Surgical management and oncological outcome of non-squamous cell carcinoma of the larynx: a bicentric study.

PURPOSE: Non-squamous cell carcinoma (non-SCC) accounts for about 5% of laryngeal malignancies. Survival data are limited, and consensus on management principles is lacking. The present study reviews our experience in the surgical treatment of non-metastatic non-SCC of the larynx and compares oncological and functional outcomes in a cohort of patients affected by traditional SCC. METHODS: We collected data on 592 patients affected by laryngeal neoplasms. Univariate and multivariable survival analyses were performed using Cox proportional-hazards models; survival estimates were reported by hazard ratios (HR) with 95% confidence intervals (CI), and survival curves were established with the Kaplan-Meier method. RESULTS: We identified 326 patients affected by untreated SCC, while 21 had non-SCC histotypes. The non-SCC cohort was composed of 5 soft tissue sarcomas, 8 chondrosarcomas, 2 adenoid cystic carcinomas, 2 neuroendocrine carcinomas, 2 solitary fibrous tumors, 1 Kaposi's sarcoma, and 1 malignant peripheral nerve sheath tumor. Overall survival and disease-specific survival were not significantly different according to histology (p = 0.6 and p = 0.349, respectively). The non-SCC group showed an increased risk of recurrence (HR 5.87; CI95 2.15-16.06; p < 0.001). Nonetheless, no significant difference (p = 0.31) was found at multivariable analysis between the two groups in total laryngectomy-free survival with an organ preservation rate over 5 years of 81% for the non-SCC histologies. CONCLUSION: Non-SCC is a broad spectrum pathology, but generalized laryngeal surgical management principles are still feasible and it is possible to identify patients amenable to conservative surgical treatment without affecting survival.

Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy.

INTRODUCTION: Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol. METHODS: Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent. RESULTS: Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%). CONCLUSION: The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature.

Validation of the European Laryngological Society classification of glottic vascular changes as seen by narrow band imaging in the optical biopsy setting.

PURPOSE: In 2016, the European Laryngological Society (ELS) proposed a classification for vascular changes occurring in glottic lesions as visible by narrow band imaging (NBI), based on the dichotomic distinction between longitudinal vessels (not suspicious) and perpendicular ones (suspicious). The aim of our study was to validate this classification assessing the interobserver agreement and diagnostic test performance in detecting the final histopathology. METHODS: A retrospective study was carried out by reviewing clinical charts, preoperative videos, and final pathologic diagnosis of patients submitted to transoral microsurgery for laryngeal lesions in two Italian referral centers. In each institution, two physicians, independently re-assessed each case applying the ELS classification. RESULTS: The cohort was composed of 707 patients. The pathologic report showed benign lesions in 208 (29.5%) cases, papillomatosis in 34 (4.8%), squamous intraepithelial neoplasia (SIN) up to carcinoma in situ in 200 (28.2%), and squamous cell carcinoma (SCC) in 265 (37.5%). The interobserver agreement was extremely high in both institutions (k = 0.954, p < 0.001 and k = 0.880, p < 0.001). Considering the diagnostic performance for identification of at least SIN or SCC, the sensitivity was 0.804 and 0.902, the specificity 0.793 and 0.581, the positive predictive value 0.882 and 0.564, and the negative predictive value 0.678 and 0.908, respectively. CONCLUSION: The ELS classification for NBI vascular changes of glottic lesions is a highly reliable tool whose systematic use allows a better diagnostic evaluation of suspicious laryngeal lesions, reliably distinguishing benign ones from those with a diagnosis of papillomatosis, SIN or SCC, thus paving the way towards confirmation of the optical biopsy concept.

Palato-maxillary reconstruction by the angular branch-based tip of scapula free flap.

