Results and clinical aspects of primary endonasal endoscopic dacryocystorhinostomy with silicone tube.

OBJECTIVE: Endonasal endoscopic dacryocystorhinostomy (DCR) is a common treatment for saccal and post-saccal stenosis of the lacrimal pathway or chronic dacryocystitis (DC). The main symptom is chronic epiphora (tearing) and dacryocystitis (infection). The objective of this study is to assess the short-term surgical result of this treatment based on possible prognostic factors; such as gender, age, the pathogen spectrum and the histopathological result as well as the influence of these parameters on hospital stay. METHODS: It is a retrospective analysis, which includes 197 cases in 177 patients, who received an endonasal endoscopic DCR with a silicone tube between January 2009 and December 2016, as primary procedure. The follow-up was carried out 3 months after the surgery, with the silicone tube being removed as part of the last examination including a flushing of the tear ducts with saline. This procedure is part of determining to measure the short-term success of the intervention. The definition of success of the surgery is an absence of epiphora or an acute infection of the nasolacrimal duct system, as well as an absent reflux in case of flushing the tear duct. RESULTS: The success rate was 86.3% (N = 170). Higher incidence was seen in females (N = 146; 74.1%) and patients with a mean age of 65.4 (± 17.2). The presence of pathogens as well as the histopathological result do not have an impact on the short-term surgical success. Patients diagnosed with rheumatic diseases appear to have a worse prognosis with relation to procedure success. Also, the length of hospital stay was related to possible prognostic factors. Type II diabetes and glaucoma had a significant influence on a longer hospital stay. CONCLUSION: The endonasal endoscopic DCR is a surgical procedure with high success rate. Patients with rheumatic diseases should be aware of increased failure rates. Patients with glaucoma and Type II diabetes might need a more intense aftercare.

Course of social support and associations with distress after partial laryngectomy.

PURPOSE: Social support has been shown to be positively associated with quality of life and adjustment after a cancer diagnosis. The present study investigates the course of social support up to one year after partial laryngectomy and its association with distress. DESIGN: Longitudinal questionnaire study. SAMPLE: A total of 428 patients after partial laryngectomy (mean age: 64, SD = 11, 91% male). METHODS: Patients completed questionnaires before treatment (t1), one week after a partial laryngectomy (t2), 3 months (t3), and one year (t4) thereafter. Social support was evaluated at t2, t3, and t4 using a brief version of the Social Support Questionnaire. Distress was measured at t2, t3, and t4 using the HADS. Descriptive statistics for social support were computed across the three measurement points. Changes were analyzed by Wilcoxon signed-rank tests. Associations with distress were identified using linear regression analyses. FINDINGS: Social support increased between t2 and t3 and decreased to baseline level between t3 and t4. Distress at t2 was associated with social support at t2 (B = -0.15, p < 0.01) and distress at t3 with social support at t3 (B = -0.19, p < 0.01). Distress at t4 was related to social support at t2 (B = -0.10, p = 0.05). CONCLUSIONS: Although perceived social support increases after partial laryngectomy, it decreases again during the course of aftercare. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS OR POLICY: Social support resources should be assessed to identify patients at risk for worse psychological well-being.

Effects of Finding the Speech-Language Pathologist Likeable on Postlaryngectomy Speech Intelligibility Outcomes.

