Rehabilitation After Total Laryngectomy: An Integrated Protocol Remotely Delivered During COVID-19

The aim of this paper was to evaluate the results of an integrated treatment delivered remotely to laryngectomized patients with voice prosthesis. Eighteen laryngectomized patients were treated remotely in groups co-led by a speech therapist and a psychologist ("Online Group"). The results were compared with those of 17 patients ("In-Person Group") previously studied. The two groups obtained comparable results on all parameters of the INFVo perceptual rating scale, in the DEP, ANX, PHO and HOS areas of the Symptom Check List-90-Revised questionnaire, and in the areas investigated by the WHOQOL-B questionnaire. The "In-Person Group" obtained statistically better results on the Italian Self-Evaluation of Communication Experiences after Laryngeal Cancer questionnaire. Although the in-person treatment favored the acceptance of the new voice and the development of conversational skills, telerehabilitation guaranteed an adequate level of assistance in terms of voice acquisition, prevention of anxiety and depression, and recovery of a good QoL. © 2023, University Library System, University of Pittsburgh. All rights reserved.

Early detection of recurrent HPV+ hypopharyngeal squamous cell carcinoma by circulating tumor DNA

Circulating tumor DNA is a liquid biomarker that offers a highly specific method to assess HPV-associated tumor burden via a blood draw. It has the potential for many clinical applications in cancer care, including prognostication, monitoring treatment response, and surveillance for disease recurrence. In this case report, we present a case of recurrent HPV-associated hypopharyngeal squamous cell carcinoma first detected by circulating tumor HPV DNA that demonstrates the role of circulating tumor HPV DNA tests in posttreatment surveillance and the utility of HPV testing in all HPV-mediated tumors, regardless of subsite.Copyright © 2023 Elsevier Inc.

Incidence and medical complications of COVID-19 in the total laryngectomy population: A population-based study.

OBJECTIVES: Laryngeal and hypopharyngeal cancers treated with total laryngectomy (TL) may provide a unique avenue for COVID-19 to infect cancer patients. The objective of this investigation was to identify incidence of COVID-19 infection and potential complications in TL patients. MATERIALS AND METHODS: Data was extracted from TriNetX COVID-19 research network from from 2019 to 2021 and ICD-10 codes were utilized to query for laryngeal or hypopharyngeal cancer, and outcomes of interest. Cohorts were propensity score-matched based on demographics and co-morbidities. RESULTS: A query of active patients in TriNetX from January 1, 2019 to December 31, 2021 identified 36,414 patients with laryngeal or hypopharyngeal cancer out of the 50,474,648 active patients in the database. The overall COVID-19 incidence in the non-laryngeal or hypopharyngeal cancer population was 10.8% compared to 18.8% (p < 0.001) in the laryngeal and hypopharyngeal cancer group. Those who underwent TL had a statistically significant increased incidence of acquiring COVID-19 (24.0%) when compared to those without TL (17.7%) (p < 0.001). TL patients with COVID-19 had a higher risk of developing pneumonia RR (risk ratio) 1.80 (1.43, 2.26), death 1.74 (1.41, 2.14), ARDS 2.42 (1.16, 5.05), sepsis 1.77 (1.37, 2.29), shock 2.81 (1.88, 4.18), respiratory failure 2.34 (1.90, 2.88), and malnutrition 2.46 (2.01, 3.01) when matched with those COVID-19 positive cancer patients without TL. CONCLUSIONS: Laryngeal and hypopharyngeal cancer patients had a higher rate of acquiring COVID-19 than patients without these cancers. TL patients have a higher rate of COVID-19 compared to those without TL and may be at a higher risk for sequalae of COVID-19.

Resurgence of Emergency Total Laryngectomy: An Impact of COVID-19 Pandemic.

Laryngeal cancer is one of the most common head and neck cancers in India. Surgery is the preferred modality of treatment in majority of cT4a cases and selective cT3 cases of Carcinoma Larynx. COVID-19 outbreak became a global pandemic and caused significant delays and disruptions in every aspect of cancer care. Similarly, patients of laryngeal cancer presented with advanced disease and significant stridor. In such cases, Emergency total laryngectomy (ETL) proved to be a valid treatment modality in the place of conventional workup and treatment. We present our experience with Emergency laryngectomy during the COVID-19 pandemic and how we overcame its challenges. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03422-5.