The angular branch (AB)-based tip of scapula free flap is a valuable reconstructive option in palato-maxillary defects needing significant structural support. We herein retrospectively evaluate our surgical series with special focus on functional outcomes and postoperative morbidity. Ninety-seven consecutive palatomaxillary oncologic resections were performed at our institution between August 2008 and November 2015. The analysis focused on those reconstructed by an AB-based tip of scapula free flap (N = 18; 19 %). A prospective assessment of donor site morbidity was performed by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in 12 (67 %) patients. Among patients reconstructed by an AB-based tip of scapula free flap, 13 (72 %) had a Class II and 5 (28 %) a Class III defect according to Okay classification. Flap success rate was 94 %, with one failure requiring an anterolateral thigh flap. Eight (44 %) patients experienced recipient site complications, while donor site problems occurred in two only (11 %). Eleven (61 %) subjects were able to maintain a normal and 7 (39 %) a soft-to-firm diet. The mean DASH score was 10.5. Our results confirm that the AB-based tip of scapula free flap is a reliable choice in palatomaxillary reconstruction, with both satisfactory functional outcomes and negligible donor site morbidity.

Tracheal and Crico-Tracheal Resection and Anastomosis for Malignancies Involving the Thyroid Gland and the Airway.

OBJECTIVES: To evaluate outcomes in different malignancies involving the thyroid and infiltrating the airway submitted to tracheal (TRA) or crico-tracheal resection and anastomosis (CTRA). METHODS: Retrospective charts review of 27 patients affected by thyroid malignancies involving the airway treated by TRA/CTRA in a single academic institution. Kaplan-Meier curves were used to evaluate the overall (OS) and disease-specific (DSS) survivals and local (LC) and loco-regional control (LRC). Impact on survival of age, comorbidities, previous radiotherapy, types of TRA/CTRA, Shin's stage (II, III, IV), grading (well vs poorly differentiated), and length of airway resected was calculated by the log-rank test. RESULTS: Overall survival and DSS at 3 and 5 years were 82.3% and 71.6%, respectively. Local control and LRC in the entire group were 82.3% at 3 and 5 years. Crico-tracheal resection and anastomosis involving the cricoid arch and plate (type C) and tumor differentiation significantly affected OS and DSS (both P < .001). Type C CTRA and tumor differentiation significantly impacted on LC (P = .002 and P = .009, respectively). CONCLUSIONS: Grading and extension of CTRA to the cricoid plate are the most important factors for oncologic outcomes in thyroid malignancies infiltrating the airway. Except for poorly differentiated tumors, TRA/CTRA allows adequate LC even in advanced stage lesions involving the crico-tracheal junction.

Prospective analysis of functional swallowing outcome after resection of T2 glottic carcinoma using transoral laser surgery and external vertical hemilaryngectomy.

56 patients affected by T2 glottic carcinoma were treated in two institutes using transoral laser microsurgery (TLM) in 40 cases and vertical hemilaryngectomy in 16 cases between September 2012 and September 2015. In the TLM group, different subtypes of type V cordectomy were used according to the extent of tumor. In the vertical hemilaryngectomy group, classical operation was used in most of the cases and the resection was extended in few cases. Analysis of post-operative swallowing function was done using videofluoroscopy (VFS), functional endoscopic evaluation of swallowing, and subjectively using MD Anderson dysphagia inventory. Objective evaluation of swallowing has been made by obtaining different measures from VFS (pharyngeal transit time, pharyngeal constriction ratio, and hyoid displacement for example). Analysis also included the need and duration of tracheostomy and nasogastric tube, ICU admission, and hospitalization time. Statistical analysis was performed with the Mann-Whitney U and Pearson Chi-square tests. Comparison of incidence of aspiration and swallowing outcome showed significantly better results in the laser group than in the vertical group (p < 0.001). The duration of ICU, tracheostomy, nasogastric tube, and hospital stay was also significantly shorter in the laser group (p < 0.001). This study shows that TLM had significantly better overall postoperative outcome than vertical hemilaryngectomy. It was associated with significantly shorter hospital stay and less need for tracheostomy, nasogastric tube, and ICU admission). Measures obtained from VFS are useful for detection and follow-up of postoperative aspiration, because it is a definitive technique for anatomical and physiological study of swallowing.

The diagnostic value of narrow band imaging in different oral and oropharyngeal subsites.