INTRODUCTION: Speech-language pathologists (SLPs) work with patients after total laryngectomy (TL) to regain verbal communication. The influence of the quality of the therapeutic relationship on the success of TL voice rehabilitation in terms of speech intelligibility is not known. Finding each other likeable is an important factor in establishing and maintaining interpersonal relationships in everyday life. The fit of therapist and client is relevant to the therapeutic relationship. The purpose of this study therefore was to assess the association between the degree of SLPs' likeability ratings and postlaryngectomy speech intelligibility. METHODS: In a multicentre prospective cohort study, participants rated their SLPs' likeability after finishing TL rehabilitation. Speech intelligibility was measured objectively with the Post-Laryngectomy Telephone Intelligibility Test and subjectively with the Questionnaire for Adjustment after Laryngectomy. The association of SLPs' likeability with speech intelligibility was analysed using hierarchical logistic regression, expressed with odds ratios (OR) with corresponding 95% confidence intervals (CI). RESULTS: Altogether 124 patients from 13 institutions participated. The degree of finding the SLP likeable was not significantly associated with objective speech intelligibility (OR 1.30; 95% CI 0.78-2.18; p = 0.32) or subjective speech intelligibility (OR 1.01; 95% CI 0.60-1.72; p = 0.96) after controlling for age, sex and education factors. DISCUSSION/CONCLUSION: In this patient cohort, there was no evidence for an association between ratings of SLPs' likeability and speech intelligibility outcomes after rehabilitation. Future studies could consider the use of alternative instruments for measuring likeability.

Quality of life during the first year after partial laryngectomy: Longitudinal study.

BACKGROUND: This prospective study was conducted to assess changes in quality of life (QOL) of patients who undergo a partial laryngectomy. METHODS: The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires Core and Head and Neck (EORTC-QLQ-C30, QLQ-H&N35) were used preprocedure (n = 218), 1 week (n = 159), 3 months (n = 122), and 1 year after partial laryngectomy (n = 88). Changes over time were analyzed with the Wilcoxon signed rank test and the Holm-Bonferroni method, and interpreted regarding clinical relevance. RESULTS: Most subscales worsened 1 week postprocedure, but many recovered to baseline level after 1 year. Dyspnea and cognitive functioning deteriorated over time, with worst scores recorded after 1 year. Financial difficulties and fatigue increased after surgery and maintained that level throughout the follow-up period; sticky saliva remained worse than at baseline, despite some improvements over time. CONCLUSION: The discovered limitations of QOL should be observed more closely during follow-up treatment, and patients should be informed about these potential effects before partial laryngectomy.

Feasibility and safety of dilatational tracheotomy using the rigid endoscope: a multicenter study.

BACKGROUND: Fiberoptic tracheo-bronchoscopy is the most commonly used procedure for percutaneous dilational tracheotomy (PDT). However, PDT can be associated with major complications, including death. Furthermore it is unclear, whether the tracheal ring fractures may contribute to the development of tracheal stenosis after PDT nor whether tracheal ring fractures can be prevented by using a rigid endoscope for this procedure. The purpose of this study was to evaluate the feasibility of and the incidence of complications for PDT using the rigid tracheotomy endoscope (TED). METHODS: In a prospective multicenter observational study from 2006 to 2010, 180 adult patients in intensive care and those scheduled for ear, nose and throat surgery underwent PDT using TED. Data collection was performed using a structured protocol. The patients were observed according to PDT phase (phase 1: puncture, phase 2: dilatation and phase 3: cannula insertion). The descriptive data are given as the number (percent) of cases and the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant. RESULTS: PDT was performed in 179 patients. The procedure time was 14.8 ± 6.2 (mean ± SD) minutes. Pneumothorax or procedure-related lethal complications did not occur. Other adverse events included tracheal ring fractures (17.1%), desaturations (6.8%), special incidents (6.2%), bleeding (5.5%), anesthesia complications (4.5%) and posterior tracheal wall injuries (1.1%). CONCLUSION: The use of TED in PDT is feasible, and the incidence of complications and adverse events was comparable with that of PDT using the flexible endoscope. Tracheal ring fractures in PDT cannot be avoided by the use of a rigid endoscope. With TED, the airway always remains open thus the use of jet ventilation via the TED during PDT is possible.

Tobacco and alcohol consumption after total laryngectomy and survival: A German multicenter prospective cohort study.

