Treatment discordance in the utilization of neck dissection for stage I-II supraglottic tumors.

BACKGROUND: In 2018, the National Comprehensive Cancer Network treatment guidelines began recommending the use of neck dissection during surgical management of stage I-II supraglottic laryngeal squamous cell carcinoma (LSCC). METHODS: Trends and factors associated with the use of neck dissection during larynx-preserving surgery for patients with cT1-2, N0, M0 supraglottic LSCC in the National Cancer Database (2004-2020) were evaluated using multivariable-adjusted logistic regression. RESULTS: Of the 2080 patients who satisfied study eligibility criteria, 633 (30.4%) underwent neck dissection. Between 2018 and 2020, the rate of neck dissection was 39.0% (114/292). After multivariable adjustment, academic facility type, undergoing biopsy prior to surgery, and more radical surgery were significant predictors of receiving neck dissection. CONCLUSIONS: The results of this national analysis suggest that the utilization of guideline-concordant neck dissection for management of stage I-II supraglottic LSCC remains low and highlight the need to promote the practice of neck dissection for this patient population.

Impact of Functional Conservation Surgery on Sleep Respiration of Patients with Glottic Cancer.

Objective: Laryngeal cancer is a common tumor in the head and neck, and surgery is one of the main treatment methods for laryngeal cancer. Laryngeal cancer surgery destroys the laryngeal cartilage scaffold, leading to structural changes in the laryngeal cavity and affecting respiratory compliance during sleep. However, less attention has been paid to the impact of changes in laryngeal structure on sleep breathing conditions. This article conducts a prospective study on the effects of preserving laryngeal function in cancer glottic surgery on sleep and respiratory status in patients, in order to understand the preoperative and postoperative OSAHS(obstructive sleep apnea-hypopnea syndrome) of glottic cancer patients , as well as the impact of surgery on OSAHS of patients. Provide a reference for improving the sleep quality of postoperative patients with laryngeal cancer. Methods: 47 patients with glottic cancer who underwent laryngeal function preservation surgeries were studied. They are divided into 28 cases of T1 and T2, who underwent vertical lateral frontal partial laryngectomy (VLFPL), and 19 cases of T3 and T4 who underwent vertical lateral frontal subtotal laryngectomy (VLFSL). All patients' sleep breathing statuses were recorded using a portable sleep breathing monitor one week before surgery and two months after the removal of the tracheal cannula. Analyze the proportion of OSAHS in the 47 patients before and after surgery and compare the obstructive sleep apnea scores of these patients using the Wilcoxon rank sum test of paired grade data. The paired data t-test was used to analyze the apnea-hypopnea index (AHI), apnea index (AI), hypopnea index (HI), minimum blood oxygen saturation (LSaO2), and mean blood oxygen saturation (MSaO2) of all study subjects, patients undergoing VLFPL and VLFSL. Results: 1. Among the 47 patients with glottic cancer, 42.6% (20 / 47) were in line with OSAHS before the operation, and 57.4% (27 / 47) were in line with OSAHS after the operation. 47 patients showed an increasing trend in the OSAHS scores (no, mild, moderate, and severe) after surgery compared to the before-surgery scores, and the difference was statistically significant (P < 0.05). 2. Among the 47 study subjects, AHI and HI increased after surgery compared to preoperative, while LSaO2 and MSaO2 decreased after surgery compared to preoperative (P < .05); There was no statistically significant difference between postoperative and preoperative AI (P > .05). Among 28 patients undergoing VLFPL, LSaO2 decreased after surgery compared to before surgery (P < .05) and there was no statistically significant difference in AHI, AI, MSaO2, and HI after surgery compared to before surgery (P > .05). Among 19 patients undergoing VLFSL, AHI, and HI increased after surgery, while LSaO2 and MSaO2 decreased after surgery (P < .05) and there was no statistically significant difference in postoperative AI compared to preoperative (P > .05). Conclusion: The prevalence of OSAHS in patients with glottic cancer before and after surgery was higher than that in the general population. The effect of functional preservation surgery on sleep breathing in patients with glottic cancer is related to the degree of destruction of the thyroid cartilage scaffold and the scope of surgery. Surgery mainly increases the degree of OSAHS by aggravating patients' hypoventilation rather than apnea.

