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The New England Journal of Medicine Jun 1991We performed a prospective, randomized study in patients with previously untreated advanced (Stage III or IV) laryngeal squamous carcinoma to compare the results of... (Clinical Trial)
Clinical Trial Comparative Study Randomized Controlled Trial
BACKGROUND
We performed a prospective, randomized study in patients with previously untreated advanced (Stage III or IV) laryngeal squamous carcinoma to compare the results of induction chemotherapy followed by definitive radiation therapy with those of conventional laryngectomy and postoperative radiation.
METHODS
Three hundred thirty-two patients were randomly assigned to receive either three cycles of chemotherapy (cisplatin and fluorouracil) and radiation therapy or surgery and radiation therapy. The clinical tumor response was assessed after two cycles of chemotherapy, and patients with a response received a third cycle followed by definitive radiation therapy (6600 to 7600 cGy). Patients in whom ther was no tumor response or who had locally recurrent cancers after chemotherapy and radiation therapy underwent salvage laryngectomy.
RESULTS
After two cycles of chemotherapy, the clinical tumor response was complete in 31 percent of the patients and partial in 54 percent. After a median follow-up of 33 months, the estimated 2-year survival was 68 percent (95 percent confidence interval, 60 to 76 percent) for both treatment groups (P = 0.9846). Patterns of recurrence differed significantly between the two groups, with more local recurrences (P = 0.0005) and fewer distant metastases (P = 0.016) in the chemotherapy group than in the surgery group. A total of 59 patients in the chemotherapy group (36 percent) required total laryngectomy. The larynx was preserved in 64 percent of the patients overall and 64 percent of the patients who were alive and free of disease.
CONCLUSIONS
These preliminary results suggest a new role for chemotherapy in patients with advanced laryngeal cancer and indicate that a treatment strategy involving induction chemotherapy and definitive radiation therapy can be effective in preserving the larynx in a high percentage of patients, without compromising overall survival.
Topics: Adult; Aged; Antineoplastic Combined Chemotherapy Protocols; Carcinoma, Squamous Cell; Cisplatin; Combined Modality Therapy; Female; Fluorouracil; Humans; Laryngeal Neoplasms; Laryngectomy; Male; Middle Aged; Neoplasm Recurrence, Local; Prospective Studies; Survival Rate
PubMed: 2034244
DOI: 10.1056/NEJM199106133242402 -
European Annals of Otorhinolaryngology,... Jan 2023
Topics: Humans; Anniversaries and Special Events; Laryngectomy
PubMed: 36404207
DOI: 10.1016/j.anorl.2022.10.006 -
International Journal of Surgery... Mar 2022Although guidelines indicate that thyroidectomy should be performed routinely during total laryngectomy in patients with advanced laryngeal cancer, its clinical... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Although guidelines indicate that thyroidectomy should be performed routinely during total laryngectomy in patients with advanced laryngeal cancer, its clinical indications remain controversial. Some researchers believe that thyroid invasion is uncommon and that thyroid preservation should be considered in most cases.
OBJECTIVE
This study aimed to identify the incidence and predictors of thyroid invasion in patients with laryngeal cancer to facilitate decision-making regarding whether to perform thyroidectomy during total laryngectomy.
MATERIALS AND METHODS
The author conducted a systematic review and meta-analysis of all published articles retrieved from a search of the MEDLINE (1982-2020) and EMBASE (1971-2020) databases. The published studies of advanced laryngeal cancer with total laryngectomy and partial or total thyroidectomy for laryngeal cancer were selected. The incidence and predictors of thyroid invasion were analyzed.
RESULTS
We analyzed 25 studies (2177 cases), of which 176 people (8.08%) had thyroid invasion. Subglottic tumors (odds ratio [OR], 3.74; 95% CI, 1.75-7.99), T4 stage tumors (OR, 2.39; 95% CI, 1.20-4.75), subglottic extension (OR, 3.85; 95% CI,2.09-7.11), and thyroid cartilage invasion (OR, 3.98; 95% CI, 1.47-10.75) are risk factors for thyroid invasion, and no statistically significant difference was noted between recurrent tumor and thyroid invasion.
CONCLUSION
The risk of thyroid invasion was significantly higher when advanced laryngeal cancer involved subglottic tumors, T4 stage tumors, subglottic extension, and thyroid cartilage invasion. The overall incidence of thyroid gland invasion was low; therefore, thyroidectomy may be performed for cases deemed risky rather than as a routine measure of total laryngectomy. RESEARCH REGISTRY UIN: reviewregistry1226.