Implementation of Enhanced Recovery After Surgery (ERAS) in Total Laryngectomies

Aim: The Enhanced Recovery After Surgery (ERAS) protocol for total laryngectomies was first implemented in our tertiary head and neck centre from November 2019. It includes pre-operative carbohydrate loading and an early swallow test which facilitates recommencement of oral intake to improve outcomes. Protocol adherence rate and patient outcomes were measured to determine the effectiveness and benefits of ERAS in laryngectomy patients. Method: 22 total laryngectomy patients from November 2019 to September 2021 were enrolled onto the ERAS protocol, 18 primary and 3 salvage cases. An analysis of the respective patient cohorts was performed to determine adherence to the ERAS protocol and outcomes such as complications and length of inpatient stay were measured. Results: 19 patients (86%) received pre-operative carbohydrate loading successfully, while 3 patients were contraindicated due to background of diabetes. Early swallow test was performed in 59% of patients. Potential reasons for delay were stoma dehiscence or clinical suspicion of neo-pharyngeal leak. 59% of primary cases were deemed medically fit for discharge within the target timeframe of 12-14 days whereas no target was set for salvage cases due to expected poor healing. Main complication in primary cases was neo-pharyngeal leak followed by stoma dehiscence with 28% and 11% respectively. Conclusion: Limitations of our study include small sample size due to the COVID-19 pandemic. Despite its infancy, the ERAS protocol has achieved good outcomes in early recommencement of oral intake post-laryngectomy and encouraging early safe discharge from hospital. Future plans include establishment of Prehab Clinic and application of ERAS to neck dissection patients.

Characteristics associated with communicative participation after total laryngectomy.

PURPOSE: The purpose of this study was to identify individual characteristics that are associated with communicative participation after total laryngectomy (TL). METHODS: This study was a single-institution investigation of individuals who had undergone TL. Data were collected at a single timepoint via patient self-report and medical record review. Thirty-five participants completed a questionnaire containing a communication survey as well as several published, validated instruments. Independent variables included characteristics related to demographics, health and medical history, social network composition, and communication. The dependent variable was communicative participation, which was assessed using the Communicative Participation Item Bank (CPIB). Correlations between the independent variables and CPIB scores were calculated to assess the influence of these characteristics on communicative participation. The study participants were subdivided into three distinct groups based on whether their primary method of communication was spoken or non-spoken and the frequency of using alternate methods of communication. Outcomes across the three groups were then compared. A follow-up survey was also conducted to examine the impact of "stay at home" orders during the COVID-19 pandemic of 2020-21. RESULTS: There were significant correlations between communicative participation and some non-communication-related characteristics. Reduced communicative participation was associated with younger age, less time since TL, a history of reconstructive surgery, poorer self-rated health, more depressive symptoms, worse quality of life, and a weaker social network of friends. Several communication-related characteristics were also associated with CPIB scores. Increased communicative participation was associated with using fewer non-spoken communication methods, higher levels of satisfaction with speech and communication, and better communicative effectiveness. There were significant differences between the three groups for communicative effectiveness and satisfaction with speech. The three groups did not differ significantly for satisfaction with communication or communicative participation. There were no significant differences in CPIB scores measured before and during the pandemic. CONCLUSIONS: Communicative participation is a complex measure that may be affected by a variety of factors related to demographics, health, social network status, and communication. Despite poorer communicative effectiveness and lower levels of satisfaction, individuals who use non-spoken methods of communication after TL did not demonstrate worse communicative participation than those using spoken methods. Surprisingly, CPIB scores did not decline as a result of social distancing.

Impact of the COVID-19 pandemic on the stage and the type of surgical treatment of laryngeal cancer.

