Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery.

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

The usefulness of the transcricothyroid injection laryngoplasty via contralateral paramedian approach.

OBJECTIVE: Several laryngeal injection techniques are technically difficult and have limitations. In this study, we modified a transcricothyroid approach for injections to enhance needle visualization during procedures. The objective of this study was to investigate the efficacy of this alternative injection technique. METHODS: We performed a retrospective analysis of 51 patients who had undergone injection laryngoplasty for unilateral vocal paralysis between March 2014 and February 2015. In total, 17 patients underwent a transcricothyroid injection laryngoplasty via the contralateral paramedian approach (ILC) and 34 patients underwent transcricothyroid injection laryngoplasty via the conventional approach (ipsilateral approach, ILI). Acoustic analyses, aerodynamic analyses, voice handicap index (VHI), and GRBAS scale were assessed pre-operatively and at 2 weeks and 3 months postoperatively. RESULTS: From our acoustic and aerodynamic analyses, jitter, shimmer, noise-to-harmonic ratio (NHR), maximum phonation time (MPT), and mean flow rate (MFR) were all significantly improved in both groups after injection. VHI and GRBAS scales also improved postoperation. There were no significant differences between the pre-operative and postoperative subjective and objective parameters between both groups. The total injection volume used on the ILI group was larger than the volume given to the ILC group. CONCLUSION: The transcricothyroid injection laryngoplasty via the contralateral paramedian approach is potentially more beneficial to performing injection laryngoplasty under local anesthesia. One important advantage of this approach to conventional approaches is its enhanced visualization of the needle during procedures.

Efficacy of 18F-fluorodeoxyglucose positron emission tomography/CT imaging for extracapsular spread of laryngeal squamous cell carcinoma.

BACKGROUND: We evaluated the use of fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT for the identification of extracapsular spread (ECS) with supporting histologic correlations in laryngeal cancer. METHODS: We reviewed the medical records of 89 patients with laryngeal cancer who underwent FDG PET/CT before surgery. RESULTS: ECS was present in 38.2% (18 of 47) of dissected necks and in 32.2% (20 of 62) of dissected cervical levels. There was a significant difference in the standardized uptake value maximum (SUVmax ) between cervical lymph nodes with and without ECS (6.39 ± 4.53 vs 1.21 ± 1.70; p < .001); the cutoff value for differentiating nodes with ECS from those without ECS was 2.8, with a sensitivity of 85.7% and specificity of 85.6%. CONCLUSION: A median SUVmax cutoff value >2.8 was associated with an increased risk of cervical lymph node metastasis and ECS in patients with laryngeal cancer.

A prospective randomized controlled trial of the laryngeal mask airway versus the endotracheal intubation in the thyroid surgery: evaluation of postoperative voice, and laryngopharyngeal symptom.

BACKGROUND: The present study was performed to determine whether thyroidectomy patients undergoing general anesthesia provided with a laryngeal mask airway (LMA) have a lower risk of voice-related complications and laryngopharyngeal symptoms than those undergoing endotracheal intubation (ETI). MATERIALS AND METHODS: In a prospective, double-blinded, randomized clinical trial, we studied 64 patients undergoing elective thyroid lobectomy between July 2013 and February 2014. Acoustic analyses were performed preoperatively and at 48 h and 2 weeks postoperatively. The voice handicap index (VHI), M.D. Anderson dysphagia index (MDADI), and laryngopharyngeal symptom score (LPS) were determined preoperatively and at 24 h, 48 h, 1 week, and 2 weeks post-thyroidectomy. RESULTS: In acoustic analysis, jitter, shimmer and noise-to-harmonic ratio showed significantly better results in the LMA group than the ETI group 48 h after surgery, but there was no difference at 2 weeks. The incidence of postoperative lower-pitched voice in the LMA group was also significantly lower than that in the ETI group. In the LMA group, the VHI, MDADI, and LPS were better compared to those in the ETI group at 24 h postoperatively, and improved to the preoperative state within 1 week. However, those in the ETI group remained poorer than the preoperative values 1 week after surgery. CONCLUSIONS: Use of the LMA in general anesthesia for thyroid surgery has advantages over the ETI in decreasing patients' subjective and objective voice symptoms, reducing the duration of symptoms, and relieving the laryngopharyngeal symptoms.

Endoscope-assisted facelift thyroid surgery: an initial experience using a new endoscopic technique.

