Neurofibromatosis laríngea: a propósito de un caso / Laryngeal neurofibromatosis: a case report

Resumen El neurofibroma laríngeo es poco frecuente, representa menos del 0,1% de las neoplasias benignas de la laringe. Puede presentarse aislado, o más comúnmente asociado a neurofibromatosis tipo I. Se presenta el caso de un paciente varón de 40 años, ya diagnosticado de neurofibromatosis tipo I, que presenta masa supraglótica submucosa asintomática, diagnosticada como hallazgo casual en una intubación por una cirugía previa programada.

Abstract Laryngeal neurofibroma is rare, representing less than 0.1% of benign tumors of the larynx. It can occur in isolation or more commonly associated with type I neurofibromatosis. The case of a 40-year-old male patient, already diagnosed with type I neurofibromatosis, is presented with an asymptomatic submucosal supraglottic mass, diagnosed as a chance finding in intubation due to a previous scheduled surgery.

Rabdomiosarcoma laríngeo en un adulto, descripción de un caso y revisión de la literatura / Adult laryngeal rhabdomyosarcoma. Case report and literature review

Resumen El rabdomiosarcoma laríngeo es un cáncer infrecuente en cabeza y cuello, y aún más en adultos. Describimos el caso de un varón de 55 años con un rabdomiosarcoma del músculo cricoaritenoideo posterior izquierdo tratado mediante laringectomía total y linfadenectomía funcional bilateral.

Abstract Laryngeal rhabdomyosarcoma is an uncommon cancer in head and neck, especially in adults. We report a 55 years old male with a rhabdomyosarcoma from the left posterior cricoarytenoid muscle treated with a total laryngectomy and double functional cervical lymphadenectomy.

Tumor miofibroblástico inflamatorio de laringe: a propósito de un caso / Inflammatory myofibroblastic tumor of the larynx: a case report

Resumen El tumor miofibroblástico inflamatorio (TMI) es una patología muy poco frecuente. Los TMI localizados en laringe pueden ocasionar disfonía o sensación de cuerpo extraño. El diagnóstico se realiza a través de pruebas de imagen y visualización directa con obtención de muestras para estudio histopatológico. Presentamos el caso de una mujer de 43 años, con antecedentes personales de carcinoma indiferenciado de nasofaringe, tratado con radioterapia y quimioterapia, que acude a revisiones periódicas en consulta de otorrinolaringología. Se objetiva por nasofibroscopia una lesión rugosa en cuerda vocal izquierda. Se realiza biopsia con fibroscopio de canal, compatible con tumoración fusocelular atípica, con áreas celulares y mixoides, sospechosa de malignidad, con necesidad de completar estudio inmunohistoquímico. En comité de tumores de cabeza y cuello se decide cirugía programada (laringectomía supracricoidea con cricohioidoepiglotopexia) y posterior tratamiento adyuvante con quimioterapia y/o radioterapia, según resultados del estudio histopatológico. Como conclusión, el TMI es una patología que se encuentra predominantemente en el pulmón, siendo rara la afectación laríngea. Su pronóstico es favorable y el diagnóstico histopatológico es de vital importancia. El diagnóstico correcto va seguido de una escisión local amplia para prevenir la recurrencia, sin embargo, el tratamiento debe adaptarse a la ubicación del tumor y al estado del paciente.

Abstract Inflammatory myofibroblastic tumor (IMT) is a very rare pathology. IMTs located in the larynx can cause dysphonia or foreign body sensation. The diagnosis is made through imaging tests and direct visualization and confirmation with samples for histopathological study. We present the case of a 43-year-old woman with a personal history of undifferentiated carcinoma of the nasopharynx treated with radiotherapy and chemotherapy, who attended periodic check-ups in an otolaryngology clinic. A rough granulomatous lesion was observed by nasofibrolaryngoscopy in the left vocal cord. A canal fibroscope biopsy is performed, compatible with an atypical spindle cell tumor, with cellular and myxoid areas, suspicious of malignancy, requiring an immunohistochemical study to be completed. The head and neck tumor committee decides on scheduled surgery (supracricoid laryngectomy with cricohyoidoepiglottopexy) and subsequent adjuvant treatment with chemotherapy and/or radiotherapy, according to the results of the histopathological study. As a conclusion finally, the IMT is a pathology found predominantly in the lung, laryngeal involvement being rare. Its prognosis is favorable and the histopathological diagnosis is of vital importance to be able to be differentiated from other malignant neoplasms. The correct diagnosis is followed by a wide local excision to prevent recurrence, however, treatment must be tailored to the location of the tumor and the condition of the patient.

Feasibility and perioperative safety of transoral robotic surgery with da Vinci Xi platform / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the feasibility and perioperative safety of transoral robotic surgery with da Vinci Xi platform for pharyngolaryngeal tumors. Methods: A retrospective analysis was performed on 55 consecutive cases with resection of pharyngolaryngeal tumors by transoral robotic surgery with da Vinci Xi platform from July 27, 2020 to October 31, 2021 in the Department of Head and Neck Surgery, Fudan University Eye, Ear, Nose and Throat Hospital, including 44 males and 11 females, aged 25-79 years. There were 41 cases of oropharyngeal tumors, 9 cases of parapharyngeal space tumors, 2 cases of laryngeal tumors, 2 cases of hypopharyngeal tumors and 1 case of retropharyngeal space tumor. Operative time, intraoperative blood loss, postoperative hospital stay, perioperative tracheotomy, nasal feeding, hemorrhage and other complications were analyzed. Results: Of the 55 patients, 54 received resection of pharyngolaryngeal tumors by da Vinci robot through oral approach, and only 1 case of pyriform sinus carcinoma underwent a conversion to open surgery due to poor exposure of lower margin. The average surgical time for the patients with transoral robotic surgeries was 64.4 min, the average blood loss was 24.8 ml, the average postoperative hospital stay was 6.9 d, and the average oral feeding time was 11.1 d. Seventeen patients (30.9%) underwent preventive tracheotomy during surgery. Among 38 cases of laryngeal cancer, 28 underwent simultaneously neck dissection. No serious complications occurred in all patients during and after operation. The follow-up time was 1-15 months. Aside from 1 patient had a relapse 10 months after surgery, other patients had no recurrence or metastasis. Conclusion: Transoral robotic surgery with da Vinci Xi is safe, effective and minimally invasive for resection of pharyngolaryngeal tumors under reasonable indications.

