Robotic and endoscopic trans-oral total laryngectomy, a systematic review and meta-analysis

Trans-oral total laryngectomy (TOTL) is a novel minimally invasive approach to narrow-field laryngectomy. The objective of this study was to review published data on robotic and endoscopic-assisted TOTL to examine oncologic, functional, and adverse outcomes. MEDLINE, Web of Science, and Cochrane databases were searched between January 2009 and December 2023. PRISMA guidelines were used for data abstraction independently by two reviewers. Proportional meta-analysis (random effects model) was used for analysis. Main outcomes included oncologic outcomes (margin status, recurrence rate) and surgical complications (fistula, hemorrhage, need for second operation). Eight studies were included (total of 37 patients). Cases included 31 robotic-assisted, 3 endoscopic-assisted, and 3 robotic cases which required conversion to open approach. Most cases were performed for laryngeal SCC (22 patients, 59.5%). Primary closure was achieved in all patients. Negative margins were achieved in 20 of 21 patients with LSCC. Recurrence data was reported in 20 LSCC patients with disease recurrence in 4 patients (20%). Follow-up was described for 15 patients (mean of 3.5 years, range 1.6-5.8 years). Eleven complications occurred including fistula, bleed, and stomal stenosis with a pooled rate of 33.7% (95% CI: 16.4-53.0%, I2 = 0). Six fistulas occurred with a pooled rate of 23.2% (95% CI: 5.8-45.4%, I2 = 0). TOTL is an emerging treatment modality appropriate for select patients requiring TL and offers a minimally invasive approach with less tissue disruption. This is the first systematic review and meta-analysis to examine its oncologic outcomes and complications. Larger case series with adequate follow-up are needed to better characterize TOTL outcomes.

Reliability and outcomes of lymph nodes biopsy in cT1-cT2 N0 supraglottic laryngeal squamous cell carcinoma

BACKGROUND

In oral and oropharyngeal squamous cell carcinoma (SCC), sentinel node biopsy (SNB) was described as a reliable and reproductive alternative to elective neck dissection for the staging of clinical N0 T1-T2 patients. The SNB technique in supraglottic laryngeal SCC was successfully described in small series. The aim of this study is to analyze retrospectively the results of SNB technique in supraglottic SCC in CHU Godinne, to determine if the technique is reliable and may be proposed in a future multicentral prospective trial.

METHODS

The study involved a retrospective analysis of 39 patients who underwent surgery between 2003 and 2019 at CHU Godinne. All patients presented with clinical N0 neck status. The SNB procedure included general anesthesia, 99-technetium colloid peritumoral injection, and lymphoscintigraphy. The hand-held gamma probe was utilized for SNB after tumoral resection during the same operating session. Out of 39 patients, 36 underwent SNB as the sole staging tool, while 3 patients received SNB in combination with elective neck dissection. Primary outcome was the 2-years neck recurrence-free survival (RFS). Secondary outcomes were the 2- and 5-years disease-specific survival (DSS). Additionally, sensitivity and negative predictive value (NPV) of the SNB technique were analyzed.

RESULTS

Sentinel nodes were successfully identified in all 39 patients. An average of 4 nodes excised per patient. Positives SN were detected in 23% (9 in 39) cases, leading to subsequent selective neck dissection. Two cases of neck recurrence were observed, both considered as false negatives, occurring after an average of 3.5 months. Th median follow-up period was 48 months with a 2-year RFS of 95%. Sensitivity and NPV of the SNB technique were found to be 82% and 94%, respectively. Two and five years DSS were 84% and 71.7%, respectively.

CONCLUSIONS

The results suggest that SNB in T1-T2 supraglottic SCC is a feasible and reliable technique for managing the neck in N0 early-stage patients. However, to establish its oncological equivalence with selective node dissection, further prospective and comparative studies are warranted. The findings of this study underscore the importance of ongoing research in refining and validating the role of SNB in the management of supraglottic SCC, potentially paving the way for more widespread adoption in clinical practice.

Treatment of supraglottic squamous cell carcinoma with advanced technologies: observational prospective evaluation of oncological outcomes, functional outcomes, quality of life and cost-effectiveness (SUPRA-QoL)

BACKGROUND

Over the past decade, therapeutic options in head and neck supraglottic squamous cell carcinoma have constantly evolved. The classical total laryngectomy has been partially replaced by alternative organ- and function-sparing techniques with the same prognosis but less morbidity, such as Radiotherapy, Transoral Laser Microsurgery (TLM) and Trans-Oral Robotic Surgery (TORS). Up to now, a prospective comparison of these innovant techniques has not been conducted.

METHODS/DESIGN

We will conduct an original international multicentric prospective nonrandomized clinical trial to compare the efficacy between these treatments (Arm 1: Radiotherapy ± chemotherapy; Arm 2: TLM and Arm 3: TORS) with 4 classes of outcomes: quality of life (QoL), oncological outcomes, functional outcomes and economic resources. The population will include cT1-T2 /cN0-N1/M0 supraglottic squamous cell carcinoma. The primary outcome is a Clinical Dysphagia QoL evaluation assessed by the MD Anderson Dysphagia questionnaire. Secondary outcomes include others QoL evaluation, oncological and functional measures and cost parameters. The sample size needs to reach 36 patients per arm (total 108).

