Lateral cervical approach for supracricoid partial laryngectomy

Introduction

The supracricoid partial laryngectomy has been described for the treatment of T3 laryngeal glottic and supraglottic tumors as well as upfront and salvage surgery. Good oncological and functional outcomes are expected, while the post-operative rehabilitation can be quite difficult for the patient. Early and late complications can occur especially in salvage surgery. Neck dissection according to the T stage is often associated with the resection of the primary tumor.

Repeated transoral laser microsurgery for early and advanced recurrence of early glottic cancer after primary laser resection

Objectives

To analyze the oncological results of repeated transoral laser microresection (TLM) in case of failure after primary laser resection of early glottic cancer (pTis-pT2).

Methods

Fifty-six patients with local or loco-regional recurrence of early glottic cancer were treated between 1988 and 2005 by repeated TLM followed, if necessary, by neck dissection and/or adjuvant radio- or radiochemotherapy. Data on overall survival, disease-specific survival, and loco-regional control rates were analyzed retrospectively and calculated by the Kaplan–Meier method.

Results

Forty-four patients (78.6%) presented with early local recurrence (rTis-rT2N0; Stage I/II) and 12 patients (21.4%) had advanced local or loco-regional recurrence (pT3 and pT4N0/N+; Stage III/IV). Three- and five-year overall survival rates for patients with early and advanced recurrence were 75.1% vs. 51.6% and 61.6% vs. 25.8%, respectively. The corresponding three- and five-year disease-specific survival rates were 87.2% vs. 85.7% and 81.0% vs. 85.7%, respectively. Three- and five-year loco-regional control was significantly higher for patients treated for early recurrence (67.6% vs. 27.5% and 63.6% vs. 27.5%, respectively; p = 0.02). Salvage laryngectomy rates for patients with early and advanced recurrence were 9.1 and 25.0%, respectively. In patients with early local recurrence, anterior commissure involvement (n = 11) did not affect the oncological results.

Conclusions

In case of early local recurrence after primary TLM of early glottic cancer, further TLM seems to be justified as an organ-preserving treatment option. In contrast, salvage laryngectomy should be considered early for patients with advanced local or loco-regional recurrence.     

Results after supracricoid horizontal partial laryngectomy

Objectives

This study analyzed oncological and functional results of supracricoid horizontal partial laryngectomy.

Methods

A retrospective study was conducted involving 20 patients with squamous cell carcinoma (SCC) of the larynx who underwent SCPL between 1996 and 2005 in Faculty of Medical Sciences of Santa Casa Hospital of Sao Paulo, Brazil. There were 18 male and 2 female patients with ages ranging from 39 to 74 years (median = 58 years), of whom 19 were smokers and 14 alcoholics. The tumors were present in the glottis in 16 cases and supraglottis in 4; 5 were stage I or II and 15 were stage III or IV. We analyzed treatment given when rehabilitation was unsuccessful, oncological results of SCPL, including local and regional recurrences, time to recurrence and treatment given, distal metastases, global survival, survival free of disease, and appearance of second primary tumors. We also calculated the index of functional preservation of the larynx.

Results

Rehabilitation of swallowing capabilities and speech was achieved in 18 patients. Removal of the tracheostomy varied between 1 and 9 months. Rehabilitation was unsuccessful in two patients. Three patients required a total laryngectomy, two for unsuccessful rehabilitation and one for recurrence. The preservation of a functional larynx was 85%, with 10% of patients requiring a total laryngectomy after failed rehabilitation.

Conclusions

Supracricoid horizontal partial laryngectomy is an efficient surgical oncology technique that yields good functional results for the treatment of laryngeal cancer.     

Voice-related quality of life in patients after total and partial laryngectomy

Objective

To assess the voice-related quality of life (V-RQOL) in patients after total and partial laryngectomy.

Materials and methods

96 patients treated for laryngeal cancer were enrolled in the study. The cohort of patients was divided into three groups depending on the surgical procedure carried out: total laryngectomy (TL), supracricoid partial laryngectomy (SCL) and/or horizontal glottectomy (HG). The maximum phonation time (MPT) and syllable diadochokinesis, were used for the aerodynamic assessment; Yanagihara score was used for acoustic analysis of the sustained /a/ and the GRBAS scale was used for perceptual assessment. Each of the patients completed the VHI. The Kruskal–Wallis and Mann–Whitney tests were used to analyse the mean difference among the three groups of patients.