Preventing and treating anterior commissure adhesion with mucosal flap: a study in canines and clinical cases / 中华耳鼻咽喉头颈外科杂志

Objective: To evaluate the effectiveness of mucosal flap combined with silicone keel for preventing and treating anterior commissure adhesion in canines and clinical cases. Methods: A prospective experiment was performed from November 2019 to June 2021. Twenty five canines were randomly divided into 5 groups(A, B, C, D, E). Group A, B, C, D received anterior commissure injury by CO2 laser, then separately treated with free mucosal flap-keel complex,intralaryngeal mucosal flap-keel complex, silicone keels and without treatment, group E didn't injure the vocal cord after intubation. The keel was removed after 2 weeks, the larynx was harvested after 4 weeks. The effectiveness of anterior commissure adhesion prevention was evaluated by manifestation under laryngoscope, standard vocal cord length and standard glottic area. A retrospective analysis was performed on sixteen patients with anterior commissure lesion, who underwent mucosal flap-keel technique in Huashan Hospital of Fudan University from January 2019 to January 2021 (10 cases with free mucosal flap-keel complex and 6 cases with intralaryngeal mucosal flap-keel complex). All the patients underwent evaluation of laryngeal function included manifestation under laryngoscope each month and voice analysis before and 3 month after surgery. SPSS 20.0 software was used for statistical analysis. Results: No surgery accident or complication happened in canines and patients. The standard vocal cord length and standard glottic area after 4 weeks in group B were significantly higher than those in group A, C, D (Hstandard vocal cord length=31.688, Hstandard glottic area=16.444, P<0.05). The standard vocal cord length and standard glottic area after 4 weeks in group A were also significantly higher than those in group C, D(Hstandard vocal cord length=20.936, Hstandard glottic area=11.786, P<0.05). The standard vocal cord length and standard glottic area after 4 weeks in group A, B, E were not significantly different to that before surgery(tA left standard vocal cord length=2.636, tA right standard vocal cord length=2.582, tB left standard vocal cord length=2.707, tB right standard vocal cord length=2.673, tE left standard vocal cord length=0.370, tE right standard vocal cord length=0.821, tA standard glottic area=2.731, tB standard glottic area=2.753, tE standard glottic area=-0.529, P>0.05). The standard vocal cord length and standard glottic area after 4 weeks in group C, D were significantly lower than those before surgery(tC left standard vocal cord length=16.137, tC right standard vocal cord length=13.984, tD left standard vocal cord length=11.903, tD right standard vocal cord length=14.587, tC standard glottic area=10.280, tD standard glottic area=22.974, P<0.05). During 6-18 months of follow-up in clinical patients, no one developed a glottic web. Three months after surgery, Jitter, Shimmer, noise to harmonic ratio(NHR), the maximum phonation time(MPT)in all patients were significantly different from preoperative(tintralaryngeal mucosal flap jitter=24.885, tintralaryngeal mucosal flap shimmer=22.643, tintralaryngeal mucosal flap NHR=6.202, tintralaryngeal mucosal flap MPT=-9.661, tfree mucosal flap jitter=25.459, tfree mucosal flap shimmer=18.683, tfree mucosal flap NHR=5.705, tfree mucosal flap MPT=-20.840, P<0.05). Conclusion: Mucosal flap combined with silicone keel is an effective technique for preventing and treating anterior commissure adhesion. The effect of pedicled intralaryngea lmucosal flap is better.

Comparación de sutura mecánica con sutura manual de la faringe en laringectomía total / Comparison of mechanical suture with manual suture of the pharynx in total laryngectomy

Introducción: La sutura mecánica es una opción para el cierre de la faringorrafia en laringectomía total por cáncer de laringe. Objetivo: Comparar el uso de sutura mecánica lineal con sutura manual de la faringe durante la laringectomía total por cáncer de laringe. Material y Método: Se realizó un estudio de tipo experimental prospectivo. Se compararon dos grupos pacientes: Los pacientes con sutura mecánica desde 2018 a marzo de 2020 y los pacientes con sutura manual previa a enero de 2018 en el Servicio de Otorrinolaringología del Hospital Barros Luco. Se analizaron fístula faringo-cutánea posoperatoria (FFC), tiempo operatorio, estadía hospitalaria y costo. Resultados: El estudio incluyó a 14 pacientes, cada grupo con n = 7. El grupo con sutura mecánica presento 0% de FFC y el grupo sutura manual 28%. El grupo con sutura mecánica reinicio alimentación a los 7 días y el grupo con sutura manual en promedio a los 11,5 (7-23) días. (p = 0,0023). El tiempo promedio de cirugía para el grupo experimental es de 288 ± 37,4 minutos y con sutura manual 311 ± 32,4 minutos. (p = 0,0176). El promedio de hospitalización para el grupo experimental fue de 11 ± 2,6 días (9 a 16), y para el grupo control fue de 21 ± 14 días (10 a 49) (p < 0,0001). Conclusión: La sutura mecánica es un procedimiento fácil de usar y seguro. Existiría un beneficio en el uso de sutura mecánica para el cierre faríngeo al compararlo con la sutura manual al disminuir el número de FFC, el tiempo operatorio y los días de hospitalización.

