Decreased Rates of Radiation-induced Trismus and Lowered Mastication Structure Doses in Patients Treated for Head and Neck Cancer During the Last Two Decades.

AIMS: To investigate how absorbed doses to mastication structures in modern radiotherapy (RT) technique for head and neck cancer (HNC) compared with earlier RT techniques and with published trismus tolerance doses. To compare the incidence of radiation-induced trismus by earlier and newer RT techniques. MATERIALS AND METHODS: This study investigated two HNC patient cohorts treated with RT in 2007-2012 (three-dimensional conformal radiotherapy [3DCRT] and/or intensity-modulated radiotherapy [IMRT]; n =121 [Cohort 1]) and 2017-2020 (volumetric-modulated arc therapy [VMAT]; n =124 [Cohort 2]). All patients underwent RT without mastication structure-sparing intent, had normal mouth-opening ability before RT, and were prospectively assessed. Trismus was defined as the maximal interincisal opening ≤35 mm at any follow-up (3-, 6-, and 12-months post-RT). The temporomandibular joints (TMJs), masseter, and medial/lateral pterygoid muscles were delineated on the planning CT:s. Mean doses were compared between cohorts, and evaluated with respect to published trismus tolerance doses. P values ≤ 0.05 indicated statistical significance. RESULTS: Within 12 months post RT, 74/121 (61%) of patients in Cohort 1 had experienced trismus compared to 11/124 (9%) in Cohort 2. Averaged mean doses (±S.D.) for the masseter muscles were 35.2±8.3 Gy in Cohort 1 and 20.2±8.7 Gy in Cohort 2 (P <0.001). Corresponding numbers were 19.1±16.2 and 4.3±4.3 Gy for the TMJs, 53.7±10.1 and 40.2±16.8 Gy for the medial pterygoid muscles, and 29.2±18.7 and 9.2±8.4 Gy for the lateral pterygoid muscles (all P <0.001). Masseter muscle doses were below tolerance doses in 23% of patients in Cohort 1 compared with 90% in Cohort 2. The corresponding numbers were 52% and 96% for the TMJs, 8% and 36% for the medial pterygoid muscles and 72% and 100% for the lateral pterygoid muscles. CONCLUSION: Mastication structure mean doses by more recent RT techniques were generally below proposed tolerance doses, with dose reductions of 10-20 Gy compared with earlier techniques. Modern RT without mastication-structure-sparing intent resulted in below 10% of HNC patients experiencing trismus compared with 60% treated with earlier techniques.

Investigation of self-reported dizziness in the elderly when lying down or turning over in bed, and possible benign paroxysmal positional vertigo.

OBJECTIVES: This study aimed to investigate the rate of dizziness and occurrence of benign paroxysmal positional vertigo in the elderly by physical examination in those reporting dizziness symptoms when lying down or turning over in bed. METHODS: A total of 498 people, aged 70-85 years, were asked to complete a questionnaire regarding dizziness symptoms. Subjects answering that they became dizzy in bed were asked to participate in a physical examination and diagnostic manoeuvres investigating benign paroxysmal positional vertigo. RESULTS: A total of 324 participants (65 per cent) completed the questionnaire. More than one-quarter (29 per cent) reported dizziness and 32 (10 per cent) reported dizziness when turning in bed. Of these 32 persons, 22 (69 per cent) underwent a physical examination. Six participants tested positive for benign paroxysmal positional vertigo. CONCLUSION: Ten per cent of the elderly participants reported positional symptoms, and 6 out of 22 fulfilled diagnostic criteria for benign paroxysmal positional vertigo. Furthermore, benign paroxysmal positional vertigo was established despite a delay between questionnaire completion and investigation, emphasising that this type of dizziness may not be a self-limiting disorder.

Mucosal microflora in head and neck cancer patients.

