Primary Total Laryngectomy for Endolaryngeal cT3-4M0 Squamous Cell Carcinoma: A STROBE Analysis.

OBJECTIVES: To document 10-year oncologic outcome of primary total laryngectomy (TL) for patients with cT3-4M0 endolaryngeal squamous cell carcinoma (SCC). STUDY DESIGN: Observational inception cohort of 531 patients with isolated untreated endolaryngeal cT3-4M0 SCC review over 40 years using STROBE guideline. 94% of patients were followed until death or for a minimum of 10 years. SETTING: Academic tertiary referral care center. METHODS: All patients underwent primary TL. Prior tracheotomy, induction chemotherapy, thyroid gland resection, level II-IV neck dissection, level VI dissection, and postoperative radiation therapy were associated in 6%, 40%, 43%, 89%, 47%, and 74% of cases, respectively: The main objective was to determine the 10-year actuarial local control estimate. Accessory objectives comprised screening for clinical variables increasing the risk of local recurrence, and analysis of long-term oncologic consequences of local recurrence. RESULTS: The 10-year actuarial local control estimate was 89.7%. Local recurrence was salvaged in 11% of cases, resulting in 92% overall local control. On multivariate analysis, none of the study variables correlated with local recurrence. Local recurrence resulted in significantly reduced nodal control, distant metastasis control, and survival. Postoperative complications, persistent index SCC, intercurrent disease, and metachronous second primary cancer accounted for respectively 3%, 37%, 33%, and 28% of the 334 deaths noted during the 10 years following TL. CONCLUSION: The present study underscored the long-term oncologic efficacy of primary TL, the dangers of local recurrence, the key role of local control for survival, and the importance of a long-term oncologic watch policy. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2288-2294, 2024.

Characteristics, natural evolution and surgical treatment outcomes of unilateral laryngeal paralysis versus ankylosis: A longitudinal cohort study.

AIMS: Although unilateral laryngeal immobility (ULI) can results from paralysis or ankylosis of the cricoarytenoid joint, no comparative study exists to date. Aim of this study was to compare clinical features, aetiologies, spontaneous recovery and evolution after surgical treatment of ULI according to its mechanism. METHODOLOGY: Longitudinal observational cohort study between 1992 and 2017 in a tertiary care referral centre and university teaching hospital. All adult patients with isolated ULI were included. Presenting symptoms and demographic data were recorded at baseline. During follow-up, natural recovery and, if a surgical treatment was performed, treatment failure rate were noted. RESULTS: 994 patients were included, 56.4% of male and with a mean age of 58 years. Overall, 91% had paralysis and 9% had ankylosis. Dysphonia was the main symptom in both groups (>96%). Dyspnoea was more frequent in patients with ankylosis (26.1% vs 4.2% in those with paralysis) whereas dysphagia was more frequent in those with paralysis (31.1% vs 20% in those with ankylosis). With a mean follow-up of 2.3 years (±5.1), spontaneous recovery did not differ according to ULI's aetiology (hazard ratio 1.43, 95% confidence interval 0.85-2.40). Overall, 37.1% underwent a surgical treatment, and paralysis was associated with a lower odd of treatment failure (hazard ratio 0.27, 95% confidence interval 0.10-0.70) over a mean follow-up of 3.1 years (±4.1). CONCLUSION: ULI resulting from paralysis or ankylosis differ in their symptoms and responses to surgical treatment, whereas natural evolution was similar.

[Thyroid tumors in the adult revealed by unilateral laryngeal paralysis]. / Tumeurs thyroïdiennes de l'adulte révélées par une paralysie laryngée unilatérale.

GOAL: To analyze the characteristic of thyroid tumor associated with ipsilateral unilateral laryngeal paralysis (ULP) in the adult patient. MATERIALS AND METHODS: Retrospective analysis of a cohort of 30 patients with ULP related to an ipsilateral thyroid tumor (group A) and comparison with a cohort of 99 patients in whom ULP revealed a non-thyroid tumor (group B). RESULTS: Group A consisted of 66.6% of women with a mean age of 69 years. Comparison between both groups noted that female gender was more frequent in group A (66.6% vs. 17.1%, P<0.0001), and the underlying tumor was more frequently malignant in group B (89.9% vs. 43.4%, P<0.0001). Within group A, the incidence for recovery of laryngeal motion varied form 0% for malignant tumor to 50% for benign tumor. In patients with a benign thyroid tumor in whom recovery of laryngeal motion did not occur, the watch policy initiated allowed to detect a pathology (malignant tumor or neurological) explaining persistent ULP in 57% of cases. CONCLUSION: The present series confirm that ULP in the face of thyroid tumor does not allow to distinguish formally between benign and malignant tumors and highlight the value of a long term watch policy in patients with benign thyroid tumor pathology in whom recovery of laryngeal mobility does not occur.