DISCUSSION

In the current literature, no prospective head-to-head trials are available to compare objectively these different treatments. With the increase of highly efficient treatments and the increase of oncological survival, it is imperative also to develop management strategies that optimize QoL and functional results. We will conduct this innovate prospective trial in order to obtain objective data in these two main issues.

TRIAL REGISTRATION

NCT05611515 posted on 10/11/2022 (clinicaltrial.fgov).

Aggressive recurrent respiratory papillomatosis: A series of five consecutive patients successfully treated with adjuvant intravenous bevacizumab. A single Belgian academic center experience

BACKGROUND

Recurrent respiratory papillomatosis (RRP) is a currently incurable benign neoplasm caused by human papilloma virus (HPV) infection. It usually reduces voice, respiratory, and general quality of life, and is sometimes life-threatening. Patients usually need repeated operations. The use of adjuvant bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor A, has been described in several case reports, with a good efficacy and safety profile.

METHODS

We report the cases of five patients with aggressive RRP who were treated with adjuvant systemic bevacizumab in a single Belgian tertiary center.

RESULTS

A complete response was achieved in four patients after a median of 4.5 months, and a partial response in one. In all cases, the number of surgeries was drastically reduced, and quality of life improved. Toxicity was easily managed.

CONCLUSIONS

Systemic bevacizumab seems to be an effective and safe adjuvant treatment for aggressive RRP.

Transoral radiofrequency of the terminal branches of the recurrent nerve in the treatment of adductor spasmodic dysphonia: our experience over 11 patients

PURPOSE

Spasmodic dysphonia (SD) or laryngeal dystonia is as a rare vocal disorder characterized by involuntary action-induced endolaryngeal contraction. In the last decade, botulin toxin injection has become the standard treatment in adductor spasmodic dysphonia necessitating repetitive injections. The purpose of this study is to analyze retrospectively data from patients treated with the minimal-invasive transoral radiofrequency-induced thermotherapy (RFITT) of the terminal branches of the recurrent nerve.

METHODS

Between 2009 and 2015, 11 patients (six females and five males aged from 32 to 91 years) with adductor SD were treated with RFITT. Pre-operative and post-operative vocal assessments (VHI-30, GRBASI, and acoustic-aerodynamics measurements), number of surgical revisions, delay between procedures, and post-operative complications were recorded. Statistical analyses were carried out on the first vocal assessment performed 2-8 weeks after the first procedure.

RESULTS

Based on available data from ten patients, voice handicap index (VHI) showed improvement with a mean value of -17.7 points (p-value (pval) = 0.014, adjusted p-value (adj pval) = 0.21); instability has also revealed improvement in six patients (pval = 0.05, adj pval = 0.31). Four patients underwent only one procedure including one patient showing still long-term beneficial results after 5 years of follow-up. Other patients required one to three new procedures with an average time between procedures of 15.3 months. Over 24 surgeries performed on a total of 11 patients, one definitive treatment-related severe adverse event was reported.

CONCLUSION

Thanks to long-lasting effect, repetitive treatments are less frequent compared to botulin toxin therapy. In our opinion, RFITT is a promising alternative to botulin toxin as a second-step procedure in case of toxin resistance or patient's lack of compliance.

Single-port transoral robotic surgery hypopharyngectomy

Transoral robotic surgery (TORS) is an established treatment for many subsites of Head and Neck cancer. With the improved flexibility and access of the single-port (SP) robotic system, tumors within the distal upper aerodigestive tract can now be reached and successfully treated with all the published advantages of transoral endoscopic surgery. Here in we offer the first published surgical technique for SP TORS for resectable hypopharyngeal carcinoma. The video presented demonstrates many important aspects utilizing the enhanced robotic system, including adjustments of the semi-flexible endoscope and use of the third transoral surgical instrumentation. As previously reported, TORS hypopharyngectomy should be considered for resectable tumors to improve upon the deleterious effects of open surgical resection or chemoradiation therapy.

Anatomical-based classification for transoral base of tongue resection

BACKGROUND

To propose a classification of transoral base of tongue (BOT) procedures able to provide uniform terminology in order to better define postoperative results.

METHODS

The classification resulted from the consensus of the different authors and is based on anatomical and surgical principles.

RESULTS

The classification comprises three types of BOT resections: type 1 is the resection of the entire lingual tonsil to the muscular plane; type 2 is performed by removing the entire lingual tonsil and part of BOT muscles; type 3 is performed by removing the entire lingual tonsil and the entire BOT muscles. Based on the extension of the dissection, we can use the suffix A (contralateral BOT), B (supraglottic larynx), C (lateral oropharynx), and/or D (oral tongue).

CONCLUSION

The proposed classification could allow us to easily compare data from different centers.

The Use of Traffic Sounds to Make Street Crossings by Persons who are Visually Impaired

Orientation and mobility O&M specialists are concerned with the ability of a person who is visually impaired to use hearing as well as vision in independent travel. Yet, there is no published research on the auditory requirements for making effective street crossings by individuals who are visually impaired or by individuals who are both visually and hearing impaired. Thus, this article presents the frequency and intensity measurements for traffic sounds under different conditions. It then compares these measurements to audiograms to illustrate how, given certain limitations and cautions, O&M specialists can estimate a traveler's ability to make safe traffic crossings.

