Current Role of Total Laryngectomy in the Era of Organ Preservation

Outcomes of Supracricoid Partial Laryngectomy Performed in the United States: A Systematic Review

OBJECTIVE

The primary objective of this study was to evaluate oncologic outcomes of all published cases of supracricoid partial laryngectomy (SCPL) performed in the United States. The secondary objective was to assess the functional outcomes associated with this procedure.

REVIEW METHODS

A systematic review of PubMed, SCOPUS, and Embase for all English-language studies pertaining to SCPL performed in the United States was conducted until August 2021. Primary outcomes included disease-specific survival (DSS), overall survival, and local recurrence rate. Secondary outcomes included larynx preservation rate, gastrostromy tube dependency, days to gastrostomy tube removal, decannulation rate, and days to decannulation.

RESULTS

A total of six studies were included in the analysis. A total of 113 patients (58.5%) underwent SCPL surgery as a primary treatment method whereas 80 patients (41.5%) underwent SCPL as salvage surgery. The 5-year DSS rates were 87.8% and 100% for primary and salvage procedures, respectively. Approximately 10.3% of patients undergoing a salvage SCPL procedure experienced a local recurrence whereas only 1.85% of primary SCPL procedures resulted in local recurrence. The rates of decannulation following primary and salvage SCPL were 92.7% and 88.1%, respectively. With regard to swallowing, primary and salvage SCPL procedures demonstrated comparably low postoperative gastrostomy tube dependency rates of 3.66% and 4.76%, respectively.

CONCLUSIONS

SCPL performed in the United States is an effective surgical technique that produces excellent outcomes in qualifying patients, thus validating its viability as an organ-preserving surgical alternative. Laryngoscope, 134:3003-3011, 2024.

Videofluoroscopic swallowing study to detect pharyngeal leak after total (pharyngo-) laryngectomy: Retrospective assessment of a single-institution protocol

BACKGROUND

We aimed to assess the effectiveness of a single-institution protocol of videofluoroscopic swallowing study (VFSS) for the detection of pharyngeal leak (PL) and its usefulness to mitigate evolution into subsequent pharyngocutaneous fistula (PCF) after total (pharyngo-) laryngectomy (TL).

METHODS

This retrospective single-center study was conducted between February 2014 and December 2022. We included all patients who underwent TL and performed a VFSS between Day 7 and Day 14 postoperatively to detect a subclinical PL.

RESULTS

Two-hundred and forty-eight patients met the inclusion criteria. Among the 186 patients (75%) with a negative VFSS, 11 patients (5.9%) developed a secondary PCF after oral intake resumption (false negative of VFSS). Among the 62 patients (25%) with a positive VFSS, the occurrence of a PCF was avoided in 59.7% of cases.

CONCLUSION

This study showed a good effectiveness of VFSS in the detection of PL after TL, alongside a usefulness to mitigate evolution into subsequent PCF.

Predictors of multiple dilations and functional outcomes after total laryngectomy and laryngopharyngectomy

BACKGROUND

Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown.

METHODS

Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022.

RESULTS

A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group.

CONCLUSIONS

Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

A novel approach to predict acute radiation dermatitis in patients with head and neck cancer using a model based on Bayesian probability

PURPOSE

In this study, we aimed to establish a method for predicting the probability of each acute radiation dermatitis (ARD) grade during the head and neck Volumetric Modulated Arc Therapy (VMAT) radiotherapy planning phase based on Bayesian probability.

METHODS

The skin dose volume >50 Gy (V50), calculated using the treatment planning system, was used as a factor related to skin toxicity. The empirical distribution of each ARD grade relative to V50 was obtained from the ARD grades of 119 patients (55, 50, and 14 patients with G1, G2, and G3, respectively) determined by head and neck cancer specialists. Using Bayes' theorem, the Bayesian probabilities of G1, G2, and G3 for each value of V50 were calculated with an empirical distribution. Conversely, V50 was obtained based on the Bayesian probabilities of G1, G2, and G3.

RESULTS

The empirical distribution for each graded patient group demonstrated a normal distribution. The method predicted ARD grades with 92.4 % accuracy and provided a V50 value for each grade. For example, using the graph, we could predict that V50 should be ≤24.5 cm3 to achieve G1 with 70 % probability.

CONCLUSIONS

The Bayesian probability-based ARD prediction method could predict the ARD grade at the treatment planning stage using limited patient diagnostic data that demonstrated a normal distribution. If the probability of an ARD grade is high, skin care can be initiated in advance. Furthermore, the V50 value during treatment planning can provide radiation oncologists with data for strategies to reduce ARD.

Survival in an era of organ preservation: an update on laryngeal cancer in Ireland

BACKGROUND

Laryngeal cancer epidemiology has changed in recent years, with falling incidence observed internationally. Organ preservation therapies have revolutionised management, though some patients may be unsuitable and survival was noted to fall in the 2000s. This study examines trends in laryngeal cancer in Ireland.

METHODS

A retrospective cohort study of National Cancer Registry of Ireland data from 1994 to 2014.