Laringectomía total en el adulto mayor, Guantánamo 2015-2019 / Laringectomia total em idosos, Guantánamo 2015-2019 / Total laryngectomy in older adult, Guantanamo 2015-2019

Introducción: El cáncer laríngeo en el adulto mayor tiene una incidencia elevada por múltiples factores que se incrementan con la edad, pero con un tratamiento específico adecuado como la laringectomía total permiten mejorar y elevar la calidad de vida de estos pacientes. Objetivo: Caracterizar el resultado de las intervenciones por laringectomía total realizadas en pacientes adultos mayores en el servicio de Otorrinolaringología del Hospital General Docente "Dr. Agostinho Neto", provincia Guantánamo, en el período de enero de 2015 a diciembre de 2019. Método: Se realizó un estudio descriptivo, retrospectivo de corte transversal en el total de pacientes (n=32) de 60 años y más a los que se les realizó laringectomía total durante el periodo estudiado. Las variables estudiadas fueron: edad, sexo, hábitos tóxicos, condicionantes prequirúrgicas, técnica quirúrgica y complicaciones más frecuentes. Los datos se obtuvieron de las historias clínicas. Resultados: La mayoría de los pacientes correspondió al sexo masculino (90,6 porciento) entre 70-74 años; el 71,8 porciento de los pacientes fumaba. La laringectomía total combinada con tiroidectomía unilateral o bilateral y vaciamiento cervical selectivo fue la técnica quirúrgica más empleada y el faringostoma la complicación predominante. Conclusiones: La caracterización de los resultados de la laringectomía total en el adulto mayor portador de carcinoma epidermoide laríngeo aporta datos que permiten una mejor atención integral a este grupo poblacional(AU).

Introduction: Laryngeal cancer has a high incidence in older adult due to various factors which has been increasing in frequency with age. However, assuming an adecuated and specific treatment like total laryngectomy, allows improving and enhancing the patient's quality of life. Objective: To characterize the outcomes of total laryngectomy in older adult patients treated in the otorhinolaryngology service at the Hospital General Docente "Dr. Agostinho Neto" in Guantánamo, from January 2015 to December 2019. Method: A descriptive, retrospective, and cross-sectional study was conducted on the total of patients (n=32) 60 and older, who underwent total laryngectomy during the mentioned period. Variables used were as follow: age, sex, toxic habits, preoperative conditions, surgical technique and, most frequent complications. Data was gathered from medical records. Results: Male patients 70 to 74 years were predominant (90.6 percent) and most of them smoked (71.8 percent). Total laryngectomy combined with unilateral or bilateral thyroidectomy and selective neck dissection was the most common surgical technique used and pharyngostoma was the predominant complication. Conclusions: The characterization of total laryngectomy outcomes in older adult with laryngeal squamous cell carcinoma provides important data for better comprehensive care in this population group(AU).

Introdução: O câncer de laringe em idosos apresenta alta incidência devido a múltiplos fatores que aumentam com a idade, mas com um tratamento específico adequado como a laringectomia total, melhoram e melhoram a qualidade de vida desses pacientes. Objetivo: Caracterizar o resultado da laringectomia total realizada em pacientes idosos no serviço de Otorrinolaringologia do Hospital General Docente "Dr. Agostinho Neto", província de Guantánamo, no período de janeiro de 2015 a dezembro de 2019. Método: Estudo descritivo, retrospectivo e transversal em todos os pacientes (n=32) com 60 anos ou mais que realizaram laringectomia total. durante o período estudado. As variáveis estudadas foram: idade, sexo, hábitos tóxicos, condições pré-cirúrgicas, técnica cirúrgica e complicações mais frequentes. Os dados foram obtidos dos prontuários médicos. Resultados: A maioria dos pacientes era do sexo masculino (90,6 porcento) entre 70-74 anos; 71,8 porcento dos pacientes fumavam. A laringectomia total combinada com tireoidectomia unilateral ou bilateral e dissecção cervical seletiva foi a técnica cirúrgica mais utilizada e a faringostomia a complicação predominante. Conclusões: A caracterização dos resultados da laringectomia total em idosos com carcinoma espinocelular de laringe fornece dados que permitem uma melhor assistência integral a este grupo populacional(AU).