Results

A comparison with the values found between groups noted that the TL group showed significantly higher scores of G, R and Yanagihara score, while the HG group showed a significantly higher score of B. No differences were found in the aerodynamic and acoustic measures among the 3 groups. The mean ± standard deviations of VHI total score were 35.3 ± 24.5 for TL group, 30.1 ± 21.6 for SCL group, 35.8 ± 9.6 for HG group. No significant difference was found across the three groups.

Conclusions

V-RQOL seems to be similar in patients who underwent significantly different surgical procedures even if the voice characteristics were different. These findings need to be considered in patient's counselling together with other data on general quality of life after total and partial laryngectomy.     

Simultaneous squamous cell carcinoma with leiomyosarcoma of the larynx

Objective

To present the first reported case of a simultaneous squamous cell carcinoma with a leiomyosarcoma of the larynx, our treatment of the patient, and the 9-month follow-up results.

Study design

Case study.

Methods

Review of diagnostic studies, the operative technique, and the patient's chart for the 9-month period after treatment.

Results

A case with double laryngeal tumors with simultaneous evolution but different histological patterns is described. The squamous cell carcinoma and leiomyosarcoma involved both the vocal cords and the anterior commissure. A partial laryngectomy was performed, and the patient has been free of disease for 9 months.

Conclusions

Multiple laryngeal tumors are exceedingly rare. To our knowledge, no previous reports of a simultaneous squamous cell carcinoma and a leiomyosarcoma of the larynx have been reported. Both tumors were not invasive in this case, so conservation surgery was feasible.     

Hypopharyngeal mucosal flap reconstruction in endoscopic supraglottic laryngectomy

Purpose

Preservation of voice, swallowing and airway is mandatory in early to moderately advanced supraglottic cancers. Here, we propose an endoscopic laryngoplasty to improve swallowing recovery in patients treated by extended CO₂ laser supraglottic laryngectomy.

Methods

We describe a new mucosal flap reconstruction technique in a cohort of seven laryngeal cancer patients with posterior extension, treated by CO₂ laser resection. Clinical endoscopic and videofluoroscopy postoperative exams were performed, and swallow function was tested by the MD Anderson Dysphagia Inventory (MDADI) questionnaire.

Results

No early complications were observed. Absence of aspiration after two days in all cases was confirmed, and MDADI mean value result was 98.

Conclusions

We suggest the harvest of a hypopharyngeal mucosal flap in all patients who require a laryngeal supraglottic posterior resection, with or without arytenoidectomy.     

Transoral laser microsurgery for recurrence after primary radiotherapy of early glottic cancer

Objective

To analyze oncological results of transoral laser microsurgery (TLM) on recurrent early glottic cancer after primary radiotherapy.

Methods

The records of 53 patients treated by TLM for early (rTis–rT2) and advanced (rT3, rT4) recurrence after curative radiotherapy were retrospectively analyzed. Data on loco-regional control, overall survival, and disease specific survival were calculated by the Kaplan–Meier method. The larynx preservation rates were given absolutely.

Results

Mean post-therapeutic follow-up time after TLM for patients alive was 87.9 months. Twenty-two patients (42%) were cured by the first TLM procedure, but one of them underwent total laryngectomy after TLM due to chondronecrosis without evidence of residual tumor. Thirty-one patients (58%) developed another recurrence after TLM. Ten of them were cured by further laser procedures alone. Therefore, in 31 patients (58%), local recurrences were successfully treated by TLM alone. In 20 patients, recurrences could not be controlled by TLM: 14 patients underwent salvage laryngectomy and six palliative treatment. Three- and five-year loco-regional control rates for all patients were 46.1 and 38.8%. Three- and five-year overall survival rates were 67.5 and 53.3%. The corresponding 3- and 5-year disease specific survival rates were 68.6%, each. There was no statistically significant difference in loco-regional control or survival between patients presenting initially with early and advanced recurrence. Further recurrence after the first TLM procedure was associated with a statistically significant decrease in 3- and 5-year overall (56.6% vs. 81.8% and 40.2% vs. 70.5%; p = 0.03) and disease specific (48.9% vs. 100%, each; p = 0.001) survival. Ultimate local control rate including repeated TLM and salvage laryngectomy was 77.4%.