The diagnostic value of narrow band imaging (NBI) in the "optical biopsy" of leukoplakias (LP) and erythroplakias (EP) in different oral cavity (OC) and oropharyngeal (OP) subsites is still to be defined. We evaluated 128 unbiopsied and untreated OC/OP LP and EP by conventional oral examination (COE), white light (WL) endoscopy, and NBI and categorized them as "suspicious" or "innocuous". All lesions were treated by excisional biopsy. True positives were those considered as "suspicious" and with histopathology ranging from mild dysplasia to invasive carcinoma. Epithelia were classified as follows: type 1, keratinized thick stratified (gingiva, hard palate, dorsal tongue); type 2a, non-keratinized thin stratified (floor of mouth, vestibule, ventral tongue, soft palate, palatine tonsils, base of tongue); type 2b, non-keratinized, very thick stratified (retromolar trigon, lateral tongue, labial and buccal mucosa). Histopathology revealed 32 % benign lesions, 13 % mild to moderate dysplasias, 15 % severe dysplasias/carcinoma in situ, 16 % microinvasive, and 23 % invasive carcinomas. The false positive rates were 32 % at COE, 27 % at WL, and 15 % at NBI. The false negative rates were 49, 22, and 11 %, respectively. Diagnositic performance was higher for NBI compared to COE (p < 0.001) and to WL (p = 0.004). Comparison of the diagnostic value of NBI among different OC/OP subsites did not show statistically significant difference. NBI as an "optical biopsy" tool significantly reduces the rates of false positives and false negatives in diagnosis of OC/OP cancer compared with COE and WL. No statistically significant difference was noted in its diagnostic value among different OC/OP subsites.

Intraoperative narrow band imaging better delineates superficial resection margins during transoral laser microsurgery for early glottic cancer.

OBJECTIVE: The high rate of positive margins after transoral laser microsurgery (TLM) remains a matter of debate. This study investigates the effect of intraoperative narrow band imaging (NBI) examination on the incidence of positive superficial surgical margins in early glottic cancer treated by TLM. METHODS: Between January 2012 and October 2013, 82 patients affected by Tis-T1a glottic cancer were treated with TLM by type I or II cordectomies. Intraoperative NBI evaluation was performed using 0-degree and 70-degree rigid telescopes. Surgical specimens were oriented by marking the superior edge with black ink and sent to a dedicated pathologist. Comparison between the rate of positive superficial margins in the present cohort and in a matched historical control group treated in the same way without intraoperative NBI was calculated by chi-square test. RESULTS: At histopathological examination, all surgical margins were negative in 70 patients, whereas 7 had positive deep margins, 2 close, and 3 positive superficial margins. The rate of positive superficial margins was thus 3.6% in the present group and 23.7% in the control cohort (P<.001). CONCLUSION: Routine use of intraoperative NBI increases the accuracy of neoplastic superficial spreading evaluation during TLM for early glottic cancer.

Complications after tracheal and cricotracheal resection and anastomosis for inflammatory and neoplastic stenoses.

OBJECTIVE: This study aimed to evaluate complications and success rates of tracheal resection and anastomosis (TRA) and cricotracheal resection and anastomosis (CTRA) in patients treated in 2 academic institutions. METHODS: Retrospective charts review of 137 patients submitted to TRA/CTRA. Fifty (36.5%) had neoplastic (group A) and 87 (63.5%) benign (group B) stenoses. Using univariate analysis, age, medical comorbidities, previous radiotherapy, type of TRA/CTRA, association with neck dissection and thyroidectomy, length of resected airway, and preoperative tracheotomy were evaluated to identify factors predictive of complications and outcomes. RESULTS: The mean length of resected airway was 2.7 and 3 cm in groups A and B, respectively. Overall decannulation and complication rates for group A were 96% and 36%, and 99% and 46% for group B, respectively. Length of airway resected and presence of preoperative tracheotomy had a statistically significant effect on major surgical complications. Age older than 70 and cardiovascular and pulmonary comorbidities were significantly associated with the incidence of major medical complications. No statistically significant difference was found considering the complication rates of group A versus group B. CONCLUSION: Even though the overall success rate of TRA/CTRA is high, it should always be regarded as a major surgical procedure with a non-negligible incidence of complications.

