Current Status of Partial Laryngeal Surgery for Advanced Laryngeal Cancer: When and Why?

PURPOSE OF REVIEW: This paper aims to evaluate the evolution and current status of partial laryngeal surgery in the treatment of advanced laryngeal cancer (LC). Specifically, recent progress in the selection of both patients and tumors, together with surgical and rehabilitation innovations, have contributed to balancing oncological control with the maintenance of quality of life in naïve and radiorecurrent patients. The main aspect is represented by the recognized role of open partial horizontal laryngectomies (OPHLs) in this new era of laryngeal cancer treatment. RECENT FINDINGS: Recent advancements highlight OPHLs' efficacy for conservative management of intermediate to advanced stages of LC. Innovations such as supratracheal partial laryngectomy have expanded surgical options, offering a modular approach to complex cases. Improved understanding of tumor biology, enhanced imaging techniques, and more precise preoperative planning have led to better patient outcomes, emphasizing the importance of a conservative function-preserving surgical treatment. These advancements reflect a broader trend towards individualized treatment plans that prioritize both survival and quality of life. OPHLs play an important role in current management of intermediate/advanced LC, effectively balancing oncological control with the preservation of laryngeal functions. Critical factors include meticulous patient and tumor selection, the impact of surgical and technological refinements on functional outcomes, and the necessity of a multidisciplinary approach in treatment planning. Current evidence justifies the use of these interventions in many intermediate T-stage laryngeal tumors, even at risk of upstaging on pathological examination. The oncological results, the preservation of laryngeal function and the laryngectomy-free survival achieved with OPHLs appear to be highly competitive with those of non surgical organ-preservation protocols, aiming to introduce a new standard in the LC treatment.

Isoprognostic functional CT map for open partial horizontal laryngectomy.

PURPOSE: To identify a radiological map of laryngeal subsites whose involvement by the tumor could predict patients' functional outcomes after open partial horizontal laryngectomy (OPHL). METHODS: The present retrospective analysis concerned 96 patients with glottic squamous cell carcinoma, who were radiologically staged with contrast-enhanced neck CT scans before undergoing supracricoid or supratracheal laryngectomy. A radiological map of patients' functional risk was developed by considering the distribution of functional outcomes in relation to the laryngeal subsites involved. The functional outcomes considered were: (i) decannulation at discharge; (ii) time to removal of the nasogastric feeding tube (NFT); (iii) postoperative complication rate; and (iv) length of hospital stay. RESULTS: Involvement of the anterior supraglottis was related to a longer need for NFT, and a longer hospital stay (p = 0.003, and p = 0.003, respectively). Involvement of the posterior glottis negatively affected the time to decannulation, and the likelihood of postoperative complications (p = 0.000, and p = 0.002, respectively). CONCLUSIONS: Anterior glottic small tumors (without significant subglottic and/or supraglottic extension) are related to the best functional outcomes after OPHL, since the suprahyoid epiglottis and both the arytenoids are likely to be spared.

Impact of lymph node ratio and number of lymph node metastases on survival and recurrence in laryngeal squamous cell carcinoma.

INTRODUCTION: The aim of this study is to assess the impact of lymph node ratio (LNR) and number of positive lymph nodes (NPLN) on mortality and recurrence rates in patients with laryngeal squamous cell carcinoma. MATERIALS AND METHODS: We conducted a retrospective multicenter international study involving 24 Otorhinolaryngology-Head and Neck Surgery divisions. Disease-specific survival (DSS) and disease-free survival (DFS) were evaluated as the main outcomes. The curves for DSS and DFS according to NPLN and LNR were analyzed to identify significant variations and establish specific cut-off values. RESULTS: 2507 patients met the inclusion criteria. DSS and DFS were significantly different in the groups of patients stratified according to LNR and NPLN. The 5-year DSS and DFS based on LNR and NPLN demonstrated an improved ability to stratify patients when compared to pN staging. CONCLUSION: Our data demonstrate the potential prognostic value of NPLN and LNR in laryngeal squamous cell carcinoma.

Partial Laryngectomy for pT4a Laryngeal Cancer: Outcomes and Limits in Selected Cases.

