Prophylactic Swallowing Therapy During Head-and-Neck Cancer Radiotherapy: Effect of Service-Delivery Mode and Overall Adherence Level on Swallowing Function and Muscle Strength-the PRESTO Trial.

Prophylactic swallowing exercises (PSE) during head-and-neck cancer (HNC) (chemo)radiotherapy (CRT) have a positive effect on swallowing function and muscle strength. Adherence rates to PSE are, however, moderate to low, undermining these effects. PRESTO already showed that the service-delivery mode (SDM), the way the exercises are offered, can influence adherence. The aim of this study was to investigate the effect of SDM on swallowing function and muscle strength during and post-CRT. In addition, the effect of overall adherence (OA), independent of SDM, was also investigated. A total of 148 HNC patients, treated with CRT, were randomly assigned to one of the three SDM's (paper-supported, app-supported, or therapist-supported PSE) and performed a 4-week PSE program. OA was calculated based on the percentage of completed exercises. Patients were divided into OA levels: the OA75+ and OA75- group performed respectively ≥ 75 and < 75% of the exercises. Swallowing function based on Mann Assessment of Swallowing Ability-Cancer (MASA-C), tongue and suprahyoid muscle strength during and up to 3 months after CRT were compared between the SDM's and OA levels. Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction was used. No significant differences were found between the three SDMs. Significant time effects were found: MASA-C scores decreased and muscle strength increased significantly during CRT. By the end of CRT, the OA75+ showed significantly better swallowing function compared to OA75-. Muscle strength gain was significantly higher in the OA75+ group. SDM had no impact on swallowing function and muscle strength; however, significant effects were shown for OA level. Performing a high level of exercise repetitions is essential to benefit from PSE.Trial registration ISRCTN, ISRCTN98243550. Registered December 21, 2018-retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search.

Preoperative imaging for hyperparathyroidism often takes upper parathyroid adenomas for lower adenomas.

We retrospectively evaluated how accurately preoperative imaging localizes parathyroid adenoma in superior versus inferior parathyroids. Over 6 years, 104 patients with primary hyperparathyroidism underwent parathyroid surgery in a single centre. Of these, 103 underwent ultrasound, 97 [99mTc]pertechnetate/MIBI SPECT/CT and 30 [18F]fluorocholine (FCH) PET/CT. One patient with a unilateral double adenoma was excluded from the analysis. Surgical findings with histopathologic confirmation of adenoma were used as the standard. Ultrasound misjudged 5 of 48 detected lower adenomas as upper, but 14 of 29 upper adenomas as lower (error rate 10 vs 48%, p = 0.0002). The corresponding error rates for [99mTc]pertechnetate/MIBI SPECT/CT were 3 versus 55% (p = 0.000014), and for [18F]FCH PET/CT 17 versus 36% (p = 0.26). Our results suggest that about half of the superior parathyroid adenomas which are detected, are erroneously assigned to the inferior position by both ultrasound and SPECT/CT imaging whereas the opposite mistake is significantly less frequent with ultrasound and SPECT/CT.

Increasing Adherence to Prophylactic Swallowing Exercises During Head and Neck Radiotherapy: The Multicenter, Randomized Controlled PRESTO-Trial.

BACKGROUND: Prophylactic swallowing exercises (PSE) during radiotherapy can significantly reduce dysphagia after radiotherapy in head and neck cancer (HNC). However, its positive effects are hampered by low adherence rates during the burdensome therapy period. Hence, the main goal of this multicenter randomized controlled trial (RCT) was to investigate the effect of 3 different service-delivery modes on actual patients' adherence. METHODS: A total of 148 oropharyngeal cancer patients treated with primary (chemo)radiotherapy were randomly assigned to a 4 weeks PSE program, either diary-supported (paper group; n = 49), app-supported (app group; n = 49) or therapist-supported (therapist group; n = 50). Participants practiced 5 days/week, daily alternating tongue strengthening exercises with chin tuck against resistance exercises. Adherence was measured as the percentage of completed exercise repetitions per week (%reps). Statistical analysis was performed by means of SPSSv27, using Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction. RESULTS: Adherence and evolution of adherence over time was significantly different between the three groups (p < .001). Adherence rates decreased in all three groups during the 4 training weeks (p < .001). During all 4 weeks, the therapist group achieved the highest adherence rates, whilst the app group showed the lowest adherence rates. CONCLUSIONS: PSE adherence decreased during the first 4 radiotherapy weeks regardless of group, but with a significant difference between groups. The therapist group achieved the highest adherence rates with a rather limited decline, therefore, increasing the face-to-face contact with a speech-language therapist can overcome the well-known problem of low adherence to PSE in this population. TRIAL REGISTRATION: Trial registration: ISRCTN, ISRCTN98243550. Registered December 21, 2018 - retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search .