Introduction: Mechanical suture is an option for the closure of the pharyngorrhaphy in total laryngectomy due to laryngeal cancer. Aim: To compare the use of linear mechanical suture with manual pharyngeal suture during total laryngectomy for laryngeal cancer. Material and Method: A prospective experimental study was carried out. Two patient groups were compared: patients with mechanical suture from 2018 to March 2020 and patients with manual suture prior to January 2018 at the otorhinolaryngology service of the Barros Luco Hospital. Postoperative pharyngocutaneous fistula (FFC), operative time, hospital stay and cost were analyzed. Results: The study included 14 patients, each group with n = 7. The group with mechanical suture presented 0% of FFC and the group with manual suture 28%. The group with mechanical suture restarted feeding at 7 days and the group with manual suture on average at 11.5 (7-23) days (p = 0.0023). The average surgery time for the experimental group was 288 ± 37.4 minutes, while for the group with manual suture was 311 ± 32.4 minutes (p = 0.0176). The mean hospitalization for the experimental group was 11 ± 2.6 days (9 to 16), and for the control group it was 21 ± 14 days (10 to 49) (p < 0.0001). Conclusion: The mechanical suture is an easy to use and safe procedure. There would be a benefit in the use of mechanical suture for pharyngeal closure when buying it with manual suture by reducing the number of FFCs, operative time and days of hospitalization.

Debulking obstructing laryngeal cancers to avoid tracheotomy / Redução de volume tumoral em câncer obstrutivo de laringe para evitar traqueotomia

Abstract Introduction: Upper airway obstruction, secondary to neoplasms presenting with stridor, is traditionally treated by tracheostomy. However, this common procedure can potentially have an impact on the long-term outcome, with tumor implantation into the tracheostomized wound leading to peristomal recurrence after laryngectomy, with the risk of stomal recurrence. Objective: To describe our clinical experience with tumor debulking as an alternative treatment choice of tracheotomy in patients with advanced larynx cancer at a tertiary referral center. Methods: A retrospective chart review of 87 subjects who had advanced larynx cancer (T3/4) with airway obstruction from our institutional database was conducted. Medical records including demographics, daily notes during hospitalization, and operative notes were used for clinical data of patients. The strategy for maintaining the airway patency was tracheotomy (emergency or awake) and tumor debulking (laser or coblation). Endophytic and exophytic laryngeal tumors were also noted. Results: In 41/87 (47.1%) patients, a tracheotomy was performed as an initial treatment (11 were emergency, 30 were planned) to maintain airway patency. Tumor debulking was performed in 28 exophytic and 18 endophytic lesions by laser or coblation (17 and 29 patients, respectively). Tracheotomy was performed in 5 patients (4 endophytic, 1 exophytic) who could not tolerate debulking surgery due to aspiration, edema and dyspnea. Three of the them who required subsequent tracheotomy was in the laser group and two in the coblation group. The success rate of laser debulking was 82.35% (14/17) and 93.1% (27/29) for coblation. Conclusion: Tumor debulking is a safe and effective method to avoid awake tracheotomy in patients suffering from airway obstruction due to advanced larynx cancer.

Resumo Introdução: A obstrução das vias aéreas superiores com estridor, secundária a neoplasias, é tradicionalmente tratada com traqueotomia. No entanto, este procedimento comum pode potencialmente ter um impacto sobre o desfecho a longo prazo, com a implantação do tumor na ferida cirúrgica da traqueotomia, o que leva à recorrência peristomal após laringectomia, com o risco de recorrência do estoma. Objetivo: Descrever nossa experiência clínica com a redução do volume tumoral como tratamento alternativo à traqueotomia em pacientes com câncer avançado de laringe em um centro de referência terciário. Método: Foi realizada uma revisão retrospectiva de prontuários de 87 indivíduos com câncer avançado de laringe (T3/T4) com obstrução das vias aéreas em nosso banco de dados institucional. Registros médicos incluindo dados demográficos, anotações diárias durante a hospitalização e anotações operacionais foram utilizados como dados clínicos dos pacientes. A estratégia para manter a patência das vias aéreas foi a traqueotomia (emergência ou em pacientes acordados) e redução do volume tumoral (por laser ou coblation). Tumores endofíticos e exofíticos da laringe também foram anotados. Resultados: Uma traqueotomia foi realizada como tratamento inicial em 41/87 (47,1%) pacientes (11 foram de emergência, 30 foram eletivas) para manter a patência das vias aéreas. A redução do volume tumoral foi realizada em 28 lesões exofíticas e 18 endofíticas por laser ou coblation (17 e 29 pacientes, respectivamente). A traqueotomia foi realizada em 5 pacientes (4 endofíticos, 1 exofítico) que não podiam tolerar a cirurgia de redução de volume devido à aspiração, edema e dispneia. Três deles que necessitaram de uma traqueotomia subsequente estavam no grupo de laser e dois no grupo coblation. A taxa de sucesso da redução tumoral foi de 82,35% (14/17) para o laser e 93,1% (27/29) para coblation. Conclusão: A redução do volume tumoral é um método seguro e eficaz para evitar a traqueotomia com paciente acordado, nos casos de obstrução das vias aéreas devido ao câncer de laringe avançado.