Individualized Prophylactic Neck Irradiation in Patients with cN0 Head and Neck Cancer Based on Sentinel Lymph Node(s) Identification: Definitive Results of a Prospective Phase 1-2 Study

PURPOSE

This prospective, nonrandomized, interventional phase 1-2 study investigated the individualization of elective node irradiation in clinically N0 head and neck squamous cell carcinoma by sentinel lymph node (SLN) mapping with single-photon emission computed tomography/computed tomography (SPECT/CT) and its impact on tumor control and radiation-related toxicity.

METHODS AND MATERIALS

Forty-four patients with clinically N0 head and neck squamous cell carcinoma treated with definitive (chemo-)radiation therapy were imaged with SPECT/CT after ^99mTc nanocolloid injection around the tumor. The neck levels containing up to the 4 hottest SLNs were selected for prophylactic irradiation. A comparative virtual planning was performed with the selection of neck levels based on the current international guidelines. Regional control was monitored as a function of the selected volume. Dosimetric data for the organs at risk were compared between the plans. Normal tissue complication probability (NTCP) rates were derived for xerostomia, dysphagia, and hypothyroidism to predict the clinical benefit and correlated to quality-of-life (QoL) assessments at 6 months.

RESULTS

Sixteen percent of patients presented unpredicted lymphatic drainage, and 48% drained unilaterally. The nodal clinical target volume based on lymphoscintigraphy was smaller than the nodal clinical target volume based on international guidelines by a factor of 2 (P < .0001). After a median follow-up of 46 months, only 1 patient experienced a regional relapse in a nonirradiated area. Significant median dose reductions to organs at risk were observed, particularly to contralateral salivary glands in patients with unilateral drainage (14.6-28.1 Gy) and to the thyroid gland in all patients (22.4-48.9 Gy). Median NTCP reductions were observed for xerostomia (0.3% to 13.7%), dysphagia (1.7% to 10.8%), and hypothyroidism (14.0% to 36.1%). QoL at 6 months was improved, particularly in patients irradiated unilaterally.

CONCLUSIONS

Neck SLN mapping with SPECT/CT individualizes and reduces the elective nodal target volumes without compromising the regional control. The NTCP rates were reduced and favorable QoL were observed in all patients, particularly in the case of unilateral irradiation.

Family Environment and Psychological Distress in Persons who are Visually Impaired

This study investigated the relationship between perceived family environment and psychological distress in 76 persons who are visually impaired, aged 18 to 94, who had undergone at least four months of rehabilitation classes. The results indicated that family environmental traits strongly influenced these persons’ adjustment to vision loss.

Bleeding Complications After Transoral Robotic Surgery: A Meta-Analysis and Systematic Review

OBJECTIVE

Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS), the severity of which can range from minor bleeding treated with observation to catastrophic hemorrhage leading to death. To date, little is known about the incidence, risk factors, and management of post-TORS hemorrhage.

STUDY DESIGN

Systematic Review and Metanlysis.

METHODS

A systematic review of the published literature using the Cochrane Handbook for Systematic Reviews of Interventions was performed and examined TORS, postoperative hemorrhage, and the use of prophylactic transcervical arterial ligation (TAL).

RESULTS

A total of 13 articles were included in the analysis. To date, there have been 332 cases of hemorrhage following a total of 5748 TORS. The pooled median post-TORS hemorrhage rate was 6.47%. The overall incidence of minor and major hemorrhage was 5.29% and 2.90%. Patients with prior radiation (relative risk [RR] = 1.46, 95% confidence interval [CI] = 1.00-2.12), large tumors (RR = 2.11, 95% CI = 1.48-2.99), and those requiring perioperative coagulation (RR = 2.25, 95% CI = 1.54-3.28) had significantly higher relative risks of hemorrhage. There was no significant difference in the relative risk of overall hemorrhage with TAL. Looking at major hemorrhage, patients undergoing TAL had a large but insignificant relative risk reduction in post-TORS hemorrhage (RR = 0.40, 95% CI = 0.15-1.07).

CONCLUSION

The incidence of post-TORS hemorrhage is low (5.78%), and for major hemorrhage requiring emergent embolization, TAL, or tracheotomy to control hemorrhage it is even lower (2.90%). Large tumors, perioperative anticoagulation, and prior radiation were associated with significantly increased risk of post-TORS hemorrhage. TAL does not reduce the overall incidence of post-TORS hemorrhage but may lead to fewer severe hemorrhages.

LEVEL OF EVIDENCE

III Laryngoscope, 131:95-105, 2021.

Mercury and metal(loid) deposition to remote Nova Scotia lakes from both local and distant sources

