Learning Modern Laryngeal Surgery in a Dissection Laboratory

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is ...

Candiolo Cancer Institute, FPO-IRCCS

The aim was to investigate telephonic voice intelligibility in patients treated for laryngeal cancer using different approaches. In total, 90 patients treated for laryngeal cancer using different approaches and 12 healthy volunteers were recruited. Each patient and each healthy control read a list of words and sentences during a telephone call. Six auditors listened to each telephonic recording and transcribed the words and sentences they understood. Mean intelligibility rates for each treatment were assessed and compared. Regarding words, the poorest intelligibility was noted for type II open partial horizontal laryngectomies, followed by total laryngectomies. The best intelligibility was found for transoral laser microsurgery, followed by radiotherapy alone. For sentences, the poorest intelligibility was noted for type II open partial horizontal laryngectomies, followed by chemoradiotherapy. The best intelligibility was found for radiotherapy alone and transoral laser microsurgery. More aggressive surgery as well as chemoradiotherapy correlated with significantly poorer outcomes. Transoral laser microsurgery or radiotherapy alone ensured the best telephonic voice intelligibility. Intermediate-advanced T stages at diagnosis also showed significantly poorer intelligibility outcomes, suggesting that T stage represents an independent negative prognostic factor for voice intelligibility after treatment.

Telephonic voice intelligibility after laryngeal cancer treatment: is therapeutic approach significant?

Several studies have previously analyzed the relationship between QOL and signs of dysphagia in patients treated for head and neck cancer and have reported heterogeneous findings. To the best of our knowledge, no study has previously investigated this relationship among patients who underwent open partial horizontal laryngectomy (OPHL). The aim of the study is to determine if patient-reported swallowing-related QOL can discriminate between safe and unsafe swallowing in OPHL patients.

Relationship between swallowing-related quality of life and fiberoptic endoscopic evaluation of swallowing in patients who underwent open partial horizontal laryngectomy.

Dysphagia is common after an open partial horizontal laryngectomy (OPHL). The mechanisms causing lower airways' invasion and pharyngeal residue are unclear. The study aims to examine physio-pathological mechanisms affecting swallowing safety and efficiency after OPHL. Fifteen patients who underwent an OPHL type IIa with arytenoid resection were recruited. Videofluoroscopic examination of swallowing was performed. Ten spatial, temporal, and scalar parameters were analyzed. Swallowing safety and efficiency were assessed through the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Swallowing was considered unsafe or inefficient for a DIGEST safety or efficiency grade ≥2, respectively. Videofluoroscopic measurements were compared between safe vs. unsafe swallowers, and efficient vs. inefficient swallowers. Seven patients (46.7%) showed unsafe swallowing and 6 patients (40%) inefficient swallowing. Unsafe swallowers had worse laryngeal closure ( = 0.021). Inefficient swallowers presented a longer pharyngeal transit time ( = 0.008), a reduced pharyngoesophageal segment opening lateral ( = 0.008), and a worse tongue base retraction ( = 0.018 with solids and  = 0.049 with semisolids). In conclusion, swallowing safety was affected by incomplete laryngeal closure, while swallowing efficiency was affected by increased pharyngeal transit time, reduced upper esophageal sphincter opening, and incomplete tongue base retraction. The identified physio-pathological mechanisms could represent targets for rehabilitative and surgical approaches in patients with dysphagia after OPHL.

Swallowing Safety and Efficiency after Open Partial Horizontal Laryngectomy: A Videofluoroscopic Study.

The primary aim of the present study was to report our multi-institutional experience in surgical salvage with open partial horizontal laryngectomies (OPHL) after failed radiotherapy (RT) for laryngeal squamous cell carcinoma (LSCC). Secondary aims were to analyze the prognostic meaning of the main clinical and pathological parameters in relation to the oncologic outcome and to compare our results with the available literature.

Salvage open partial horizontal laryngectomy after failed radiotherapy: A multicentric study.

The application of CO fiber laser technology to ENT surgery has led to new interesting scenarios, both in endoscopic and in open surgical approaches.

Open partial horizontal laryngectomy using CO fiber laser.