Application of enhanced recovery after surgery in laryngeal cancer surgery with multi-disciplinary team / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the application value of enhanced recovery after surgery (ERAS) with the multidisciplinary team (MDT) model in laryngeal cancer surgery. Methods: Eighty patients with laryngeal cancer treated in Department of Otorhinolaryngology Head and Neck Surgery of Yantai Yuhuangding Hospital from May 2016 to June 2017 were selected, including 76 males and 4 females, aged 45 to 75 years old. By random number table method, they were divided into ERAS group (40 cases) and control group (40 cases). Visual analogue scale (VAS), general comfort questionnaire (GCQ) and self-rating Anxiety Scale (SAS) were used to evaluate the symptoms and signs and psychological state of the two groups before and after operation. Mann Whitney U test was used for non-normal distribution data, and chi square test, Fisher exact probability method and covariance analysis were used for classification data. Repeated measures analysis of variance was used for the comparison of each group at different time points. Results: Two cases in the ERAS group and six cases in the control group withdrew from the study for some reason. Finally, 38 cases in the ERAS group and 34 cases in the control group were enrolled in this study. The postoperative pain scores of the two groups were the highest at 6 h after operation, and then gradually decreased. At different time points after operation, the pain scores of ERAS group were lower than those of the control group. At 24 h after operation, the pain relief degree of ERAS group was significantly higher than that of the control group, with a statistically significant difference (P<0.05). Compared to control group, ERAS group had lower preoperative thirst score [(0.15±0.36) vs. (4.29±1.17), Z=-7.695, P<0.001] and hunger score [(0.38±0.49) vs. (3.44±1.13), Z=-7.426, P<0.001]. The total number of postoperative adverse reactions (8 vs.16), oral feeding time [(4.06±4.42) d vs. (9.06±2.42) d] and postoperative hospital stay [(5.91±0.97) d vs. (11.03±2.11)d] in ERAS group were lower than those in control group (statistics 5.461, -4.558, -7.347, P<0.05), but there was no significant difference in postoperative catheter indwelling time and neck drainage tube indwelling time between the two groups (P>0.05). Before discharge, the comfort of ERAS group was significantly higher than that of control group [(60.37±8.78) vs. (50.38±8.08), Z=-4.370, P<0.001]. Before discharge, the anxiety level of ERAS group decreased, while that of the control group increased significantly, which was higher than that of ERAS Group [(59.12±6.43) vs. (52.62±6.25), Z=-4.179, P<0.001]. Conclusion: The application of multidisciplinary ERAS in laryngeal cancer surgery can improve preoperative hunger and thirst, postoperative pain and mental state, shorten the length of hospital stay and reduce postoperative adverse reactions.

Supracricoid laryngectomy: the impact of senescence on swallowing safety / Laringectomia supracricóidea: o impacto da senescência na segurança da deglutição

ABSTRACT: Objective: To investigate the association between aging and the functional aspects of swallowing (laryngeal penetration and laryngotracheal aspiration) in individuals who underwent supracricoid laryngectomy in the late period and without complaints. Methods: A total of 70 patients, 56 (80%) aged >60 years and 14 (20%) <60 years, under outpatient follow-up, after cancer treatment and with no complaints of swallowing, performed functional evaluation using the swallowing videofluoroscopy. Image classification was performed using the penetration-aspiration scale developed by Rosenbek. The χ2 test and logistic regression were applied to associate the age categories to the outcomes (penetration and aspiration). Results: Patients aged over 60 years had a higher prevalence of penetration (24.29%) and aspiration (48.57%) than patients aged under 60 years. In this sample, aspiration was associated with age. Patients aged over 60 years were more likely to present penetration (27% more) during swallowing than patients under 60 years. Patients aged over 60 years had an approximately four-fold greater probability of laryngotracheal aspiration than patients aged under 60 years. Conclusion: In patients without complaints of swallowing in the late postoperative period of supracricoid laryngectomy, there is a greater probability of laryngotracheal aspiration in elderly aged over 60 years than in individuals under 60 years.

RESUMO Objetivo: Investigar a associação entre o envelhecimento e os aspectos funcionais da deglutição (penetração laríngea e aspiração laringotraqueal) em indivíduos submetidos à laringectomia supracricóidea no período tardio e sem queixas. Métodos: Setenta pacientes, sendo 56 (80%) >60 anos e 14 (20%) <60 anos, em acompanhamento ambulatorial, após tratamento oncológico e sem queixas de deglutição, realizaram avaliação funcional por meio da videofluoroscopia da deglutição. A classificação das imagens foi realizada por meio da escala de penetração-aspiração desenvolvida por Rosenbek. O teste do χ2 e a regressão logística foram aplicados para associação das categorias de idade aos desfechos (penetração e aspiração). Resultados: Os pacientes com idade acima de 60 anos apresentaram maior prevalência de penetração (24,29%) e aspiração (48,57%) do que aqueles com idade inferior a 60 anos. Nesta amostra, a aspiração se mostrou associada à idade. Pacientes acima de 60 anos tiveram chance 27% maior de penetração durante a deglutição do que os com menos de 60 anos. Pacientes acima de 60 anos tiveram chance aproximadamente quatro vezes maior de aspiração laringotraqueal do que pacientes com menos de 60 anos. Conclusão: Em pacientes sem queixas de deglutição no pós-operatório tardio de laringectomia supracricóidea, há maior chance de aspiração laringotraqueal em idosos acima de 60 anos do que em indivíduos abaixo de 60 anos.

Reconstrução atípica de laringe: avaliação funcional pós-laringectomia supratraqueal ampliada com cricoglossohioidopexia / Atypical reconstruction of the larynx: functional assessment after enlarged supratracheal laryngectomy with cricoglossohioidopexy

RESUMO Em tumores transglóticos estendidos para base de língua, a indicação para ressecção do osso hioide descarta a possibilidade de realização de uma laringectomia parcial horizontal clássica, devido ao grande risco de complicações pulmonares oriundas de uma disfagia grave. O objetivo deste estudo foi descrever os aspectos funcionais de deglutição e voz de um paciente submetido à laringectomia supratraqueal ampliada com cricoglossohioidopexia. Trata-se de um homem de 69 anos, com tumoração transglótica na hemilaringe direita, submetido à laringectomia supratraqueal ampliada, com ampliação para base de língua, osso hioide e aritenoide direita. Na videofluoroscopia da deglutição, observou-se aspiração silente para líquido fino durante a deglutição e resíduo em base de língua, valécula, aritenoide, esfíncter esofágico superior e recessos piriformes em todas as consistências e volumes. Na videolaringoscopia, observou-se voz por meio da vibração da unidade cricoaritenóidea esquerda, associada à base de língua e constritores da faringe. No protocolo Consensus Auditory-Perceptual Evaluation of Voice (CAPE V), notou-se grau moderado de rouquidão e soprosidade. O paciente apresentou preservação parcial das funções laríngeas, grau moderado de disfonia e alimentação e hidratação exclusivas por via oral, com sólidos macios e líquido espessado em néctar, sem prejuízos à saúde pulmonar, até o momento.