Kejimkujik National Park, in Nova Scotia, Canada, is a sensitive region for metal(loid) contamination, such as mercury, in part due to long-range atmospheric deposition from global and regional industrial centers. The region is remote from industrial centres, but is downwind of major pollution sources in the Eastern United States and Canada, and historically had numerous gold mining sites. Due to a paucity of long-term atmospheric deposition monitoring in this region, little is known about the response of Kejimkujik lakes to multiple changing global, regional and local atmospheric Hg and metal(loid) sources. Here, we used multiple lake sediment cores to reconstruct anthropogenic depositional fluxes of metal(loid)s of concern for the last ~210years. Results showed that Kejimkujik lake sediments are highly enriched in lead (Pb), antimony (Sb) and tin (Sn), with post-industrial metal(loid) concentrations being >4-fold greater than natural baseline levels (prior to ~1800) and moderately enriched in silver (Ag), bismuth (Bi), cadmium (Cd), copper (Cu), mercury (Hg), rubidium (Rb), tellurium (Te), thallium (Tl), vanadium (V), tungsten (W) and zinc (Zn), with post-industrial metal(loid) concentrations being between 1.5 and 4-fold greater than natural baseline levels (prior to ~1800). Lake sediment core reconstructions of total atmospheric Hg deposition matched well with Hg wet deposition monitoring data from the overlapped period (1997-2010) being 9.1±2.7μg/m²/yr and 7.0±0.7μg/m²/yr respectively. Lakes closest to historic gold mining sites show spikes in Ag, Cd, Sb, Tl, Zn and W during mining periods (~1880 and 1950). Most of the enriched metal(loid)s (EF >1.5) (Ag, Bi, Cu, Hg, Pb, Sb, Sn, V and W) do not appear affected by redox and remobilisation issues. For the other enriched metal(loid)s (EF >1.5) (Cd, Tl, and Zn), remobilisation from upper sediments appears to be occurring within these acidic and DOC rich Kejimkujik lakes.

Surgical consensus guidelines on sentinel node biopsy (SNB) in patients with oral cancer

BACKGROUND

The eighth international symposium for sentinel node biopsy (SNB) in head and neck cancer was held in 2018. This consensus conference aimed to deliver current multidisciplinary guidelines. This document focuses on the surgical aspects of SNB for oral cancer.

METHOD

Invited expert faculty selected topics requiring guidelines. Topics were reviewed and evidence evaluated where available. Data were presented at the consensus meeting, with live debate from panels comprising expert, nonexpert, and patient representatives followed by voting to assess the level of support for proposed recommendations. Evidence review, debate, and voting results were all considered in constructing these guidelines.

RESULTS/CONCLUSION

A range of topics were considered, from patient selection to surgical technique and follow-up schedule. Consensus was not achieved in all areas, highlighting potential issues that would benefit from prospective studies. Nevertheless these guidelines represent an up-to-date pragmatic recommendation based on current evidence and expert opinion.

Transoral Robotic Surgery Total Laryngectomy

OBJECTIVE

The aim of our study is to demonstrate our technique for performing transoral robotic surgical total laryngectomy (TORS-TL) with the use of the da Vinci robotic system.

MATERIALS AND METHODS

We provide a comprehensive description of the TORS-TL operative techniques. Two fresh-frozen human cadavers were selected after ethics approval to describe the appropriate step-by-step surgical resection. We adopted a 5-step procedure that was later applied to 2 of our patients. The first patient presented initially with a squamous cell carcinoma (SCC) in the laryngeal glottis area. A lack of clinical response to initial treatment by chemoradiotherapy led to the decision of performing salvage TL surgery. The second patient had a previous history of head and neck SCC (HNSCC); he had no recurrence of his primary tumor but suffered significantly from postoperative breathing and swallowing difficulties due to severe laryngeal incompetence.

RESULTS

TORS-TL was successfully performed in all cases. The operative time for the cadavers was approximately 65 and 55 min, respectively. It was significantly longer for the patients, 210 and 235 min, respectively, despite the fact that exactly the same steps were followed throughout all procedures. There were no intra- or postoperative complications or surgical morbidity related to the use of the da Vinci system.

CONCLUSION

TORS-SL for SCC was performed in a safe, reliable, and smooth manner and was shown to be successful in treating our patients. We thus believe that our step-by-step surgical technique for TORS-SL is efficient and reproducible.

Recurrent Masses after Testicular Cancer: Growing Teratoma Syndrome. A Case Report and Review of the Literature

Background

Growing teratoma syndrome is a rare syndrome that affects patients with nonseminomatous germ-cell tumors (NSGCTs). It is characterized by recurrent growing masses that appear during or after chemotherapy in the presence of normal levels of tumor markers. Histological examination is the only way to confirm the diagnosis.

Case Presentation

We present the case of a 36-year-old man who developed recurrent masses after curative treatment for NSGCT of the testicle. His tumor markers were normal. The patient was cured after multiple surgical procedures.

Conclusions

Close follow-up after treatment for NSGCT is very important for early detection of this syndrome, which can occur even many years after tumor onset. Normal blood makers can be misleading, and surgery remains the only curative treatment.

Consistency of effects of tropical-forest disturbance on species composition and richness relative to use of indicator taxa