Conclusions

Many patients with recurrent glottic carcinoma after primary radiotherapy can be cured by single or repeated TLM as an organ-preserving procedure. However, in case of failure after TLM for the first recurrence, salvage laryngectomy should be considered early as local control by further laser surgery is unfavorable.     

Clinical outcome of early glottic carcinoma in Serbia

Objective

Proposed methods for treating early glottic carcinoma are cordectomy through laryngofissure, laser cordectomy, and radiotherapy. The aim of the study was to conduct comprehensive study to evaluate oncological and functional results of different treatment modalities for Tis and T1 glottic carcinoma, identify prognostic factors for the outcome of treatment and decide where we stand in applying worldwide standards of early glottic carcinoma treatment.

Methods

Prospective study was conducted on 221 patients treated with Tis and T1 glottic carcinoma from 1998 to 2003 (72 patients were treated endoscopically with CO₂ laser, 75 patients with cordectomy through laryngofissure and 74 with radiotherapy), with follow-up period from 38 to 107 months. Important demographic and clinical variables were analyzed. Voice quality after the treatment was assessed using multidimensional voice analysis.

Results

Comparing oncological results of three modalities of treatment, there were no significant differences. Functional results of treatment were better after laser cordectomy and primary radiotherapy than following the open cordectomy. Five-year survival rate was almost identical in all three groups of patients, and important prognostic factors for survival were age and histological grade of the tumor.

Conclusion

Considering that the choice of treatment in our country is also greatly influenced by other paramedical factors, such as distance from treatment facility, reliability of follow-up, significant time delay of radiotherapy because of small number of radiology centers and strong patients’ surgeon and treatment preference, we consider endoscopic laser surgery highly efficient and preferred choice of treatment for early glottic carcinoma.     

The Rintala flap: a versatile procedure for nasal reconstruction

Introduction

For the nasal reconstruction, local flap using the adjacent tissue is selected from an esthetic viewpoint. The Rintala flap is a useful option, and reconstruction of the glabellar over the nasal tip with this flap is ideal, for which the procedure was modified to increase the blood flow to the Rintala flap to extend its clinical applications.

Methods

For defects of the glabellar over the middle one third of nasal dorsum, the Rintala flap is transferred employing the original design and technique dissected on supraperiosteal plane. For defects of the lower one third of nasal dorsum over the nasal tip, blood supply through the lateral nasal artery is added to the distal end of the flap, preparing a long flap with stable blood supply like Maruyama described in 1997.

Results

This procedure was applied for nasal reconstruction in 15 patients. The Rintala flap was applied in 12 and the modified Rintala flap with adding blood flow from the lateral nasal artery was applied in 3. Blood supply to the flap was very stable in all patients, and favorable outcomes were achieved.

Conclusions

Using this procedure, the natural contour and morphology of the glabellar over the nasal tip may be reconstructed. The technique is simple and easy. Using this procedure, clinical applications of the Rintala flap can be extended, showing that it is a useful nasal reconstructive procedure.     

Myringoplasty using rotation flap of canal skin for total tympanic membrane perforation

Objective

To evaluate the efficacy of a novel technique of using rotation flap of canal skin in patients with total or subtotal tympanic membrane (TM) perforation with no anterior residual tympanic membrane.

Methods

A retrospective study of 50 patients with total or subtotal perforation repaired with rotation flap of canal skin. Clinical and audiometric data were recorded.

Results

The overall perforation closure rate was 96%. A statistically significant shortened healing time was observed.

Conclusion

The rotation flap of canal skin could be an effective and safe technique for perforations with no anterior residual TM.     

Management of complex glottic stenosis in children with recurrent respiratory papillomatosis

Objectives

To describe our management of complex glottic stenosis in tracheotomy dependent children with severe recurrent respiratory papillomatosis.

Methods

Retrospective chart review at a tertiary care children's hospital.

Results

Three children with complex glottic stenosis secondary to severe recurrent respiratory papillomatosis were treated at our institution since 2011. Two patients had complete stenosis, and the third had near-complete stenosis. Two patients were managed using balloon dilation alone, and the third also underwent laryngotracheal reconstruction with posterior costal cartilage grafting. Two patients have been successfully decannulated and the third has been tolerating continuous tracheotomy capping for greater than twelve months. All three patients underwent aggressive debridement of papillomatosis and balloon dilation every 4–6 weeks until their burden of disease was controlled. In two patients, the glottic airway was patent, and the third continued to have complete restenosis between procedures and required laryngotracheoplasty with multiple post-operative dilation procedures to establish an adequate glottic airway.