Oncologic Outcomes After Salvage Laryngectomy for Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study.

OBJECTIVE: We aimed to analyze oncologic outcomes and identify patterns of failure and negative prognostic factors in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx. METHODS: This was a retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018 for residual/recurrent/second primary SCC in the larynx or hypopharynx after initial (chemo)radiation. Prognostic factors for oncologic outcomes were identified using univariable and multivariable analysis. RESULTS: A total of 405 patients were included in the final analysis. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and locoregional relapse-free survival (LRFS) estimates were 47.7% (95% confidence interval [CI] 42.0-53.2%), 68.7% (95% CI 63.7-73.7%), 42.1% (95% CI 36.7-47.4%), and 44.3% (95% CI 38.8-49.7%), respectively. In a multivariable model, increasing clinical tumor stage of the residual/recurrent/second primary tumor, increasing number of metastatic cervical lymph nodes retrieved during neck dissection, hypopharyngeal and supraglottic tumor location, positive section margin status and perineural invasion were independent negative prognostic variables for OS, DSS, DFS, and LRFS. The type of second tumor was identified as an additional independent prognosticator for DSS, with local recurrences and second primary tumors having a better prognosis than residual tumor. CONCLUSIONS AND RELEVANCE: Favorable oncologic outcomes are reported after STL. Increasing clinical tumor stage, increasing number of metastatic cervical lymph nodes, hypopharyngeal and supraglottic tumor location, positive section margins, and perineural invasion are identified as independent negative prognosticators for all oncologic outcome measures.

Functional Outcomes and Complications After Salvage Total Laryngectomy for Residual, Recurrent, and Second Primary Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study.

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation. Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis. Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins. Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL.

Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).

BACKGROUND: Dysphagia is a common and serious complication after (chemo)radiotherapy (CRT) for head-and-neck cancer (HNC) patients. Prophylactic swallowing exercises (PSE) can have a significantly positive effect on post-treatment swallowing function. However, low adherence rates are a key issue in undermining this positive effect. This current randomized trial will investigate the effect of adherence-improving measures on patients' swallowing function, adherence and quality of life (QOL). METHODS: This ongoing trial will explore the difference in adherence and swallowing-related outcome variables during and after PSE in HNC patients performing the same therapy schedule, receiving different delivery methods. One hundred and fifty patients treated in various hospitals will be divided into three groups. Group 1 performs PSE at home, group 2 practices at home with continuous counseling through an app and group 3 receives face-to-face therapy by a speech and language pathologist. The exercises consist of tongue-strengthening exercises and chin-tuck against resistance with effortful swallow. The Iowa Oral Performance Instrument and the Swallowing Exercise Aid are used for practicing. Patients are evaluated before, during and after treatment by means of strength measurements, swallowing and QOL questionnaires. DISCUSSION: Since low adherence rates undermine the positive impact of PSE on post-treatment swallowing function, there is need to develop an efficient PSE protocol maximizing adherence rates. TRIAL REGISTRATION: ISRCTN, ID: ISRCTN98243550. Registered retrospectively on 21 December 2018.

Transoral Robotic Surgery for Obstructive Sleep Apnoea-Hypopnoea Syndrome.

Obstructive sleep apnoea-hypopnoea (OSAH) syndrome constitutes a major health care problem. Surgical modalities for the treatment of OSAH are regaining momentum in view of the increasing prevalence of OSAH and the low compliance rates associated with continuous positive airway pressure. There are several investigations to complement clinical examination in accurately determining the level of airway collapse to ensure correct patient selection and a targeted surgical approach. The most commonly employed include drug-induced sleep endoscopy and imaging with the tongue base and epiglottis often revealed as the major sites of airway narrowing during sleep. In the continuing search for the optimal approach to address these areas, transoral robotic surgery (TORS) has been successfully used for tongue base reduction and epiglottoplasty. With sufficient experience, this technique is safe and well tolerated. Meticulous work-up and careful patient selection are crucial. Multiple studies have demonstrated very good short-term results of TORS for OSAH, with significant reduction in both the Apnoea-Hypopnea Index (AHI) and Epworth Sleepiness Score (ESS). With the appropriate infrastructure, proctoring, and access to robotic surgical technology, it is possible for these results to be reproduced more widely. Further prospective long-term clinical evaluation will ultimately determine the exact role of TORS in the treatment of OSAH.