Does thyroid-sparing total laryngectomy decrease the risk of hypothyroidism?

BACKGROUND: Thyroid lobectomy is recommended with total laryngectomy for laryngeal cancer in the National Comprehensive Cancer Network ('NCCN') guidelines. However, it is associated with a 32-89 per cent risk of hypothyroidism, with or without adjuvant radiotherapy. OBJECTIVE: The study aimed to determine whether preserving the whole thyroid, compared to a single lobe, does indeed significantly lower the incidence of hypothyroidism in the setting of total laryngectomy. METHOD: A retrospective study was conducted at Groote Schuur Hospital in Cape Town, South Africa. RESULTS: Eighty-four patients met the inclusion criteria. The overall incidence of hypothyroidism was 45.2 per cent. The incidence of hypothyroidism was significantly reduced in patients who underwent thyroid-sparing total laryngectomy compared to hemithyroidectomy (p = 0.037). Adjuvant radiotherapy was associated with a higher incidence of hypothyroidism (p = 0.001). CONCLUSION: Thyroid-preserving laryngectomy should be advocated in carefully selected patients with advanced laryngeal carcinoma, as it reduces the incidence of hypothyroidism.

Does Thyroid Gland Preserving Total Laryngectomy Affect Oncological Control in Laryngeal Carcinoma?

INTRODUCTION: Thyroid lobectomy is recommended with total laryngectomy in the National Comprehensive Cancer Network guidelines. However, it is associated with a 32% to 89% risk of hypothyroidism, which is a problem for patients without access to thyroid hormone monitoring and replacement. A number of studies have reported a low incidence of thyroid gland involvement and recommended preserving the thyroid gland in favorable cases. Yet there are no studies that report whether thyroid preserving laryngectomy for laryngeal cancer adversely affects oncologic outcomes compared to patients who have undergone thyroid lobectomy. OBJECTIVES: To determine whether patients who underwent thyroid gland preserving laryngectomy had higher local recurrence rates or poorer disease-free survival. METHOD: A retrospective folder review of patients who underwent a total laryngectomy over a 12-year period was conducted. Local recurrence and disease-free survival were determined for patients who had both their thyroid lobes preserved and compared with those who had a thyroid lobectomy. RESULTS: Sixty-nine patients had thyroid preserving laryngectomy and 73 patients had a thyroid lobectomy. The duration of follow-up was 18 to 132 months (median, 30; IQR, 30). There was no significant difference in local recurrence rates (P = .76) or survival curves between the two groups. CONCLUSION: Thyroid preserving laryngectomy in selected patients with advanced laryngeal carcinoma does not increase local recurrence rates, nor does it negatively affect disease-free survival. Thyroid preservation is appropriate when intraoperative inspection of the larynx shows no extralaryngeal extension or when paratracheal nodal metastases are not a concern. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 130:1465-1469, 2020.

Thyroid and Parathyroid Functions After Pharyngo-Laryngo-Esophagectomy for Cervical Esophageal Cancer.