BACKGROUND: We examined the relation of tobacco and alcohol consumption after total laryngectomy with overall survival (OS). METHODS: Tobacco and alcohol consumption was assessed at 5 time points after total laryngectomy. Patients were followed up for survival until December 31, 2014. A multivariate Cox regression was fitted to test for differences in OS. RESULTS: Three hundred fifty-nine patients were included in this study. Compared to former smokers, never smokers had hazard ratios (HRs) of 0.88 (95% confidence intervals [CIs] = 0.50-1.59), and continuous smokers 1.31 (95% CI = 0.87-1.96). Constantly high alcohol consumption after total laryngectomy had an HR of 2.19 (95% CI = 1.30-3.67). Duration of smoking (HR = 1.00; 95% CI = 0.99-1.01) and last known status of alcohol consumption (HR = 1.00; 95% CI = 0.76-1.33) was not related to OS. CONCLUSION: Patients who smoke after total laryngectomy have a 30% higher risk of dying than people who gave up smoking, and constant high alcohol consumption is also a strong risk factor for dying. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1324-1329, 2016.

Quality of life before and after total laryngectomy: results of a multicenter prospective cohort study.

BACKGROUND: The purpose of this study was to determine what quality of life (QOL) areas improve and deteriorate during the first year after total laryngectomy and to identify predictors of these changes. METHODS: One hundred seventy-four patients completed the European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaires before laryngectomy, n = 133 before discharge from hospital, n = 110 at the end of rehabilitation, and n = 86 1 year after laryngectomy. Multivariate regression analysis was performed to estimate the effect of potential predictors on QOL. RESULTS: Areas that did not recover to baseline level were physical functioning, role functioning, social functioning, fatigue, dyspnea, appetite loss, financial difficulties, senses, speech, and social contact, whereas global health status, coughing, and weight improved. There was no evidence for predicting effects of age, sex, education, and tumor site. Tumor stage, recurrent disease, radiotherapy, and mental health did display predicting effects. Smoking status before the treatment had marginally significant effects. CONCLUSION: QOL decreases initially after laryngectomy; some QOL areas recover slowly over the course of the year after surgery, and some remain significantly worse than at baseline.

Speech rehabilitation during the first year after total laryngectomy.

BACKGROUND: Gaining a new voice is one of the major aims after total laryngectomy. The objective of this study was to describe the process and results of speech rehabilitation during the first year after surgery. METHODS: Speech intelligibility was measured 6 months (n = 273) and 1 year (n = 225) after total laryngectomy. RESULTS: Objective (23.4 to 47.5 points, p < .0001) and subjective (51.6 to 64.7 points, p < .0001) speech intelligibility improved between 6 months and 1 year after total laryngectomy. Patients who used tracheoesophageal puncture (TEP) had the best results in speech intelligibility 6 months and 1 year after total laryngectomy. In all, 12% of the patients who used TEP initially no longer used it 1 year later. Patients who had received rehabilitation had better objective speech intelligibility than those who did not. CONCLUSIONS: Speech improves considerably between 6 months and 1 year after total laryngectomy. Nonattendance of rehabilitation is associated with a worse functional outcome in speech rehabilitation.

Motivation as a predictor of speech intelligibility after total laryngectomy.

BACKGROUND: It has often been argued that if patients' success with speech rehabilitation after laryngectomy is limited, it is the result of lacking motivation on their part. This project investigated the role of motivation in speech rehabilitation. METHODS: In a multicenter prospective cohort study, 141 laryngectomees were interviewed at the beginning of rehabilitation and 1 year after laryngectomy. Speech intelligibility was measured with a standardized test, and patients self-assessed their own motivation shortly after the surgery. Logistic regression, adjusted for several theory-based confounding factors, was used to assess the impact of motivation on speech intelligibility. RESULTS: Speech intelligibility 1 year after laryngectomy was not significantly associated with the level of motivation at the beginning of rehabilitation (odds ratio [OR], 1.3; 95% confidence interval [CI], 0.7-2.3; p = .43) after adjusting for the effect of potential confounders (implantation of a voice prosthesis, patient's cognitive abilities, frustration tolerance, physical functioning, and type of rehabilitation). CONCLUSIONS: Motivation is not a strong predictor of speech intelligibility 1 year after laryngectomy.

Clinical relevance of quality-of-life data in laryngectomized patients.