Transoral laser exoscopic surgery of the larynx: state of the art and comparison with traditional transoral laser microsurgery.

Objective: To evaluate the efficacy of transoral laser exoscopic surgery (TOLES) in a unicentric series of patients affected by benign and malignant glottic and supraglottic lesions, and compare outcomes with those of transoral laser microsurgery (TOLMS). Methods: To demonstrate the non-inferiority of TOLES in terms of operative time, margin status and complication rates, we compared outcomes of 93 patients treated by TOLES between July 2021 and July 2023 with those of a match-paired group of 107 historical patients treated by TOLMS. To perform a multiparametric ergonomic evaluation of TOLES vs TOLMS, we used observational methods for biomechanical overload risk assessment and wearable technologies comparing 15 procedures with TOLES vs a paired match of 13 surgeries performed with TOLMS by the same surgeon. Results: No significant differences were found in terms of surgical duration, positive margins, or complications between TOLES and TOLMS. Ergonomics assessment by inertial measurement units and electromyographic surface electrodes demonstrated a reduced biomechanical overload with TOLES compared to TOLMS. Conclusions: The many advantages of TOLES, such as its superior didactic value, better digital control of light even through small-bored laryngoscopes, improved binocular vision, and increase in surgical performance by 3 or 4-hand techniques, are difficult to be quantified. In contrast, its non-inferiority in terms of oncological results and better ergonomics compared to TOLMS are demonstrated herein.

Thyroid cartilage infiltration in advanced laryngeal cancer: prognostic implications and predictive modelling.

Objective: Detection of laryngeal cartilage invasion is of great importance in staging of laryngeal squamous cell carcinoma (LSCC). The role of prognosticators in locally advanced laryngeal cancer are still widely debated. This study aimed to assess the impact of volume of thyroid cartilage infiltration, as well as other histopathologic variables, on patient survival. Materials and methods: We retrospectively analysed 74 patients affected by pT4 LSCC and treated with total laryngectomy between 2005 and 2021 at the Department of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia, Italy. We considered as potential prognosticators histological grade, perineural (PNI) and lympho-vascular invasion (LVI), thyroid cartilage infiltration, and pTN staging. Pre-operative CT or MRI were analysed to quantify the volume of cartilage infiltration using 3D Slicer software. Results: The 1-, 3-, and 5-year disease free survivals (DFS) were 76%, 66%, and 64%, respectively. Using machine learning models, we found that the volume of thyroid cartilage infiltration had high correlation with DFS. Patients with a higher volume (>670 mm3) of infiltration had a worse prognosis compared to those with a lower volume. Conclusions: Our study confirms the essential role of LVI as prognosticator in advanced LSCC and, more innovatively, highlights the volume of thyroid cartilage infiltration as another promising prognostic factor.

Function preservation using transoral laser surgery for T2-T3 glottic cancer: oncologic, vocal, and swallowing outcomes.

Aim of this study was to retrospectively analyze oncologic and functional results of a cohort of T2 and selected T3 glottic tumors treated by transoral laser surgery (TLS). Eighty-nine patients affected by T2 and T3 glottic tumors were treated by TLS from 2005 to 2010 at an academic institution by Type V cordectomies using an "en bloc" or, more frequently, a "piece-meal" technique depending on a number of variables. Kaplan-Meier curves were used to evaluate 5-year overall, disease-specific survivals, local control with laser, and organ preservation rates. Univariate analysis of the impact of different variables was performed. At least 1 year after surgery, we examined: subjective voice evaluation by voice handicap index (VHI), perceptive analysis by GRBAS scale, objective measurements with multidimensional voice program (MDVP), swallowing assessment with the M.D. Anderson Dysphagia Inventory (MDADI), videonasal endoscopic evaluation of swallowing (VEES), and videofluoroscopy (VFS). Fifty-nine patients were pT2 and 30 pT3. The 5-year overall, disease-specific survivals, local control with laser, and organ preservation rates were 92.4, 98.7, 68.5, and 82.1 %, respectively. VHI mean score was 20 (mild dysphonia). Mild and moderate dysphonias were detected by GRBAS in 82 and 18% of patients, respectively. Mean values of Jitter, Shimmer, and noise-to-harmonic ratio by MDVP resulted 7.87%, 24.8%, and 0.37, respectively. Mean value of MDADI was 95.75. Only 2% of patients at VEES and 4% at VFS showed tracheal aspiration. Our results highlight that T2 and selected T3 glottic tumors treated by TLS have favorable oncologic and functional outcomes.