ABSTRACT In transglottic tumors extended to the base of the tongue, the indication for resection of the hyoid bone rules out the possibility of performing a classic horizontal partial laryngectomy due to the high risk of pulmonary complications resulting from severe dysphagia. This study aims to describe the functional aspects of swallowing and voice of a patient undergoing an enlarged supratracheal laryngectomy with cricoglossohioidopexy. This is a 69-year-old man with a transglottic tumor in the right hemilarynx, who underwent an extended supratracheal laryngectomy with enlargement to the base of the tongue, hyoid bone and right arytenoid. In swallowing videofluoroscopy, silent aspiration was observed in fine liquid and residue on the basis of tongue, valecule, arytenoid, upper esophageal sphincter and pyriform recesses in all consistencies and volumes. In videolaryngoscopy, a voice was observed through the vibration of the left cricoarytenoid unit associated with the base of the tongue and constrictors of the pharynx. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE V) showed a moderate degree of hoarseness and breathiness. The patient had partial preservation of laryngeal functions, with a moderate degree of dysphonia and exclusive oral feeding and hydration with soft solids and thickened liquid in nectar without impairing lung health until the study.

Plasmocitoma extramedular de laringe: a propósito de un caso / Extramedullary plasmacytoma of the larynx: a case report

Resumen Los plasmocitomas solitarios son una rara forma de presentación de neoplasias de células plasmáticas. Deben ser diferenciados del mieloma múltiple en el momento del diagnóstico y realizar un seguimiento estricto por el riesgo de transformación a mieloma. La localización de los mismos en la laringe es muy inusual, dado que sólo se han publicado 56 casos. Se presenta el caso de una paciente con un plasmocitoma extramedular de laringe que se trató mediante cirugía y radioterapia. Se revisan los criterios diagnósticos y los problemas terapéuticos.

Abstract Solitary plasmacytomas are a rare form of plasma cell neoplasms. They should be differentiated from multiple myeloma at the time of diagnosis and strictly monitored for the risk of transformation to myeloma. Their location in the larynx is very unusual, since only 56 cases have been published. We present the case of a patient with extramedullary plasmacytoma of the larynx that has been treated with surgery and radiotherapy. We reviewed the literature for diagnostic criteria and therapeutic problems.

Which risk factors are associated with stomal recurrence after total laryngectomy for laryngeal cancer? A meta-analysis of the last 30 years / Quais fatores de risco estão associados à recorrência estomal após laringectomia total para câncer de laringe? Uma meta-análise dos últimos 30 anos

Abstract Introduction Stomal recurrence is a troublesome complication after total laryngectomy. Despite a large number of studies having been performed, there is still controversy about which risk factors are most significant for the development of stomal recurrence. Objective The objective of the present meta-analysis was to analyze the potential factors leading to stomal recurrence after total laryngectomy. Methods PubMed, Web of Science, Cochrane Library, and Ovid databases were systematically searched using multiple search terms. Eighteen studies with 6462 patients were identified. The quality of evidence was assessed by The National Institute for Health and Clinical Excellence. Results The results showed that, tumor subsite (supraglottic vs. subglottic, RR = 0.292, 95% CI 0.142-0.600, p = 0.001; glottic vs. subglottic, RR = 0.344, 95% CI 0.175-0.676, p = 0.002), T stage (RR = 0.461, 95% CI 0.286-0.742, p = 0.001), preoperative tracheotomy (RR = 1.959, 95% CI 1.500-2.558, p < 0.001) were the high-risk factors associated with the development of stomal recurrence. Conclusion From the results of our study, tumor subsite, T stage and preoperative tracheotomy were the significant risk factors for stomal recurrence. Methodologically high-quality comparative investigations are needed for further evaluation.

Resumo Introdução A recorrência estomal pós-laringectomia total e é uma complicação de difícil manejo. Apesar de um grande número de estudos ter sido feito, ainda há controvérsias sobre quais fatores de risco são mais significativos para o seu desenvolvimento. Objetivo O objetivo da presente meta-análise foi analisar os fatores potenciais para recorrência estomal após a laringectomia total. Método As bases de dados PubMed, Web of Science, Cochrane Library e Ovid foram sistematicamente pesquisadas com vários termos de busca. Dezoito estudos com 6.462 pacientes foram identificados. A qualidade da evidência foi avaliada pelo National Institute for Health and Clinical Excellence. Resultados Os resultados mostraram que o subsítio tumoral (supraglótico vs. subglótico, RR = 0,292, IC 95% 0,142 ± 0,600, p = 0,001; glótico vs. subglótico, RR = 0,344, IC 95% 0,175 ± 0,676, p = 0,002), estágio T (RR = 0,461, IC 95% 0,286 ± 0,742, p = 0,001), traqueotomia pré-operatória (RR = 1,959, IC 95% 1.500 ± 2.558, p < 0,001) foram os fatores de alto risco associados ao desenvolvimento de recorrência estomal. Conclusão Com base nos resultados de nosso estudo, o subsítio do tumor, o estágio T e a traqueotomia pré-operatória foram fatores de risco significativos para recorrência estomal. São necessárias investigações comparativas metodologicamente de alta qualidade para maior avaliação.

Salvage total laryngectomy: is a flap necessary? / Laringectomia total de resgate: o uso de retalho é necessário?

Abstract 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.