RESULTS

From a cohort of 2651, glottic disease was most common (62%, n = 1646). Incidence rose to 3.43 cases/100,000/year for 2010-2014. 5-year disease-specific survival (DSS) was 60.6% and did not change significantly over time. Overall survival (OS) for T3 disease managed with primary radiotherapy was similar to primary surgery (HR 0.98, p = 0.9). DSS for T3 disease improved with primary radiotherapy (HR 0.72, p = 0.045).

CONCLUSION

Incidence of laryngeal cancer in Ireland rose despite international trends, while survival changed little. Radiotherapy improves DSS for T3 disease but does not improve OS, possibly secondary to poor organ function post-radiotherapy.

Strategies for Inhibition of Biofilm Formation on Silicone Rubber Voice Prostheses: A Systematic Review

BACKGROUND

Lifetime elongation of the silicone voice rubber prostheses by inhibition of biofilm formation is a primary objective in voice restoration of laryngectomized patients. This systematic review sought to explore the existing strategies in this direction.

MATERIALS

We conducted a systematic search of both in vitro and in vivo literature published in PubMed, Scopus, and Cochrane Central Register of Controlled Trials, until December 31, 2022, for published and unpublished trials assessing the strategies for inhibiting biofilm formation on silicone rubber voice prostheses, and appraised quality assessment with the modified Consolidated Standards of Reporting Trials tool. We analyzed the infection prevention capacity of the included antibacterial and antifungal agents.

RESULTS

The qualitative synthesis showed that both surface modification methods and prophylactic treatment of silicone rubber voice prostheses present adequate antibiofilm activity. Of note, the majority of the suggested prosthetic surfaces were not chronically exposed to both human fluids and biofilm-forming microorganisms.

CONCLUSION

Various experimental methods provide promising antibiofilm activity and, thus, possible lifespan elongation of silicone rubber voice prostheses.

Survival Outcomes in T3 Laryngeal Cancers: Primary Total Laryngectomy vs. Concurrent Chemoradiation or Radiation Therapy-A Meta-Analysis

BACKGROUND

The management of cT3 laryngeal cancers remains controversial, with studies recommending surgical or non-surgical approaches. Despite the many papers that have been published on the subject, there is a lack of studies showing which treatment has better results in terms of survival.

OBJECTIVE

To determine the difference in survival outcomes following total laryngectomy (TL), concurrent chemoradiation (CRT) or radiation therapy (RT) alone in T3 laryngeal cancers.

METHODS

Search of PubMed, Scopus, and Google Scholar databases from 1995 to 2023 employing specific keywords and Boolean operators to retrieve relevant articles. Statistical analysis was conducted using a random-effects model, and heterogeneity was evaluated using the Q-test and I2 statistic. Funnel plot asymmetry was assessed using rank correlation and regression tests.

RESULTS

The qualitative data synthesis comprised 10,940 patients from 16 included studies. TL was performed in 2149 (19.4%), CRT in 6723 (61.5%), RT in 295 (2.7%), while non-surgical treatment was not specified in 1773 (16.2%) patients. The pooled 2-year overall survival (OS) rates were TL = 73%, CRT = 74.7%, RT = 57.9%, 3-year OS rates were TL = 64.3%, CRT = 62.9%, RT = 52.4%, and 5-year OS rates were TL = 54.2%, CRT = 52.7%, RT = 40.8%. There was a significant heterogeneity in the included studies. There was no statistically significant difference in 2-year OS (logOR= -0.88 (95% confidence interval (CI): -1.99 to 0.23), p = 0.12), 3-year OS (logOR = -0.6 (95% CI: -1.34 to 0.15), p = 0.11), and 5-year OS (logOR = -0.54 (95% CI: -1.29 to 0.21), p = 0.16) between TL and CRT. Instead, there was significant difference in 2-year OS (logOR= -1.2383 (95% CI: -2.1679 to -0.3087), p = 0.009), 3-year OS (-1.1262 (95% CI: -1.6166 to -0.6358), p < 0.001), and 5-year OS (-0.99 (95% CI: -1.44 to -0.53)), p < 0.001) between TL and RT alone.

CONCLUSIONS AND SIGNIFICANCE

TL followed with adjuvant (chemo)radiation on indication and CRT with salvage surgery in reserve appear to have similar OS outcomes. Both resulted in better OS outcomes compared to RT alone in the treatment of T3 laryngeal cancers. If patients are unfit for chemotherapy, making CRT impossible, surgery may become the choice of treatment.