Ten-year outcome of curative "exclusive" chemotherapy in N0M0 squamous cell carcinoma of the larynx and pharynx with complete clinical response.

BACKGROUND: The aim of our study was to document 10-year outcome after curative "exclusive" chemotherapy in N0M0 squamous cell carcinoma of the larynx and pharynx. METHODS: Retrospective nonrandomized analysis of an inception cohort of 191 patients. Platinum salt and 5-fluorouracil were used in all patients. RESULTS: The 3-, 5-, 10-year overall actuarial survival and local control estimates were 83.3%, 74.4%, and 55.4% and 62.1%, 62.1%, and 55.3%, respectively. Main causes of death were metachronous second primary cancer (n = 39) and intercurrent disease (n = 28). No clinical variables were associated with increased risk of local recurrence. Salvage treatment resulted in 94.7% ultimate local control and 88.4% organ preservation. "Exclusive" chemotherapy was considered "beneficial" in 62.3% and "detrimental" in 7.8% of cases. CONCLUSION: The high rate of local recurrence may be thought not to justify this treatment. Nevertheless, many patients avoided surgery and remained free of disease. Therefore, this approach deserves further study in the era of immune checkpoints inhibitors.

Mucocele development after endoscopic sinus surgery for nasal polyposis: A long-term analysis.

The aim of the present study was to determine the prevalence of long-term mucocele development after functional endoscopic sinus surgery (FESS) for nasal polyposis, to search for a statistical relationship with preoperative variables and to analyze the management of this complication. A retrospective analysis of 153 patients who underwent FESS for nasal polyposis, with a minimum of 7 years of follow-up, was performed. Mucocele diagnosis was based on regular clinical and radiologic evaluation. Univariate and multivariate statistical analysis was performed. The postoperative mucocele rate was 13.1% (20 patients). The mean delay between surgery and mucocele diagnosis was 6.25 years. A high preoperative Lund-Mackay score (>19) was a risk factor for postoperative mucocele (p = 0.04). Asthma and aspirin intolerance did not increase the risk of this complication. Endoscopic marsupialization of mucoceles was successful in 19 patients, with only one recurrent frontal mucocele. One patient required external approaches for two frontal mucoceles. In conclusion, mucocele risk after FESS for nasal polyposis is significant, especially in case of a high preoperative Lund-Mackay score (>19). Long-term clinical follow-up is recommended, imaging being prescribed based on symptoms or abnormal findings on clinical examination. Endoscopic marsupialization is very effective, but frontal mucoceles are more likely to recur.

Impact of previous head and neck cancer on postoperative complications after surgical resection for lung cancer: a case-control study.

BACKGROUND: Head and neck cancer (HNC) and lung cancer are often linked because of common risk factors. We aimed to assess the risk of postoperative complications in patients with previous HNC undergoing thoracic surgery for lung cancer. METHODS: Patients with previous HNC undergoing surgery for lung cancer were included in this retrospective, monocentric, case-control study. All patients were matched for age, sex, FEV1, smoking history, and year of surgery with lung cancer patients without previous HNC. Major postoperative complication was defined as at least one of the following during the first 30 days post lung resection (LR): death, shock, need for mechanical ventilation, and pneumonia. RESULTS: From January 2006 to May 2012, 65 patients with previous HNC underwent LR. Fifty-nine of these patients were included and matched with 120 control patients without HNC. Major complications occurred in 25 [42.4% (95% CI, 29.4-55.4%)] vs. 19 [15.8% (95% CI, 9.2-22.5%)] patients in the HNC and non-HNC groups, respectively (P<0.001). Among the complications, pneumonia occurred in 19 (32.2%) vs. 12 (10%) (P=0.01), and death occurred in 5 (8.5%) vs. 2 (1.7%) patients in the HNC and non-HNC groups, respectively (P=0.04). The following factors were identified by multivariate analysis to be independently associated with postoperative complications: previous HNC [odds ratio (OR) =4.24; (95% CI, 1.84-9.74)], male gender [OR =8.99; (95% CI, 1.05-76.78)], cumulative smoking [OR =1.02 per unit; (95% CI, 1.01-1.04)] and elevated Charlson score [OR =1.45; (95% CI, 1.07-1.96)]. CONCLUSIONS: Previous HNC is a major independent risk factor for serious postoperative complications after LR for lung cancer. Postoperative pneumonia (POP) is the most frequent complication.