Resumo Introdução: A fístula faringocutânea é a complicação mais significativa após laringectomia total de resgate em pacientes que receberam tratamento prévio com radioterapia com ou sem quimioterapia. Objetivo: Revisar a taxa de fístula em pacientes irradiados submetidos a laringectomia total de resgate, para determinar se o uso de interposição de retalho do peitoral maior reduz a incidência e a duração da fístula e examinar outros fatores de risco. Método: Fizemos uma revisão retrospectiva de pacientes submetidos à laringectomia total de resgate para câncer exclusivamente laríngeo após falha da radioterapia curativa primária entre 2000 e 2017. Dados gerais dos pacientes, fatores de risco e outras complicações foram analisados. Resultados: Foram identificados 27 pacientes com média de 66,4 anos, principalmente do sexo masculino (92,5%). O grupo de fechamento primário sem retalho de peitoral maior incluiu 14 pacientes e o grupo de fechamento com retalho de peitoral maior incluiu 13 pacientes. Fístula faringocutânea esteve presente em 15 pacientes (55,5%). A taxa global de fístula faringocutânea foi maior no grupo de pacientes sem retalho de peitoral maior em comparação com aqueles que receberam o retalho (78,6% vs. 30,8%, p = 0,047). Além disso, as fístulas faringocutâneas que precisaram ser reparadas através de cirurgia (64,3% vs. 7,7%, p = 0,03) e grandes faringostomias (64,3% vs. 0%, p = 0,0004) apresentaram uma taxa mais alta no grupo fechado primariamente sem retalho do peitoral maior. Não encontramos outros fatores de risco com significância estatística. O início da dieta oral (84 dias vs. 21,5 dias, p = 0,039) e a duração da internação (98,3 dias vs. 27,2 dias, p = 0,0041) foram muito menores nos pacientes com uso preventivo do retalho do peitoral maior. Dois pacientes morreram em consequência de complicações de grandes faringostomias. Conclusões: O uso profilático do retalho do peitoral maior reduziu a incidência, a gravidade e a duração da fístula e deve ser considerado durante a laringectomia total de resgate.

Profile of Laryngeal Microsurgeries in Patients Over 60 Years Old

Abstract Introduction The increase in life expectancy is an incentive to the development of researches with the elderly population aiming at actions that may ensure healthy and active aging. Objective To analyze the profile of laryngeal microsurgery performed in patients > 60 years old. Methods A retrospective observational study, with a cross-sectional design. A retrospective analysis of the medical records of elderly patients submitted to laryngeal microsurgery was performed at a private hospital in Curitiba, state of Paraná, Brazil, between January 2004 and December 2016. Were included all of the patients > 60 years old that underwent laryngeal microsurgery during this period. Results During the studied period, 213 laryngeal microsurgeries were performed in 181 patients > 60 years old. There was a preponderance of male patients. The mean age was 67.6 years old. Squamous cell carcinoma (SCC) was the most prevalent disorder (26%), followed by Reinke edema (20%), papillomatosis (14%), polyps (11%), leukoplakia (8%), minor structural alterations (8%), associated lesions (9%), and others (4%). Men presented a higher probability of SCC diagnosis, regardless of the age group, while Reinke edema was more frequently observed in women. A directly proportional relation between the frequency of laryngeal cancer and age increase was also observed. No significant differences were observed in professional voice users. Conclusion Further researches are required to properly comprehend the factors associ- ated with laryngeal lesions and determine prevention and treatment approaches.

Cirugía transoral en cáncer de laringe estadificado T1-T2 / Transoral surgery in T1-T2 staged laryngeal cancer

Se realizó un estudio prospectivo y descriptivo, incluyendo 103 pacientes que fueron tratados por cáncer de laringe en etapa inicial (T1-T2) con cirugía transoral. De ellos, 55 se diagnosticaron en estadio T1, 16 en estadio T1-b y 32 en estadio T2. El control local inicial (CLI) en pacientes con tumores malignos de laringe estadificados T1 fue 91%, el control local con rescate (CLR) 96%, la preservación de la función de la laringe (PFL) 93% y la sobrevida específica 96%. En T1-b, el CLI fue 81%, el CLR 94%, la PFL 94% y la sobrevida específica 94%. En T2, el CLI fue 63%, el CLR 94%, la PFL 72% y la sobrevida específica 78%. La cirugía transoral en cáncer de laringe con T inicial tiene resultados oncológicos similares a otros tratamientos (cirugía externa o radioterapia), pero consideramos que es la mejor opción por su baja morbilidad, menor duración del tratamiento, y porque deja abiertas todas las posibilidades para tratar posibles recurrencias. (AU)

A prospective and descriptive study was conducted, including 103 patients who were treated for early stage laryngeal cancer (T1-T2) with transoral surgery. Of these, 55 were diagnosed in stage T1, 16 in stage T1-b and 32 in stage T2. The initial local control (CLI) in patients with malignant T1 laryngeal tumors was: 91%, local control with rescue (CLR) 96%, preservation of larynx function (PFL) 93% and specific survival 96%. In T1-b the CLI was 81%, the CLR 94%, the PFL 94% and the specific survival 94%. In T2 the CLI was 63%, the CLR 94%, the PFL 72% and the specific survival 78%. Transoral surgery in laryngeal cancer with initial T has oncological results similar to other treatments (external surgery or radiotherapy), but we consider that it is the best option because of its low morbidity, shorter duration of treatment, and because it leaves open all the possibilities to treat possible recurrences. (AU)

Swallowing, voice and quality of life of patients submitted to extended supratracheal laryngectomy / Deglutição, voz e qualidade de vida de pacientes submetidos à laringectomia supratraqueal alargada

ABSTRACT Objective To describe functional and quality of life results after extended supratracheal laryngectomy. Methods In the period from September 2009 to January 2018, 11 male subjects were submitted to extended supratracheal laryngectomy. Swallowing abilities were assessed through videofluoroscopy and the clinical scale Functional Communication Measures of Swallowing. The voices were classified by means of the perceptual-auditory analysis Consensus Auditory-Perceptual Evaluation of Voice. All subjects completed a self-assessment questionnaire for voice and swallowing. Results Aspiration was found in four patients and all presented stasis in different structures. All subjects in this study were exclusively orally fed and hydrated. In the evaluation of quality of life in swallowing, patients had mean >80 in all areas (83.47 mean of scores). The general degree and the presence of roughness were the highest means present in Consensus Auditory-Perceptual Evaluation of Voice (37.81 and 49.36, respectively). The mean of 33.36 (±22.56) had little impact on quality of life under the perspective of vocal aspects. Conclusion After supratracheal laryngectomy, swallowing was sufficiently restored and the quality of life was satisfactory. The voice presents severely impaired quality and preserved oral communication, with low impact on the activities of daily living. All individuals who maintained two cricoarytenoid units presented better functional results in swallowing and voice.