BACKGROUND: A new approach to modifying facelift incision was recently developed for robotic thyroid surgery that seemed to be advantageous over other existing approaches. In this study, we aimed to investigate the feasibility and safety of the facelift approach not only for robotic thyroid surgery, but also for endoscope-assisted thyroid surgery. METHODS: Endoscope-assisted facelift thyroid lobectomy was performed for 11 patients with papillary microcarcinoma. RESULTS: All 11 operations were successfully performed endoscopically. This approach through a modified facelift incision provided safe dissection of the laryngeal nerves and exposed an adequate working space. We identified and preserved all neighboring critical structures (parathyroid gland and superior and recurrent laryngeal nerves) during surgery. The operative duration for simple thyroid lobectomy with central lymph node dissection in 11 patients was 120-180 min (average duration: 140 min). Sensory change around the earlobe occurred in three patients and was recovered within 2 months after surgery in all patients. No patient displayed laryngeal nerve palsy or a low-pitched voice. CONCLUSIONS: The facelift approach seems to provide a shorter and more direct route to the thyroid, requiring minimal dissection, and an adequate workspace not only for robotic surgery but also for endoscopic surgery. It is worthwhile to develop and refine the surgical techniques of endoscopic facelift thyroid surgery.

The therapeutic decision making of the unilateral vocal cord palsy after thyroidectomy using thyroidectomy-related voice questionnaire (TVQ).

The objective of this study was to investigate the efficacy of early management of post-thyroidectomy unilateral vocal cord palsy (UVCP) and the clinical utility of the thyroidectomy-related voice questionnaire (TVQ) when planning UVCP treatment. The study group comprised 48 consecutive patients diagnosed with UVCP after thyroidectomy. Laryngoscopic examination and voice analysis were conducted, and the TVQ was administered pre-thyroidectomy and at 2 weeks and 1, 3, 6, and 12 months post-thyroidectomy. Twenty-five patients with aspiration symptoms and severe vocal difficulties received injection laryngoplasty, and 23 with no aspiration symptoms and relatively mild vocal difficulties underwent voice therapy. We performed a video fluoroscopic swallowing study on each patient 2 weeks after thyroidectomy and 1 month following the procedure. The average total TVQ scores 2 weeks post-thyroidectomy were 51.92 ± 11.42 in the injection laryngoplasty group and 35.78 ± 12.99 in the voice therapy group. Both subjective and objective parameters improved significantly at 1 month after treatment and continued to improve slowly over the next 12 months (p < 0.01) in both groups. TVQ scores were significantly lower in the injection laryngoplasty group than in the voice therapy group 1 month post-intervention (p < 0.01). At the study end point, the greatest improvement in subjective symptoms occurred in temporary VCP patients who underwent injection laryngoplasty. The optimal TVQ score cut-off distinguishing the two groups was 45 (68.0 % sensitivity, 78.3 % specificity). In conclusion, early management following timely diagnosis of post-thyroidectomy UVCP can improve symptoms within 1 month. Moreover, application of TVQ will aid clinicians to plan treatment for postoperative VCP patients.

Transoral endoscopic thyroidectomy via the tri-vestibular routes: results of a preclinical cadaver feasibility study.

The concept of natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates skin incisions using an endoscope passed through a natural orifice (e.g., mouth, urethra, or anus). This study was designed to evaluate the feasibility and safety of thyroid resection via an entirely transoral tri-vestibular route using endoscopy, and to introduce NOTES to the head and neck area of medicine. We performed ten complete endoscopic thyroid lobectomies with central lymph node dissection via a tri-vestibular approach in fresh-frozen cadavers. A 5-mm endoscope with a deflectable tip was used to visualize the surgical field. Three cannulas were inserted through the midline and bilateral incision sites in the vestibule to position the instruments and endoscope. We refined and described the surgical technique in each step using video clips. We identified and preserved neighboring critical structures during surgery. We also confirmed that there were no obvious remnant thyroid tissues and no injury to the neighboring structures after exploration. The transoral tri-vestibular approach seems to provide a good view and surgical field for endoscopic thyroidectomy. However, the transoral approach for thyroidectomy remains experimental, and the detailed surgical technique should be refined via further clinical studies.

How can we screen voice problems effectively in patients undergoing thyroid surgery?