OBJECTIVE: To analyse the tongue and buccal microflora prospectively in head and neck cancer patients treated with radiation therapy (RT). METHODS: In 33 dentate patients, microbial samples from the tongue and buccal mucosa were collected pretreatment, during treatment, and 6 months, 1 year and 2 years post-treatment. Microorganisms associated with oral health and oral disorders were analysed using cultivation technique. Oral mucositis was scored at the appointment during treatment. RESULTS: Compared with pretreatment, lactobacilli and Candida increased on the tongue, while streptococci and Neisseria decreased during treatment. Two years post-treatment, Neisseria and Prevotella were decreased and Candida increased. On the buccal mucosa, an increased growth of lactobacilli and increased detection frequencies of the opportunistic bacteria Staphylococcus aureus, Gram-negative enteric rods and enterococci were seen during treatment compared with pretreatment. Seventy per cent showed severe mucositis during treatment. Two years post-treatment the total count as well as streptococci, Neisseria and Fusobacterium nucleatum were decreased and lactobacilli increased compared with pretreatment. CONCLUSION: Despite improvements in treatment for cancer in the head and neck region, microorganisms associated with oral health decrease during treatment and mucosal pathogens increase. Two years post-treatment, levels of acid-tolerant (lactobacilli and Candida) were increased, while acid-sensitive microorganisms (Neisseria and F. nucleatum) were decreased, plausibly due to persisting decreased salivary secretion rate.

Explorative study on mucosal and major salivary secretion rates, caries and plaque microflora in head and neck cancer patients.

OBJECTIVE: To analyse mucosal and major salivary secretion rates, caries and plaque microflora in connection with treatment for cancer in the head and neck region. METHODS: Thirty-three patients were included and the number of teeth, filled surfaces and caries lesions registered. The labial and buccal gland secretion and stimulated whole salivary secretion rates were determined. Supragingival plaque microflora was analysed using cultivation technique. Data were collected pretreatment, during treatment and 6 months, 1 year and 2 years post-treatment. RESULTS: Two years post-treatment, 36% had new caries lesions, which had been restored. The labial secretion was comparable with pretreatment, while the buccal secretion was lower (P < .001). The stimulated secretion rate was lower compared with pretreatment (P < .001) and was ≤0.7 mL/minute for 50%. Growth of lactobacilli increased during treatment (P < .001) and remained increased (P < .001), while growth of mutans streptococci was decreased (P < .01) 2 years post-treatment. Growth of Candida increased over time and was higher 2 years post-treatment compared with pretreatment (P < .001) while growth of Prevotella was lower (P < .01). CONCLUSIONS: Two years post-treatment, the stimulated salivary secretion rate was substantially decreased, acid-tolerant lactobacilli and Candida increased, acid-sensitive microorganisms decreased, and the caries prevalence was low.

Temporal patterns of patient-reported trismus and associated mouth-opening distances in radiotherapy for head and neck cancer: A prospective cohort study.

OBJECTIVES: To identify temporal patterns of patient-reported trismus during the first year post-radiotherapy, and to study their associations with maximal interincisal opening distances (MIOs). DESIGN: Single institution case series. SETTING: University hospital ENT clinic. PARTICIPANTS: One hundred and ninety-six subjects who received radiotherapy (RT) for head and neck cancer (HNC) with or without chemotherapy in 2007-2012 to a total dose of 64.6/68 Gy in 38/34 fractions, respectively. All subjects were prospectively assessed for mouth-opening ability (Gothenburg Trismus Questionnaire (GTQ), European Organization for Research and Treatment of Cancer quality of life Questionnaire (EORTC QLQ-H&N35), and MIO) pre-RT and at 3, 6 and 12 months after RT. MAIN OUTCOME MEASURES: Correlations between temporally robust GTQ symptoms and MIO as given by Pearson's correlation coefficients (Pr ); temporally robust GTQ-symptom domains as given by factor analysis; rates of trismus with respect to baseline by risk ratios (RRs). RESULTS: Four temporally robust domains were identified: Eating (3-7 symptoms), Jaw (3-7), Pain (2-5) and Quality of Life (QoL, 2-5), and included 2-3 persistent symptoms across all post-RT assessments. The median RR for a moderate/severe (>2/>3) cut-off was the highest for Jaw (3.7/3.6) and QoL (3.2/2.9). The median Pr between temporally robust symptoms and MIO post-radiotherapy was 0.25-0.35/0.34-0.43/0.24-0.31/0.34-0.50 for Eating/Jaw/Pain/QoL, respectively. CONCLUSIONS: Mouth-opening distances in patients with HNC post-RT can be understood in terms of associated patient-reported outcomes on trismus-related difficulties. Our data suggest that a reduction in MIO can be expected as patients communicate their mouth-opening status to interfere with private/social life, a clinical warning signal for emerging or worsening trismus as patients are being followed after RT.