Hemicricoidectomy with modified rotational thyro-crico-tracheal anastomosis: a newborn in the family of crico-tracheal resection and anastomosis techniques.

Objective: The aim of the present study is to describe our novel surgical technique of hemicricoidectomy and reconstruction with modified rotational thyro-crico-tracheal anastomosis for the treatment of non-squamous cell subglottic tumours. The procedure has been defined as Type E crico-tracheal resection and anastomosis (CTRA) following the University of Brescia (C)TRA classification introduced elsewhere. Methods: A detailed anatomical step-by-step dissection was reproduced and illustrated on a cadaveric laryngo-tracheal specimen. Moreover, oncological and functional outcomes of the first 5 patients who underwent Type E CTRA at our Institution between October 2016 and September 2022 are described. Results: Three patients underwent Type E CTRA for cricoid chondrosarcoma (CS) and 2 patients for subglottic adenoid cystic carcinoma (ACC). No post-operative complication was reported. All patients maintained intact oral intake and an intelligible voice at discharge. All but one patient with obstructive sleep apnoea hypopnea syndrome and lung comorbidity were successfully decannulated before discharge. At the last follow-up (April 2023), one patient experienced local recurrence of CS that was still amenable to conservative treatment by transoral debulking, while the remaining patients were free of disease. Conclusions: With the proper indications, Type E CTRA is a feasible and effective conservative surgical technique for selected non-squamous cell subglottic tumours.

Quantitative analysis of videokymography in normal and pathological vocal folds: a preliminary study.

Videokymography (VKG) captures high-speed images of the vocal folds independently of the periodicity of the acoustic signal. The aim of this study was to preliminarily assess a software package that can objectively measure specific parameters of vocal fold vibration. From August 2009 until December 2010, we prospectively evaluated 40 subjects (Group A, 18 normal subjects; Group B, 14 patients with benign lesions of the middle third of the vocal fold, such as polyps and cysts; Group C, 8 patients treated by endoscopic excision of vocal fold benign lesions) by videoendoscopy, videolaryngostroboscopy, and VKG. A VKG camera was coupled to a 70° telescope and video was recorded during phonation. Images were objectively analyzed by a post-processing software tool (VKG-Analyser) with a user-friendly interface developed by our group. Different parameters were considered, including the ratio between the amplitude of the vibration of one vocal fold with respect to the contralateral (R(amp)), the ratio between the period of one vocal fold vibration and the opposite one (R(per)), and the ratio between the duration of the open and closed phase within a glottal cycle (R(oc)). Mean values for R(amp), R(per), and R(oc) in Group A were 1.05, 1.04, and 1.35, respectively; in Group B were 1.63, 0.92, and 0.97, respectively; and in Group C were 1.13, 0.91, and 1.85, respectively. Quantitative analysis of videokymograms by the herein presented tool, named VKG-Analyser, is useful for objective evaluation of the vibratory pattern in normal and pathologic vocal folds. Important future developments of this tool for the study of both physiologic and pathologic patterns of vocal fold vibration can be expected.

Magnetic resonance imaging to assess cartilage invasion in recurrent laryngeal carcinoma after transoral laser microsurgery.