BACKGROUND: Cervical esophageal cancer (CEC) patients whose larynx function cannot be preserved often undergo chemoradiotherapy, whereas those with residual or recurrent lesions undergo a pharyngo-laryngo-esophagectomy (PLE); however, some need to undergo a pharyngolaryngectomy with total esophagectomy (PLTE) for synchronous or metachronous esophageal cancer. We retrospectively evaluated the relationship between preoperative irradiation (or the extent of esophageal resection) and postoperative endocrine complications in CEC, including hypothyroidism and hypoparathyroidism. METHODS: The cancers of 35 (5.4%) of 678 esophageal cancer patients with esophagectomy treated in 2000-2017 were CECs. We also analyzed the 17 cases of CEC patients who underwent PLE with thyroid lobectomy-11 with irradiation before PLE and 6 without irradiation. Seven patients underwent a PLTE. RESULTS: Hypothyroidism and hypoparathyroidism occurred in 14 and 12 patients, respectively. The hypothyroidism rate was significantly higher in patients with irradiation versus those without irradiation (100% vs. 50%; p = 0.010), and the hypoparathyroidism rate was significantly higher in the PLTE versus non-PLTE patients (100% vs. 50%; p = 0.026). The mean levothyroxine dosage was 1.60 µg/kg/day in the PLE patients post-irradiation. CONCLUSIONS: Irradiation appears to be a risk factor for hypothyroidism after PLE with thyroid lobectomy, while PLTE might have some effect on hypoparathyroidism. Due to vocal function loss, PLE patients may experience symptoms from endocrine complications. Levothyroxine treatment soon after PLE for post-irradiation patients and patients requiring as-needed calcium or vitamin D supplementation based on biochemical hypocalcemia for PLE (especially PLTE), may be effective in preventing symptomatic endocrine complications.

Perioperative Management of Total Laryngectomy Patients: A Survey of American Head and Neck Society Surgeons.

OBJECTIVES: Standards of care for total laryngectomy (TL) patients in the postoperative period have not been established. Perioperative care remains highly variable and perhaps primarily anecdotally based. The aim of this study was to survey members of the American Head and Neck Society to capture management practices in the perioperative care of TL patients. METHODS: In this survey study, an electronic survey was distributed to the international attending physician body of the American Head and Neck Society. Forty-five-question electronic surveys were distributed. A total of 777 members were invited to respond, of whom 177 (22.8%) fully completed the survey. The survey elicited information on management preferences in the perioperative care of TL patients. Differences in management on the basis of irradiation status and pharyngeal repair (primary closure vs regional or free flap reconstruction) were ascertained. Main outcomes and measures were time to initiate oral feeding, perioperative antibiotic selection and duration, and estimated pharyngocutaneous fistula rates. These measures were stratified by patient type. RESULTS: Most respondents completed head and neck fellowships (77.0%) and practice at academic tertiary centers (72.3%). Ampicillin/sulbactam was the most preferred perioperative antibiotic (43.2%-49.1% depending on patient type), followed by cefazolin and metronidazole in combination (32.0%-33.7%) and then clindamycin (10.8%-12.6%). Compared with nonirradiated patients, irradiated patients were significantly more likely to have longer durations of antibiotics ( P < .05), longer postoperative times to initiate oral feeding ( P < .05), and higher estimated fistula rates ( P < .05). Additionally, in nonirradiated patients, flap-repaired patients (vs primary repair) were significantly more likely to have longer durations of antibiotics (odds ratio, 1.29; 95% confidence interval, 1.13-1.48) and postoperative times to initiate oral feeding (odds ratio, 2.24; 95% confidence interval, 1.76-2.84). CONCLUSIONS: Perioperative management of TL patients is highly variable. Management of antibiotics and oral feeding are significantly affected by irradiation status and scope of pharyngeal repair. Further studies are needed to standardize perioperative care for this unique patient population.

From VA Larynx to the future of chemoselection: Defining the role of induction chemotherapy in larynx cancer.

Organ preservation protocols utilizing induction chemotherapy as a selection agent have played a critical role in the treatment of advanced laryngeal squamous cell carcinoma (LSCC). The selection of patients who will have a good response to chemoradiation allows for organ preservation in a significant group of patients and minimizes the rate of surgical salvage. While there remains debate regarding its utility when compared to surgery or other organ preservation regimens, the data does suggest an important role for induction chemotherapy in LSCC. In addition, there are continued opportunities to identify pretreatment biomarkers for induction chemotherapy, whether genetic, epigenetic or cellular, that could predict response to treatment and select patients to therapy (whether organ preservation or surgery). As our understanding of the biology of larynx cancer advances, induction paradigms have utility for the development and adoption of novel agents and therapeutics. The background of induction chemotherapy as a selection agent and future directions of this approach are discussed.

Modified technique of functional vertical hemilaryngectomy for cancer invading 1 hemicricoid.