Topics: Carcinoma, Squamous Cell; Humans; Laryngeal Neoplasms; Laryngectomy; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Retrospective Studies; Thyroid Gland; Thyroid Neoplasms; Thyroidectomy
PubMed: 35172203
DOI: 10.1016/j.ijsu.2022.106262 -
Respiratory Research Feb 2023Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration... (Review)
Review
BACKGROUND
Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration prevention. Surgical intervention is indicated for intractable aspiration to prevent potentially life-threatening complications. Since the 1970s, several surgical treatments to prevent aspiration have been reported, and various aspiration prevention surgeries have been introduced, but little is known about them or their benefits. This is a review of the types of aspiration prevention surgery, with the aim of increasing aspiration prevention surgery awareness and their clinical outcomes among medical professionals, which will guide the choices of aspiration prevention surgeries for patients with intractable aspiration.
MAIN BODY
Aspiration prevention surgeries can be categorized into three according to their approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx. Aspiration prevention surgeries to remove the larynx include total and central-part laryngectomy. Aspiration prevention surgeries to alter the structure of the trachea include tracheoesophageal diversion, laryngotracheal separation, and the tracheal flap method. Surgeries to close the larynx can be divided into supraglottic laryngeal closure, glottic laryngeal closure, and subglottic laryngeal closure. Aspiration prevention surgeries prevent aspiration and increase oral intake in 50-80% of patients. Most patients lose vocal function after aspiration prevention surgeries; however, some patients who have undergone total laryngectomy or laryngotracheal separation restored their speech function through tracheoesophageal puncture and use of voice prosthesis. Postoperative suture failure is frequent after epiglottic flap closure and total laryngectomy but rare after central-part laryngectomy, laryngotracheal separation, glottic closure, and subglottic closure. Furthermore, aspiration prevention surgeries improve the quality of life of patients and their caregivers by decreasing suctioning frequency.
CONCLUSIONS
In this review, we described the history and development of aspiration prevention surgeries. Medical professionals need to continually improve their knowledge and skills to facilitate appropriate aspiration prevention surgeries according to patient condition.
Topics: Humans; Quality of Life; Pneumonia, Aspiration; Trachea; Larynx; Laryngectomy; Retrospective Studies
PubMed: 36747240
DOI: 10.1186/s12931-023-02354-0 -
European Archives of... Jan 2018Esophageal speech (ES), tracheoesophageal speech (TES) and/or electrolarynx speech (ELS) are three speech rehabilitation methods which are commonly provided after total... (Review)
Review
BACKGROUND
Esophageal speech (ES), tracheoesophageal speech (TES) and/or electrolarynx speech (ELS) are three speech rehabilitation methods which are commonly provided after total laryngectomy (TL).
METHODS
A systematic review of the literature was conducted to evaluate comparative acoustic, perceptual, and patient-reported outcomes for ES, TES, ELS and healthy speakers.
RESULTS
Twenty-six articles could be included. In most studies, methodological quality was low. It is likely that an inclusion bias exists, many studies only included exceptional speakers. Significant better outcomes are reported for TES compared to ES for the acoustic parameters, fundamental frequency, maximum phonation time and intensity. Perceptually, TES is rated with a significant better voice quality and intelligibility than ES and ELS. None of the speech rehabilitation groups reported clearly better outcomes in patient-reported outcomes.
CONCLUSIONS
Studies on speech outcomes after TL are flawed in design and represent weak levels of evidence. There is an urge for standardized measurement tools for evaluations of substitute voice speakers. TES is the favorable speech rehabilitation method according to acoustic and perceptual outcomes. All speaker groups after TL report a degree of voice handicap. Knowledge of caretakers and differences in health care and insurance systems play a role in the speech rehabilitation options that can be offered.
Topics: Humans; Laryngectomy; Patient Reported Outcome Measures; Speech Intelligibility; Speech, Alaryngeal; Treatment Outcome; Voice Quality
PubMed: 29086803
DOI: 10.1007/s00405-017-4790-6 -
BMC Research Notes Dec 2023Total laryngectomy (TL) is a complex procedure, and patients undergoing TL are at high risk for readmission, which exposes them to hospital-acquired complications....
BACKGROUND
Total laryngectomy (TL) is a complex procedure, and patients undergoing TL are at high risk for readmission, which exposes them to hospital-acquired complications. Readmission rate is a metric for quality of care. We aimed to identify the rate, causes, and predictors of hospital readmission within 60 days after discharge following TL.
METHODS
This is a 12-year retrospective study where we included all patients undergoing TL in a single tertiary care center between 2008 and 2022. Patient charts were reviewed for demographics, comorbidities, and causes for readmission.
RESULTS
Of 83 patients who underwent TL, 12 (14.50%) were readmitted within 60 days. Common causes were surgical site infection (33.33%) and mucocutaneous fistula (25%). Significant predictors for readmission were tobacco use (P = 0.003), African ethnicity (P = 0.004), being unmarried (P < 0.001), lower preoperative serum albumin (P < 0.001), higher preoperative TSH (P = 0.03), higher preoperative neutrophil count (P = 0.035), higher American Society of Anesthesiology (ASA) score (P = 0.028), and higher Cumulative Illness Rating Scale (CIRS) score (P = 0.029).
