia. Amplitude and duration of movement of PES was analysed using a non-invasive instrumental method surface electromyography. The results indicate that amplitude of PES movement was significantly higher in dysphagic group for solids and semisolids. A significantly longer duration was observed for solid consistency for dysphagic group when compared to non-dysphagic group. sEMG evidences suggestive of differences in amplitude and duration between the TL with and without dysphagia groups. Findings also revealed that TL with dysphagia group require more effort to swallow solids and semisolid consistencies when compared to the effort exerted by them during liquid and dry swallow.

Chondroradionecrosis of the larynx

PURPOSE OF REVIEW

Purpose of the present review is to revise the literature of the last 18 months, looking for novelties or new trends in diagnosis and therapeutical approaches to a very uncommon complicaton.

RECENT FINDINGS

Some comorbidities as well as prior surgical laryngeal treatment and lifestyle factors are known to increase tissue susceptibility to radiation injury and to complications due to endotracheal intubation.

SUMMARY

Chondroradionecrosis (CRN) of the larynx is a rare and severe complication of radiotherapy and endotracheal intubation which can be fatal if not managed promptly. In recent years, the trend in oncological surgery is organ preservation even in the advanced stage of laryngeal malignancies. However, in certain stages of squamous cell carcinomas, radiotherapy is necessary as a first or second line of treatment. Endotracheal intubation has also been associated with chondronecrosis and it is thought to be secondary to excessive pressure of the endotracheal tube or its cuff on the cartilage itself. Clinical diagnosis of CRN is extremely difficult and should be placed in differential diagnosis with postradiation outcomes and cancer recurrence. PET is useful, but biopsy is still required to confirm the diagnosis. The use of the laryngeal mask airway should prevent this complication and is a reasonable choice through which to administer general anesthesia in selected patients.

Speech synthesis from ECoG using densely connected 3D convolutional neural networks

OBJECTIVE

Direct synthesis of speech from neural signals could provide a fast and natural way of communication to people with neurological diseases. Invasively-measured brain activity (electrocorticography; ECoG) supplies the necessary temporal and spatial resolution to decode fast and complex processes such as speech production. A number of impressive advances in speech decoding using neural signals have been achieved in recent years, but the complex dynamics are still not fully understood. However, it is unlikely that simple linear models can capture the relation between neural activity and continuous spoken speech.

APPROACH

Here we show that deep neural networks can be used to map ECoG from speech production areas onto an intermediate representation of speech (logMel spectrogram). The proposed method uses a densely connected convolutional neural network topology which is well-suited to work with the small amount of data available from each participant.

MAIN RESULTS

In a study with six participants, we achieved correlations up to r  =  0.69 between the reconstructed and original logMel spectrograms. We transfered our prediction back into an audible waveform by applying a Wavenet vocoder. The vocoder was conditioned on logMel features that harnessed a much larger, pre-existing data corpus to provide the most natural acoustic output.

SIGNIFICANCE

To the best of our knowledge, this is the first time that high-quality speech has been reconstructed from neural recordings during speech production using deep neural networks.

Long noncoding RNA XIST increases the aggressiveness of laryngeal squamous cell carcinoma by regulating miR-124-3p/EZH2

The long non-coding RNAs (lncRNAs) are an emerging class of cancer regulators. The objective of the study was to elucidate the roles and underlying mechanisms of XIST in laryngeal squamous cell carcinoma. Quantitative real-time PCR (qRT-PCR) suggested that XIST was highly upregulated in laryngeal squamous cancerous (LSCC) tissues. Knockdown of XIST, mediated by lentiviral transfection of XIST-specific short-hairpin RNA (shRNA), led to the inhibition of proliferation, migration, and invasion of LSCC cells in vitro. In vivo, XIST knockdown also suppressed the growth of LSCC xenografts in mice. Upregulation of miR-124 and downregulation of EZH2 were concomitantly observed after XIST knockdown, and our data suggested that XIST served as the competitive endogenous RNA of miR-124 to modulate EZH2 expression. Moreover, ectopic overexpression of EZH2 prominently attenuated the anti-proliferation activity by XIST knockdown. Therefore, XIST plays an important role in progression of LSCC by modulating the miR-124-EZH2 axis.