A standard for assessing swallowing function after open partial horizontal laryngectomy (OPHL) is still not established. The variability in the measures used to investigate swallowing functional outcomes after OPHL limits the communication among clinicians and the possibility to compare and combine results from different studies. The study aims to adapt the PAS to the altered anatomy after OPHLs using fiberoptic endoscopic evaluation of swallowing (FEES) and to test its reliability. To adapt the PAS, two landmarks were identified: the entry of the laryngeal vestibule and the neoglottis. Ninety patients who underwent an OPHL were recruited (27 type I, 31 type II and 32 type III). FEES was performed and video-recorded. Two speech and language therapists (SLTs) independently rated each FEES using the PAS adapted for OPHL (OPHL-PAS). FEES recordings were rated for a second time by both SLTs at least 15 days from the first video analysis. Inter- and intra-rater agreement was assessed using unweighted Cohen's kappa. Overall, inter-rater agreement of the OPHL-PAS was k = 0.863, while intra-rater agreement was k = 0.854. Concerning different OPHL types, inter- and intra-rater agreement were k = 0.924 and k = 0.914 for type I, k = 0.865 and k = 0.790 for type II, and k = 0.808 and k = 0.858 for type III, respectively. The OPHL-PAS is a reliable scale to assess the invasion of lower airway during swallowing in patients with OPHL using FEES. The study represents the first attempt to define standard tools to assess swallowing functional outcome in this population.

The Penetration-Aspiration Scale: Adaptation to Open Partial Laryngectomy and Reliability Analysis.

The current trend for treatment of intermediate-early advanced laryngeal cancer is essentially oriented toward preservation of organ and laryngeal function, and with a good potential for treating the disease. This goal can be achieved by adopting open laryngeal organ preservation surgery (OLOPS), at present mainly represented by open partial horizontal laryngectomies (OPHLs). An approach using rigorous selection criteria based on both the general condition of the patient and the local and regional extent of the disease gives excellent oncological and functional results in untreated patients. Similar outcomes, albeit slightly worse, are also obtainable in radio-recurrent and laser-recurrent patients. Troublesome postoperative management and the inconsistency of functional recovery are the main limitations for extensive application of this therapeutic strategy. The future direction is represented by simplification of the indications identifying iso-prognostic sub-categories within the T-stage, wider consensus on rehabilitation protocols, hybrid approaches to the larynx, and open minimally invasive access.

Limitations and Opportunities in Open Laryngeal Organ Preservation Surgery: Current Role of OPHLs.

 Speech impairment is common in patients affected by head and neck cancer and impact on quality of life. Therefore, specific instruments are required for its evaluation. The aim of this study is to evaluate the psychometric properties of the Italian Speech Handicap Index.  Data were obtained from 50 patients and 75 asymptomatic subjects. The study consisted of five phases: (1) item generation, (2) internal consistency and reliability analysis, (3) normative data generation, (4) validity analysis, performed by comparing the Italian Speech Handicap Index scores obtained in patients and asymptomatic subjects, and by correlating its scores with the results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module, and (5) cut-off value.  Internal consistency was good (Cronbach  = 0.9) and the test-retest reliability was strong. A significant difference in Italian Speech Handicap Index total score between patients and asymptomatic subjects was found. Moderate correlations between the two questionnaires were observed. A cut-off value of 14.5 demonstrated a sensitivity of 96% and a specificity of 100%.  The Italian Speech Handicap Index is a reliable and valid clinical tool. Its application in everyday practice and outcome research is recommended. IMPLICATIONS FOR REHABILITATION Rehabilitation of speech in head and neck cancer patients is frequently needed, especially after surgical treatment. Speech impairment represents one of the most essential factors influencing the quality of life in head and neck cancer patients. The evaluation of the speech impairment should be performed using dedicated assessment tools.

Psychometric properties of the Italian version of the Speech Handicap Index.

Over the past three decades, the incidence of oropharyngeal squamous cell carcinoma has increased, primarily related to the spread of human papillomavirus. Treatment has always been preferentially unimodal (surgery or radiotherapy) for early stage disease and multimodal (surgery with adjuvant therapy or concomitant chemoradiotherapy) for advanced stages. Recently, the surgical approach has gained renewed interest due to the morbidity of non-surgical treatments and also to technical innovations. We have coined the term 3Des (3D exoscope surgery) to describe the use of the 3D Vitom Exoscope System for transoral surgery of oropharyngeal cancers. During the period from June 2017 to May 2018, 10 patients with oropharyngeal cancer were treated by oropharyngeal surgery with the 3Des approach at FPO IRCCS Institute of Candiolo. The aim of the present prospective study was to evaluate the utility of 3Des for the treatment of early-stage oropharyngeal cancer. 3Des could represent a viable alternative to the operating microscope and robotic surgery thanks to its excellent ability to provide 3D visual information, depth of field, magnification, image contrast, color imaging, and low running costs. It promises great utility in the learning process, with the possibility of recording in high definition.

Erika Crosetti

Head and Neck Oncology Unit

Candiolo Cancer Institute, FPO-IRCCS

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Erika Crosetti

.css-o250i3{font-size:18px;font-family:Open Sans,sans-serif;line-height:21.6px;}Head and Neck Oncology Unit

Candiolo Cancer Institute, FPO-IRCCS

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Head and Neck Oncology Unit