OBJECTIVES/HYPOTHESIS: Statistically significant differences in health-related quality of life (HRQL) are not always clinically relevant. It is also plausible that patients perceive other changes to be relevant than health professionals do. The objective of this study was to find thresholds for HRQL that laryngectomees consider to be clinically relevant 1 year after surgery, (i.e., the level of HRQL that patients rate as satisfactory). A second aim was to investigate how many laryngectomized patients reached those targets. STUDY DESIGN: Multicenter cross-sectional study. METHODS: A total of 28 patients 1 year following laryngectomy and 24 healthcare professionals (HCPs) defined target values for the QLQ-C30 and QLQ-H&N35. In another sample of 157 laryngectomized patients 1 year following laryngectomy, we determined what percentage of patients reached these thresholds. RESULTS: Patients are the most accepting of sensory impairments (56.5), coughing (53.6), and dyspnea (44.0), whereas constipation (9.1) and nausea/vomiting (10.7) were rated as being the most troublesome symptoms. HCPs assessed more of the studied complaints as being tolerable than patients did, especially in psychosocial domains. Between 34.5% (senses) and 86.5% (constipation) of the reference group hit the predefined targets at different scales. CONCLUSIONS: Symptoms caused by disease are easier for patients to live with than more general nonspecific symptoms. Taking into account that some adverse effects of disease or therapy are partially irreversible, target values additional to changes of HRQL can be helpful when interpreting data.

Validation of the EORTC QLQ-C30 and EORTC QLQ-H&N35 in patients with laryngeal cancer after surgery.

BACKGROUND: The aim of this study was to test the validity of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (QLQ-C30) and Head and Neck Module (QLQ-H&N35) for patients who have undergone surgery due to laryngeal cancer. METHODS: A total of 323 patients from 6 different centers in Germany who had been operated on completed the QLQ-C30 and the QLQ-H&N35 in addition to being surveyed in a personal interview. RESULTS: Multitrait scaling analysis confirmed the proposed scale structure of both questionnaires. Cronbach's alpha of the QLQ-C30 scales ranged from 0.64 (Cognitive Functioning) to 0.94 (Global Health Status); the alpha of the QLQ-H&N35 ranged from 0.55 (Speech) to 0.90 (Sexuality). Known-groups comparisons showed multiple differences in sociodemographic and clinical variables. CONCLUSION: It can be concluded that the QLQ-H&N35, in conjunction with the QLQ-C30, is a reliable instrument that is able to differentiate between diverse groups of patients with laryngeal cancer after surgery.

Sexual problems after total or partial laryngectomy.

OBJECTIVES: To investigate sexual problems that can occur after laryngeal and hypopharyngeal cancer surgery and to specify possible influencing factors. STUDY DESIGN: Multi-institutional cross-sectional study. METHODS: Two hundred six patients were interviewed in person using the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire, Head and Neck Module (EORTC QLQ-H&N35), the Hospital Anxiety and Depression Scale, and a structured interview assessing alcohol and tobacco consumption, sociodemographic data, and specific sexual problems. Type of surgery, tumor site, and tumor stage were documented according to the participants' medical records. Multivariate analysis of variance was used to assess the independent impact of each factor. RESULTS: More than half of the patients in our study reported having reduced libido and sexual enjoyment after treatment. Sixty percent considered it an important issue for their contentment with life. Sexual difficulties were found to be unrelated with gender, formal education, alcohol and tobacco consumption, type of surgery (partial vs. total laryngectomy), radiotherapy, and tumor site. Psychological distress (F = 46.27, P < .001) was seen to have a strong independent impact on the occurrence of sexual difficulties and stage of disease (F = 4.50, P < .05) and age (F = 4.79, P < .05), a moderate independent impact. CONCLUSIONS: Reduced libido and sexual enjoyment is a common problem after laryngeal and hypopharyngeal cancer surgery. However, it is not caused by the oncological treatment but rather by the cancer itself. Depression is often associated with sexual problems. Both should be discussed in medical consultations with head and neck cancer patients when appropriate to provide adequate treatment.