Horizontal (vs. vertical) closure of the neo-pharynx is associated with superior postoperative swallowing after total laryngectomy

We conducted a cross-sectional study to compare the horizontal and vertical methods used in the surgical closure of the neo-pharynx after total laryngectomy in terms of their effect on swallowing function, swallowing-related quality of life (QOL), and overall QOL. We also assessed the potential influence of age (≤64 vs. ≥65 yr) and the type of treatment modality (primary, salvage, or total laryngectomy with radiotherapy) on outcomes. Our final study population was made up of 34 patients-31 men and 3 women, aged 49 to 89 years (mean: 66.8)-who had undergone a total laryngectomy. One year after surgery, all patients were asked to complete the M.D. Anderson dysphagia inventory (MDADI), which quantifies swallowing function and swallowing-related QOL, and the University of Washington quality-of-life questionnaire (UW-QOL), which quantifies overall QOL. Of the 34 patients, 16 had undergone a horizontal surgical closure of their neo-pharynx and 18 a vertical closure. According to the MDADI, patients in the horizontal group experienced significantly better swallowing function/QOL; the mean composite MDADI scores were 91.5 in the horizontal group and 68.3 in the vertical group (p = 0.005). We found no significant difference in terms of overall QOL, as the respective mean UW-QOL scores were 81.0 and 80.8 (p = 0.93). The population correlation coefficient was positive in both groups, but more so in the horizontal group (ρ_horizontal = 0.876 and ρ_vertical = 0.676). Neither age nor the type of treatment modality employed influenced swallowing function/QOL (p_age = 0.10, p_{treatment modality} = 0.78) or overall QOL (p_age = 0.08, p_{treatment modality} = 0.59). We conclude that horizontal closure of the neo-pharynx is superior to vertical closure in terms postoperative swallowing function/QOL but not overall QOL.

Community listeners' perceptions of voice function post-radiotherapy for laryngeal cancer

PURPOSE

Successful communication is influenced by communication partners, the community and communication environment. This study examines community members' perceptions of voice function following laryngeal cancer management compared to ratings by clinicians and patients.

METHOD

Sixty-six (Tis-T3) laryngeal cancer patients post-radiotherapy, 10 community members and three speech-language pathologists (clinicians) were recruited. Patients completed voice recordings and self-rated voice quality and acceptability, six months post-radiotherapy. Community members and clinicians rated patient voice recordings using (a) Voice Quality/Acceptability questionnaire, (b) Communicative Suitability Scale (voice function in different vocally demanding environments) and (c) a gender perception question.

RESULT

Ratings for voice quality differed significantly (p < 0.001) between community members and clinicians and approached significance (p= 0.08) between community members and patients. No significant difference for voice acceptability was noted between community members and clinicians/patients. Community members rated the irradiated voice significantly different (p ≤ 0.02) across communication environments with more vocally demanding environments being rated as "Barely Sufficient". Incorrect sex identification (gender perception) occurred with 25% of females.

CONCLUSION

Community communication partners identify functional voice impairments post-radiotherapy, particularly across more vocally demanding environments and for female speakers. Implications for voice rehabilitation including appropriate patient selection is highlighted.