Lawton et al. (1998) found, in a highly cited study, that the species richness of 8 taxa each responds differently to anthropogenic disturbance in Cameroon forests. Recent developments in conservation science suggest that net number of species is an insensitive measure of change and that understanding which species are affected by disturbance is more important. It is also recognized that all disturbance types are not equal in their effect on species and that grouping species according to function rather than taxonomy is more informative of responses of biodiversity to change. In a reanalysis of most of the original Cameroon data set (canopy and ground ants, termites, canopy beetles, nematodes, and butterflies), we focused on changes in species and functional composition rather than richness and used a more inclusive measure of forest disturbance based on 4 component drivers of change: years since disturbance, tree cover, soil compaction, and degree of tree removal. Effects of disturbance on compositional change were largely concordant between taxa. Contrary to Lawton et al.'s findings, species richness for most groups did not decline with disturbance level, providing support for the view that trends in species richness at local scales do not reflect the resilience of ecosystems to disturbance. Disturbance affected species composition more strongly than species richness for butterflies, canopy beetles, and litter ants. For these groups, disturbance caused species replacements rather than just species loss. Only termites showed effects of disturbance on species richness but not composition, indicating species loss without replacement. Although disturbance generally caused changes in composition, the strength of this relationship depended on the disturbance driver. Butterflies, litter ants, and nematodes were correlated with amount of tree cover, canopy beetles were most strongly correlated with time since disturbance, and termites were most strongly correlated with degree of soil disturbance. There were moderately divergent responses to disturbance between functional feeding groups. Disturbance was most strongly correlated with compositional differences of herbivores within beetles and nematodes and humus feeders within termites. Our results suggest that consideration of the impact of different forms of disturbance on species and functional composition, rather than on net numbers of species, is important when assessing the impacts of disturbance on biodiversity.

Feasibility of tongue strength measurements during (chemo)radiotherapy in head and neck cancer patients

PURPOSE

The aim of this study was to investigate the feasibility of tongue strength measures (TSMs) and the influence of bulb location, sex, and self-perceived pain and mucositis in head and neck cancer (HNC) patients during chemoradiotherapy (CRT).

METHODS

Twenty-six newly diagnosed HNC patients treated with CRT performed anterior and posterior maximal isometric tongue pressures by means of the Iowa Oral Performance Instrument (IOPI). The Oral Mucositis Weekly Questionnaire (OMWQ) and a Visual Analogue Scale (VAS) for pain during swallowing were completed weekly from baseline to 1 week post CRT.

RESULTS

Feasibility of TSMs during CRT declines significantly from 96 to 100% at baseline to 46% after 6 weeks of CRT. But post-hoc analyses reveal only significant differences in feasibility between baseline and measurements after 4 weeks of treatment. No effect of gender or bulb location was established, but feasibility is influenced by pain and mucositis.

CONCLUSIONS

Feasibility of TSMs declines during CRT and is influenced by mucositis and pain. For the majority of subjects, TSMs were feasible within the first 4 weeks, which provides a window of scientific and clinical opportunities in this patient population.

A european multicenter study evaluating the flex robotic system in transoral robotic surgery

OBJECTIVES/HYPOTHESIS

To evaluate the application of the Flex Robotic System in transoral robotic surgery (TORS).

STUDY DESIGN

Multicenter, prospective, open-label, single-armed clinical study.

METHODS

A prospective clinical follow-up multicenter study was performed from July 2014 to October 2015 assessing the safety and efficacy of the Medrobotics Flex Robotic System for access and visualization of the oropharynx, hypopharynx, and larynx as well as for resection of benign and malignant lesions. A total of 80 patients were enrolled. Access and visualization of five anatomic subsites (base of tongue, palatine tonsil area, epiglottis, posterior pharyngeal wall, and false vocal cords) were individually graded by the surgeon. Setup times, access and visualization times, surgical results, and adverse events were documented.

RESULTS

The relevant anatomic structures could be exposed and visualized properly in 75 patients, who went on to have a surgical procedure performed with the Flex Robotic System. Access and visualization of the palatine tonsil area, posterior pharyngeal wall, epiglottis, and posterior pharyngeal wall were excellent. However, false vocal cords and vocal cords were more difficult to expose. Seventy-two patients were treated successfully with the Flex Robotic System. There were no serious or unanticipated device-related adverse events caused by the Flex Robotic System.

CONCLUSIONS

Lesions in the oropharynx, hypopharynx, and larynx could be successfully resected with the Flex Robotic System, specifically developed for TORS. Our study provides evidence that the Flex Robotic System is a safe and effective tool in TORS. Laryngoscope, 2016 127:391-395, 2017.

Subtotal Carbon Dioxide Laser Arytenoidectomy for the Treatment of Bilateral Vocal Fold Immobility: Long-Term Results

Sixty-nine patients underwent subtotal carbon dioxide laser arytenoidectomy for treatment of bilateral vocal fold immobility between 1985 and 2000. The population included 69 patients whose mean age was 56 years (SD, 16 years; range, 11 to 82 years). The mean follow-up was 50 months (SD, 44 months; range, 1 to 181 months). The overall postoperative peak expiratory/peak inspiratory flow ratio (normal value, 1) significantly improved (closer to 1; p = .0036). Voice analyses were also undertaken for 27 patients, almost exclusively after operation, given the context of initial emergency. The maximum phonation time averaged 6.57 seconds (median, 6 seconds). The phonation quotient remained high, with a mean of 503 (median, 440), and the mean conversational voice intensity remained around 59 dB. The median frequency analysis type was 3. The advantage of subtotal arytenoidectomy lies in the fact that it maintains a certain degree of rigidity along the posterior limit of the arytenoid frame, preventing inward collapse of the mucosa and thus lowering the risk of aspiration.

Oncologic Outcomes After Transoral Robotic Surgery: A Multi-institutional Study

IMPORTANCE

Large patient cohorts are necessary to validate the efficacy of transoral robotic surgery (TORS) in the management of head and neck cancer.