Νanomaterial-Loaded Polymer Coating Prevents the In Vitro Growth of Candida albicans Biofilms on Silicone Biomaterials

Early failure of silicone voice prostheses resulting from fungal colonization and biofilm formation poses a major concern in modern ear nose throat surgery. Therefore, developing new infection prevention techniques to prolong those implants' survivorship is crucial. We designed an in vitro laboratory study to include nanomaterial-enhanced polymer coating with a plasma spraying technique against Candida albicans growth to address this issue. The anti-biofilm effects of high- and low-dose Al₂O₃ nanowire and TiO₂ nanoparticle coatings were studied either alone or in conjunction with each other using checkerboard testing. It was demonstrated that both nanomaterials were capable of preventing fungal biofilm formation regardless of the anti-fungal agent concentration (median absorbance for high-dose Al₂O₃-enhanced polymer coating was 0.176 [IQR = 0.207] versus control absorbance of 0.805 [IQR = 0.381], p = 0.003 [98% biofilm reduction]; median absorbance for high-dose TiO₂-enhanced polymer coating was 0.186 [IQR = 0.024] versus control absorbance of 0.766 [IQR = 0.458], p < 0.001 [93% biofilm reduction]). Furthermore, synergy was revealed when the Bliss model was applied. According to the findings of this work, it seems that simultaneous consideration of Al₂O₃ and TiO₂ could further increase the existing antibiofilm potential of these nanomaterials and decrease the likelihood of localized toxicity.

Salvage surgery in laryngeal cancer after radiotherapy and partial surgery - comparative results

Objective

The study is a retrospective comparison of the usefulness of salvage surgery between a group of previously radiotherapy-treated patients (RTPs) and a group of patients who previously underwent partial surgery with both local and ± nodal recurrence.

Study Design

Retrospective study.

Setting

Multi-center academic hospital.

Materials and Methods

The former group was comprised 30 previously RTPs, whereas the latter group consisted of 20 patients after partial laryngeal surgery with optional subsequent adjuvant radiotherapy (PSPs). Treatment efficacy was compared in both groups in relation to overall survival (OS) and the locoregional control rate (LCR). Local and ± nodal recurrence was considered primary treatment failure. All patients underwent total laryngectomy.

Results

The updated 5-year OS in the PSPs was 31%, while the percentage of the updated 5-year LCR was 42%. In the RTPs the updated 5-year OS was 21%, and the percentage of 5-year LCR was 38%. No statistically significant differences were found in terms of the comparison of OS or the comparison of LCR results in both groups (P = 0.427, P = 0.704, respectively).

Conclusions

Based on the analysis, it was found that irrespective of the initial treatment, salvage surgery was associated with decreased survival and cure rates (by 50%) compared to the group of patients with advanced laryngeal cancer who underwent primary total laryngectomy.

Salvage vs. Primary Total Laryngectomy in Patients with Locally Advanced Laryngeal or Hypopharyngeal Carcinoma: Oncologic Outcomes and Their Predictive Factors

BACKGROUND

The aims of this study were to compare the survival outcomes of salvage vs. primary total laryngectomy (TL) in patients with locally advanced laryngeal or hypopharyngeal carcinoma and to determine their predictive factors.

METHODS

Overall (OS), cause-specific (CSS) and recurrence-free survival (RFS) of primary vs. salvage TL were compared in univariate and multivariate analysis taking into account other potential predictive factors (tumor site, tumor stage, comorbidity level etc.).

RESULTS

A total of 234 patients were included in this study. Five-year OS was 53% and 25% for the primary and salvage TL groups, respectively. Multivariate analysis confirmed the independent negative impact of salvage TL on OS (p = 0.0008), CSS (p < 0.0001) and RFS (p < 0.0001). Hypopharyngeal tumor site, ASA score ≥ 3, N-stage ≥ 2a and positive surgical margins were the main other predictors of oncologic outcomes.

CONCLUSIONS

Salvage TL is associated with significantly worse survival rates than primary TL highlighting the need for careful selection of patients who are candidates for larynx preservation. The predictive factors of survival outcomes identified here should be considered in the therapeutic decision-making, especially in the setting of salvage TL, given the poor prognosis of these patients.

Current Therapeutic Strategies for Patients with Hypopharyngeal Carcinoma: Oncologic and Functional Outcomes

Hypopharyngeal cancer is usually diagnosed at an advanced stage and is associated with a high risk of recurrence and poor survival rates. Although they differ greatly in terms of prognosis, hypopharyngeal cancers are usually treated together with laryngeal cancers in clinical trials. Therefore, there are very few studies that focus specifically on patients with hypopharyngeal carcinoma. As a result, the therapeutic management of these patients is highly debated, and their clinical outcomes are poorly reported. The aim of this review is therefore to discuss the current therapeutic options in patients with hypopharyngeal carcinoma and their oncologic and functional outcomes. Patients with early-stage tumors can be treated either by conservative surgery (including transoral robot-assisted surgery) or by RT alone. However, most patients are diagnosed with locally advanced tumors that cannot be treated surgically without total laryngectomy. In this situation, the critical issue is to select the patients eligible for a larynx preservation therapeutic program. However, radical surgery with total laryngectomy still plays an important role in the management of patients with hypopharyngeal carcinoma, either as the primary treatment modality (T4 resectable primary tumor, contraindication to larynx preservation therapies) or, more commonly, as salvage treatment.