Baclofen-mediated gastro-oesophageal acid reflux control in patients with established reflux disease.

AIM: To explore the effect of baclofen on oesophageal acid exposure in patients with gastro-oesophageal reflux disease. METHODS AND MATERIALS: Twenty patients with established reflux disease were included in this double-blind, randomized, crossover study. Baclofen, 40 mg, or placebo was given as a single dose with a washout period of 4 weeks. Symptoms were assessed by a visual analogue scale. Oesophageal pH was registered for 12 h and analysed for the whole period and for the 0-4-h, 4-8-h, 8-12-h and 2-h post-prandial periods. RESULTS: Baclofen significantly reduced the number of reflux episodes during the 0-4-h (7.9 vs. 16.5, P < 0.0001; post-prandially: 6.0 vs. 11.2, P < 0.0001) and 0-12-h (46.5 vs. 73, P=0.0001; post-prandially: 18.8 vs. 29.3, P < 0.0001) periods. The fraction of time with pH < 4 was significantly lowered during the 0-4-h period (9.3 vs. 15.6, P=0.0019; post-prandially: 16.1 vs. 23.5, P=0.0083). Similar results were also obtained in patients with a hiatus hernia (n=13). Belching was significantly reduced (32 vs. 69 episodes, P < 0.01). CONCLUSIONS: A single oral dose of 40 mg baclofen significantly reduced both the number of reflux episodes and the fraction of time with pH < 4, an effect primarily found during the first 4 h after dosing.

Serum and cerebrospinal fluid pathology in patients with sudden sensorineural hearing loss.

The serum and cerebrospinal fluid (CSF) pathology of patients with sudden sensorineural hearing loss (SHL), both seropositive and seronegative to Borrelia burgdorferi (Bb), was prospectively studied. Nineteen consecutive patients were included and trends between the degree of hearing recovery and serum/CSF pathology and given therapy were examined. The pilot study showed a high prevalence (68%) of pathology in serum and CSF in patients with SHL. In 54% of the patients, elevated levels of CSF proteins and/or pathological CSF cell counts were present without positive antibodies to Bb. Positive levels of antibodies against Bb or pathological proteins in CSF were associated with better hearing recovery (means of 47.2 and 51.7%, respectively). The audiometric configuration "high frequency sloping" hearing impairment was associated with the lowest degree of hearing recovery. Patients with SHL and positive serology to Bb who received antibiotic treatment (oral tetracycline), with or without steroids, had the best hearing recovery in this study (61.7 and 48.4%, respectively). In conclusion, we found a high prevalence of serum and CSF pathology in a consecutive group of patients with SHL. Early appropriate antibiotic treatment may prevent the development of major late complications of Lyme disease/borreliosis. We also find it justified to perform more general serological analyses, including CSF analysis, in patients with SHL. A more liberal approach to testing and development of test protocols for SHL patients will increase our knowledge in this field.

Health-related quality of life in patients with laryngeal cancer: a post-treatment comparison of different modes of communication.

INTRODUCTION: The effects of different treatment modalities and voice and speech rehabilitation methods on the quality of life in patients with laryngeal cancer are not fully understood. MATERIALS AND METHODS: A cross-sectional post-treatment questionnaire survey of 125 patients with laryngeal cancer was performed. The response rate was 74%. Three patient groups were identified: patients treated with radiotherapy and communicating with preserved larynx (n = 70), laryngectomized patients using a tracheoesophageal prosthesis (TEP) for speech (n = 14), and laryngectomized patients communicating with an electrolarynx (n = 5). Two established generic questionnaires, the Sickness Impact Profile (SIP) and the Hospital Anxiety and Depression (HAD) scale, were used. RESULTS: The radiotherapy and the TEP groups displayed similar SIP and HAD profiles. No significant differences were seen in favor of the radiotherapy group, whereas the TEP group reported fewer problems in the SIP sleep/rest subscale. In 10 of 12 SIP categories, the numerically highest proportion of patients with clinically important dysfunction (SIP scores >10) was found in the small electrolarynx group. CONCLUSION: Successful speech rehabilitation with a TEP after laryngectomy may be as effective as conservative treatment with radiotherapy for laryngeal cancer with regard to psychosocial adjustment and functional ability, as measured with generic quality of life instruments.