A large multi-institutional case series of laryngeal cancer (LC) T4a was carried out, including 134 cases treated with open partial horizontal laryngectomies (OPHL) +/- post-operative radiation therapy (PORT). The goal was to understand better whether OPHL can be included among the viable options in selected pT4a LC patients who refuse a standard approach, represented by total laryngectomy (TL) + PORT. All 134 patients underwent OPHL type I (supraglottic), II (supracricoid), or III (supratracheal), according to the European Laryngological Society Classification. Comparing clinical and pathological stages showed pT up-staging in 105 cases (78.4%) and pN up-staging in 19 patients (11.4%). Five-year data on overall survival, disease-specific survival, disease-free survival, freedom from laryngectomy, and laryngo-esophageal dysfunction-free survival (rate of patients surviving without a local recurrence or requiring total laryngectomy and without a feeding tube or a tracheostomy) were, respectively, 82.1%, 89.8%, 75.7%, 89.7%, and 78.3%. Overall, complications were observed in 22 cases (16.4%). Sequelae were observed in 28 patients (20.9%). No patients died during the postoperative period. This large series highlights the good onco-functional results of low-volume pT4a laryngeal tumors, with minimal or absent cartilage destruction, treated with OPHLs. The level of standardization of the indication for OPHL should allow consideration of OPHL as a valid therapeutic option in cases where the patient refuses total laryngectomy or non-surgical protocols with concomitant chemo-radiotherapy.

Pre-operative CT cephalometry and functional outcomes after open partial horizontal laryngectomy.

Objectives: To identify pre-operative radiological parameters that are able to predict the functional outcomes of open partial horizontal laryngectomy (OPHL). Methods: The present retrospective study concerned a cohort of 96 patients with laryngeal squamous cell carcinoma who underwent pre-operative radiological staging with contrast-enhanced computerised tomography of the neck, and subsequent supracricoid or supratracheal laryngectomy. Univariate and multivariate analyses were run to assess the prognostic value of the main demographic and surgical variables, and the pre-operative cephalometric values, respectively, in terms of predicting patients' functional outcomes. Results: Multivariate analysis showed that a larger anteroposterior cross-sectional dimension of the aero-digestive tract in the mid-retroglossal area, and a greater distance between the genial tubercle and the hyoid bone in the mid-sagittal plane correlated significantly with better functional outcomes in terms of decannulation rate at discharge. Conclusions: Our findings show that larger pre-operative upper aero-digestive tract diameters and volumes coincide with better post-operative functional outcomes after OPHL.

The role of adjuvant therapy in pT4N0 laryngectomized patients: Multicentric observational study.

BACKGROUND: To retrospectively evaluate oncological outcomes in two groups of patients with pT4aN0 glottic SCC treated with total laryngectomy (TL) and neck dissection (ND) who underwent postoperative radiotherapy or exclusive clinical and radiological follow-up. METHODS: It includes patients with pT4N0 glottic SCC who underwent TL and unilateral or bilateral ND with or without PORT. Divided in two comparison groups: the first group underwent adjuvant RT (TL-PORT); the second group referred to clinical and radiological follow-up (TL). RESULTS: PORT was associated with a better OS while no differences were found in terms of DSS. A better local control is achieved when PORT is administered while no differences in terms of regional and distant control rates were found. Bilateral ND positively impacts on the regional control while the PNI negatively impact the regional control. CONCLUSIONS: A tailored PORT protocol might be considered for pT4N0 glottic SCC treated with TL and ND, both considering the ND's extent and presence of PNI.

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

OBJECTIVE: The present study evaluates voice and communication after open partial horizontal laryngectomies (OPHLs), according to surgery and patient-related variables. METHODS: Fifty-eight patients were included: 18 type I OPHL, 20 type II OPHL and 20 type III OPHL. Acoustic, aerodynamic, endoscopic, perceptual and self-assessment analyses were carried out. Surgery-related variables and patient-related variables were considered for the analysis. RESULTS: Type I OPHL revealed the best phonatory outcomes. Type II and type III OPHL showed similar and poor results, with a highly deteriorated voice quality. A significant difference in MTP was found for patients who had both arytenoids/cricoarytenoid units preserved. Age and time from surgery showed significant correlations with voice quality after OPHLs. CONCLUSIONS: Voice and communication outcomes after OPHLs are heterogeneous and might be influenced by several factors. Knowing variables with a substantial impact on phonatory outcomes may help clinicians in the preoperative decision-making process and the postoperative rehabilitative program.

Fragility and contagiousness of the total laryngectomy patient in the COVID-19 pandemic.