OBJECTIVES

To review oncologic outcomes of TORS from a large multi-institutional collaboration and to identify predictors of disease recurrence and disease-specific mortality.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of records from 410 patients undergoing TORS for laryngeal and pharyngeal cancers from January 1, 2007, through December 31, 2012, was performed. Pertinent data were obtained from 11 participating medical institutions.

INTERVENTIONS

Select patients received radiation therapy and/or chemotherapy before or after TORS.

MAIN OUTCOMES AND MEASURES

Locoregional control, disease-specific survival, and overall survival were calculated. We used Kaplan-Meier survival analysis with log-rank testing to evaluate individual variable association with these outcomes, followed by multivariate analysis with Cox proportional hazards regression modeling to identify independent predictors.

RESULTS

Of the 410 patients treated with TORS in this study, 364 (88.8%) had oropharyngeal cancer. Of these 364 patients, information about post-operative adjuvant therapy was known about 338: 106 (31.3) received radiation therapy alone, and 72 (21.3%) received radiation therapy with concurrent chemotherapy. Neck dissection was performed in 323 patients (78.8%). Mean follow-up time was 20 months. Local, regional, and distant recurrence occurred in 18 (4.4%), 15 (3.7%), and 10 (2.4%) of 410 patients, respectively. Seventeen (4.1%) died of disease, and 13 (3.2%) died of other causes. The 2-year locoregional control rate was 91.8% (95% CI, 87.6%-94.7%), disease-specific survival 94.5% (95% CI, 90.6%-96.8%), and overall survival 91% (95% CI, 86.5%-94.0%). Multivariate analysis identified improved survival among women (P = .05) and for patients with tumors arising in tonsil (P = .01). Smoking was associated with worse overall all-cause mortality (P = .01). Although advanced age and tobacco use were associated with locoregional recurrence and disease-specific survival, they, as well as tumor stage and other adverse histopathologic features, did not remain significant on multivariate analysis.

CONCLUSIONS AND RELEVANCE

This large, multi-institutional study supports the role of TORS within the multidisciplinary treatment paradigm for the treatment of head and neck cancer, especially for patients with oropharyngeal cancer. Favorable oncologic outcomes have been found across institutions. Ongoing comparative clinical trials funded by the National Cancer Institute will further evaluate the role of robotic surgery for patients with head and neck cancers.

Long-term complications after facial, pharyngeal, laryngeal and tracheal traumas

Long-term complications after facial, pharyngeal, laryngeal and tracheal traumas.

OBJECTIVE

To review and summarize the existing evidence for long-term anatomical and functional complications after pharyngeal, laryngeal and tracheal traumas.

DATA SOURCES

The MEDLINE database and the bibliographies of relevant studies were selected, analysed and appraised prior to December 2015.

METHODS

With regard to the search strategy, the selected items were: ((long-term complications) AND pharyngeal) AND laryngeal) AND tracheal) AND traumas. Abstracts and titles were screened for relevance, while full articles of the se- lected records were evaluated and critically appraised after inclusion. Data concerning life-threatening situations, as well as long-term severe adverse effects were collected.

Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer

PURPOSE

Optimum management of the N0 neck is unresolved in oral cancer. Sentinel node biopsy (SNB) can reliably detect microscopic lymph node metastasis. The object of this study was to establish whether the technique was both reliable in staging the N0 neck and a safe oncological procedure in patients with early-stage oral squamous cell carcinoma.

METHODS

An European Organisation for Research and Treatment of Cancer-approved prospective, observational study commenced in 2005. Fourteen European centres recruited 415 patients with radiologically staged T1-T2N0 squamous cell carcinoma. SNB was undertaken with an average of 3.2 nodes removed per patient. Patients were excluded if the sentinel node (SN) could not be identified. A positive SN led to a neck dissection within 3 weeks. Analysis was performed at 3-year follow-up.

RESULTS

An SN was found in 99.5% of cases. Positive SNs were found in 23% (94 in 415). A false-negative result occurred in 14% (15 in 109) of patients, of whom eight were subsequently rescued by salvage therapy. Recurrence after a positive SNB and subsequent neck dissection occurred in 22 patients, of which 16 (73%) were in the neck and just six patients were rescued. Only minor complications (3%) were reported following SNB. Disease-specific survival was 94%. The sensitivity of SNB was 86% and the negative predictive value 95%.

CONCLUSION

These data show that SNB is a reliable and safe oncological technique for staging the clinically N0 neck in patients with T1 and T2 oral cancer. EORTC Protocol 24021: Sentinel Node Biopsy in the Management of Oral and Oropharyngeal Squamous Cell Carcinoma.

Partial laryngeal surgery in recurrent carcinoma

With the growing acceptance of nonsurgical therapies for laryngeal squamous cell carcinomas (LSCCs), it has become important to delineate surgical salvage strategies for disease recurrences. Total laryngectomy is often recommended, but appropriately selected laryngeal recurrences may be treated successfully with partial laryngeal surgery: laryngeal function can be preserved with oncological efficacy. The main available studies dealing with partial laryngeal surgery in recurrent carcinoma were critically reviewed. The most appealing feature of salvage transoral laser surgery (TLS) is the opportunity to make tumor-tailored excisions without any reconstructive limitations and retaining the option to switch to open partial laryngectomy. A recent detailed review of 11 series found a pooled local control rate of 57% after a first TLS procedure. Supracricoid laryngectomy (SCL) seems to achieve good local control rates in selected cases of recurrent supraglottic-glottic carcinoma: one review considering seven series calculated that 85% of the patients treated with salvage SCL after radiotherapy experienced no local recurrence; and total laryngectomy after failure of salvage SCL afforded an overall local control rate of 65%. Neck dissection is mandatory in all cases of local LSCC recurrence with evidence of neck metastases, and routine elective neck dissection is recommended for recurrent supraglottic and transglottic cancers.