Absence of bacterial infection in the mucosal secretion in chronic laryngitis.

OBJECTIVES: To examine whether an infectious process is present in the laryngeal secretion in patients with chronic laryngitis. STUDY DESIGN: Mucosal secretion from vocal cords and ventricular folds from 14 patients with chronic laryngitis was examined. Twelve patients with healthy larynxes served as control subjects. METHODS: Secretion from the laryngeal mucosa was sampled with an imprint technique during general anesthetic. The samples were stained and examined by light and fluorescence microscopy. The numbers of leukocytes and bacteria and the extension of phagocytosis were estimated. RESULTS: In the secretion from eight of the patients with chronic laryngitis we could observe huge numbers of bacteria, whereas only few bacteria were seen in the secretion from the control subjects. However, in both groups, only a few neutrophils were observed and phagocytosis was not present, indicating that the bacteria were present as colonizers. CONCLUSIONS: No infectious process is present in the secretion in chronic laryngitis. Further studies concerning the pathogenesis should focus on the pathological processes or conditions of the mucosa.

A cross-sectional validation study of Self-Evaluation of Communication Experiences after Laryngeal Cancer--a questionnaire for use in the voice rehabilitation of laryngeal cancer patients.

A psychometric evaluation of the questionnaire 'Self-Evaluation of Communication Experiences after Laryngeal Cancer' (S-SECEL) addressing communication dysfunction in patients with laryngeal cancer was carried out. Ninety-three patients with laryngeal cancer were studied. For comparison of response patterns and external validation, 21 patients with non-small cell lung cancer (NSCLC) and 26 patients with hoarseness, caused by benign laryngeal disease, were included in the analysis. The patients completed three questionnaires; the S-SECEL, the Sickness Impact Profile (SIP) and the Hospital Anxiety and Depression scale (HAD). The S-SECEL questionnaire was well-accepted by the patients, compliance was satisfactory, and missing value rates were low. The reliability of the S-SECEL was satisfactory for the Environment and Attitude subscales, whereas the General subscale did not reach the reliability levels recommended for group comparisons. In general, the response pattern in the three diagnostic groups and the pattern of correlations between the S-SECEL scores and the SIP- and HAD-subscales and dimensions lent support to the construct validity of the S-SECEL.

Acoustic and perceptual evaluation of voice and speech quality: a study of patients with laryngeal cancer treated with laryngectomy vs irradiation.

OBJECTIVE: To compare voice and speech function in patients who underwent laryngectomy with that of 2 control groups. DESIGN: A cross-sectional study comparing acoustic and temporal variables with perceptual evaluations in 3 subject groups. SETTING: University hospital in Göteborg, Sweden. SUBJECTS: Two groups of patients with laryngeal carcinoma were examined: 12 male patients who had laryngectomy and were using a tracheoesophageal prosthesis and 12 male patients treated with radical radiotherapy who had a preserved larynx. The third group consisted of 10 normal controls without laryngeal disease. MAIN OUTCOME MEASURES: Acoustic variables were fundamental frequency, absolute fundamental frequency perturbation, speech rate, and maximum phonation time. Perceptual evaluation included 15 listeners' perceptual evaluation and the patients' self-assessment of speech intelligibility, voice quality, and speech acceptability. RESULTS: No significant acoustic or temporal differences were found between the laryngectomy and radical radiotherapy groups. There was a significant difference between the patient groups in perceptual evaluation. Both groups of patients differed from normal controls in acoustic and temporal measures, where the laryngectomy group generally deviated more from the normal controls than the patient group treated with radiotherapy. There was a weak, but significant, correlation between absolute fundamental frequency perturbation and perceived voice quality. CONCLUSIONS: Perceptual evaluations could indicate significant differences between the patients who underwent laryngectomy and irradiated patients, where the acoustic analysis failed to reflect these differences. Both patient groups could be distinguished according to acoustic and temporal measures when compared with normal controls. The acoustic analyses were more sufficient in voices without severe dysfunction.