Evaluation of the efficacy of the 4 tests (p16 immunochemistry, polymerase chain reaction, DNA, and RNA in situ hybridization) to evaluate a human papillomavirus infection in head and neck cancers: a cohort of 348 French squamous cell carcinomas.

It is now established that human papillomavirus (HPV) plays a role in the development of a subset of head and neck squamous cell carcinomas (SCCs), notably oropharyngeal (OP) SCCs. However, it is not clear which test one should use to detect HPV in OP and non-OP SCCs. In this study, using 348 head and neck SCCs (126 OP SCCs and 222 non-OP SCCs), we evaluated diagnostic performances of different HPV tests in OP and non-OP SCCs: polymerase chain reaction, p16 immunostaining, in situ hybridization targeting DNA (DNA-CISH) and RNA (RNA-CISH), combined p16 + DNA-CISH, and combined p16 + RNA-CISH. HPV DNA (polymerase chain reaction) was detected in 26% of all tumors (44% of OP SCCs and 17% of non-OP SCCs). For OP SCCs, RNA-CISH was the most sensitive stand-alone test (88%), but p16 + RNA-CISH was even more sensitive (95%). Specificities were the same for RNA-CISH and DNA-CISH (97%), but it was better for p16 + RNA-CISH (100%). For non-OP SCCs, all tests had sensitivities less than 50%, and RNA-CISH, DNA-CISH, and p16 + DNA-CISH had 100%, 97%, and 99% specificities, respectively. As a stand-alone test, RNA-CISH is the most performant assay to detect HPV in OP SCCs, and combined p16 + RNA-CISH test slightly improves its performances. However, RNA-CISH has the advantage of being one single test. Like p16 and DNA-CISH, RNA-CISH performances are poor in non-OP SCCs to detect HPV, and combining tests does not improve performances.

Postsurgical Disfigurement Influences Disgust Recognition: A Case-Control Study.

BACKGROUND: Little is known about how emotion recognition may be modified in individuals prone to elicit disgust. OBJECTIVE: We sought to determine if subjects with total laryngectomy would present a modified recognition of facial expressions of disgust. METHODS: A total of 29 patients presenting with a history of advanced-stage laryngeal cancer were recruited, 17 being surgically treated (total laryngectomy) and 12 treated with chemoradiation therapy only. Based on a validated set of images of facial expressions of fear, disgust, surprise, happiness, sadness and anger displayed by 6 actors, we presented participants with expressions of each emotion at 5 levels of increasing intensity and measured their ability to recognize these emotions. RESULTS: Participants with (vs without) laryngectomy showed a higher threshold for the recognition of disgust (3.2. vs 2.7 images needed before emotion recognition, p = 0.03) and a lower success rate of correct recognition (75.5% vs 88.9%, p = 0.03). CONCLUSION: Subjects presenting with an aesthetic impairment of the head and neck showed poorer performance in disgust recognition when compared with those without disfigurement. These findings might relate either to some perceptual adaptation, habituation phenomenon, or to some higher-level processes related to emotion regulation strategies.

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis.

OBJECTIVE: To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management. METHODS: Longitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed. RESULTS: The frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement. CONCLUSIONS: Our long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions.

Survival and laryngeal preservation tradeoff in advanced laryngeal cancer: From the otorhinolaryngology patient to the managing physician.

BACKGROUND: The purpose of this study was to document the tradeoff between survival and laryngeal preservation in advanced-stage laryngeal cancer amenable to chemoradiation or total laryngectomy. METHODS: We conducted a prospective analysis based on a questionnaire completed by 209 laryngeal cancer specialists and 269 volunteers from an otorhinolaryngology clinic. RESULTS: Of the responders, 34.5% would not consider any decrease in survival to preserve their larynx. This percentage varied from 52% in otorhinolaryngologists to 27.3% in radiotherapists and 28.6% in volunteers (P < .001). Among the responders prepared to trade, the percentage of survival they were willing to trade to preserve their larynx varied from 5% to 100% (median 30%). On univariate analysis, 3 variables significantly affected this percentage: (1) the living status (single or not); (2) the existence of children; and (3) the study group (volunteers, radiation therapists, or otorhinolaryngologists) to whom the responders belong. CONCLUSION: The significant variations noted should develop modes of practice that cater to this and stimulate further research in this field.

Sinonasal Inverted Papilloma: Risk Factors for Local Recurrence After Surgical Resection.