Docetaxel-Cisplatin-Fluorouracil Induction Chemotherapy for Larynx Preservation in Patients with Locally Advanced Hypopharyngeal Cancer: Predictive Factors of Oncologic and Functional Outcomes

BACKGROUND

The aims of this study were to evaluate the clinical outcomes and their predictive factors in locally advanced hypopharyngeal cancer (HC) patients included in a docetaxel-cisplatin-fluorouracil induction chemotherapy (ICT)-based larynx preservation (LP) program.

METHODS

Between 2005 and 2021, 82 patients with a locally advanced resectable HC who received ICT in an LP program were included in this retrospective study. The predictors of oncologic and swallowing outcomes were determined in univariate and multivariate analyses.

RESULTS

The three- and five-year overall survival (OS) rates were 67 and 54%, respectively. The T4 tumor stage was the only predictive factor of poor response to ICT (p = 0.03). In multivariate analysis, a T stage = 4 (p = 0.02), an ICT cycle number < 3 (p = 0.003) and the absence of a response to ICT (p = 0.03) were significantly associated with worse OS. A low body mass index before therapy (p = 0.003) and enteral nutrition during therapy (p = 0.005) were significantly associated with severity of dysphagia 6 months after treatment.

CONCLUSIONS

The T stage, number of ICT cycles performed and response to ICT are the main predictors of oncologic outcomes. Patients with T4 HC are poor candidates for LP and should be referred to immediate radical surgery.

A deep learning-based model predicts survival for patients with laryngeal squamous cell carcinoma: a large population-based study

OBJECTIVES

To assess the performance of DeepSurv, a deep learning-based model in the survival prediction of laryngeal squamous cell carcinoma (LSCC) using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

In this large population-based study, we developed and validated a deep learning survival neural network using pathologically diagnosed patients with LSCC from the SEER database between January 2010 and December 2018. Totally 13 variables were included in this network, including patients baseline characteristics, stage, grade, site, tumor extension and treatment details. Based on the total risk score derived from this algorithm, a three-knot restricted cubic spline was plotted to exhibit the difference of survival benefits from two treatment modalities.

RESULTS

Totally 6316 patients with LSCC were included in the study, of which 4237 cases diagnosed between 2010 and 2015 were selected as the development cohort, and the rest (2079 cases diagnosed from 2016 to 2018) were the validation cohort. A state-of-the-art deep learning-based model based on 23 features (i.e., 13 variables) was generated, which showed more superior performance in the prediction of overall survival (OS) than the tumor, node, and metastasis (TNM) staging system (C-index for DeepSurv vs TNM staging = 0.71; 95% CI 0.69-0.74 vs 0.61; 95% CI 0.60-0.63). Interestingly, a significantly nonlinear association between total risk score and treatment effectiveness was observed. When the total risk score ranges 0.1-1.5, surgical treatment brought more survival benefits than nonsurgical one for LSCC patients, especially in 70.5% of patients staged III-IV.

CONCLUSIONS

The deep learning-based model shows more potential benefits in survival estimation for patients with LSCC, which may potentially serve as an auxiliary approach to provide reliable treatment recommendations.

[Historical and modern aspects of rehabilitation of voice function after laryngectomy]

The literature review presents historical and modern aspects of the rehabilitation of vocal function after laryngectomy, in particular, external devices, tracheopharyngeal bypass surgery, esophageal speech, tracheoesophageal bypass surgery without the use of a prosthetic device, voice prostheses are described. The advantages and disadvantages of each voice restoration technique, functional results, complications, prosthesis designs, their service life, bypass techniques, methods of prevention and treatment of damage to the valve apparatus of the prosthesis by colonies of microorganisms, fungal flora are analyzed.

Effectiveness of a nurse-led coaching of self-care agency intervention for elderly patients with total laryngectomy: study protocol for a randomised controlled trial

INTRODUCTION

Due to functional defects and structural destruction after total laryngectomy, patients experienced the poor quality of life, especially for elderly. The barriers to accessing self-care in elderly patients were considered to result from complex and multifaceted interactions of biologic and social factors. Therefore, specific efforts to improve elderly patients' quality of life are needed. The purpose of our study is to verify nurse-led coaching of elderly patient self-care approaches, which can reduce logistic burden of patients and obtain the successful functional rehabilitation ultimately.

METHODS AND ANALYSIS

Elderly patients (n=60) scheduled for total laryngectomy will be randomly divided into the intervention group and the control group. Patients in the control group received routinely nursing during hospitalisation and thereby at home after discharge received conventional family care without regular supervision of nurses. Patients in the intervention group will receive a series of self-care intervention based on the transtheoretical model during hospitalisation. During home after discharge, nurses will additionally evaluate and supervise the self-care effect of patients. The two groups of patients' self-care agency, self-efficacy, quality of life and nutritional status will be recorded separately at different time points. Primary outcome is the improvement of patients' self-care agency, and secondary outcome is the improvements of patients' self-efficacy, quality of life, nutritional states and 3-month unplanned readmission rate.