Up-front and Salvage Transoral Robotic Surgery for Head and Neck Cancer: A Belgian Multicenter Retrospective Case Series.

INTRODUCTION/AIM: We analyzed the functional and oncologic outcomes of primary and salvage transoral robotic surgery (TORS) procedures, performed in three Belgian institutions with a similar philosophy. PATIENTS AND METHODS: A total of 86 patients who underwent TORS between 24-12-2009 and 25-09-2015 were retrospectively reviewed. Descriptive statistics, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS; Kaplan-Meier), and the variation of these outcomes according to whether patients had primary or salvage TORS were evaluated (univariate log-rank analysis). RESULTS: Of 86 patients, 56 (65.1%) underwent TORS as a primary treatment and 30 (34.9%) as a salvage procedure for recurrent or second primary cancer. Tumor location was mainly oropharynx (N = 63; 73.3%) followed by supraglottic larynx (N = 11; 12.8%), hypopharynx (N = 11; 12.8%), and glottic larynx (N = 1; 1.2%). In the up-front TORS group, most tumors were classified as cT1 (N = 23; 41.1%)/pT1 (N = 24; 42.9%) or cT2 (N = 27; 48.2%)/pT2 (N = 27; 48.2%) and cN0 (N = 18; 32.1%), cN1 (N = 13; 23.2%), or cN2 (N = 25; 44.6%). In the salvage TORS group, most tumors were cT1-rT1 (N = 18; 60.0%)/pT1-rpT1 (N = 18; 60.0%) or cT2-rT2 (N = 12; 40.0%)/pT2-rpT2 (N = 7; 23.3%) and cN0 (N = 25; 83.3%). Neck dissection was performed in 87.5% of primary cases and 30.0% of salvage cases. In the up-front TORS group, patients were postoperatively submitted to follow-up (N = 13; 23.2%) or received adjuvant radiotherapy, either as single modality (N = 26; 46.4%) or with concomitant cisplatin (N = 15; 26.8%). On the other hand, most salvage TORS patients did not receive any adjuvant therapy (N = 19; 63.3%). Mean and median follow-up was 23.1 and 21.2 months, respectively. Functional results were excellent (no definitive tracheostomy, long-term tube feeding in 1.8% of primary cases, and 20% of salvage cases). In the up-front TORS group, estimated 2-year OS was 88.5% (SE = 5.0%), 2-year DSS was 91.8% (SE = 4.6%) and 2-year DFS was 86.1% (SE = 5.3%). In the salvage TORS group, estimated 2-year OS was 73.5% (SE = 10.9%), 2-year DSS was 93.3% (SE = 6.4%), and 2-year DFS was 75.8% (SE = 9.7%). Comparing outcome of primarily treated patients to salvage patients, a non-statistically significant trend toward better OS (p = 0.262) and DFS (p = 0.139) was observed. CONCLUSION: This retrospective study confirms favorable oncologic and functional outcomes of TORS for selected head and neck malignancies, both in the primary and in the salvage setting.

Long-term results of a modified expansion sphincter pharyngoplasty for sleep-disordered breathing.

Our aim was to evaluate the long-term objective and subjective results of a modified expansion sphincter pharyngoplasty (ESP) technique in patients with sleep-disordered breathing. Single center prospective study of 35 patients underwent an ESP as a primary surgical treatment between June 2012 and September 2015 at the hospital AZ Sint-Jan Bruges-Ostend. Patients were divided into non-OSAS and OSAS (AHI >5). Primary outcome parameters were the Epworth Sleeping Scale (ESS, reduction and score less then 10) and the Visual Analogue Score of snoring (VAS, assessed by partner) evaluated at 3 months and 1 year. In addition, the OSAS group underwent a polysomnography after 6 months to calculate the Apneu-Hypopneu Index (AHI) change. Secondary outcome parameters were possible complications and morbidity rate. The overall Epworth Sleepiness Scale showed a steady total reduction of, respectively, 42 and 48% at the two timepoints. All patients had a post-operative score of less than ten points. The Visual Analogue Score improved in 92% of the patients; of these, the snoring was reduced in 86% and disappeared in 6%. In the OSAS group, we noticed a reduction in AHI of more than 50 in 53% of the patients. A considerable reduction was found in the severe OSAS group, where we found a mean pre-operative average AHI of 41.3/h that was reduced 6 months after the operation to 17.4/h. There were no severe complications or increased morbidity rate observed. This first long-term study shows that the modified ESP seems to be a safe and promising technique in palatal surgery for patients with sleep-disordered breathing. Surgical effectiveness is sustained after 1 year, both in OSAS as in snoring pathology. The technique seems as approachable for the basic ENT surgeon as the uvulopalatopharynoplasty.