The da Vinci robotic system in head and neck surgery

Intuitive Surgical Inc. (Sunnyvale, Ca, USA) extended the use of the da Vinci robot to head and neck surgery in 2005 following the previous use in urological, gynecological and cardiothoracic surgery. It then gained wide popularity throughout the globe. Our aim is to describe the da Vinci Robot System and discuss its applications in head and neck surgery. Continued refinements and applications in robotic surgery for otolaryngology will in time be possible as new robotic procedures are developed for endolaryngeal work.

Functional outcomes after transoral robotic surgery for squamous cell carcinoma of the oropharynx

Over the past decade, the development of transoral robotic surgery (TORS) brought a new opportunity in the treatment of early T-stage oropharyngeal squamous cell carcinoma (OPSCC). The objective of this study is to review the functional outcomes after TORS. Indeed, dysphagia is among the most commonly cited functional impairments in OPSCC survivors treated by surgeries with an open approach or conventional radiotherapy. We performed a review of the literature and analysed functional outcomes after TORS. Althought the technique is very recent, early functional and oncologic outcome data are promising and the major studies analysing these parameters support that TORS is feasible and safe as well as oncologically and functionally efficacious.

Transoral robotic surgery for base of tongue neoplasms

Surgery to the base of tongue (BOT) in the presence of neoplasm is a challenging topic for head and neck surgeons. This area is difficult to access and includes important neurovascular structures such as the hypoglossal nerve and lingual artery. The pivotal role of the tongue base in swallowing makes planning the surgical approach more challenging. The surgical approaches vary from open neck/mandibulotomy to transoral laser surgery (TLS) which have significant disadvantages. After introduction of transoral robotic surgery (TORS) to otolaryngology practice with the da Vinci Surgical system, we have in our armamentarium a new approach to the BOT. The improved exposure with new retractors, 3-dimensional (3-D) visualization and magnification and advanced motion capacity allow for increased ease to perform surgery in this difficult area. In recent years, several articles published the data about safety and feasibility of TORS for various conditions. This article presents our approach to the BOT for neoplasms including malignant and benign lesions.

Transoral robotic tongue base reduction in surgical management of obstructive sleep apnea syndrome

Management of base of tongue (BOT) is a challenging topic in surgical management of obstructive sleep apnea syndrome. After the introduction of transoral robotic surgery technology (TORS) into the otolaryngology practice, surgery on the BOT was performed more effectively. Base of tongue reduction can be performed alone or as a part of a multilevel surgery. Patient selection is important and will be discussed further in this study. Available studies show promising and encouraging results for TORS future use in BOT.

SPECT/CT lymphoscintigraphy of sentinel node(s) for superselective prophylactic irradiation of the neck in cN0 head and neck cancer patients: a prospective phase I feasibility study

Background

Clinically node negative HNSCC patients have a risk ranging between 18 and 45% of occult metastases, making prophylactic irradiation mandatory. Selective irradiation of nodal target volume based on international guidelines is practice. Anyway, about half the tumours lying in an anatomical subsite known to potentially drain bilaterally effectively do so, leading to unnecessary large volume irradiation. Moreover, 15% of the tumours show drainage outside of predicted basin, increasing the risk for potential geographical misses. Three-dimensional SPECT/CT lymphoscintigraphy (LS) of sentinel node(s) may help to individualize nodal target volume selection. This prospective phase I study explores its feasibility and the dosimetric impact.

Methods

Ten cN0 HNSCC patients eligible for definitive radiotherapy were imaged with SPECT/CT after ^99mTc nanocolloid injection around the tumour. The neck levels containing up to four hottest nodes were identified and selected for prophylactic irradiation (CTVn-LS) by volumetric modulated arc therapy. A comparative virtual planning was performed with volumes selected according to international guidelines (CTVn-IG).

Results

Migration was observed in all patients (one with gamma probe only). 2.9 sentinel nodes were detected per patient on average. In some patients, accurate localization was difficult when not using thermoplastic mask for SPECT/CT. CTVn-LS was totally encompassed by CTVn-IG in all patients but one (unpredicted drainage in retropharyngeal level). On average, CTVn-LS and related planning target volumes were two times smaller than IG ones. This led to significant dose decrease in identified organs at risk as well as remaining volume at risk.

Conclusions

SPECT/CT LS is a promising tool to individualize prophylactic node CTV in cN0 HNSCC patients eligible for definitive radiotherapy. Oncological safety must be confirmed by ongoing phase II study.

[Laryngeal metastasis of a colonic adenocarcinoma]

We report the case of a 63 year old man with laryngeal metastasis of a colonic adenocarcinoma recurrent after partial cordectomy by CO2 Laser microlaryngoscopy. This patient was followed for this condition between 2009 and 2010. The rarity of metastatic laryngeal metastases, particularly when the primary tumor is colic, justifies this presentation.