Safety and practicability of percutaneous translaryngeal tracheotomy (Fantoni technique) in surgery of maxillofacial and oropharyngeal tumours--own results and review of the literature.

BACKGROUND: The study examines the suitability of the Fantoni method of translaryngeal tracheotomy (TLT) for airway management after surgery due to oropharyngeal and maxillofacial tumours. PATIENTS AND METHODS: During a 4-year period, 156 translaryngeal pull-through tracheotomies were performed in 145 patients. This method is the only puncture tracheotomy technique that involves a dilatation process from inside the trachea to the outside through the skin and differs from other established puncture methods regarding practicability and frequency of complications. RESULTS: The mean puncture time (from puncture of the trachea to correct tube placement) was 10.1+/-4.8 min. With an oxygen supply of FiO(2)=1.0 the oxygen saturation prior to TLT was 98.4+/-1.29%, and the lowest median saturation value during the TLT procedure was 96.7+/-3.9%. No serious complications such as bleeding, loss of airway, pneumothorax or death were observed. Complications occurring during the TLT procedure were exclusively technical and at no time were they life-threatening. CONCLUSIONS: TLT is a technique with few complications and a straightforward procedure for those familiar with the method. It has some advantages compared with other puncture techniques which appear to commend TLT in terms of safety for the patient.

Screening for mental disorders in laryngeal cancer patients: a comparison of 6 methods.

OBJECTIVES: The aim of this study was to determine how accurate mental distress screening instruments are in identifying psychological sequelae in ambulatory laryngeal cancer patients who have undergone surgery. METHODS: Two-hundred and fifty subjects were tested for mental disorders according to the guidelines defined in the Diagnostic Statistical Manual of Psychological Illnesses, Version 4. Screening instruments tested were: the 'Hospital Anxiety and Depression Scale' (HADS), the subscale 'Emotional Functioning' of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the 'Hornheider Fragebogen' (HFB), and a single-item visual analogues scale (VAS). Accuracy was assessed by calculating the sensitivity rates, specificity rates, and areas under the curve from the receiver operating characteristic curves. RESULTS: The relative frequency of mental disorders was 19.8%. All of the screening instruments tested were found to be highly accurate. The best levels of sensitivity and specificity were associated with the total score of the HADS. CONCLUSIONS: These results confirm that a significant minority of laryngeal cancer patients suffer from severe mental distress, and that accurate screening for clinically significant mental disorders is possible using any of the instruments evaluated here.

Quality of life correlates after surgery for laryngeal carcinoma.

OBJECTIVES: To assess the correlation of operation mode, postoperative radiotherapy, and disease stage factors with the health-related quality of life (HRQL) measures after surgery for laryngeal carcinoma. STUDY DESIGN: Reanalysis of data of two multi-institutional cross-sectional studies. PATIENTS AND METHODS: We interviewed 218 laryngectomees and 153 partial laryngectomy patients in and near Leipzig, Germany, in two cross-sectional studies, using the general and the head- and neck-specific quality of life questionnaires of the European Organization for the Research and Treatment of Cancer (EORTC QLQ-C30 and EORTC QLQ-H&N35). Multifactorial univariate and multivariate models were calculated, with laryngectomy vs. partial laryngectomy, radiotherapy (irradiated or not), and disease stage (International Union Against Cancer [UICC] stages I/II vs. III/IV) as influencing factors and the HRQL scales and items as dependent variables. Analyses were adjusted for the patient's age and the time elapsed since the operation. RESULTS: Laryngectomees were more affected in their sense of smell (P < or = .000). Among irradiated patients, functioning levels and many symptom scales showed worse results (P < or = .05). Both operation mode and postoperative radiotherapy were independently associated with head- and neck-specific HRQL in multivariate analysis. Differences between disease stage groups, however, were not significant. Patient's age was an influencing factor on HRQL, but time since operation was not. CONCLUSIONS: : Postoperative radiotherapy seems to have the greatest impact on patients' HRQL independent of other clinical factors following surgery for laryngeal carcinoma. Aftercare of irradiated laryngeal carcinoma patients should focus more on the patient's quality of life.