PURPOSE: Changes in the entire health care system during COVID-19 epidemic have affected the management of patients with head and neck cancer and posed several clinical challenges for ENT surgeons. Therefore, the present study aimed to investigate the effect of COVID-19 on the stage and the type of surgical treatments used in laryngeal cancer (including total laryngectomy, supracricoid partial laryngectomy (SCPL) and transoral laser microsurgery (TLM)) and also to compare the results of April 2020 to April 2021 with the previous year. MATERIALS AND METHODS: This cross-sectional study was performed on all patients with a diagnosis of laryngeal cancer who underwent surgery in the tertiary care center from April 2020 to April 2021 and the year before the pandemic in the same time. Demographic, cancer stage, and treatment data of all patients were recorded and analysis in two groups. RESULTS: Patients referred at the time of the virus outbreak; 111 were male and 5 were female, and in the group of patients referred before COVID-19, 90 were male and 12 were female. The type of surgical treatment of laryngeal cancer, mean time elapsed from sampling to surgery, stage of disease and mean tumor volume was statistically significant differences in patients before and during the outbreak. CONCLUSION: Patients who referred for diagnosis and treatment at the time of COVID-19 outbreak had more advanced stages of the disease and also the tumor volume was higher in them than patients who had referred before the outbreak. It is necessary to provide new solutions, education and treatment management for patients with laryngeal cancer in such pandemics.

Discrepancies of SARS-CoV-2 testing results among patients with total laryngectomy.

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.

Shielding, hospital admission and mortality among 1216 people with total laryngectomy in the UK during the COVID-19 pandemic: A cross-sectional survey from the first national lockdown.

BACKGROUND: People with a total laryngectomy (PTL) rely on a permanent opening in their neck (stoma) to breathe. This altered anatomy may increase susceptibility to contracting and transmitting SARS-CoV-2. AIMS: To report on (1) the frequency and characteristics of PTL who tested positive for COVID-19, (2) the receipt of advice regarding shielding and patient self-reports of shielding, (3) hospital admissions and length of stay, and (4) mortality rates in this group during the first UK national lockdown. METHODS & PROCEDURES: This is a cross-sectional survey and case note review. National Health Service (NHS) centres providing care to PTL were invited to participate via the Royal College of Speech and Language Therapists' (RCSLT) Head & Neck Clinical Excellence Networks and through social media. PTL were reviewed by their speech and language therapist either in person or via telehealth between 30 March and 30 September 2020. Data were collected within the time frame covered by the Control of Patient Information (COPI) notice issued for COVID-19 and included information on COVID-19 testing, shielding, hospital admissions, length of stay and deaths. Information was submitted to the lead NHS site using a custom designed data-capture worksheet. Analysis was performed using descriptive statistics, including proportions and frequency counts. Pearson's Chi squared tests were used to compare categorical data using a 5% significance level. OUTCOMES & RESULTS: Data were obtained from 1216 PTL from 26 centres across the UK. A total of 81% were male; mean age was 70 years (28-97 years). Of the total group, 12% received a COVID-19 test. A total of 24 (2% of total sample) tested positive for COVID-19. Almost one-third of PTL (32%) received a government letter or were advised to shield by a healthcare professional. During the data collection time frame, 12% had a hospital admission (n = 151) with a median length of stay of 1 day (1-133 days), interquartile range (IQR) = 17 days. A total of 20 of these admissions (13%) had tested positive for COVID-19 with a median length of stay of 26 days, IQR = 49 days. The overall mortality was 4% (41 patients), with eight deaths occurring within 28 days of testing positive for COVID-19. CONCLUSIONS & IMPLICATIONS: This study highlighted the lack of routine national data for neck-breathers with which to compare the current findings. Greater testing in the community is necessary to understand the prevalence of COVID-19 in PTL and if this group is indeed more susceptible. The potential for nasopharyngeal and tracheal aspirates to show differing results when testing for COVID-19 in neck-breathers requires further investigation. WHAT THIS PAPER ADDS: What is already known on the subject? People with total laryngectomy (PTL) have an altered anatomy for breathing and speaking. The presence of a neck stoma poses an additional virus entry point aside from the nose, mouth and conjunctiva. This could increase the susceptibility to COVID-19 for PTL. What this paper adds? This is the first national audit to provide data on shielding, hospital admissions and mortality for patients with total laryngectomy in the UK over the pandemic. The overall mortality in PTL over the first lockdown did not appear to be higher than the "best case" estimates from previous years. However, one in three PTL who acquired COVID-19 and were admitted to hospital, died within 28 days of testing positive. These findings are relevant to the current care and management of PTL over the pandemic but also highlights important knowledge gaps. What are the potential or actual clinical implications of this work? This study highlights gaps in the collection of baseline information on hospital admissions, length of stay and mortality for people with laryngectomy in the UK, restricting comparisons between the current data and historical data. The need for further research on whether neck-breathers should be tested via both nasopharyngeal and tracheal aspirates is important not just currently, but also in case of any future respiratory epidemics.