BACKGROUND: Partial laryngectomy techniques are challenging, especially in young patients where function has to be preserved without compromising the oncologic outcome. We present a modified laryngectomy technique indicated for tumors invading one hemicricoid. METHODS: Vertical hemilaryngectomy with reconstruction of neo-glottis by hemi trachea and placement of an endolaryngeal silicon prosthesis for a 21-y old female patient presenting with a synovial sarcoma located on the left arytenoid area. RESULTS: The prosthesis was removed at 6 w with tracheotomy closure at 8w post-op. Patient underwent adjuvant radiotherapy. Functional outcome showed good swallowing without aspiration. Voice was hoarse. At 5 years post-op the patient is free of recurrence presenting only mild dyspnea upon effort. CONCLUSION: Vertical hemilaryngectomy including a hemicricoid is feasible with single stage reconstruction by a hemi-trachea of 4 to 5 rings intussuscepted into the thyroid cartilage. The functional outcome is good considering oncologic safety and avoidance of a permanent tracheostomy. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Long-term Results of a Multicenter Randomized Phase III Trial of Induction Chemotherapy With Cisplatin, 5-fluorouracil, ± Docetaxel for Larynx Preservation.

BACKGROUND: The purpose of GORTEC 2000-01 was to compare the long-term efficacy and safety of induction chemotherapy with cisplatin (P) and 5-fluorouracil (F) with or without docetaxel (T) for larynx preservation. METHODS: Operable patients with untreated stage III or IV larynx or hypopharynx invasive squamous cell carcinoma who required total laryngectomy were randomly assigned to three cycles of induction chemotherapy with either TPF or PF, followed by radiation therapy for responders. The primary endpoint was three-year larynx preservation rate. Secondary endpoints included larynx dysfunction-free survival (LDFFS), overall survival (OS), disease-free survival (DFS), loco-regional control rate (LCR), cause of death, and later toxicity rates. Survival and other data were analyzed by Kaplan-Meier methods. All statistical tests were two-sided. RESULTS: Two hundred thirteen patients were treated with median follow-up of 105 months. The five- and 10-year larynx preservation rates were 74.0% (95% CI = 0.64 to 0.82) vs 58.1% (95% CI = 0.47 to 0.68) and 70.3% (95% CI = 0.58 to 0.8) vs 46.5% (95% CI = 0.31 to 0.63, P = .01) in the TPF vs PF arm, respectively. The five- and 10-year LDFFS rates were 67.2% (95% CI = 0.57 to 0.76) vs 46.5% (95% CI = 0.36 to 0.57) and 63.7% (95% CI = 0.52 to 0.74) vs 37.2% (95% CI = 0.24 to 0.52, P = .001), respectively. OS, DFS, and LCR were not statistically improved in the TPF vs the PF arm. Statistically fewer grade 3-4 late toxicities of the larynx occurred with the TPF regimen compared with the PF arm (9.3% vs 17.1%, G-test, P = .038). CONCLUSION: Long-term follow-up confirms that induction chemotherapy with TPF increased larynx preservation and larynx dysfunction-free survival. In this larynx preservation approach using induction chemotherapy, TPF should be recommended, followed by radiation therapy.

Partial laryngectomy as salvage surgery after radiotherapy: oncological and functional outcomes and impact on quality of life. A retrospective study of 20 cases.

UNLABELLED: The gold standard for the management of laryngeal squamous cell carcinoma in a previously irradiated patient is "salvage" total laryngectomy, but surgical management by partial laryngectomy can sometimes be proposed in selected patients. OBJECTIVES: This study was designed to review the functional and oncological outcomes of patients treated by open partial laryngectomy for recurrent squamous cell carcinoma after failure of radiotherapy or involving previously irradiated tissues and to define prognostic criteria for the selection of patients eligible for this treatment strategy. MATERIALS AND METHODS: In this retrospective study, 20 patients underwent partial laryngectomy between 2000 and 2011 for recurrence or second primary stage I or II laryngeal squamous cell carcinoma in an irradiated territory (11 vertical partial laryngectomies; 9 horizontal partial laryngectomies). RESULTS: The 3-year overall survival rate in patients with negative resection margins was 66%, with higher survival rates for tumours confined to the glottis, and the 2-year local control rate was 67%. Positive resection margins requiring total laryngectomy were observed in 20% of cases. The 3-year overall survival rate was 56% in these patients. Exclusive oral feeding was restored in 75% of patients after an average of 32 days. The tracheotomy tube was removed after an average of 18 days in 90% of patients. The disease-free functional larynx preservation rate was 45%. CONCLUSIONS: Salvage partial laryngectomy in irradiated tissues is an alternative treatment option to total laryngectomy in selected patients.