Objective: The Coronavirus disease 2019 (COVID-19) pandemic has posed significant problems for patients who have undergone total laryngectomy (TL). The lack of specific guidelines and paucity of information available to the public on this topic has clearly emerged during the ongoing pandemic. The aim of the present study is to investigate our personal experience in managing the stoma in TL patients during the COVID-19 pandemic. Methods: A questionnaire was administered by phone to laryngectomised patients who had previously been seen at the outpatient otolaryngology clinics of Vittorio Veneto and Barletta Hospitals from January to December 2020. Results: A total of 92 patients were included. Twenty-five patients (27%) had been tested for SARS-CoV-2. Among these, 19 (76%) had been investigated with a nasal swab, 5 (20%) with a tracheal swab and 1 with a serological assay. Five patients were positive for SARS-CoV-2 (in 4 cases as a result of the nasal swab, in one case with the bronchial aspirate). Eighty-four patients (91%) used a heat moisture exchanger over the stoma every day, but 6 patients (6.5%) were unaware of the importance of protecting the stoma. Conclusions: We conclude that TL patients should always be adequately informed by healthcare staff about how to manage their stoma. Specific guidelines are needed for testing TL patients for SARS-CoV-2.

A new perspective during laryngo-tracheal surgery: the use of an ultra-thin endotracheal tube (Tritube®) and flow-controlled ventilation-a retrospective case series and a review of the literature.

BACKGROUND: Upper airway surgery often poses a challenge to both anesthesiologists and surgeons, as airway access, mechanical ventilation, and surgical difficulties may occur in a tricky combination. To fulfill the need for a tubeless surgery, techniques such as apneic oxygenation or jet ventilation may be used, which carry the risk of several complications. The ultrathin cuffed endotracheal tube Tritube can be used with flow-controlled ventilation (FCV) to provide adequate surgical field and ventilation. To assess the feasibility, safety, and effectiveness of this technique, we describe a series of 21 patients, with various lung conditions, undergoing laryngo-tracheal surgery with FCV delivered via Tritube. Moreover, we perform a narrative systematic review to summarize clinical data on the use of Tritube during upper airway surgery. RESULTS: All patients were successfully intubated in one attempt with Tritube. The median (interquartile range [IQR]) tidal volume was 6.7 (6.2-7.1) mL/kg of ideal body weight, the median end-expiratory pressure was 5.3 (5.0-6.4) cmH2O, and the median peak tracheal pressure was 16 (15-18) cmH2O. The median minute volume was 5.3 (5.0-6.4) L/min. Median global alveolar driving pressure was 8 (7-9) cmH2O. The median maximum level of end-tidal CO2 was 39 (35-41) mmHg. During procedures involving laser, the maximum fraction of inspired oxygen was 0.3, with the median lowest peripheral oxygen saturation of 96% (94-96%). No complications associated with intubation or extubation occurred. In one patient, the ventilator needed to be rebooted for a software issue. In two (10%) patients, Tritube needed to be flushed with saline to remove secretions. In all patients, optimal visualization and accessibility of the surgical site were obtained, according to the surgeon in charge. Thirteen studies (seven case reports, two case series, three prospective observational studies, and one randomized controlled trial) were included in the narrative systematic review and described. CONCLUSIONS: Tritube in combination with FCV provided adequate surgical exposure and ventilation in patients undergoing laryngo-tracheal surgery. While training and experience with this new method is needed, FCV delivered with Tritube may represent an ideal approach that benefits surgeons, anesthesiologists, and patients with difficult airways and compromised lung mechanics.

Modular Approach to Open Partial Horizontal Laryngectomy: Step-by-Step Anatomic Dissection.

Open partial laryngectomies still play an important role in contemporary conservative management of laryngeal cancer. A comprehensive and systematic classification of open partial horizontal laryngectomies (OPHLs) was presented by the European Laryngological Society working committee in 2014. The aim of this video is to show the main surgical steps in OPHL using a cadaveric dissection and to explain the modular approach for removal of laryngeal tumors.

The glottic-subglottic laryngectomy: Surgical technique, oncological, and functional outcomes.

OBJECTIVES: The aim of this article was to describe the surgical technique and report the oncological and functional outcomes of the partial glottic-subglottic laryngectomy (GSL). METHODS: A retrospective review of the clinical charts of patients who underwent GSL for laryngeal cancer from 1989 to 2020 at the Otolaryngology Unit of the Vittorio Veneto Hospital, a referral center for laryngeal cancer treatment. RESULTS: The present article considered 36 patients who were submitted to GSL for laryngeal cancer. The pathological exam found squamous cell carcinoma (SCC) in 16 cases, adenoid-cystic carcinoma (ACC) in 9 cases, laryngeal chondrosarcoma in 8 cases, 1 giant cell carcinoma, 1 carcinosarcoma, and 1 metastasis of colon adenocarcinoma. Considering the 16 SCC cases we observed a recurrence rate of 31%, the overall survival (OS) and disease-specific survival (DSS) were 75%. The 9 ACC cases had a recurrence rate of 23% and OS/DSS of 88%. In the 8 chondrosarcomas no relapses were reported and the OS/DSS were 100%. Among the patients without recurrence of the disease, a definitive decannulation was achieved in 21 cases (75%). CONCLUSIONS: The GSL represents a valid alternative to total laryngectomy in selected cases of laryngeal cancer involving the glottic and subglottic regions.