Quality of life and voice in patients with laryngeal carcinoma: a posttreatment comparison of laryngectomy (salvage surgery) versus radiotherapy.

OBJECTIVES: This study was designed to compare the voice and the quality of life (QOL) of laryngeal cancer patients receiving treatment with radical radiotherapy with or without laryngectomy as salvage surgery. We also compared the patients' own perceptual ratings of their voice to the perceptual ratings of a group of listeners. STUDY DESIGN: Two groups of laryngeal cancer patients were studied. METHODS: Fourteen irradiated laryngeal speakers with preserved larynx were matched with 14 salvage surgery laryngectomized patients speaking with tracheoesophageal prosthesis (TEP). To measure patients' QOL, we used the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck module (EORTC QLQ-H&N35), the Hospital Anxiety and Depression scale (HAD) and a study-specific questionnaire. For the perceptual speech evaluation we used visual analog scales. RESULTS: The perceptual ratings of speech intelligibility, voice quality, and speech acceptability showed a significant difference between the treatment groups. Both the patients who received treatment with radiotherapy and the listeners rated the irradiated laryngeal voices higher than the tracheoesophageal speech. The laryngectomized patients scored significantly better than the patients treated with radical radiotherapy on the question about hoarseness. No other significant difference was found for the QOL functions and symptoms. CONCLUSION: When patients treated with radiotherapy were compared with patients treated with laryngectomy as salvage surgery, QOL was similar, only small differences being found in the perceptual speech evaluation.

Intelligibility and perceptual ratings after treatment for laryngeal cancer: laryngectomy versus radiotherapy.

In Sweden the most common treatment for T3-T4 laryngeal carcinoma is radical radiotherapy (with surgery for salvage), because the voice is thus preserved. A Swedish study showed that surgery yielded a significantly better 5-year survival and locoregional control at 3 years in T4 laryngeal carcinoma than radical radiotherapy. With these results in mind, we wanted to compare the different modes of treatment (surgery with a tracheoesophageal [TE] fistula and radical radiotherapy) with respect to the patients' speech proficiency. Twenty-eight subjects (with 14 patients in each treatment group) were judged by inexperienced and experienced listeners according to intelligibility by transcription and three perceptual ratings. From the perceptual ratings of speech intelligibility, voice quality, and speech acceptability we conclude that there is a significant difference, the irradiated speakers being rated higher than the tracheoesophageal speakers. It is also clear that most of the TE and irradiated laryngeal speaking patients are comparable to normal laryngeal speakers in intelligibility by transcription. Experienced and inexperienced listeners are able to rate TE and irradiated laryngeal speech reliably and similarly according to intelligibility by transcription. The inexperienced listeners rated the TE speakers significantly higher than did the experienced listeners.

Advanced laryngeal cancer T3-T4 in Sweden: a retrospective study 1986-1990. Survival and locoregional control related to treatment.

Different treatment modalities for advanced laryngeal cancer are much discussed in the literature. One-hundred-and-sixty patients with T3-4, N0-3, M0-1 laryngeal cancer diagnosed in Sweden between 1986 and 1990 were retrospectively analysed. One hundred (65 T3: 35 T4) received radical radiotherapy with salvage surgery (RRSS) in case of residual or recurrent disease. Thirty-eight (11T3: 27 T4) patients received surgery with or without radiotherapy (S +/- RT). Twenty-two patients received no treatment. After a median follow up of 4.4 years, the estimated 5-year actuarial corrected survival and 3-year locoregional control were 59% and 44% for T3 RRSS and 47% and 54% for T3 S +/- RT. No significant difference between the different treatment modalities was found. The 5-year corrected survival rate and the locoregional control at 3 years between T4-RRSS (32%; 26%) and T4-S + RT (58%; 68%) groups were significantly different (p < 0.05 and p < 0.01). This might suggest that surgery with or without radiotherapy still has its place as a treatment modality for patients with advanced T4 laryngeal carcinoma.