Impact of race/ethnicity on laryngeal cancer in patients treated at a Veterans Affairs Medical Center.

OBJECTIVES/HYPOTHESIS: Black patients generally present with advanced head and neck cancer resulting in decreased survival. The objective of this study was to determine whether equal access to laryngeal cancer care in a tertiary care Veterans Affairs (VA) Medical Center would result in similar survival for white and black patients. STUDY DESIGN: Retrospective chart review. METHODS: Patient and tumor characteristics, compliance with National Comprehensive Cancer Network (NCCN) guidelines, and survival outcomes were collected for 205 male patients with squamous cell carcinoma of the larynx treated between 2000 and 2012 at the Michael E. DeBakey Veterans Affairs Medical Center. RESULTS: Black patients constituted 33% of the entire cohort, were older (mean age, 65.1 vs. 62.1 years), and consumed less tobacco (46.6 vs. 65.8 mean pack-years) than white patients. Disease stage and compliance with NCCN guidelines were not affected by race. Mean follow up time was 3.6 years. A higher recurrence rate was noted among white patients (24% vs. 15%, P < .05). Neither disease-free survival (DFS) nor overall survival (OS) was significantly different between black and white patients (DFS 69% vs. 68%, P = .7; OS 68% vs. 77%, P = .1). CONCLUSIONS: Utilization of a multidisciplinary approach to laryngeal cancer care at the VA medical center allows for high compliance with NCCN guidelines and excellent oncologic outcomes. Ethnicity did not impact stage at presentation, treatment selection, or treatment intensity in this patient cohort. Our data suggest that cancer care at a VA medical center results in clinical outcomes that do not significantly vary based on patient race.

A minimally invasive method to prevent postlaryngectomy major pharyngocutaneous fistula using infrahyoid myofascial flap.

INTRODUCTION: To prevent postoperative pharyngocutaneous fistula (PCF) after total (pharyngo)laryngectomy, simultaneous coverage of pharyngeal anastomosis with vascularised flaps such as pectoralis major muscle, anterolateral thigh or radial forearm, has been reported to be effective. As an alternative to the invasive methods using distant flaps, we used the infrahyoid myofascial flap (IHMFF), which was harvested from the same operation field of (pharyngo)laryngectomy, for covering the site of pharyngeal anastomosis. Herein, we describe the safety and effectiveness of our minimally invasive method for preventing PCF. METHODS: Eleven patients who were at a high risk of developing PCF due to previous chemoradiotherapy underwent simultaneous coverage of pharyngeal anastomosis with IHMFF after total (pharyngo)laryngectomy. The incidence of PCF and the rate of major fistula requiring surgical closure were determined, and the results were compared with the control group (23 patients without IHMFF cover after laryngectomy). RESULTS: PCF developed in 2 of the 11 patients (18.2%). The fistulae of these two patients were closed conservatively and did not require additional surgery. PCF developed in 6 of 23 patients (26.1%) in patients without IHMFF cover. All the six patients with fistula required additional closure surgery. The incidence of PCF did not differ in patients with or without IHMFF cover (Fisher's exact probability test; p=0.939, NS). However, the rate of major PCF requiring surgical closure was significantly lower in patients with IHMFF cover (Fisher's exact probability test; p=0.036<0.05). CONCLUSIONS: For (pharyngo)laryngectomy patients, IHMFF cover is a minimally invasive method that can prevent major PCF.

[Results of combined treatment in locally advanced cancer of the larynx using preoperative thermochemoradiotherapy].