ETHICS AND DISSEMINATION

The Ethics Committee of Hubei Cancer Hospital has approved this protocol (KYLLBA2020006). The findings of the trial will be disseminated through peer-reviewed journals, national or international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100043731.

Patient experience of the acute post-surgical period following total laryngectomy during the COVID-19 era

BACKGROUND

Total laryngectomy (TL) results in permanent functional changes requiring rapid development of complex new skills. A significant portion of this learning happens in the acute post-surgical stage. There is increasing interest in enhanced recovery after surgery (ERAS) protocols in TL; however, implementation has been difficult. COVID-19 has placed significant pressures on acute services, requiring rapid service changes for TL patients.

AIMS

To understand the acute patient experience of having a TL both before and during COVID-19.

METHODS & PROCEDURES

Semi-structured interviews using a pre-designed topic guide were conducted with 10 people who had undergone a TL within the last 2 years. Participants were recruited by their speech and language therapists using purposive sampling. Braun and Clarke's iterative approach to data collection and thematic analysis was used to generate key themes from the data.

OUTCOMES & RESULTS

Thematic analysis identified four main themes: (1) pre-operative information-giving: 'it was just words'; (2) decision-making influences: 'I just wanted them to get it all out and get it over with'; (3) coping with adjustment to the new normal: 'this is part of me now'; and (4) the importance of relationship-building: 'when you've had something like this, you need some care and understanding'.

CONCLUSIONS & IMPLICATIONS

The need for an individualized approach to TL intervention which incorporates medical and psycho-social approaches from pre-treatment to acute discharge is vital. ERAS models should be reviewed to shift beyond the medical model alone. Rapid service changes due to COVID-19 did not contribute any major changes to the acute patient-reported experience.

WHAT THIS PAPER ADDS

What is already known on the subject We know that ERAS protocols have the potential to improve patient outcomes following TL. However, the research does not consider anything other than the early oral feeding debate and it has therefore been difficult to implement ERAS protocols in current service models. COVID19 required head and neck cancer services to make quick changes to surgical pathways, with the potential that some ERAS protocols had been adopted inadvertently. In order to understand the impact of this, we need to understand the patient experience following TL both before and during COVID19. What this paper adds to existing knowledge This paper used qualitative interviews to understand the acute patient experience following TL both during and before COVID19. Findings from these interviews highlighted that people were on the most part, well prepared for the functional changes they would experience after surgery. However, people felt there were gaps in service delivery at the pre-treatment and early discharge home period. Overall, the gaps identified were from a more psycho-social need suggesting that future ERAS models of care should consider both medical and psycho-social principles to enhance patient experience and outcome. What are the potential or actual clinical implications of this work? Pre-treatment services provided to people who have a TL could be reviewed to help maximize long-term adjustment to life. Areas which could be reviewed include the method and mode of information delivery. Further work needs to be done in partnership with community services to improve the immediate discharge home experience.

Open partial horizontal laryngectomy for T2-T3-T4a laryngeal cancer: oncological outcomes and prognostic factors of two Italian hospitals

PURPOSE

The purpose of this study was to analyse the oncologic results of open partial horizontal laryngectomy (OPHL) and to assess the prognostic factors that could affect the survival of patients affected by T2, T3 and T4a laryngeal cancer. Using this data, we aim to identify clinical criteria to select patients amenable to conservative surgery, and to facilitate a more targeted approach in the management of advanced laryngeal cancer.

METHODS

A retrospective study was performed in patients who underwent OPHL type II for laryngeal squamous cell carcinoma from January 2005 to December 2018. We analysed a total of 170 patients; 21(12.36%) cases were staged as pT2, 116 (68.23%) as pT3 and 33 (19.41%) as pT4a.

RESULTS

Five-year overall survival (OS) was 80.9%, 79.3%, 70.4% for T2, T3 and T4 respectively. Disease-specific survival (DSS) was 90.4%, 85.3% and 77.4%. Posterior tumour extension, perineural invasion and N status showed to considerably influence survival in both uni- and multivariate analyses.

CONCLUSION

The oncological outcomes from our study show that OPHL for advanced laryngeal cancer can guarantee a high percentage of success. Accurate patient selection is of utmost importance to differentiate advanced disease amenable to conservative surgery, and treatment options should consider selected criteria based on tumour and patient features.

Comparison of Patients With Total and Salvage Laryngectomy

INTRODUCTION AND OBJECTIVES

Total laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival.

METHODS

The study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death.

RESULTS

The mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P = .000) and between fistula and infection (P = .000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P = .038), T4 (P = .026), lymphovascular invasion (P = .019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P = .005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P = .026).

CONCLUSIONS

Although organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.

Nonsurgical Risk Factors Associated With Pharyngocutaneous Fistula in Patients Who Have Undergone Laryngectomy

Importance

Pharyngocutaneous fistula (PCF) is a serious complication after total laryngectomy. Despite the well-described clinical risk factors for PCF and its association with poor quality of life, there is a paucity of data on the nonclinical factors that may be associated with this complication.