Conclusions

Severe laryngeal stenosis is a well-described complication of recurrent respiratory papillomatosis, but its management is not well-defined. Aggressive management of papillomatosis with frequent debridement is critical in successfully managing laryngeal stenosis. Balloon dilation alone may be surprisingly effective in these patients, and laryngotracheoplasty can be used as an adjunct procedure in those patients who fail balloon dilation. Given the quality of life issues and concerns regarding distal spread of disease with tracheotomies in these patients, we feel that aggressive management and early decannulation is in the patient's best interest.     

Is elective neck dissection necessary for the surgical management of T2N0 glottic carcinoma?

Objective

Evaluation of neck metastasis incidence in surgically treated T2N0M0 glottic carcinoma patients and discussion the necessity of elective neck dissection in this subset of larynx carcinomas.

Materials and methods

The patients who were staged clinically and radiologically as T2N0M0 glottic carcinoma having surgical intervention for their primary tumor and elective neck dissection between March 1996 and July 2009 with at least 2 years of follow up were included in the study. The recordings of patients were evaluated retrospectively for primary tumor location, vocal cord mobility, type of laryngectomy and neck dissection, results of histopathological examination, number of dissected lymph nodes for each specimen and for local and regional failure during the follow up.

Results

In the 13-year study period, 24 consecutive patients with a mean age of 56.4 were treated surgically with 20 frontolateral, three vertical laryngectomies and one cricohyoido-epiglottopexy; 19 lateral and 5 functional neck dissections were performed for the necks. Histopathological examinations of the neck dissection specimens revealed an average of 32 lymph nodes (8–65) and there was no metastasis in any of these specimens. After an average 58 months of follow-up, only one patient had local failure and no patients had regional failure.

Conclusion

As occult metastasis was not detected in any of the neck dissection specimens in cT2N0M0 patients and no regional failure was experienced during the follow-up period, it was concluded that the neck could be followed up without performing elective neck dissection in the surgical management of cT2N0M0 glottic carcinoma patients.     

Acellular dermal graft pharyngeal repair augmentation after laryngectomy

Purpose

Pharyngocutaneous fistula (PCF) after laryngectomy continues to be a serious complication, especially after radiation. Recruitment of non-radiated tissue into the surgical defect may decrease the risk of fistula. These techniques however have significant morbidity and increases operative time. We hypothesized that using acellular dermal graft to reinforce the pharyngeal closure could decrease the risk of fistula, without the added morbidity of a vascularized flap.

Long-term results of open cordectomy for the treatment of T1a glottic laryngeal carcinoma

Objective

To assess the long-term results and prognostic factors in patients who have undergone open cordectomy (OC) for the treatment of T_1a glottic laryngeal carcinoma.

Methods

One hundred four epidermoid cancer patients operated from January 1989 through December 1999 were included in the study. Clinical parameters, postoperative complications, and postoperative stay were retrospectively evaluated in all cases.

Results

Mean survival for the patients included in the study was 61.5 ± 24.8 months after the date of operation (range: 11–121 months). Ninety-four patients did not have recurrent tumor (90.4%). Local, regional and distant recurrence were linked with a statistical negative impact on survival rates (p < 0.05). Only sero-hematoma was significantly related to local recurrence (p < 0.05), whereas the remainder complications did not. None of the complications was associated with neck recurrence or distant metastasis (p > 0.05).

Conclusions

Open cordectomy is nowadays a valid technique for the surgical treatment of T_1a glottic laryngeal carcinoma. Its results are comparable with those of other more recent techniques.     

Horizontal glottectomy: is it an out-of-date procedure?

Purpose

The aim of the study is to illustrate our experience with horizontal glottectomy (HG), reviewing the indications and results of this uncommon partial laryngectomy.

Materials and Methods

It is a retrospective study. We completed a chart review of patients who underwent partial laryngectomy between May 2003 and June 2010. Patients who underwent HG were included in the study. Data obtained were collected and analyzed.