The impact of the COVID-19 pandemic on the quality of life of head and neck cancer survivors.

BACKGROUND: Head and neck cancer (HNC) survivors are particularly vulnerable to the deleterious consequences of lockdown and social distancing. The psychosocial effects of the COVID-19 pandemic on this group are still unknown, and we want to explore how their quality of life (QoL) has changed in this unique situation. MATERIALS AND METHODS: An online survey, composed of pandemic-specific items, plus the EORTC QLQ-C30, was administered to a cohort of HNC survivors. Using previously published reference values as a control group, we have evaluated the impact of the pandemic on their QoL. We have also explored the differences between those who had received a total laryngectomy (LP, laryngectomized population) vs other HNC patients, in order to assess the role of tracheostomy in this regard. RESULTS: One hundred and twenty-one HNC patients completed the survey. The scores of the physical (80.5 vs 85, p = 0.028), role (78 vs 84, p = 0.030), and emotional functioning (76 vs 81, p = 0.041) were significantly different in the two groups, with worse functioning in our patients. Comparing LP with the other HNC patients, social (76.6 vs 88.9, p = 0.008) and physical functioning (75.5 vs 86.1, p = 0.006) were significantly worse in the former group. LP also reported a greater perception that others are afraid to be close to them (1.67 vs 1.32, p = 0.020). No differences were found between LP with and without voice prosthesis. CONCLUSIONS: Our results show how HNC patients are at high risk for a worsening in QoL because of the ongoing COVID-19 global pandemic.

Patients With Voice Prosthesis Rehabilitation During the COVID-19 Pandemic: Analyzing the Effectiveness of Remote Triage and Management.

OBJECTIVE: To describe a remote approach used with patients with voice prosthesis after laryngectomy during the COVID-19 pandemic and the resulting clinical outcomes in terms of voice prosthesis complications management, oncological monitoring, and psychophysical well-being. STUDY DESIGN: Prospective cohort study. SETTING: Otolaryngology Clinic of the University Polyclinic A. Gemelli, IRCCS Foundation. SUBJECTS AND METHODS: All patients with voice prosthesis who underwent laryngectomy followed by our institute were offered enrollment. Patients who agreed to participate were interviewed to inquire about the nature of the need and to plan a video call with the appropriate clinician. Before and 1 week after the clinician's call, patients were tested with the Hospital Anxiety and Depression Scale. Degrees of satisfaction were investigated with a visual analog scale. A comparison between those who accepted and refused telematic support was carried out to identify factors that influence patient interest in teleservice. RESULTS: Video call service allowed us to reach 37 (50.68%) of 73 patients. In 23 (62.16%) of 37 cases, the video call was sufficient to manage the problem. In the remaining 14 cases (37.83%), an outpatient visit was necessary. Participants who refused telematic support had a significantly shorter time interval from the last ear, nose, and throat visit than patients who accepted (57.95 vs 96.14 days, P = .03). Video-called patients showed significantly decreased levels of anxiety and depression (mean Hospital Anxiety and Depression Scale total score pre- vs post-video call: 13.97 vs. 10.23, P < .0001) and reported high levels of satisfaction about the service. CONCLUSION: Remote approach may be a viable support in the management of patients with voice prosthesis rehabilitation.