Objective

To determine whether nonclinical risk factors (eg, age, sex, race and ethnicity) are associated with an increased risk of developing a PCF after total laryngectomy, and whether or not the method of reconstruction explains any differences found.

Design, Setting, and Participants

This retrospective multicenter cohort study used data from a nationally validated, risk-adjusted, outcomes-based, surgical quality improvement database (the National Surgical Quality Improvement Program) to examine outcomes in patients who underwent a total laryngectomy from 2005 to 2018. The database was queried from January 1, 2005, to December 31, 2018; data analyses were performed from September 1, 2020, to March 31, 2021.

Main Outcomes and Measures

The primary outcome was development of a PCF within 30 days of a total laryngectomy. Patient characteristics, including age, sex, race and ethnicity, comorbidities, and mode of reconstruction, were analyzed.

Results

A cohort of 1573 adult patients (median age [IQR], 63 [56-71] years; 1280 [81.4%] men; 293 [18.6%] women; 1001 [63.6%] non-Hispanic White individuals) had undergone a total laryngectomy during the study period and were included in the analyses. The overall rate of PCF formation was 4.3% (68 of 1573 patients). Hispanic patients had the highest rate (9.5%; 9 of 95 patients) of PCF formation, which was more than twice the rate among non-Hispanic White patients (3.8%; 38 of 1001) and non-Hispanic Black patients (4.7%; 11 of 236). After adjusting for clinical and other covariates, women were 1.9 times more likely to develop a PCF compared with men (adjusted odds ratio, 1.90; 95% CI, 1.08-3.35). We also found that the odds of developing a PCF were 3-fold higher among Hispanic patients compared with non-Hispanic White patients (adjusted odds ratio, 2.96; 95% CI, 1.36-6.47). The type of reconstruction did not differ across age or race and ethnicity after controlling for clinical risk factors.

Conclusions and Relevance

This multicenter cohort study found that 2 nonclinical risk factors-Hispanic ethnicity and female sex-were associated with an increased risk of PCF formation. Knowledge of these risk factors should be included in patient-physician decision-making as well as future interventions to decrease the rate of PCF formation after laryngectomy.

Total Laryngectomy: A Review of Surgical Techniques

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.

Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

Assessment of Ceragenins in Prevention of Damage to Voice Prostheses Caused by Candida Biofilm Formation

This study aimed to investigate the potential application of ceragenins (CSAs) as new candidacidal agents to prevent biofilm formation on voice prostheses (VPs). The deterioration of the silicone material of VPs is caused by biofilm growth on the device which leads to frequent replacement procedures and sometimes serious complications. A significant proportion of these failures is caused by Candida species. We found that CSAs have significant candidacidal activities in vitro (MIC; MFC; MBIC), and they effectively eradicate species of yeast responsible for VP failure. Additionally, in our in vitro experimental setting, when different Candida species were subjected to CSA-13 and CSA-131 during 25 passages, no tested Candida strain showed the significant development of resistance. Using liquid chromatography–mass spectrometry (LC-MS), we found that VP immersion in an ethanol solution containing CSA-131 results in silicon impregnation with CSA-131 molecules, and in vitro testing revealed that fungal biofilm formation on such VP surfaces was inhibited by embedded ceragenins. Future in vivo studies will validate the use of ceragenin-coated VP for improvement in the life quality and safety of patients after a total laryngectomy.

Factors Associated with Outcomes Following Salvage Surgery for Recurrent Laryngeal Cancer: A Retrospective Study of 50 Cases from a Single Center in Poland

BACKGROUND This retrospective study from a single center in Poland aimed to identify factors associated with outcomes following salvage surgery in 50 patients with recurrent laryngeal cancer. MATERIAL AND METHODS The study group consisted of 50 patients with recurrent laryngeal cancer after primary organ preservation treatment (12 patients after partial surgery, 30 patients after radiation therapy, and 8 patients after prior treatment using both methods). None of the patients received chemotherapy before salvage surgery. All patients with recurrence of laryngeal cancer underwent total laryngectomy with elective bilateral nodal surgery. Local and/or nodal recurrence was considered the failure of primary organ preservation treatment. Efficacy of treatment was assessed in relation to overall survival (OS), disease-free survival (DFS), local control (LC), and locoregional control (LRC). RESULTS Treatment results showed a poor prognosis in patients with local and/or nodal recurrence of laryngeal cancer. In the study group, the updated 5-year rates were as follows: OS rate of 26%; DFS rate of 25%; LC rate of 44%; and LRC rate of 39%. Univariate analysis showed that the stage before primary treatment was a predictive factor of OS (P=0.012). CONCLUSIONS The findings from this retrospective study of 50 patients with recurrent laryngeal carcinoma showed that salvage surgery following organ preservation treatment resulted in a 5-year OS rate of 26%.

Preventing Biofilm Formation and Development on Ear, Nose and Throat Medical Devices

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.

