Use of THRIVE for Apneic Oxygenation in Transoral Laser Microlaryngeal Surgery: A Scoping Review.

OBJECTIVES: Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted. DATA SOURCES AND REVIEW METHODS: A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023. RESULTS: From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS. CONCLUSION: THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 2024.

Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) and its Utility in Otolaryngology, Head and Neck Surgery: A Literature Review.

High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.

Management of Parastomal Recurrence Following Total Laryngectomy.

Parastomal recurrence occurs in around 5% of patients undergoing total laryngectomy for laryngeal squamous cell carcinoma. It carries a poor prognosis which has changed little over the last 50 years, and poses a significant challenge to the head and neck surgeon. At present, surgical excision offers the only realistic chance of cure, although patients must be selected carefully following thorough work-up and in-depth multidisciplinary team discussion. This article provides a review of the literature on the management of parastomal recurrence following total laryngectomy.

Pathologically Negative Excision for Biopsy-Proven Early Glottic Carcinoma.

In certain instances, patients who underwent endoscopic laser excision (ELE) for biopsy-proven early glottic carcinoma do not show any evidence of carcinomatous cells on histopathologic analysis. Our study aims to determine the incidence of this phenomenon. A retrospective analysis of patients with biopsy-proven early glottic squamous cell carcinoma who underwent ELE was conducted. 121 patients with a mean age of 68.2 ± 10.7 were included in this study. Initial biopsy showed carcinoma in situ in 38 patients, (31.4%), T1a in 41 patients (33.9%), and T1b in 42 patients (34.7%). Following ELE, a pathologically negative excision was seen in 26 patients (21.5%). Disease recurrence occurred in 3 patients who had a pathologically negative excision (11.5%). Following repeat ELE, all patients remained disease free. A significant number of early glottic carcinoma present with small volume disease which may be eradicated with diagnostic biopsy alone.

Treatment of Early Glottic cancer with Transoral Laser Microsurgery: An Australian Experience.

Introduction: Early laryngeal carcinomas may be treated by transoral laser microsurgery (TLM) or external beam radiotherapy. We review our experience of surgical treatment of laryngeal pre-malignant and malignant lesions over the past 15 years in a high-volume head neck unit. Methods: A review of a prospective patient database of patients with laryngeal SCC, who were treated with CO2 TLM between 2004 and 2019 was carried out. Results: 83 patients with a mean age of 67.7 (SD: 10.6) years underwent primary curative TLM for T1a/b SCC. 5-year overall survival was 93.2% (95%CI 86.9-100%), disease free survival was 86.0% (95%CI 78.1-94.6%), locoregional control was 91.2% (95%CI: 85.1-97.7%) and larynx preservation rate of 95.1% at 5 years. Conclusion: TLM is an excellent treatment modality for T1 early glottic SCC, with excellent locoregional control and disease-free survival. It is minimally invasive, outpatient-based, and cost-effective procedure preserving upper aerodigestive tract dysfunction for all activities of daily living.

Smell-related quality of life changes after total laryngectomy: a multi-centre study.

PURPOSE: A total laryngectomy creates an alternate airway for gas exchange that bypasses the upper aerodigestive tract. The subsequent reduction in nasal airflow, and therefore, reduction in deposition of particles to the olfactory neuroepithelium leads to hyposmia or anosmia. The aim of this study was to assess the quality of life impairment conferred by anosmia following laryngectomy and identify any specific patient-related risk factors that are associated with poorer outcomes. METHODS: Consecutive patients with a total laryngectomy presenting for review at three tertiary head and neck services (in Australia, the United Kingdom and India) over a 12-month period were recruited. Patient demographic and clinical data were collected, and each subject completed the validated assessment of self-reported olfactory functioning and olfaction-related quality of life questionnaire (ASOF). Dichotomous comparisons were performed using the student's unpaired t-test for continuous variables (SRP), a chi-squared test for categorical variables, and a Kendall's tau-b for ordinal variables (SOC) to assess for a correlation with poorer questionnaire scores. RESULTS: A total of 66 laryngectomees (13.4% female; age 65.7 ± 8.6 years) were included in the study. The mean SRP score of the cohort was found to be 15.6 ± 7.4, while the mean ORQ score was noted to be 16.4 ± 8.1. No other specific risk factors associated with poorer quality of life were identified. CONCLUSION: A significant quality of life detriment from hyposmia is conferred following laryngectomy. Further research to assess treatment options and the patient population that would best benefit from these interventions is required.