RESUMO Objetivo Descrever os resultados funcionais e de qualidade de vida após a laringectomia supratraqueal alargada. Métodos No período de setembro de 2009 a janeiro de 2018, 11 indivíduos do sexo masculino foram submetidos à laringectomia supratraqueal alargada. As habilidades de deglutição foram avaliadas por meio da videofluoroscopia e da escala clínica Functional Communication Measures . As vozes foram classificadas por análise perceptivo-auditiva da Consensus Auditory-Perceptual Evaluation of Voice . Todos os voluntários preencheram um questionário de autoavaliação para voz e deglutição. Resultados A aspiração foi encontrada em quatro pacientes, e todos apresentaram estase em diferentes estruturas. Todos os sujeitos deste estudo apresentavam alimentação e hidratação exclusivas por via oral. Na avaliação da qualidade de vida na deglutição, os pacientes demonstraram médias >80 em todas as áreas (83,47 média dos escores). O grau geral e a presença de rugosidade foram os maiores escores médios na avaliação perceptivo-auditiva da voz (37,81 e 49,36 consecutivamente). A média de 33,36 (±22,56) demonstrou pouco impacto na qualidade de vida sob a perspectiva dos aspectos vocais. Conclusão Após a laringectomia supratraqueal, a deglutição foi suficientemente restaurada, e a qualidade de vida foi satisfatória. A voz apresenta qualidade gravemente comprometida com comunicação oral preservada, demonstrando baixo impacto nas atividades da vida diária. Todos os indivíduos que mantiveram duas unidades cricoaritenóideas apresentaram melhores resultados funcionais na deglutição e na voz.

Angulação do osso hioide e segurança da deglutição pós-laringectomia parcial horizontal supracricóidea e cricohioidoepiglotopexia / Hyoid bone angle and swallowing safety post supracricoid horizontal partial laryngectomy and cricohyoidoepiglottopexy

RESUMO Objetivo investigar o possível impacto da angulação do osso hioide na segurança da deglutição de pacientes submetidos à laringectomia supracricóidea. Métodos série de casos de 13 adultos, entre 48 e 79 anos, majoritariamente homens (n=11), submetidos à laringectomia supracricóidea em pós-operatório inferior ou igual a dez meses. Realizaram videofluoroscopia da deglutição de 5 ml de líquido fino, 5 ml de alimento pastoso e sólido, em livre oferta. A medida do ângulo do osso hioide foi definida por duas linhas: uma tangente à margem superior do corpo do osso hioide e uma tangente ao ponto mais inferior de sua margem inferior, paralela ao plano horizontal da imagem. O desfecho de aspiração durante o exame seguiu a escala desenvolvida por Rosenbek et al. (1996). Resultados Dos 13 pacientes, 5 apresentaram aspiração silente e 8 não apresentaram aspiração. Dos 5 indivíduos com aspiração, apenas 1 manteve preservadas ambas as cartilagens aritenoides em sua reconstrução e a angulação do osso hioide foi abaixo de 60º, em todos os casos. Dos 8 indivíduos sem aspiração laringotraqueal, a maioria (n=5) apresentava as duas cartilagens aritenoides em sua reconstrução e a angulação do osso hioide foi acima de 60º, em todos os casos. Conclusão uma angulação maior que 60º do osso hioide parece favorecer a proteção das vias aéreas inferiores e promover maior segurança do mecanismo de deglutição.

ABSTRACT Purpose to investigate the possible impact of hyoid bone angulation on swallowing safety in patients undergoing supracricoid laryngectomy. Methods the case series comprised 13 adults, between 48 and 79 years-old, male in its majority (n=11), within ten months or less post-supracricoid laryngectomy and cricohyoidoepiglottopexy. All volunteers were submitted to videofluroscopy at rest and during swallowing of 5 ml of thin fluid, 5 ml of pureed consistency and dry solid food. Images were captured in lateral view. The hyoid angle was taken at rest and defined by two lines: a tangent to the upper margin of the body of the hyoid bone and a horizontal line, tangent to the lowest point of its lower margin. The aspiration was assessed using the scale developed by Rosenbek et al. (1996). Results five cases had silent aspiration and eight had no aspiration. In the group with silent aspiration, only one individual had both arytenoid cartilages preserved, while all individuals had the hyoid bone angle below 60º. In the group without aspiration, five individuals had both cricoarytenoids preserved, while all cases had the average hyoid bone angle above 60º. Conclusion the hyoid bone being at an angle greater than 60º seemed to increase the protection of the lower airways, promoting a safer swallowing mechanism.