Tissue-engineering the larynx: Effect of decellularization on human laryngeal framework and the cricoarytenoid joint

Decellularization approaches have been commonly used as alternative techniques to reconstruct tissues. However, due to the complex tissue compartmentation of the larynx, the decellularization process may not retain the characteristics necessary for the successful recreation of the larynx. The aim of this study was to assess the effect of the decellularization process on the framework of the human cadaveric larynx generally and the cricoarytenoid joint specifically. In this work, five freshly frozen human cadaveric larynges were decellularized utilizing a protocol that was previously demonstrated to be effective in decellularizing a porcine larynx. The decellularization protocol included: biological, chemical, and physical decellularization methods. Each specimen served as its own control to assess changes after decellularization. Studies and measurements included: histological, using Hematoxylin and Eosin (H&E) and Live/Dead™ stains; DNA quantification; micro-computed tomography (μ-CT) imaging; and biomechanical testing of the cricoarytenoid joints. The decellularization protocol took 12 days for each specimen. Microscopy of H&E stained samples demonstrated substantial removal of cells with preservation of the extracellular matrix that was more evident in cartilage than muscle specimens. Confocal microscope images of Live/Dead™ stained specimens also demonstrated almost complete removal of cells. Pre-decellularization cartilage-DNA quantity range was 27.0 to 336.8 ng/mg while post-decellularization DNA quantity range was 0 to 30.4 ng/mg (p = 0.031). For muscles, pre-decellularization DNA quantity range was 150.0 to 3,384.6 ng/mg, while post-decellularization DNA quantity range was 0 to 45.5 ng/mg (p = 0.031). μ-CT demonstrated preservation of the cartilaginous framework with a slight reduction of cricoarytenoid joint space. Furthermore, μ-CT demonstrated no significant reduction in the Housefield unit (p = 0.25) and mineral density (p = 0.25) after decellularization. Biomechanical testing demonstrated a non-significant reduction of forces required for anterior displacement of the arytenoid (mean reduction of forces, 0.1 ± 0.2 N, p = 0.16) and forces required for posterior displacement of the arytenoid (mean reduction of forces, 0.2 ± 0.3 N, p = 0.05). This study demonstrates effective decellularization of human larynges as evidenced by significant DNA depletion and preservation of extracellular matrix, which are outcomes that are required for a biological scaffold to regenerate a non-immunogenic larynx. The decellularization process caused minimal weakness in the cricoarytenoid joints due to treatment with multiple detergents and enzymes in the decellularization protocol.

Long-term functional and quality of life outcomes in laryngectomized patients after successful voice restoration using tracheoesophageal prostheses

OBJECTIVE

To assess long-term functional and quality of life (QoL) outcomes and their predictive factors in laryngectomized patients after successful voice restoration using tracheoesophageal prostheses (TEP).

METHODS

This cross-sectional study was conducted in alive and disease-free patients at least 1 year after total laryngectomy ± partial pharyngectomy. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) Core (QLQ-C30) and Head and Neck Cancer (QLQ-H&N35) QoL questionnaires, the Voice Handicap Index (VHI-10) questionnaire and the Hospital Anxiety and Depression Scale (HADS). The level of dysphagia was evaluated using the Dysphagia Handicap Index (DHI) and the Dysphagia Outcomes and Severity Scale (DOSS). Predictive factors of these clinical outcomes were determined in univariate and multivariate analysis.

RESULTS

A total of 48 patients were included in this study. Long-term QoL and functioning scales scores were all superior to 70%. Main persistent symptoms were fatigue, dyspnea, senses, speech and coughing problems. A DOSS score ≥6, indicating normal/subnormal swallowing function, and a VHI-10 score ≤20, representing light to medium voice disorders, were found in at least 75% of patients. An anxiodepressive disorder (HADS global score ≥ 15) was reported by 15 (31%) patients and represented the main predictor of QoL and voice outcomes. A strong correlation was found between VHI-10 and global QoL scores.

CONCLUSIONS

After successful voice restoration, laryngectomized patients achieved satisfactory QoL and functional outcomes. Psychological distress was the main determinant of long-term QoL and is therefore of critical importance in the multidisciplinary management of laryngectomized patients.

A dynamic prognostic nomogram to predict the benefit from surgical treatment modality for patients with laryngeal squamous cell carcinoma

BACKGROUND

Although nonsurgical treatment strategy is increasingly adopted in patients with locoregionally advanced laryngeal squamous cell carcinoma (LSCC), survival disparities were reported between surgical treatment modality and organ preservation protocols, highlighting the great importance for accurate patients' selection.

METHOD

This secondary analysis used data from the Surveillance, Epidemiology, and End Results database between 2010 and 2015 with follow-up data up to 2018. We developed and validated a dynamic prognostic nomogram for overall survival (OS) in 4237 patients with LSCC and subgroup of 2087 patients with locoregionally advanced laryngeal squamous cell carcinoma (LALSCC). Based on the total risk score derived from the dynamic nomogram, two well-matched risk groups (i.e., low- and high-risk) were created via X-tile software and 1-to-1 propensity score matching (PSM); surgical treatment modality was compared with nonsurgical one in each risk group.