Esophageal Dysmotility in Patients following Total Laryngectomy

Objectives Dysphagia is common in total laryngectomees, with some symptoms suggesting esophageal dysmotility. Tracheoesophageal (TE) phonation requires effective esophagopharyngeal air passage. Hence, esophageal dysmotility may affect deglutition or TE phonation. This study aimed to determine (1) the characteristics of esophageal dysmotility in laryngectomees, (2) whether clinical history is sensitive in detecting esophageal dysmotility, and (3) the relationship between esophageal dysmotility and TE prosthesis dysfunction. Study Design Multidisciplinary cross-sectional study. Setting Tertiary academic hospital. Subjects and Methods For 31 participants undergone total laryngectomy 1 to 12 years prior, clinical histories were taken by a gastroenterologist and a speech pathologist experienced in managing dysphagia. Esophageal high-resolution manometry was performed and analyzed using Chicago Classification v3.0. Results Interpretable manometric studies were obtained in 23 (1 normal manometry). Esophageal dysmotility patterns included achalasia, esophagogastric junction outflow obstruction, diffuse esophageal spasm, and other major (30%) and minor (50%) peristaltic disorders. The sensitivity of predicting any esophageal dysmotility was 28%, but it is noteworthy that patients with achalasia and diffuse esophageal spasm (DES) were predicted. Two of 4 participants with TE puncture leakage had poor esophageal clearance. Of 20 TE speakers, 12 had voice problems, no correlation between poor voice, and any dysmotility pattern. Conclusions Peristaltic and lower esophageal sphincter dysfunction are common in laryngectomees. Clinical history, while not predictive of minor motor abnormalities, predicted correctly cases with treatable spastic motor disorders. Dysmotility was not associated with poor phonation, although TE puncture leakage might be linked to poor esophageal clearance. Esophageal dysmotility should be considered in the laryngectomees with persisting dysphagia or leaking TE puncture.

Modeling of pharyngoesophageal segment during tracheoesophageal phonation in total laryngectomy patients with preliminary validation

For patients with large or recurrent laryngeal cancer, total laryngectomy surgery is usually performed. In the absence of a larynx, tracheoesophageal (TE) voice is the gold standard for alaryngeal phonation. The mechanisms underlying TE voice are unknown, but pharyngoesophageal (PE) segment vibration has been shown to play a key role. The aim of this study was to systematically explore the mechanics of PE segment vibration during TE phonation. A 2D axisymmetric finite-element model with two domains representing the air and PE wall was developed. Comparison was made between models with different upper esophageal sphincter (UES) radius, and with different inflow pressures. The TE voice of total laryngectomy patients was assessed using Voice Symptoms Scale and VisiPitch recording. PE segment vibration and pressure gradient (ΔP) were measured using High Resolution Manometry with concurrent video-fluoroscopy. Simulation results revealed two different resonant frequencies, with maximal displacement at high frequencies increasing towards the UES. UES displacement increased with increased inflow pressure or UES diameter. Patient studies revealed that the location of maximal PE segment vibration ranged between the fourth and sixth cervical vertebrae. Average AP varied from 11-68 mmHg during phonation among subjects, and consistent with our simulation results, patients with higher AP reported a lower score on the voice symptom scale. The fundamental frequency determined from TE voice recordings corresponded with the computer simulations (209±67 Hz).

Expression of Th1- Th2- and Th17-associated cytokines in laryngeal carcinoma

T-helper (Th) 0 cell differentiation into Th1 or Th2 cells is dependent on a number of transcription factors that act at specific time points to regulate gene expression. Th17 cells, a subset of interleukin (IL)-17-producing T cells distinct from Th1 or Th2 cells, are considered to exhibit a critical function in inflammation and autoimmune diseases, as well as cancer development. In the present study, the expression of Th1-, Th2- and Th17-associated cytokines in laryngeal cancer and pericarcinoma tissues obtained from 57 laryngeal carcinoma patients was investigated. The association between Th1, Th2 and Th17 infiltration and tumor development was also evaluated. Reverse transcription-polymerase chain reaction and western blotting results revealed that the mRNA and protein expression of Th2 cytokines was lower, while the expression of Th1 and Th17 cytokines was higher in tumor tissues than in pericarcinoma tissues. Furthermore, the early stage cancer patients exhibited a higher level of interferon-γ, IL-2 and IL-17 mRNA expression than those at advanced stages. Cancer tissues exhibited higher Th17 cytokine expression than pericarcinoma tissues. By contrast, Th1 cytokine expression was increased in pericarcinoma tissues compared with cancer tissues. These results indicate that high expression of Th1- and Th17-associated cytokines in laryngeal carcinoma may contribute to suppression of cancer development and a relatively good prognosis.