CONCLUSION
One in every seven patients were readmitted following TL. Frequent causes include wound infection and fistulas. Predictors include preoperative hypoalbuminemia, hypothyroidism, African ethnicity, being unmarried, tobacco use, and a higher baseline burden of comorbidities. Such factors can be targeted to reduce hospital readmission rates.
Topics: Humans; United States; Laryngectomy; Patient Readmission; Retrospective Studies; Risk Factors; Surgical Wound Infection; Postoperative Complications
PubMed: 38124147
DOI: 10.1186/s13104-023-06645-z -
Cureus Sep 2021Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this... (Review)
Review
Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end. Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.
PubMed: 34707956
DOI: 10.7759/cureus.18181 -
European Archives of... Apr 2022Prevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is obtained with nasopharyngeal swabs. By the way, there is no consensus regarding... (Review)
Review
PURPOSE
Prevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is obtained with nasopharyngeal swabs. By the way, there is no consensus regarding sampling in totally laryngectomized subjects (who thus breathe directly by the tracheostomy and, theoretically, may be infected in the trachea). The aim of this study is to evaluate possible differences between swab results in the trachea and in the nasopharynx of this category of patients.
METHODS
A retrospective chart review was performed in April 2021 among patients who previously had been operated on for total laryngectomy and who underwent swabs for SARS-CoV-2 research in 3 health-care centers in Northern-Eastern Italy. Data regarding the site of swabbing (trachea or nasopharynx) were analyzed. A comprehensive review of the literature regarding the same topic was then performed.
RESULTS
A total of 25 totally laryngectomized subjects underwent swabs. Among them, 5 tested positive in the trachea (1) and in the nasopharynx (4). According to the literature review, 4 more subjects tested positive in the trachea (1) and in the nasopharynx (3). Data were overall divergent and no statistically significant correlations emerged between results of the tests performed in the two sites.
CONCLUSION
Due to these discrepancies, both tracheal and nasopharyngeal swabs are recommended in these kinds of patients, to obtain a reliable test and to avoid false negatives.
Topics: COVID-19; COVID-19 Testing; Humans; Laryngectomy; Nasopharynx; Retrospective Studies; SARS-CoV-2; Specimen Handling
PubMed: 34853865
DOI: 10.1007/s00405-021-07203-8 -
Brazilian Journal of Otorhinolaryngology 2020Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with... (Review)
Review
INTRODUCTION
Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with or without chemotherapy.
OBJECTIVE
Our purpose is to review the fistula rate in radiated patients undergoing salvage total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors.
METHODS
We made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed.
RESULTS
We identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p=0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p=0.03) and large pharyngostomes (64.3% versus 0%, p=0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p=0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p=0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes.
CONCLUSIONS
Prophylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy.
Topics: Adult; Aged; Aged, 80 and over; Cutaneous Fistula; Female; Humans; Laryngeal Neoplasms; Laryngectomy; Male; Middle Aged; Neoplasm Staging; Postoperative Complications; Retrospective Studies; Risk Factors; Severity of Illness Index; Surgical Flaps
PubMed: 30683565
DOI: 10.1016/j.bjorl.2018.11.007 -
European Annals of Otorhinolaryngology,... May 2023Analysis of the quality of sexual life after total laryngectomy (TL) for cancer.
OBJECTIVES
Analysis of the quality of sexual life after total laryngectomy (TL) for cancer.
MATERIAL AND METHODS
The Cochrane, PubMed, Embase, ClinicalKey and Science Direct databases were searched using the keywords: "total laryngectomy, sexual function, sexual behavior, sexual complications, sexual dysfunction, sexuality, intimacy". The abstracts of 69 articles were read by two of the authors and 24 articles were selected. The main endpoint was the impact of impairment of quality of sexual life after TL for cancer and the methods used to assess this. The secondary endpoints were the type of sexual impairment, associated variables and their treatment.
RESULTS
The study population consisted of 1511 TL patients aged 21 to 90 years, with a male/female sex ratio of 7.49. One of the 7 validated Likert scales was used in 79% of the articles to evaluate impairment of sexual quality of life. Impaired quality of sexual life was reported by 47% of patients on average (range, 5-90%). Erectile and ejaculatory function and ejaculatory behavior of male patients decreased after TL. Other impairments comprised decreases in libido, frequency of sexual intercourse and satisfaction. Tracheostomy, advanced disease stage, young age and associated depression were factors for impairment. In all, 23% of patients reported lack of postoperative support in this area.
CONCLUSION
The quality of sexual life is severely impacted by TL for cancer. The present data are a source of information and should be taken into account before carrying out TL. A common information tool needs to be developed. There is patient demand for improved management of sexuality.
Topics: Humans; Male; Female; Coitus; Quality of Life; Laryngectomy; Sexual Behavior; Laryngeal Neoplasms
PubMed: 37142505
DOI: 10.1016/j.anorl.2023.04.001