The importance of local eosinophilia in the surgical outcome of chronic rhinosinusitis: a 3-year prospective observational study.

BACKGROUND: Patients with chronic rhinosinusitis with/without nasal polyps (CRSwNP/CRSsNP) benefit from endoscopic sinus surgery (ESS), with an estimated success rate of 80%. At present, the influence on clinical outcome after ESS of eosinophils, eosinophilic mucin (EM), and fungal hyphae (FH) in secretions remains unclear. By delineating CRS groups and subgroups based on the finding of eosinophils, EM, and FH, differences in recurrence after ESS were investigated. METHODS: A prospective monocenter study including 221 CRS patients who were unresponsive to medical treatment and underwent ESS was performed. All tissue and sinonasal secretions were microscopically examined for the presence of eosinophils, EM, and FH. Patients were followed for 3 years after surgery. Recurrence was defined according to the European position paper on rhinosinusitis and nasal polyps. RESULTS: In total, 96 CRSwNP and 125 CRSsNP patients were included. Tissue eosinophils were found in 78% of CRSwNP patients compared with 42% in CRSsNP patients. EM was observed in 52% of the CRSwNP group versus 20% of the CRSsNP group. Furthermore, secretion analysis revealed FH in 7% of CRS. Recurrence in the total group was 22% over 3 years. CRSwNP patients with tissue eosinophilic involvement showed a recurrence rate of 48%, and those with additional EM showed recurrence in 56%. CONCLUSION: The presence of eosinophils in tissue or airway secretions greatly increases the risk of recurrent disease in CRSwNP patients. The finding of tissue eosinophilia and EM provides valuable information regarding the increased likelihood of CRS recurrence after ESS, whereas the finding of FH does not.

Spectral, cepstral, and multivariate exploration of tracheoesophageal voice quality in continuous speech and sustained vowels.

OBJECTIVES/HYPOTHESIS: The quality of tracheoesophageal voice can vary substantially. Although previous research has identified acoustic differences between various types of voicing (i.e., laryngeal, tracheoesophageal, esophageal, etc.), acoustic analysis has failed to quantify the degree of alaryngeal voice quality. This study assessed the value of several cepstral, spectral, and perturbation measures in quantifying the overall quality of tracheoesophageal voice production. STUDY DESIGN: Cross-sectional, correlational. METHODS: Continuous speech and sustained vowel samples from 16 tracheoesophageal speakers were concatenated and perceptually rated in a paired comparison paradigm on overall voice quality by four experienced clinicians. After removing the nonvoiced fragments within the continuous speech samples, the concatenated samples were analyzed with 47 perturbation, spectral, and cepstral measures. Correlation between perceptual ratings and acoustic measures was assessed. Multiple regression analysis resulted in a two-factor acoustic model for the measurement of overall voice quality of the concatenated samples. RESULTS: The reliability of the perceptual judgements was moderate to high. The prominence of the cepstral peak (CPP) and of the first two spectral harmonics appeared to be the strongest correlates of tracheoesophageal voice quality. A linear regression-based combination of CPP and the height of the second harmonic produced a correlation of 0.87 with listener judgments. CONCLUSIONS: It is clinically feasible to investigate both continuous speech and sustained vowel samples of tracheoesophageal speakers with acoustic methods described and assessed in this report. Results are discussed in the context of existing literature.

Prognostic index for patients with parotid carcinoma: international external validation in a Belgian-German database.