Prognostic role of resection margin in open oncologic laryngeal surgery: survival analysis of a cohort of 139 patients affected by squamous cell carcinoma / Papel prognóstico da margem de ressecção em cirurgia oncológica aberta de laringe: análise de sobrevida de uma coorte de 139 pacientes com carcinoma de células escamosas

Abstract Introduction: The treatment of laryngeal squamous cell carcinoma needs accurate risk stratification, in order to choose the most suitable therapy. The prognostic significance of resection margin is still highly debated, considering the contradictory results obtained in several studies regarding the survival rate of patients with a positive resection margin. Objective: To evaluate the prognostic role of resection margin in terms of survival and risk of recurrence of primary tumour through survival analysis. Methods: Between 2007 and 2014, 139 patients affected by laryngeal squamous cell carcinoma underwent partial or total laryngectomy and were followed for mean of 59.44 ± 28.65 months. Resection margin status and other variables such as sex, age, tumour grading, pT, pN, surgical technique adopted, and post-operative radio- and/or chemotherapy were investigated as prognostic factors. Results: 45.32% of patients underwent total laryngectomy, while the remaining subjects in the cohort underwent partial laryngectomy. Resection margins in 73.39% of samples were free of disease, while in 21 patients (15.1%) anatomo-pathological evaluation found one of the margins to be close; in 16 subjects (11.51%) an involved resection margin was found. Only 6 patients (4.31%) had a recurrence, which occurred in 83.33% of these patients within the first year of follow-up. Disease specific survival was 99.24% after 1 year, 92.4% after 3 years, and 85.91% at 5 years. The multivariate analysis of all covariates showed an increased mortality rate only with regard to pN (HR = 5.043; p = 0.015) and recurrence (HR = 11.586; p = 0.012). Resection margin did not result an independent predictor (HR = 0.757; p = 0.653). Conclusions: Our study did not recognize resection margin as an independent prognostic factor; most previously published papers lack unanimous, methodological choices, and the cohorts of patients analyzed are not easy to compare. To reach a unanimous agreement regarding the prognostic value of resection margins, it would be necessary to carry out meta-analyses on studies sharing definition of resection margin, methodology and post-operative therapeutic choices.

Resumo Introdução: O tratamento do carcinoma de células escamosas de laringe necessita de uma estratificação precisa do risco, para a escolha da terapia mais adequada. O significado prognóstico da margem de ressecção ainda é motivo de debate, considerando-se os resultados contraditórios obtidos em vários estudos sobre a taxa de sobrevida de pacientes com margem de ressecção positiva. Objetivo: Avaliar o papel prognóstico da margem de ressecção em termos de sobrevida e risco de recorrência de tumor primário através da análise de sobrevida. Método: Entre 2007 e 2014, 139 pacientes com carcinoma de células escamosas de laringe foram submetidos à laringectomia parcial ou total e foram acompanhados por um tempo médio de 59,44 ± 28,65 meses. O status de margem de ressecção e outras variáveis, como sexo, idade, grau do tumor, pT, pN, técnica cirúrgica adotada e radio- e/ou quimioterapia pós-operatória, foram investigados como fatores prognósticos. Resultados: Dos pacientes, 45,32% foram submetidos à laringectomia total, enquanto os demais foram submetidos à laringectomia parcial. As margens de ressecção em 73,39% das amostras estavam livres, enquanto em 21 pacientes (15,1%) a avaliação anatomopatológica encontrou uma das margens próxima e 16 indivíduos (11,51%) apresentaram margem de ressecção comprometida. Apenas seis pacientes (4,31%) apresentaram recidiva, o que ocorreu em 83,33% desses pacientes no primeiro ano de seguimento. A sobrevida doença-específica foi de 99,24% em um ano, 92,4% em três anos e 85,91% em cinco anos. A análise multivariada de todas as covariáveis mostrou um aumento na taxa de mortalidade apenas em relação à pN (HR = 5,043; p = 0,015) e recidiva (HR = 11,586; p = 0,012). A margem de ressecção não demonstrou ser um preditor independente (HR = 0,757; p = 0,653). Conclusões: Nosso estudo não identificou a margem de ressecção como fator prognóstico independente; a maioria dos artigos publicados anteriormente não tem escolhas metodológicas unânimes e as coortes de pacientes analisados não são fáceis de comparar. Para chegar a uma concordância unânime em relação ao valor prognóstico da margem de ressecção, seria necessário fazer metanálises em estudos que compartilham a definição da margem de ressecção, metodologia e escolhas terapêuticas pós-operatórias.

Evaluation of lung function in patients submitted to total laryngectomy / Avaliação da função pulmonar em pacientes submetidos à laringectomia total

Abstract Introduction: The post-laryngectomy state is characterized by several alterations in lung function. A reliable estimation of lung function can be very useful in laryngectomees to prevent postoperative complications and to evaluate the results of the treatment. Objective: Characterize the presence of respiratory functional disorders and the functional pattern of laryngectomees through the use of an extratracheal device. Methods: This transversal study included 50 patients submitted to total laryngectomy at least 6 months prior to this investigation, as the treatment of choice for laryngeal cancer. Results: 56% percent of the participants had altered breathing pattern, distributed as follows: 14 with obstructive pattern with no air trapping, 11 with obstructive pattern with air trapping and only 3 with restrictive pattern. On average, the diffusion decreased (74.3%) and airway resistance increased (121.7%) when compared to the expected average values for the Brazilian individuals. Conclusion: Most patients submitted to total laryngectomy present altered lung function, usually the obstructive type, frequently associated to a history of smoking.

Resumo Introdução: A condição pós-laringectomia é caracterizada por várias alterações na função pulmonar. Uma estimativa confiável da função pulmonar pode ser muito útil em pacientes laringectomizados para prevenir complicações após as intervenções cirúrgicas e avaliar os resultados do tratamento. Objetivo: Caracterizar a presença de distúrbios funcionais respiratórios e o padrão funcional de pacientes laringectomizados através do uso de um dispositivo extratraqueal. Método: Estudo transversal que incluiu 50 pacientes submetidos à laringectomia total pelo menos seis meses antes desta investigação, como tratamento de escolha para o câncer de laringe. Resultados: Dos participantes, 56% apresentavam padrão respiratório alterado, assim distribuídos: 14 com padrão obstrutivo sem aprisionamento aéreo, 11 com padrão obstrutivo e aprisionamento aéreo e apenas três com padrão restritivo. Em média, verificou-se que a difusão encontrava-se diminuída (74,3%) e a resistência das vias aéreas aumentada (121,7%) em relação aos resultados esperados em brasileiros. Conclusão: A maioria dos pacientes submetidos à laringectomia total apresenta função pulmonar alterada, do tipo obstrutiva, quase sempre associada a história de tabagismo.