This paper analyzes the results of combined treatment with preoperative thermochemoradiotherapy in 28 patients with locally advanced laryngeal cancer (T3-4N0-3M0). Radiation therapy (RT) 32 Gy was carried out 5 times a week with splitting the daily dose of radiation on the 2 factions (interval 4 hours) on a "1 Gy + 1 Gy," in the days of the local hyperthermia (LGT)--on a "1 Gy + 3 Gy". LGT in an amount of 3-4 sessions was performed two times a week before the 2nd fraction of RT. The course of polychemotherapy was administered concurrently with RT and LGT. In 2-3 weeks after completion of the course thermochemoradiotherapy patients were operated. Organ-saving operations were performed 10 (56%) of 18 patients with primary tumors categories T3 and 2 (20%) of 10 with T4. Postoperative wounds healed by first intention in 21 (75%) patients. The cumulative 5-year overall survival in the whole group (T3-4N0-3) was 89%, for patients without regional metastases (T3-4N0)--100%. Relapse-free survival time for those patients with a primary tumor T3 equaled 94%, T4--90%. Relapse metastases occurred in 20% of patients. Thus, preoperative thermochemoradiotherapy is a highly effective method of treatment for locally advanced cancer of the larynx and does not lead to the development of severe postoperative complications.

Aortic homograft reconstruction of partial laryngectomy defects: a new technique.

OBJECTIVES: Wide-field transcervical partial laryngectomy often precludes tracheotomy decannulation. It is done infrequently today, primarily because of the popularity of chemotherapy-radiotherapy treatment regimens and limited enthusiasm for using transcervical partial laryngectomy after failed radiotherapy. We sought to identify a new reconstructive technique that would provide an alternative to total laryngectomy in as many patients as possible. METHODS: We performed a retrospective examination of 15 patients who underwent single-stage wide-field transcervical partial laryngectomy with cryopreserved aortic homograft reconstruction. Eight of the 15 patients had previously undergone failed radiotherapy. At least 40% of the cricoid circumference was resected in 8 patients. RESULTS: All 15 patients had their tracheotomy tube removed and have laryngeal phonation, and 14 of the 15 resumed oral intake. There were no major surgical complications. CONCLUSIONS: Use of aortic homografts is a new, reliable, and versatile reconstructive option for performing conservation laryngeal cancer surgery that allows for airway, swallowing, and voice preservation.

Total laryngectomy for a dysfunctional larynx after (chemo)radiotherapy.

OBJECTIVE: To evaluate the functional outcomes after total laryngectomy (TLE) for a dysfunctional larynx in patients with head and neck cancer that is in complete remission after (chemo)radiotherapy. DESIGN: Retrospective cohort study. SETTING: Tertiary comprehensive cancer center. PATIENTS: The study included 25 patients from a cohort of 217 consecutive patients with TLE who were treated between January 2000 and July 2010. The inclusion criteria for this subgroup analysis were complete remission and functional problems for which TLE was considered to be the only resolution. Quality of life assessment was carried out using the European Organization for Research and Treatment of Cancer Quality of Life C30 and Head and Neck Module 35 questionnaires and an additional study-specific questionnaire covering functional aspects, such as swallowing and dyspnea, in more detail. INTERVENTION: Total laryngectomy. MAIN OUTCOME MEASURES: Morbidity, mortality, and functional outcomes. RESULTS The indication for TLE was chronic aspiration with or without recurrent pneumonia (n = 15 [60%]), debilitating dyspnea (n = 8 [32%]), and persistent profuse hemorrhage (radiation ulcer) (n = 2 [8%]). After TLE, 14 of the 25 patients (56%) had 20 major postoperative complications, including 11 pharyngocutaneous fistulas, requiring additional treatment. Tube feeding and recurrent pneumonia incidence had decreased from 80% and 28% to 29% and 0%, respectively, 2 years after surgery. Prosthetic voice rehabilitation was possible in 19 patients (76%). Two years after surgery, 10 of 14 patients (71%) still reported TLE-related pulmonary problems despite the consistent use of a heat and moisture exchanger. The 5-year overall survival rate was 35%. CONCLUSIONS: Total laryngectomy for a dysfunctional larynx tends to have a high complication rate. However, in this study, the initial functional problems (aspiration, recurrent pneumonia, and dyspnea) did not recur. Tube feeding was significantly reduced, and the quality of life of the surviving patients appeared to be reasonable.