Biomechanics of Pharyngeal Deglutitive Function following Total Laryngectomy

OBJECTIVE

Postlaryngectomy, pharyngeal weakness, and pharyngoesophageal junction (PEJ) restriction are the candidate mechanisms of dysphagia. The aims were, in laryngectomees, whether (1) hypopharyngeal propulsion is reduced and/or PEJ resistance is increased, (2) dilatation improves dysphagia, and (3) whether symptomatic improvement correlates with reduced PEJ resistance.

DESIGN

Multidisciplinary cross-sectional study.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

Swallow biomechanics were assessed in 30 laryngectomees. Patients were stratified into severe dysphagia (Sydney Swallow Questionnaire >500) and mild/nil dysphagia (Sydney Swallow Questionnaire ≤500). Average hypopharyngeal peak (contractile) pressure (hPP) and hypopharyngeal intrabolus pressure (hIBP) were measured from high-resolution manometry with concurrent videofluoroscopy based on barium swallows (2.5 and 10 mL). In consecutive 5 patients, measurements were repeated after dilatation.

RESULTS

Dysphagia was reported by 87%, and 57% had severe and 43% had mild/nil dysphagia. hIBP increased with larger bolus volumes (P < .0001), while hPP stayed stable and PEJ diameter plateaued at 9 mm. Laryngectomees had lower hPP (110 ± 14 vs 170 ± 15 mm Hg; P = .0162) and higher hIBP (29 ± 5 vs 6 ± 5 mm Hg; P = .156) than controls. There were no differences in hPP between patient groups. However, hIBP was higher in severe than in mild/nil dysphagia (41 ± 10 vs 13 ± 3 mm Hg; P = .02). Predilation hIBP (R(2) = 0.97) and its decrement postdilatation (R(2) = 0.98) well predicted symptomatic improvement.

CONCLUSIONS

PEJ resistance correlates better with dysphagia severity than peak pharyngeal pressure and is more sensitive to bolus sizes than PEJ diameter. Both baseline PEJ resistance and its decrement following dilatation are strong predictors of treatment outcome. PEJ resistance is vital to detect, as it is reversible and can predict the response to dilatation regimens.

Prospective clinical study on long-term swallowing function and voice quality in advanced head and neck cancer patients treated with concurrent chemoradiotherapy and preventive swallowing exercises

Concurrent chemoradiotherapy (CCRT) for advanced head and neck cancer (HNC) is associated with substantial early and late side effects, most notably regarding swallowing function, but also regarding voice quality and quality of life (QoL). Despite increased awareness/knowledge on acute dysphagia in HNC survivors, long-term (i.e., beyond 5 years) prospectively collected data on objective and subjective treatment-induced functional outcomes (and their impact on QoL) still are scarce. The objective of this study was the assessment of long-term CCRT-induced results on swallowing function and voice quality in advanced HNC patients. The study was conducted as a randomized controlled trial on preventive swallowing rehabilitation (2006-2008) in a tertiary comprehensive HNC center with twenty-two disease-free and evaluable HNC patients as participants. Multidimensional assessment of functional sequels was performed with videofluoroscopy, mouth opening measurements, Functional Oral Intake Scale, acoustic voice parameters, and (study specific, SWAL-QoL, and VHI) questionnaires. Outcome measures at 6 years post-treatment were compared with results at baseline and at 2 years post-treatment. At a mean follow-up of 6.1 years most initial tumor-, and treatment-related problems remained similarly low to those observed after 2 years follow-up, except increased xerostomia (68%) and increased (mild) pain (32%). Acoustic voice analysis showed less voicedness, increased fundamental frequency, and more vocal effort for the tumors located below the hyoid bone (n = 12), without recovery to baseline values. Patients' subjective vocal function (VHI score) was good. Functional swallowing and voice problems at 6 years post-treatment are minimal in this patient cohort, originating from preventive and continued post-treatment rehabilitation programs.