Objective: To evaluate the diagnostic performance of magnetic resonance (MR) with surface coils in assessing cartilage invasion in recurrent laryngeal carcinoma after carbon dioxide transoral laser microsurgery (CO2 TOLMS). Methods: Two expert head and neck radiologists assessed cartilage invasion (infiltrated or non-infiltrated) in submucosal recurrences of laryngeal carcinoma after CO2 TOLMS: results were compared with histopathological report after salvage laryngectomy. Results: Thirty patients met the inclusion criteria and 90 cartilages were assessed. Overall sensitivity, specificity, and positive and negative predictive values for cartilage infiltration were 76, 93, 72 and 94%, respectively; for thyroid cartilage, the values were 82, 79, 69 and 88% respectively; for cricoid cartilage, all values were 100%; and for arytenoids, the values were 33, 96, 56 and 93% respectively. Conclusions: MR with surface coils was able to detect most thyroid and cricoid infiltration in the complex setting of post-CO2 TOLMS laryngeal carcinoma recurrence. In particular, the optimal performance in assessing cricoid invasion can be valuable in choosing the most appropriate treatment among total laryngectomy, open partial horizontal laryngectomies and non-surgical strategies.

Transoral Laser Microsurgery for Glottic Cancer in Patients Over 75 Years Old.

OBJECTIVES/HYPOTHESIS: Laryngeal squamous cell carcinoma (LSCC) has a non-negligible incidence in elderly patients. However, there is still no clear indication on the ideal treatment for early-intermediate glottic LSCC in this specific age group. Both surgical and nonsurgical approaches may be burdened by complications and sequelae that negatively impact patient's health. In this setting, carbon dioxide transoral laser microsurgery (CO2 TOLMS) is a promising minimally invasive treatment option. STUDY DESIGN: Retrospective case series in a single tertiary academic institution. METHODS: Patients who underwent CO2 TOLMS for Tis-T3 glottic LSCC from 1997 to 2017 were reviewed. Demographic, clinical, and tumor characteristics, as well as postoperative complications were recorded. Overall (OS), disease-specific (DSS), recurrence-free (RFS), laryngo-esophageal dysfunction free survivals (LEDFS), and organ preservation (OP) were calculated. RESULTS: A total of 134 patients (mean age, 80 ± 4 years; median, 79; range, 75-93) were included in the study. Seven lesions were classified as pTis, 65 as pT1a, 22 as pT1b, 35 as pT2, and 5 as pT3. No treatment-related death was observed. Twenty-eight (20.9%) patients reported 10 surgical and 19 medical complications. Five-year OS, DSS, RFS, LEDFS, and OP were 68.9%, 95.4%, 79.5%, 66%, and 92.5%, respectively. Age and comorbidities were associated with OS and LEDFS. Advanced T categories were negatively correlated with OS, DSS, RFS, LEDFS, and OP. Age and comorbidities were not significant risk factors for complications. CONCLUSIONS: CO2 TOLMS can be considered a valuable therapeutic approach for selected Tis-T3 glottic LSCC even in the elderly given its favorable oncologic outcomes and minimal aggressiveness. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:135-141, 2022.

The Enhanced Recovery After Surgery (ERAS) protocol in head and neck cancer: a matched-pair analysis.

Objective: In this study, we aimed to describe the prospective implementation of the Enhanced Recovery after Surgery (ERAS) protocol in an Italian tertiary academic centre. Methods: Adult patients receiving surgery for primary or recurrent clinical stage III/IV squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were enrolled. The primary objective was to evaluate the impact of the ERAS protocol on length of hospital stay (LOS). The secondary objective was to assess its impact on complications. To evaluate the results of the ERAS protocol, a matched-pair analysis was conducted, comparing ERAS patients with comparable cases treated before 2018. Results: Forty ERAS and 40 non-ERAS patients were analysed. There were no significant differences between the cohorts regarding age, gender, stage of disease, comorbidity, ASA score, and duration of surgery. A significantly shorter LOS for the ERAS group (median, 14 days; range, 10-19) than for non-ERAS patients (median, 17.5 days; range, 13-21) was observed (p = 0.0128). The incidence of complications was not significantly different (p = 0.140). Conclusions: Our study demonstrates that the introduction of an ERAS protocol in the daily practice is feasible, and can result in significant reduction in LOS.