BACKGROUND: Voice problems following thyroid surgery are well known, and perioperative voice analysis in patients undergoing thyroidectomy no longer seems optional. However, multiple means of assessing vocal function are time-consuming, require specific instruments and specialists, and increase costs. Therefore, we designed this study to develop an efficient and cost-effective screening tool for detecting voice disorders following thyroidectomy. METHODS: We developed the Perioperative Voice-Screening Protocol for Thyroid Surgery (PVST) using the Thyroidectomy-Related Voice Questionnaire (TVQ) to provide a cost-effective diagnostic flow chart for patients following thyroidectomy. The TVQ is a simple questionnaire that was developed at our institution and has already demonstrated its effectiveness in detecting pre- and postthyroidectomy voice-related disorders in our previous studies. To investigate the PVST, we enrolled 242 subjects who underwent thyroidectomy and let them follow the PVST. All subjects underwent a voice work-up by a voice specialist to verify the predictive value of the protocol. RESULTS: Using PVST, we could effectively screen for abnormal preoperative laryngeal findings with sensitivity and specificity of 82.1% and 50.5%, respectively, especially laryngeal benign mucosal disease with sensitivity and specificity of 100% and 45.6%, respectively. We could also screen for postoperative voice-related problems with sensitivity and specificity of 100% and 50.4% for detecting vocal-cord palsy, and 66.7% and 51.2% for detecting a low-pitched voice, respectively. If all 242 patients followed the protocol, US $42,768 would be saved, and the PVST was estimated to decrease costs by 43.5%. CONCLUSIONS: The PVST is a reliable and cost-effective perioperative screening tool that enables thyroid surgeons to detect patients with voice problems in their routine outpatient clinic for early and appropriate referral to voice specialists.

The effect of itopride combined with lansoprazole in patients with laryngopharyngeal reflux disease.

The objective of this study is to determine the efficacy of adding a prokinetic agent to proton pump inhibitors (PPI) for the treatment of laryngopharyngeal reflux (LPR) disease. A prospective, randomized open trial comparing lansoprazole plus itopride to lansoprazole single therapy was performed for 12 weeks. Sixty-four patients with a reflux finding score (RFS) >7 and a reflux symptom index (RSI) >13 were enrolled and received either lansoprazole 30 mg once daily with itopride 50 mg three times daily or lansoprazole 30 mg once daily for 12 weeks. RSI and RFS were completed at baseline, after 6 weeks, and after 12 weeks. During the treatment period, RSI and RFS were significantly improved compared with the pretreatment scores in both study groups. Reductions of total RSI and globus symptom were significantly higher in the lansoprazole plus itopride group compared to the lansoprazole group. In the RFS, however, there were no significant differences between the two groups. In conclusion, itopride in addition to PPI did not show any superior RFS improvement compared to PPI single therapy, but was helpful in speeding up relief of reflux symptoms in LPR patients. Thus, itopride may be considered as the secondary additive agent in the PPI treatment of LPR patients.

Early postoperative vocal function evaluation after thyroidectomy using thyroidectomy related voice questionnaire.

BACKGROUND: The objectives of this study were to evaluate a screening method for detecting postoperative vocal cord palsy and lower-pitched voice and to identify how a pre-thyroidectomy laryngeal disorder affects post-thyroidectomy voice change by using our subjective voice questionnaire. METHODS: We examined 300 consecutive patients scheduled to undergo thyroidectomies between November 2010 and August 2011. Laryngoscopic examination, thyroidectomy-related voice questionnaire (TVQ) administration, and acoustic and perceptual analyses were performed preoperatively and 2 weeks after thyroidectomy. RESULTS: Ninety-eight (32.6 %) patients had a preoperative laryngeal disorder. Postoperatively, 31 (10.3 %) patients had vocal cord palsy and 54 (18 %) had a lower-pitched voice 2 weeks after thyroidectomy. Postoperative TVQs classified 25 (8.4 %) patients as normal and 275 (91.6 %) patients as abnormal, including 79 (26.3 %) mild, 131 (43.6 %) moderate, and 65 (21.6 %) severe cases. Of the patients with vocal cord palsy, 80.6 % belonged to the severe group, and 92.6 % of patients with lower-pitched voices belonged to the moderate and severe groups. Fundamental frequency and speaking fundamental frequency were decreased significantly in women. The most efficient TVQ cutoff values for detecting post-thyroidectomy vocal cord palsy and postoperative lower-pitched voice were 35 (87.1 % sensitivity, 79.9 % specificity) and 25 (75.9 % sensitivity, 56.5 % specificity), respectively. Total TVQ scores increased more in the nonlaryngeal than in the laryngeal disorder group. CONCLUSIONS: During the early postoperative period, 28.3 % of patients had vocal cord palsy or lower-pitched voices, which could be evaluated using a simple questionnaire. Therefore, early postoperative voice evaluation is important. Patients with nonlaryngeal disorders may be more sensitive than those with laryngeal disorders to laryngeal symptoms.