Results

Seven male patients were included in the study (mean age was 78 years; range, 69-88 years). In all cases, the TNM classification was pT1bN0M0 apart from one patient who had pT1N1M0. Three patients had a moderately differentiated neoplasm (G2), whereas 4 patients had a well-differentiated tumor (G1). Tracheotomy tube removal, oral feeding, and voice analysis have been evaluated and reported in the study. Mean follow-up was 16 months.

Conclusions

Horizontal glottectomy might be a worthwhile treatment option in selected patients nowadays. In older patients with anterior commissure involvement, this procedure guarantees adequate functional and good oncological results. This study may possibly help surgeons dealing with glottic cancer involving the anterior commissure because we believe that some patients could benefit from HG, even in this radiotherapy and transoral laser surgery “era.”     

Management of naso-septal deformity in childhood: Long-term results

Objective

The classical teaching advocates a conservative approach for children presenting with various naso-septal deformities. It may not be appropriate especially when it causes nasal obstruction to the growing child. This study has two main purposes: to contribute in identifying the correct selection criteria for surgical management of pediatric patients and in selecting the most appropriate surgical technique.

Material and method

We reviewed a series of 46 cases of post-traumatic septal and naso-septal deformity not managed promptly or with recurrence of nasal deviation, following bones fracture correction alone. The mean follow-up was 10 years.

Results

Patients with naso-septal deformity managed only by septoplasty had accentuation of nasal pyramid deformity; those treated by septorhinoplasty showed a good aesthetic and functional result after long-term follow-up.

Conclusion

Our series results demonstrated that the best results were obtained when we correct all evident alterations of nasal septum and pyramid at a single stage. Unsuccessful results seen in our first group suggest that immediate correction of septum alone with delayed management of nasal pyramid deformity leads to a poorer outcome.     

Factors involved in free flap thrombosis after reconstructive surgery for head and neck cancer

Objective

Reconstructive surgery in which a free flap is used following extended resection for head and neck cancer has been popular for more than a quarter of a century. However, postoperative total flap necrosis has not been completely resolved, and few studies have analyzed the specific risk factors for this complication.

Methods

Over a three-year period from 2005 to 2007, 388 flaps were used for reconstructive surgery on 384 patients at Department of Head and Neck of the Cancer Institute Hospital of Japanese Foundation for Cancer Research, and the results for 22 flaps with thrombosis were analyzed.

Results

The only statistically significant risk factor for free flap thrombosis was the history of radical concurrent chemoradiotherapy.

Conclusions

It will be necessary to keep this observation in mind when performing salvage surgery following chemoradiotherapy, which is expected to be performed more often in the future.     

An extremely rare case of large Delphian node metastasis preceding primary laryngeal cancer

Objectives

To present an extremely rare case of large Delphian node metastasis preceding primary laryngeal cancer.

Materials and methods

A 74-year-old male who noted a mass on the lower anterior neck and consulted our department immediately. The mass rapidly grew to 6 cm from 2 cm in diameter within 2 months after the initial presentation.

Results

Fiberoptic laryngoscopy was unremarkable. Surgical excision of the lesion showed well differentiated squamous cell carcinoma with invasion into the surrounding tissues. Postoperative radiotherapy was added. During follow-up after those treatments, thickening of the right vocal cord was observed, which gradually became more apparent. Total laryngectomy was performed 13 months after the initial operation.

Conclusion

Delphian node metastasis is included in the differential diagnosis in a case of rapidly increasing mass in the anterior neck.     

Endolaryngeal posterior mucosal flap for surgical repair of posterior glottic stenosis

Objective

We report our experience with an endolaryngeal surgical procedure for posterior glottic stenosis with review of the literature.

Methods

Four patients with posterior glottic stenosis underwent endoscopic reconstruction of the posterior glottis applying an endolaryngeal posterior mucosal flap. Laryngeal function (i.e., voice and airway patency) before and after surgery was assessed.

Results

One out of four patients has been tracheostomy-dependent prior to laryngeal surgery. After endolaryngeal surgery, no primary wound healing disorders could be observed in all patients. Aspiration problems occurred in none of the patients. In three of the four patients, the mucosal flap was completely successful. In one patient, the mucosal flap was only partially successful (improvement of voice, but no improvement of airway patency).

Conclusion

We believe that the endolaryngeal posterior mucosal flap may offer an additional option in patients with mild to moderate posterior glottic stenosis.