Prognostic Nutritional Index Predicts Toxicity in Head and Neck Cancer Patients Treated with Definitive Radiotherapy in Association with Chemotherapy.

BACKGROUND: The Prognostic Nutritional Index (PNI) is a parameter of nutritional and inflammation status related to toxicity in cancer treatment. Since data for head and neck cancer are scanty, this study aims to investigate the association between PNI and acute and late toxicity for this malignancy. METHODS: A retrospective cohort of 179 head and neck cancer patients treated with definitive radiotherapy with induction/concurrent chemotherapy was followed-up (median follow-up: 38 months) for toxicity and vital status between 2010 and 2017. PNI was calculated according to Onodera formula and low/high PNI levels were defined according to median value. Odds ratio (OR) for acute toxicity were calculated through logistic regression model; hazard ratios (HR) for late toxicity and survival were calculated through the Cox proportional hazards model. RESULTS: median PNI was 50.0 (interquartile range: 45.5-53.5). Low PNI was associated with higher risk of weight loss > 10% during treatment (OR = 4.84, 95% CI: 1.73-13.53 for PNI < 50 versus PNI ≥ 50), which was in turn significantly associated with worse overall survival, and higher risk of late mucositis (HR = 1.84; 95% CI:1.09-3.12). PNI predicts acute weight loss >10% and late mucositis. CONCLUSIONS: PNI could help clinicians to identify patients undergoing radiotherapy who are at high risk of acute and late toxicity.

Laryngeal adenoid cystic carcinoma: Radical or conservative surgery?

PURPOSE: The present paper describes our experience in surgical treatment of laryngeal ACC, and discuss the effectiveness of conservative surgery. METHODS: We retrospectively reviewed the clinical charts of 17 patients with laryngeal ACC treated surgically at the Otolaryngology Unit of Vittorio Veneto Hospital (Italy) from November 1989 to April 2020. RESULTS: Fourteen patients underwent partial laryngectomy, and three had a total laryngectomy. Five patients (29%) experienced a laryngeal ACC relapse after a disease-free survival of 66.6 ± 50.1 months. The distant metastasis rate was 17%. At latest follow-up, two patients had died of distant metastatic disease after 156 and 243 months. CONCLUSIONS: Radical surgery for laryngeal ACC does not warrant free margins and even cases with positive deep margins rarely experience any relapsing disease. We recommend that surgical treatment for laryngeal ACC be as conservative as possible.

Six-Month Psychophysical Evaluation of Olfactory Dysfunction in Patients with COVID-19.

This study prospectively assessed the 6-month prevalence of self-reported and psychophysically measured olfactory dysfunction in subjects with mild-to-moderate COVID-19. Self-reported smell or taste impairment was prospectively evaluated by SNOT-22 at diagnosis, 4-week, 8-week, and 6-month. At 6 months from the diagnosis, psychophysical evaluation of olfactory function was also performed using the 34-item culturally adapted University of Pennsylvania Smell Identification Test (CA-UPSIT). 145 completed both the 6-month subjective and psychophysical olfactory evaluation. According to CA-UPSIT, 87 subjects (60.0%) exhibited some smell dysfunction, with 10 patients being anosmic (6.9%) and seven being severely microsmic (4.8%). At the time CA-UPSIT was administered, a weak correlation was observed between the self-reported alteration of the sense of smell or taste and olfactory test scores (Spearman's r = -0.26). Among 112 patients who self-reported normal sense of smell at last follow-up, CA-UPSIT revealed normal smell in 46 (41.1%), mild microsmia in 46 (41.1%), moderate microsmia in 11 (9.8%), severe microsmia in 3 (2.3%), and anosmia in 6 (5.4%) patients; however, of those patients self-reporting normal smell but who were found to have hypofunction on testing, 62 out of 66 had a self-reported reduction in sense of smell or taste at an earlier time point. Despite most patients report a subjectively normal sense of smell, we observed a high percentage of persistent smell dysfunction at 6 months from the diagnosis of syndrome coronavirus 2 (SARS-CoV-2) infection, with 11.7% of patients being anosmic or severely microsmic. These data highlight a significant long-term rate of smell alteration in patients with previous SARS-COV-2 infection.