Remote Access Thyroid Surgery: A Review of Literature.

Since the first description of endoscopic thyroid lobectomy in 1997, a variety of techniques have been developed to avoid the visible cervical scar conventionally been associated with thyroidectomy. These "remote access" approaches, which typically use either endoscopic or robotic instrumentation, have successfully avoided the anterior neck scar, which has a measurable impact on the patient's quality of life (Graves and Suh Surgery 168(5):845-850, 2020; Sakorafas World J Surg 34(8):1793-1804, 2010). The main advantage of these techniques is better cosmesis compared to conventional transcervical approaches (Graves and Suh Surgery 168(5):845-850, 2020) However, these techniques have failed to gain widespread acceptance in the surgical community because of the technical challenges, scepticism about oncological safety and cost factors. This review presents an overview of the various methods of remote access thyroid surgery (RATS) and also evaluates the selection criteria, oncological efficacy, training requirements and key advantages of this technique.

Transoral Laryngeal Surgery in Low-grade Myofibroblastic Sarcoma of Larynx: A Plausible Treatment Option.

The laryngeal tumor type, location and disease extent are essential determinants in deciding the type of surgery and the potential voice and swallowing outcomes. The surgical options available are conservative laryngeal surgeries like transoral laser microsurgery (TLM) or open conservative laryngeal surgery and Total laryngectomy. We report an unusual case of low-grade Myofibroblastic sarcoma of vocal cord which was managed by TLM.

Outcomes of Re-exploration Procedures After Head and Neck Free Flap Reconstruction.

This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.

Role of Adjuvant Radiotherapy in Early Stage Tongue Cancer: Need for Establishing Stringent Guidelines.

The primary objective of this study was to determine, using population-based data, whether the addition of postoperative radiotherapy (RT) provides an overall survival benefit in patients with early primary squamous cell carcinoma (SCC) of tongue. The study included the data of tongue cancer patients treated between January 2016 and July 2019 retrieved from our hospital database. Tumours limited to pathologic T1 and T2 category managed with primary surgery with or without postoperative external beam RT were included. Overall survival (OS) and disease-free survival (DFS) were the main outcomes of interest. A total of 211 cases of oral cancer were evaluated and all the patients had clear surgical and pathological margins. Postoperative adjuvant therapy (PORT) was received by 16 patients. Comparison of DFS and OS at 2-year follow-up depicted a similar outcome (p = 0.582 and p = 0.312 respectively). Findings from our study suggest that in the absence of any absolute advantage on quantifiable survival and disease control, it is necessary to define stringent criteria when advocating PORT in early tongue cancer.

Economic evaluations comparing Tran-oral robotic surgery and radiotherapy in oropharyngeal squamous cell carcinoma: A systematic review.