RESULTS

A more accurate and convenient dynamic prognostic nomogram based on age, marital status, T category, N category, M category, tumor size, and tumor differentiation was developed and validated, of which the predictive performance was superior to that of TNM staging system. For high-risk LALSCC selected by the dynamic nomogram, after 1-to-1 PSM, significantly improved OS was observed in patients with receiving surgical treatment compared to those receipt of nonsurgical management (restricted mean survival time at 36-month: 26.6 vs 22.7, p < 0.001; restricted mean survival time at 60-month: 36.7 vs 31.0, p = 0.003).

CONCLUSION

We establish and validate a more accurate and convenient dynamic prognostic nomogram for patients with LSCC, which may predict the benefit from surgical treatment modality for patients with high-risk LALSCC.

Description of a novel technique for creation of a custom-made prosthesis to aid vocalisation following laryngectomy

There are various options to restore phonation after laryngectomy; one option involves using tracheo-oesophageal voice by placing a speaking valve through the tracheo-oesophageal wall. Some patients struggle to obtain good fixation of an adhesive base plate to the skin; this can result in air leakage and poor voice. We describe a technique using a custom-made prosthesis to provide a better base plate for fixation of the heat and moisture exchange cassette. This technique involves making an impression of the anterior neck around the laryngectomy stoma to create an anatomically fitted prosthesis, which accurately fills the void around the stoma. The custom-made prosthesis provides a more individualised fit compared to a standard base plate, helping improve vocalisation and communication.

A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy

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.

Comparison of patients with total and salvage laryngectomy

INTRODUCTION AND OBJECTIVES

Total laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival.

METHODS

The study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death.

RESULTS

The mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P=.000) and between fistula and infection (P=.000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P=.038), T4 (P=.026), lymphovascular invasion (P=.019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P=.005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P=.026).

CONCLUSIONS

Although organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.

Increased mu-opioid receptor expression is associated with reduced disease-free and overall survival in laryngeal squamous cell carcinoma

BACKGROUND

Expression of the mu-opioid receptor (MOR) is associated with poor long-term outcomes in various types of cancer. The association between MOR expression and clinical outcomes in laryngeal squamous cell carcinoma (LSCC) is not clear.

METHODS

This retrospective study included patients who underwent laryngectomy for LSCC. The expression pattern of the MOR protein and OPRM1 gene in tumours and corresponding adjacent non-carcinoma specimens was measured. Propensity score matching was used to minimise bias. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were intraoperative sufentanil consumption, grade of surgical complications according to the Clavien-Dindo classification, and hospital length of stay.

RESULTS

A total of 207 LSCC patients were enrolled. After propensity score matching, there was a significant difference in DFS between groups at 1, 3, and 5 yr (60.2% vs 81.2%, P=0.019; 39.4% vs 50.2%, P=0.026; 37.5% vs 42.5%, P=0.023, respectively) in patients with high MOR expression. The OS rates at 1, 3, and 5 yr were significantly lower in the high MOR expression group (81.2% vs 93.2%, P=0.027; 57.7% vs 78.3%, P<0.001; 42.5% vs 60.3%, P<0.001, respectively). The multivariate analysis indicated that high MOR expression was associated with worse DFS and OS (hazard ratio: 1.52, 95% confidence interval: 1.07, 2.25, P=0.034; hazard ratio: 1.42, 95% confidence interval: 1.17, 2.34, P=0.032).

CONCLUSION

High MOR expression may be associated with poor prognosis in patients with LSCC, suggesting that MOR could be used as a valuable molecular biomarker to predict prognosis of LSCC patients.

Rational surgical neck management in total laryngectomy for advanced stage laryngeal squamous cell carcinomas

PURPOSE

Controversies exist in regard to surgical neck management in total laryngectomies (TL). International guidelines do not sufficiently discriminate neck sides and sublevels, or minimal neck-dissection nodal yield (NY).

METHODS

Thirty-seven consecutive primary TL cases from 2009 to 2019 were retrospectively analyzed in terms of local tumor growth using a previously established imaging scheme, metastatic neck involvement, and NY impact on survival.

RESULTS

There was no case of level IIB involvement on any side. For type A and B tumor midline involvement, no positive contralateral lymph nodes were found. Craniocaudal tumor extension correlated with contralateral neck involvement (OR: 1.098, p = 0.0493) and showed increased involvement when extending 33 mm (p = 0.0134). Using a bilateral NY of ≥ 24 for 5-year overall survival (OS) and ≥ 26 for 5-year disease-free survival (DFS) gave significantly increased rate advantages of 64 and 56%, respectively (both p < 0.0001).

CONCLUSIONS

This work sheds light on regional metastatic distribution pattern and its influence on TL cases. An NY of n ≥ 26 can be considered a desirable benchmark for bilateral selective neck dissections as it leads to improved OS and DFS. Therefore, an omission of distinct neck levels cannot be promoted at this time.