Open partial horizontal laryngectomy and adjuvant (chemo)radiotherapy for laryngeal squamous cell carcinoma: results from a multicenter Italian experience.

PURPOSE: To evaluate the functional and oncologic outcomes of adjuvant (chemo)radiation [(C)RT] after open partial horizontal laryngectomies (OPHLs). METHODS: Multicenter retrospective evaluation of 130 patients (116 males, 14 females) submitted between 1995 and 2017 to OPHL Types II and III for laryngeal cancer and receiving adjuvant (C)RT for one or more of the following risk factors at histopathologic examination of the surgical specimen: pT4a and/or > pN2a categories, close/positive resection margins, or presence of both perineural (PNI) and lympho-vascular invasion (LVI). The primary study endpoints were evaluation of the presence of tracheostomy and/or gastrostomy at last follow-up, and calculation of laryngo-esophageal dysfunction-free survival (LEDFS). RESULTS: Mean age of the study cohort was 60.8 ± 8.9 years (median, 62; interquartile range [IQR], 13). Mean follow-up was 50.7 ± 39.4 months (range 24-188; median, 38; IQR, 51). Adjuvant therapy consisted of CRT in 53 (41%) patients, and RT alone in 77 (59%). Five-year LEDFS was 85%. Overall survival was 71.5%, while 13% of patients remained tracheostomy- and 3% gastrostomy-dependent at the last follow-up. The only significant variable in predicting survival (p = 0.020) was tracheostomy dependence: it was maintained in 7.5% of subjects after OPHL Type II and in 34% of those submitted to OHPL Type III (p < 0.001). CONCLUSIONS: In selected patients affected by advanced laryngeal cancer, OPHLs Type II and III have a relatively good laryngeal safety profile and provide favorable oncologic outcomes even in case of need for adjuvant (C)RT.

Oncological and Functional Outcomes of Primary and Salvage Total Laryngectomy.

OBJECTIVES: To evaluate and compare the oncological and functional outcomes of total laryngectomies (TL) performed as first line treatment or for salvage after failure of conservative approaches for treating advanced laryngeal carcinoma (LSCC). STUDY DESIGN: A retrospective cohort study. METHODS: A cohort of 217 patients who underwent TL was divided according to whether the procedure was for primary treatment of their LSCC (101 patients) or for recurrences after conservative surgery or chemo-radiotherapy (116 patients). RESULTS: The overall survival rate and disease-specific survival rate were significantly higher in the primary TL group than in the salvage TL group (P = .04 and P = .01, respectively). The recurrence rate was significantly higher and the disease-free survival (in months) was shorter for patients who had salvage TL than for those who had primary TL (P = .00 and P = .01, respectively). The salvage TL group also included significantly more cases of postoperative pharyngo-cutaneous fistula needing salivary stent positioning, and experienced significantly longer hospital stays than the primary TL group (P = .04 and P = .03, respectively). CONCLUSION: Oncological and functional outcomes of primary TL were significantly better than after salvage TL. If salvage TL was performed after conservative surgery had failed, the oncological and functional results were better than after the failure of organ-preserving protocols. This could justify a first attempt at conservative surgery for intermediate-advanced LSCC in selected cases, reserving chemo-radiotherapy only for patients unsuitable for surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E569-E575, 2021.

Modular approach in OPHL: are there preoperative predictors?

OBJECTIVE: Open partial horizontal laryngectomies (OPHLs) nowadays represent the first line surgical choice for the conservative treatment of locally intermediate and selected advanced stage laryngeal cancers. Among the peculiarities of OPHLs, there is the possibility of intraoperatively modulating the procedure. It would be useful for the surgeon to recognise preoperative endoscopic and radiological factors that can predict the possibility to modulate the laryngectomy. METHODS: The present study retrospectively reviewed a cohort of 72 patients who underwent OPHL for glottic LSCC, in order to identify preoperative (endoscopic and radiological) parameters that are able to predict modulation surgery. RESULTS: The hypoglottic extension of the glottic tumour was the preoperative finding that was most informative in predicting OPHL modulation. However, it had no significant impact on oncological outcomes. CONCLUSIONS: Patients affected by tumours with hypoglottic extension and eligible for OPHL type II should be preoperatively informed about the possibility of an intraoperative switch towards OPHL type III.

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

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