BACKGROUND: Trans-oral robotic surgery (TORS) and primary radiotherapy are the two modalities used to treat early T stage oropharyngeal squamous cell carcinoma(OPSCC). Prior literature including a recent randomized controlled trial have not shown the superiority of one modality over the other. When the modalities have similar outcomes, cost-effectiveness have an important role in deciding on the appropriate treatment. There are economic evaluations comparing the two modality with contradicting conclusions. The purpose of this review is to synthesise the evidence. METHODS: This is a systematic review of economic evaluations on the treatment modalities for OPSCC, namely TORS versus radiotherapy. The main outcome measures were the Cost-utility results reported as the effectiveness and costs separately and as part of the Incremental Cost-Effectiveness Ratio. RESULTS: Literature search identified five articles reporting cost-utility analysis, eligible for the review. A strategy is considered to be dominant when the effectiveness achieved was more at a lower cost, compared to the comparator. At the willingness to pay (WTP) threshold of 50,000 to 100,000 USD per Quality Adjusted Life-Year (QALY), three studies showed dominance of strategies in the base case analysis (TORS in two and Primary Chemoradiotherapy in one). Two of the articles studied node negative patients, one of them favored TORS. Three articles had node positive patients and two of them favored TORS and one favored chemoradiotherapy in the base case analysis. On sensitivity analysis, adjuvant treatment was found to be the detrimental factor affecting the cost-effectiveness. CONCLUSIONS: TORS can be considered a cost-effective strategy in early T stage OPSCC, if the addition of adjuvant therapy involving radiotherapy can be avoided. Literature have shown that around 70% of the early cancers would require adjuvant treatment. This implies the importance of case selection while considering TORS as the initial treatment modality.

Prognostic Significance of Vocal Cord Mobility after Laryngeal Preservation Protocols in Locally Advanced Laryngopharyngeal Cancers: A Retrospective Analysis.

In the present study, we look at the prognostic implications of the recovery of vocal cord mobility after treatment in T3 laryngeal and hypopharyngeal cancers with fixed vocal cords. Patients with T3 laryngeal and hypopharyngeal carcinoma were considered for the study. All patients were treated with standard laryngeal preservation protocols as per treatment guidelines. Recovery of vocal cord functions was assessed with serial flexible laryngoscopic evaluation. Recovery of vocal cord mobility was compared with oncological outcomes. Twenty seven patients were available for final analysis. Cases, where vocal cords remained fixed or continued to have restricted mobility on follow up, were categorised as "unfavourable" and those with complete recovery of function as compared to pre treatment FOL as "Favourable". Thirteen (48%) patients did not regain complete mobility of vocal cords. Six patients from the 'unfavourable' group (46%) developed recurrence, whereas only one patient from the 'favourable' group (7%) had a recurrence (p = 0.03). The findings of the present study suggest that failure to regain complete vocal cord mobility after CTRT is a poor prognostic factor in T3 laryngeal and hypopharyngeal cancers.

Selective embolization of lingual artery in transoral robotic surgery for the management of recurrent base of tongue carcinomas.

BACKGROUND: The incidence of oropharyngeal carcinoma has been on the rise in recent decades. About 30% of patients who undergo definitive chemoradiation as the initial treatment present with residual/recurrent disease. In such a situation, surgical salvage either in the form of traditional open surgery or transoral robotic surgery (TORS) remains a viable treatment option. However, the extensive vascular supply of the posterior tongue and tonsillar bed increases the risk of perioperative bleeding, which is a key concern. The article describes the technique of selective pre-operative embolization to reduce the risk of perioperative bleeding and enumerate its advantages in providing a bloodless field during surgery. METHODS: Prospective study of 5 patients with recurrent or residual midline BOT tumours who underwent TORS after selective lingual artery embolization at our centre. RESULTS AND CONCLUSIONS: None of the patients had any major perioperative bleeding or post procedural complications. All the patients after TORS had their tongue vascularity preserved with adequate recovery of tongue functions. Selective embolization of the feeder vessels provides a favorable bloodless surgical field without affecting the vascular integrity of the remnant tongue. This added advantage helps restoring the normal oral phase of swallowing.

Circulating tumour cells in head and neck cancers: Biological insights.

Tumour metastasis is one of the leading cause of cancer-related mortality. Circulating tumour cells (CTCs) have been implicated in loco-regional and distant metastasis and its role is being extensively studied in various malignancies, including those from the head and neck region. The main challenge in understanding their significance lies in the rarity of these cells in the blood. However, newer technologies have attempted to overcome these pitfalls. This review explores the evolution of CTC research and other related areas, including its biological significance, sustainability within the circulating vascular environment and possible clinical implications.