COVID-19 and Total Laryngectomy-A Report of Two Cases.

OBJECTIVE: To date, no cases have been reported on the effects of COVID-19 in laryngectomees. CASE PRESENTATION: We herein presented two clinical cases of laryngectomized patients affected by COVID-19, detailing their clinical course and complications. DISCUSSION: In our experience, permanent tracheostomy did not significantly affect the choice of treatment. However, dedicated devices and repeated tracheal toilettes may be needed to deal with oxygen-therapy-related tracheal crusting. CONCLUSION: In conclusion, laryngectomees should be considered a vulnerable population that may be at risk for worse outcomes of COVID-19 due to anatomical changes in their airways. The role of the ENT specialist is to guide airway management and inform the support-staff regarding specific needs of these patients.

Diagnostic Accuracy of Narrow Band Imaging in Patients with Oral Lichen Planus: A Prospective Study.

OBJECTIVE: Oral lichen planus (OLP) is a chronic mucocutaneous immune-mediated disease affecting 1% to 4% of the worldwide population. Development of malignant lesions is reported but only affects a minority of patients. The aim of our study was to assess the diagnostic potential of narrow band imaging (NBI) in OLP patients; focusing on the identification of high-grade dysplasia/carcinoma in newly developed lesions. METHODS: Prospective evaluation of 56 patients with histopathologic diagnosis of OLP and presenting newly developed lesions not responding to medical treatment. All lesions were assessed by high-definition (HD) white light (WL) and HD-NBI endoscopy. All patients underwent biopsy regardless of the appearance at HD-WL and HD-NBI. Histology was defined as "positive" in case of high-grade dysplasia or carcinoma. RESULTS: Five lesions (9%) were diagnosed as high-grade dysplasia/carcinoma. In this setting, overall diagnostic potential of HD-NBI was optimal, with a sensitivity of 100% (95% CI, 48-100), specificity of 96% (95% CI, 86-99), negative predictive value of 100% (95% CI, not calculable), positive predictive value of 71% (95% CI, 39-91), and accuracy of 96% (95% CI, 88-100). CONCLUSIONS: Despite the diffuse inflammatory pattern derived from OLP, NBI improved the diagnostic accuracy and the capability to detect high-grade dysplasia/carcinoma. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1156-E1161, 2021.

Long-term Oncologic Outcomes of 1188 Tis-T2 Glottic Cancers Treated by Transoral Laser Microsurgery.

OBJECTIVE: To evaluate long-term disease-specific survival (DSS) and organ preservation (OP) rates in patients affected by Tis-T2 glottic squamous cell carcinoma (SCC) treated by carbon dioxide transoral laser microsurgery (CO2 TOLMS). STUDY DESIGN: Single-center retrospective cohort study. SETTING: Tertiary academic hospital. METHODS: The study included patients treated by CO2 TOLMS for Tis-T2 glottic SCC at the Department of Otorhinolaryngology-Head and Neck Surgery of the University of Brescia, Italy, from 1988 to 2018. The male:female ratio was 11.2:1, and the mean age was 64 years (range, 31-95). T categories were distributed as follows: 124 (10%) Tis, 646 (54%) T1a, 172 (15%) T1b, and 246 (21%) T2. RESULTS: Ten- and 20-year DSS rates were 97.6% and 96.3%, respectively, and 10- and 20-year OP rates were 94.7% and 93%. During the follow-up, 91% of patients were treated by CO2 TOLMS alone, while the remaining needed adjunctive treatments. Assessing the impact of multiple sessions of CO2 TOLMS, DSS showed no significant difference in terms of patients treated by 1, 2, or >2 procedures. Conversely, patients treated by >2 sessions of CO2 TOLMS showed a significantly worse OP rate. CONCLUSIONS: Our series validates CO2 TOLMS as a long-term treatment strategy for early glottic SCC. Salvage CO2 TOLMS provided optimal results in terms of DSS and OP in patients with recurrence after previous transoral surgery.