Safety of intralesional cidofovir in patients with recurrent respiratory papillomatosis: an international retrospective study on 635 RRP patients

Intralesional use of cidofovir (Vistide(®)) has been one of the mainstays of adjuvant therapy in patients with recurrent respiratory papillomatosis (RRP) since 1998. In 2011, a communication provided by the producer of cidofovir addressed very serious side effects concerning its off-label use. As this was a general warning, it was inconclusive whether this would account for its use in RRP. The aim of this study is to determine whether nephrotoxic, neutropenic, or oncogenic side effects have occurred after intralesional use of cidofovir in patients with RRP. Update of recent developments in RRP, a multicentre questionnaire and a multicentre retrospective chart review. Sixteen hospitals from eleven countries worldwide submitted records of 635 RRP patients, of whom 275 were treated with cidofovir. RRP patients received a median of three intralesional injections (interquartile range 2-6). There were no statistical differences in occurrence of neutropenia or renal dysfunction before and after cidofovir. There was no statistical difference in occurrence of upper airway and tracheal malignancies between the cidofovir and the non-cidofovir group. In this retrospective patient chart review, no clinical evidence was found for more long-term nephrotoxicity, neutropenia or laryngeal malignancies after the administration of intralesional cidofovir in RRP patients.

Abdominal pain and a raised amylase? It's not always pancreatitis

We report the case of a 72 year old man with a history of COPD and heavy alcohol consumption who was initially diagnosed with acute pancreatitis based on a presentation with epigastric pain and elevated serum amylase. Review of his notes revealed several previous similar admissions and extensive normal investigations apart from persistently elevated amylase. Further analysis showed evidence of macroamylasaemia which accounted for the apparently high serum amylase level.

[Clinical case of the month. Left recurrent neck abscess revealing a fourth branchial cleft fistula]

The fourth branchial cleft fistula, which can be the origin of a recurrent left neck abscess, is a rare congenital malformation. Its diagnosis can be difficult. A ten-year-old girl presented with a left painful swelling of the neck. At ultrasonography and tomodensitometry, the diagnosis of thyroglossal cyst was suspected. Antibiotics were prescribed before surgical resection. The intervention was successful and the peroperative macroscopic aspect of the lesion suggested a dermoid cyst. Four months later, the same symptoms reappeared with fever. An intravenous antibiotic therapy was started while a magnetic resonance imaging demonstrated a possible aero-digestive tract fistula. Two days later, the patient developed an aero-cutaneous fistula. Oral antibiotics were started. Five months later, the girl came back for a second recurrence. A few days after her admission, she developed again an aero-cutaneous fistula. The diagnosis of surinfected fourth cleft fistula was made. An antibiotic therapy was started until the second intervention. After discussion about embryology, we describe the physiopathology, the differential diagnosis and the management of a fourth branchial cleft fistula causing recurrent left neck abscess.

Outcomes following transoral robotic surgery: supraglottic laryngectomy

OBJECTIVES/HYPOTHESIS

To describe a single center outcomes following transoral robotic surgery for supraglottic laryngectomy (TORS-SL).

STUDY DESIGN

Prospective data collection.

METHODS

Patient records receiving TORS-SL for squamous cell carcinoma (SCCA) with at least 12 months follow-up fit inclusion for this study. Two patients with previous SCCA were excluded.

RESULTS

18 patients (14 male, 4 female) were included in the study, having a mean follow-up time of 28.1 months (SD = 12.1). All patients had negative margins confirmed on final pathology. Nine (50%) patients received postoperative chemoradiation therapy for advanced neck disease. No (0%) patients received tracheostomy or gastrostomy tubes. There were no (0%) local recurrences, and three (16.7%) regional recurrences. Five (27.8%) patients experienced temporary postoperative complications. Overall 2-year outcomes reached 83%, 100%, and 89% for locoregional control, disease-specific survival, and overall survival respectively.

CONCLUSIONS

Initial outcomes for TORS-SL are encouraging and are comparable to previously described treatment modalities. Larger studies are encouraged.

Clinical Thermal Effects of Flexible Fiber CO2 Laser

Objective: To date no clinical investigations have reported on the coagulation effects of flexible fiber CO2 laser delivery to head and neck tissue, the results of which have a direct impact for the progression of transoral laser microsurgery. The objective of the present study was to investigate the histopathologic thermal effects of a flexible fiber CO2 laser delivery system.

Method: A prospective histopathologic analysis of 15 consecutive transoral laser microsurgery specimens using the same CO2 fiber system were subjected to dedicated histopathologic analyses. Repeated coagulation depth measurements of 2 independent clinical pathologists were averaged. Specimens were stratified into lymphoid or epitheloid groups for further comparison.

Results: The mean coagulation depth across all specimens was 81.53 um (SD, 38.73; range, 15.00-360.34). Although the mean coagulation depth in lymphoid tissues (mean, 75.38 um; SD, 15.91) was elevated over the mean depth of epitheloid tissues (mean, 90.74 um; SD, 31.21), there was no significant difference ( P = .11).

Conclusion: With an average coagulation depth of 81.53 um the flexible fiber thermal effect compares favorably to tissue effect of line-of-sight lasers. Epitheloid and lymphoid tissues displayed equivalent coagulative effects. To our knowledge, this is the first clinical description of flexible CO2 laser delivery thermal effects of tissues of the head and neck.