Pharyngoesophageal junction neoplasia--therapeutic management.

Not only the anatomy but the treatment and the prognosis of these tumors are intermediate between hypopharyngeal and esophageal tumors. After a portion of the esophagus is removed or complete esophagectomy, a conduit must be established. The authors reviewed the experience of Prof. Cristian Popescu in total pharyngo-laryngectomy and his technique of pharyngoesophageal reconstruction with synthetic esophageal prosthesis. We have some 21 patients who underwent an esophageal reconstruction with Montgomery esophageal tube. This is a very important new, modem, interdisciplinary approach bewteen the head and neck surgeon and the general/thoracic surgeon to treat the pharyngo-laryngo-esofageal neoplasia with one stage reconstruction. The follow up for these patients shows that this reconstruction method is a good, reliable choice with low costs and considerable advantages for the quality of life. Surgery for these patients should be considered primarily palliative and the optimal reconstruction should preserve the quality of life for the duration of survival.

Necessity of routine ipsilateral hemithyroidectomy during laryngopharyngectomy for pyriform sinus cancer.

PURPOSE: The aim of this study was to revisit the role of hemithyroidectomy in the treatment of pyriform sinus cancer by determining the incidence of thyroid gland invasion by the tumor. MATERIALS AND METHODS: Medical records of 27 patients with pyriform sinus cancer who underwent laryngopharyngectomy with ipsilateral hemithyroidectomy from 1999 to 2010 at a National Cancer Institute-designated comprehensive cancer center were retrospectively reviewed. Computed tomographic scans of the neck, operative notes, and surgical specimens were examined to determine the presence of thyroid gland invasion by imaging, clinical appearance, and pathology. RESULTS: There were 19 male and 8 female patients (age range, 44-79 years; mean, 59.9 years). Most of the cases (85%) had advanced-stage disease. Extralaryngeal spread of tumor with thyroid cartilage invasion was noted in the computed tomographic scans of 5 patients; however, there was no radiologic evidence of thyroid gland invasion in any patient. No gross thyroid gland invasion by the tumor was appreciated in any patient during surgery. No histologic evidence of tumoral invasion of the thyroid gland was found in any of 27 surgical specimens. CONCLUSIONS: Results of this study suggest that thyroid gland invasion by pyriform sinus cancer is not common. Therefore, a routine ipsilateral hemithyroidectomy may not be necessary in the treatment of every patient with pyriform sinus cancer, unless there is evidence of thyroid gland invasion.

[Olfactory rehabilitation after total laryngectomy]. / Rehabilitación olfativa tras la laringectomía total.

OBJECTIVES: To analyze the olfactory function in patients after total laryngectomy and evaluate the outcomes of the use of the induced nasal airflow manoeuvre. MATERIAL AND METHODS: A prospective clinical intervention study was carried out with 41 patients who had undergone total laryngectomy, of which 39 were male and 2 female. After verifying that there were no anatomical disorders, the patients were given an olfaction test that classified them into two groups, those with olfactory perception and those without. All underwent rehabilitation using the induced nasal airflow technique and, subsequently, the olfaction test was repeated to enable a comparison with the first results obtained. A semi-structured interview was held to evaluate the senses of taste and smell of the participants, also taking into account their own opinion. RESULTS: Out of the 41 patients included in the study, 9 had olfactory perception before rehabilitation, according to the first olfaction test. The use of the nasal airflow maneuver meant the recovery or improvement of the olfactory capacity in 90.24% of the patients. CONCLUSIONS: The induced nasal airflow technique enables an important recovery of olfaction and improvement of taste after total laryngectomy. This technique is easy to learn and to repeat. It does not require expensive materials. The recovery of olfaction and taste implies an improvement in quality of life for the patient, so this technique should be included in all protocols of comprehensive rehabilitation after total laryngectomy.