BACKGROUND: Prognostic indices for recurrence-free interval in patients with parotid carcinoma were developed and validated in a nationwide database. International validation would increase generalizability. METHODS: In a Belgian-German database that contained 237 consecutive patients with parotid carcinoma, a pretreatment prognostic index (PS1) and a post-treatment prognostic index (PS2) were validated by calculating both indices for each patient, comparing coefficients, constructing survival curves, calculating the concordance measure C, and performing Wald tests for scale and weight optimization of included variables and for the possible inclusion of new variables. RESULTS: Sixty-nine percent of patients (standard error, 5%) were disease free at 5 years. The defined cutoff points for PS1 resulted in 5-year disease-free rates from 94% (PS1 = 1) to 42% (PS1 = 4), and the cutoff points for PS2 resulted in 5-year disease-free rates from 93% (PS2 = 1) to 40% (PS2 = 4). Concordance measure C was good with 0.74 for both PS1 and PS2. Neither index could be improved statistically using this international database. There was some evidence that additional inclusion of the variable 'number of positive lymph nodes in the neck dissection specimen' could enhance the prognostic power of PS2. CONCLUSIONS: The prognostic indices performed adequately in this validation sample. Prospective generalized use seems to be well supported.

Long term effects of cutting forceps in endoscopic sinus surgery.

BACKGROUND: At present, some authors prefer cutting forceps to conventional non-cutting forceps in Endoscopic Sinus Surgery, based on the assumption of superior wound healing due to mucosal preservation, without any proof of better clinical outcome. The purpose of this study was to elaborate our previously reported short-term results, by evaluating the long-term outcome. METHODS: One hundred consecutive patients, who underwent a bilateral Endoscopic Sinus Surgery procedure, received follow-up in a prospective, double-blinded way. Cutting forceps had been randomly used on one side and non-cutting forceps on the other side. Lateralised symptoms (headache, maxillary pressure, nasal obstruction and secretions) and endoscopic findings (secretion, pus, blood, crusts, oedema, polyps and adhesions) were evaluated on both sides 1 year postoperatively. RESULTS: Both types of instruments gave satisfactory healing situations. Similar to the short-term follow-up results, no significant difference in the global symptom and endoscopic score between the 2 types of instruments was found. The analysis of individual symptoms and endoscopic parameters also showed no difference. CONCLUSION: Cutting forceps do not result in a better subjective or endoscopic healing evaluation after one year, compared to non-cutting forceps.

Patterns of lymph node spread of cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: Among patients with cutaneous squamous cell carcinoma (SCC) of the head and neck, recent studies have shown that those with involvement of the parotid gland also have a high incidence of neck node involvement. Treatment of the neck by either surgery or radiotherapy is therefore recommended among patients with parotid SCC, even if clinical examination is negative. The aim of this study was first to analyze patterns of metastatic spread in the parotid and cervical lymph nodes and then to correlate the pattern of involved nodes with the primary cutaneous site in order to guide the appropriate extent of surgery, should neck dissection be used to treat the neck in patients with parotid SCC. METHODS: A cohort of 209 patients with cutaneous SCC of the head and neck and clinically evident regional metastatic disease was reviewed retrospectively from 3 Australian institutions. The distribution of involved nodes was obtained from pathology reports; the anatomic sites of primary cutaneous cancers were then correlated with these findings. RESULTS: Among 209 patients, 171 (82%) had clinical parotid involvement. Of these, 28 had clinical neck disease, whereas 143 had parotid disease alone. Thirty-eight (18%) patients had neck disease only. A total of 199 patients were treated surgically, whereas 10 received radiotherapy alone. Surgery included 172 parotidectomies and 151 neck dissections (93 of which were elective). Primary sites were cheek (21.7%), pinna (20.4%), temple (15.8%), forehead (15.8%), postauricular region (5.9%), neck (5.3%), anterior scalp (5.3%), posterior scalp (3.3%), periorbital (3.3%), nose (2.6%), and chin (0.6%). Among pathologically positive necks, level II was most frequently involved (79%). Level IV (13%) and level V (17%) were only involved in extensive lymph node disease, the exception being for isolated level V metastases from the posterior scalp. CONCLUSIONS: Primary sites were mainly localized to the lateral aspect of the head. Among patients with cutaneous SCC involving the parotid and neck, level II was the most commonly involved neck level. The distribution of involved nodes suggests that in a patient with parotid involvement and a clinically negative neck with an anterolateral primary, a supraomohyoid neck dissection, always including the external jugular lymph node(s) would be appropriate. In the case of a posterior primary, level V should be dissected as well. In patients with parotid SCC and a clinically positive neck, a comprehensive neck dissection is recommended.