[Perceived stigmatisation following laryngectomy]. / Stigmatisierungsgefühle nach Kehlkopfentfernung.

Patients who have had a cancer-related total laryngectomy (N = 217) were studied in order to investigate possible associations between perceived stigmatisation and such physical and social factors as: type and intelligibility of the replacement alaryngeal voice, mental health, and gender. The laryngectomees participated in structured interviews. The German questionnaire "Fragebogen zur pyschosozialen Anpassung nach Laryngectomie" (Questionnaire for Psychosocial Adjustment after Laryngectomy, FPAL) was used to measure patients' perceived stigmatisation. Speech intelligibility was measured both by using the Post-laryngectomy Telephone Intelligibility Test (PLTT) and by taking into account patients' own evaluation of how well they are able to speak. Patients' mental health was measured with the Hospital Anxiety and Depression Scale (HADS). Multi-factorial analysis of variance and covariance was used to test the effects of the parameters. Results show that stigmatisation is associated with anxiety (F = 5.992, p < 0.05 and F = 12.895, p < 0.001) but not with speech intelligibility, alaryngeal voice type, gender, or depression. There is a correspondence between the degree to which patients feel stigmatised because of their voice or tracheostomy and their sense of loneliness (F = 4.917, p < 0.05 and F = 6.271, p < 0.05). We can conclude that perceived stigmatisation is frequently accompanied by anxiety and loneliness. Men are apparently as often concerned as women. Stigmatisation is not increased when patients do use electronic devices for communication, and it is not lower in patients whose operation dates back several years.

Preoperative detection of laryngeal cancer in mucosal swabs by slide-based cytometry.

The aim of our study was to evaluate slide-based cytometry in screening for laryngeal cancer using swabs a minimally invasive approach. Laser scanning cytometry (LSC) was used for the multiparametric analysis of cells stained for cytokeratin and DNA to determine the DNA-index (DI) of the tumour cells. Histograms with DI < 0.95, 1.05 < DI < 1.9, and 2.1 < DI were defined as DNA aneuploid. After subsequent haemotoxylin-eosin (HE)-staining, single cells were re-localised and an analysis by conventional cytology was performed. Additionally, routine histopathology of parallel biopsies was obtained in all cases. Fifty one swabs from 49 lesions were analyzed. Seven and 17 swabs, were classified as insufficient for LSC and cytology, respectively. One and two benign lesions, were misclassified as malignant, respectively. Out of 34 malignant lesions, LSC detected 25 and cytology 14. LSC was superior to cytology in all of the statistical parameters tested. This pilot study demonstrates the validity of LSC for the preoperative detection of malignancy in laryngeal tumours using swabs.

Second family with hearing impairment linked to 19q13 and refined DFNA4 localisation.

Until now, over 30 loci have been identified by linkage analysis of affected families that segregate non-syndromic and dominantly inherited forms of hearing impairment (DFNA). A German family with a non-syndromic progressive hearing impairment transmitted in autosomal dominant mode was linked to 19q13.3-q13.4 by a genome-wide scan. Due to the low lod-score (1.85 at theta=0.05) for APOC2-locus we extended the fine mapping attempt with further markers in the same chromosomal region. This resulted in significant evidence for linkage to the markers D19S246 and D19S553 (two-point lod-score of 4.05 and 3.55 at theta=0.0) and a candidate critical region of 14 cM between markers D19S412 and D19S571. This region shows partial overlap with the previously reported DFNA4 critical region. The human gene BAX is orthologous to the rodent Bcl2-related apoptosis gene that is temporally expressed during the postnatal period in the developing inner ear of the mouse. BAX, mapping at a distance of no more than 0.73 cM distally to marker D19S553 appeared a likely candidate in our pedigree but genomic sequencing of coding regions and exon/intron boundaries excluded disease-related mutations. However, additional ESTs in the same region remain to be tested.