OBJECTIVES: Sinonasal inverted papillomas (SIP) present a potential for recurrence years after the surgery, but most studies report short-term follow-up, and risk factors for recurrence are still debated. Furthermore, several classifications are described, and no consensus exists regarding which one should be used. The aims of this study were to report our long-term results, investigate for potential risk factors for recurrence, and compare the existing 8 staging systems. METHODS: Over a 28-year period, 110 patients with a diagnosis of SIP were enrolled. The median follow-up time was 55.6 months. RESULTS: In multivariate Cox regression modeling, history of previous surgery was the only variable associated with recurrence (hazard ratio = 4.91, 95% CI, 1.80-13.39). Recurrences occurred up to 60 months after the surgery. Among the 8 staging systems, none proved to be associated with recurrence. CONCLUSION: The only factor associated with recurrence of SIP was prior surgery, probably corresponding to an incomplete initial resection. Due to late recurrences, an extended follow-up of at least 5 years is mandatory. In the absence of a classification predicting prognosis, Krouse's staging system should be used to homogenize studies' report since it is the most widely used.

Clar as Mud? Origins of the head mirror: A historical note.

In Europe, the name "Clar" immediately evokes to any otorhinolaryngologist the classic head mirror that remains a symbol of our profession. Yet, the origin of Clar has never been investigated. In this clinical and historical review, based on an Internet and PubMed database search together with perusal of Fischer's Biographical Lexikon, the authors seek to elucidate this medical enigma. The data presented suggest that Clar was not a physician but rather a term picked by the company that designed the mirror by the end of the 19th century to underscore the bright and sharp view provided by this then innovative medical device. © 2015 Wiley Periodicals, Inc. Head Neck 38: 930-932, 2016.

Salvage Conservation Laryngeal Surgery After Radiation Therapy Failure.

Conservation laryngeal surgery (CLS) includes time-honored approaches such as the vertical partial laryngectomy and the open horizontal supraglottic laryngectomy, as well as the supracricoid partial laryngectomy and transoral laser microsurgery. Carefully selected patients can undergo transoral endoscopic or open CLS for early to intermediate stage recurrent tumors of the glottic and supraglottic larynx. Patient factors, such as comorbid pulmonary disease, are essential in selecting patients for CLS, especially after previous radiation therapy. This article reviews the preoperative indications and postoperative management of salvage CLS after radiation therapy for laryngeal cancer.

Postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx.

OBJECTIVE: Assessment of incidence, risk factors, management, and outcome of postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx. METHODS: Retrospective review of a cohort of 514 cancers of the lateral oropharynx consecutively resected. RESULTS: Incidence of postoperative hemorrhage was 3.6%. In 31.5% of cases, onset was after hospital discharge. No hemorrhages occurred after the end of the fourth postoperative week. Variables associated with increased risk of hemorrhage were advanced age (P=.004), antithrombotic treatment (P=.012), and robotic assistance (P=.009). When the source of hemorrhage could be identified, hemostasis, performed transorally in most cases, was highly effective; no patients in this subgroup showed recurrence. In spontaneously resolved hemorrhage under observation or when no active site of bleeding was found on exploration under general anesthesia, the recurrence rate was 18.1%. Overall, hemorrhage resulted in death in 2 patients. CONCLUSION: Exploration under general anesthesia in case of active bleeding and observation with discussion of arterial exploration of the ipsilateral external carotid system in patients in whom no source of bleeding can be identified are the keys to successful management of this potentially lethal complication.

Early and severe dyspnea after supracricoid partial laryngectomy.

We present the case of a not-yet-reported complication that occurred during the immediate postoperative period after supracricoid partial laryngectomy. We include a review of the literature on complications following this procedure, emphasizing technical considerations that are critical during this surgery. Clinical, diagnostic, and operative findings are presented, as is a differential diagnosis for early and severe postoperative dyspnea following supracricoid laryngectomy.

[Unilateral laryngeal nerve paralysis in the adult: Epidemiology, symptoms, physiopathology and treatment]. / Paralysies laryngées unilatérales de l'adulte : épidémiologie, symptomatologie, physiopathologie et traitement.

In France, the main causes for unilateral laryngeal nerve paralysis in the adult patient are surgery and malignant tumors. Most of unilateral laryngeal nerve paralysis following thyroid surgery will recover within the first six postoperative months. At the time of unilateral laryngeal nerve paralysis, swallowing impairment and dyspnea occur in around 30% and 5% of cases, respectively. In the face of a unilateral laryngeal nerve paralysis occurring without a history of trauma of surgery, the main paraclinical examination to perform is a computed laryngeal nerve examination analyzing the whole length of the nerve involved. Speech therapy efficiency is related to the degree of severity of the symptoms related to unilateral laryngeal nerve paralysis. In the vast majority of cases, laryngeal medialization approaches improve dysphonia and swallowing impairment related to unilateral laryngeal paralysis, but not dyspnea.