Evaluation of voice quality after supraglottic laryngectomy

OBJECTIVE

Supraglottic laryngectomy is a surgical procedure that preserves laryngeal functions. This technique allows extensions including removal of tongue base or 1 arytenoid. We aimed to compare vocal results of supraglottic laryngectomy and extended procedures.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary care hospital.

SUBJECTS AND METHODS

Thirty-three males who underwent supraglottic laryngectomy were included in the study. Fifteen patients (45.5%) were applied standard supraglottic laryngectomy (standard supraglottic laryngectomy group). In 11 patients (33.3%), unilateral arytenoid cartilage was totally resected by separation at the cricoarytenoid joint (laterally extended group), and the tongue base was removed in 7 patients (anteriorly extended group) (21.2%). Twenty male smokers constituted control group. Acoustic and aerodynamic voice analyses were performed for the assessment of objective results. Grade, roughness, breathiness, asthenia, and strain scale (GRBAS) scores were analyzed for perceptual assessment. Voice Handicap Index-30 was used to evaluate subjective results.

RESULTS

The comparison of supraglottic laryngectomy group with the control group revealed that the mean maximum phonation time and fundamental frequency were significantly lower in the supraglottic laryngectomy group (P < .001), and the mean jitter, shimmer, and noise-to-harmonics ratio were significantly higher in the supraglottic laryngectomy group (P < .001). Maximum phonation time and fundamental frequency were higher in the standard supraglottic laryngectomy group in comparison to extended groups. Jitter value was also lower in the standard supraglottic laryngectomy group compared to extended groups. Perceptual and subjective analyses revealed no difference among standard supraglottic laryngectomy and extended groups.

CONCLUSION

The results of this study indicate that supraglottic laryngectomy patients have acceptable voice quality, as determined by perceptual and subjective assessment.

Management of locally advanced laryngeal cancer

Background

Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer.

Methods

Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center.

Results

A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis.

Conclusion

This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.

Transoral laser microsurgery elevates fundamental frequency in early glottic cancer

OBJECTIVE

To evaluate the long-term voice characteristics and quality of life of early glottic cancer patients after definitive treatment.

STUDY DESIGN

Case series with chart review in a tertiary care medical center in Taiwan.

METHODS

Forty-two consecutive patients who received radiation therapy (RT) or transoral laser microsurgery (TLM) for early glottic cancer over 12 months were evaluated for voice laboratory data and quality-of-life measurements.

RESULTS

Twenty-four patients received RT, and 18 underwent TLM. There was no difference between the two groups on acoustic and aerodynamic voice measures except for modal fundamental frequency in males. In the Functional Assessment of Cancer Therapy-Head and Neck survey, the TLM group had better communication than the RT group, but there were no differences in voice quality and strength. There was also no significant difference in the Voice Handicap Index 10 evaluation.

CONCLUSIONS

Male patients who received TLM have higher modal fundamental frequency than male patients who received RT and norms. Voice-related life quality is similar in patients regardless of RT or TLM treatment for early glottic cancer, but those who receive TLM have better communication abilities than those who receive RT.

Effect of repeated laser microsurgical operations on laryngeal cancer prognosis

BACKGROUND

The aim of this study was to evaluate whether repeated sessions of transoral CO(2) laser microsurgery (TLM) aiming to achieve clear histologic margins carry a negative effect on the prognosis of laryngeal cancer.

METHODS

This was a retrospective evaluation of 763 cases that underwent primary TLM treatment for laryngeal cancer. Cases were compared for overall survival and local control rates with respect to status of surgical margins and number of procedures necessary to achieve these margins.

RESULTS

No significant differences were noted among cases with negative surgical margins regardless of the number of procedures necessary to achieve these margins. On the other hand, positive margins at the end of surgical treatment carried significant negative prognostic effect.

CONCLUSION

The prognostic effect of negative surgical margins in TLM for laryngeal cancer is significant regardless of the number of procedures required to obtain such margins.

Dysphagia After Total Laryngectomy

Previous thought was that total laryngectomy and difficulty with swallowing were incongruous. Patients were counseled that the loss of their larynx would leave them without a vocal source, but that swallowing would not be affected. Successful rehabilitation was defined as being cancer-free and regaining functional communication. Patients were not queried and frequently did not complain of dysphagia as long as they were able to maintain an oral diet. Knowledge has changed, and this article will focus on dysphagia in the patient with laryngectomy and will discuss anatomical sites to physiologic problems.

Comparison among different available surgical approaches in T1 glottic cancer

OBJECTIVES/HYPOTHESIS

This study aims to assess the oncologic results of open and transoral surgical techniques in T1a and T1b category glottic carcinomas.

STUDY DESIGN

Retrospective clinical study.

METHODS

The files of 438 T1a and T1b glottic cancer cases managed with primary surgery were reviewed. Transoral laser surgery and open surgical procedures used to treat these cases, including cordectomy, vertical partial laryngectomy, and frontolateral partial laryngectomy, were compared for disease specific survival and local control rates. In addition, all techniques were compared for incidence of major complications and related tracheotomies.

RESULTS

No statistically significant differences were noted between laser surgery and open procedures with regard to disease specific survival and local control for both T1a and T1b cases. Laser surgery showed a significantly lower incidence of complications and tracheotomies.

CONCLUSIONS

Laser surgery appears to be a very effective management modality for T1 glottic cancer with comparable results to open procedures and a lower incidence of complications. A transcervical approach should be reserved only for selected cases where individual anatomic factors do not permit complete tumor exposure during diagnostic microlaryngoscopy.

Resection margins and other prognostic factors regarding surgically treated glottic carcinomas

BACKGROUND AND OBJECTIVES

This study aims to assess the prognostic significance of free histopathologic margins in the surgical treatment of glottic cancer. Furthermore, it evaluates other prognostic factors regarding cases that receive surgical management for glottic lesions.

METHODS

A retrospective case-series study was conducted at an academic tertiary referral center. The files of 1,314 cases that underwent primary surgical treatment for glottic cancer were studied. Various prognostic factors, including age, surgical procedure, T classification, N classification, histological grade, and status of margins were assessed in univariate and multivariate analyses. All variables were investigated for their association with local and regional disease control as well as disease specific and overall survival.

RESULTS

Status of margins significantly affected disease specific survival and local control regardless of tumor stage in this series. All other variables assessed in the univariate analysis for their association with survival were also found to be significant. However, status of surgical margins and N classification were the only significant variables in multivariate analysis.

CONCLUSION

The prognostic value of negative surgical margins for the treatment of glottic cancer cannot be overestimated. Responsibility of the surgeon during primary surgical treatment of glottic carcinomas is emphasized.

[Communication of needs in laryngectomized patients: Pictorrino]

OBJECTIVE

To design, create and validate a pictogram, called Pictorrino, as a tool to obtain direct and simple communication with laryngectomized patients.

PATIENTS AND METHODS

In a prospective sample of 10 laryngectomized patients within the first postoperative week, their principal needs and demands were evaluated, and were confirmed in a retrospective second sample of 10 laryngectomized patients who attended reviews in the outpatient clinic. Thereafter, pictograms were created to state such needs in as clear a fashion as possible.

RESULTS

A pictogram was designed and validated, named and registered as Pictorrino, consisting of a board, which showed these pictograms on one of its sides, and a visual analogue scale of pain, with the aim of enabling the patient to express the demand or need at every moment.

CONCLUSIONS

With Pictorrino we have achieved a multicultural tool that allows a more direct communication with laryngectomized patients.

Radiological balloon dilatation of post-treatment benign pharyngeal strictures

Aims:

To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer.

Materials and methods:

Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire.

Results:

Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula.

Conclusion:

Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.