Acoustic parameters of speech: Lack of correlation with perceptual and questionnaire-based speech evaluation in patients with oral and oropharyngeal cancer treated with primary surgery.

BACKGROUND: Acoustic evaluation of speech is the least explored method of speech evaluation in patients with oral cavity and oropharyngeal cancer. The purpose of this study was to explore acoustic parameters of speech and their correlation with questionnaire evaluation and perceptual evaluation in patients with oral cavity and oropharyngeal cancer. METHODS: One hundred seventeen subjects (65 consecutive patients with oral cavity and oropharyngeal cancer and 52 controls) participated in this study. Formant frequencies (by Linear Predictive Coding), Speech Handicap Index, and London Speech Evaluation scale were used for acoustic evaluation, questionnaire evaluation, and perceptual evaluation, respectively. RESULTS: Men showed significant elevation in second formant (F2) values for patients with oral cavity cancer and those who underwent surgery alone. Female patients with early T classification cancers and those who underwent surgery and chemoradiation showed significant reduction in the mean F2 values. Importantly, however, acoustic evaluation parameters did not correlate with either perceptual evaluation or questionnaire evaluation parameters, although there was moderate correlation between questionnaire evaluation and perceptual evaluation speech parameters. CONCLUSION: Acoustic evaluation modalities have no clear role in the management of patients with oral cavity and oropharyngeal cancer.

Exploring the link between human papilloma virus and oral and oropharyngeal cancers.

Squamous cell carcinoma involving the oral cavity (OC) and oropharynx regions are a major cause of morbidity and mortality world-wide. The recent discovery of a strong association between human papilloma virus (HPV) infection and OC and oropharyngeal (OP) cancer has prompted world-wide research into the exact etiology and pathogenesis of these cancers in relation to the HPV. HPV-positive OC/OP cancers generally present at a relatively advanced stage (by virtue of cervical nodal involvement) and are more commonly seen in younger patients without significant exposure to alcohol or tobacco. These factors are implicated in prognosis, regardless of HPV association. In this article, we review the biology and epidemiology, risk factors, association, molecular analyses, treatment response and prognosis of HPV-related cancers. Role of HPV vaccination in HPV-related OC/OP cancers has also been discussed.

Systematic review of carcinoma arising in pharyngeal diverticula: a 112-year analysis.

BACKGROUND: Carcinoma is a rare complication of pharyngeal diverticula. There is a paucity of information about its incidence, presentation, management, and treatment outcomes. A systematic review and analysis of all reported cases has been carried out. METHODS: A comprehensive literature search for pharyngeal diverticula carcinoma was performed from 1896 to 2008. Descriptive analyses were carried out by analyzing the absolute and relative frequencies. Comparison of groups was illustrated with Kaplan-Meier curves and tested statistically using the log-rank test. A cohort of 56 patients with benign pharyngeal diverticula was selected for comparison with the accumulated cohort of pharyngeal diverticula carcinoma, and a Fisher's exact test was carried out on the extracted clinical characteristics of this cohort to evaluate for differences between benign and malignant pharyngeal diverticula. RESULTS: Forty-three articles reporting 60 cases satisfied the inclusion criteria. The mean age at presentation was 68.8 years (SD = 9.8 years). Five-year cancer-specific survival (CSS) rates for patients who underwent excision alone, excision + postoperative radiotherapy (PORT), and radiotherapy alone were 0.74 versus 0.63 versus 0.0, respectively (p = .39). Five-year CSS rates of patients <65 versus ≥65 years were 0.43 versus 0.78, respectively (p = .046). CONCLUSION: Irregular symptoms in benign diverticula should raise suspicion of malignancy. Management consists of surgical excision ± PORT. © 2014 Wiley Periodicals, Inc. Head Neck 36: 1368-1375, 2014.

Evaluation of speech outcomes using English version of the Speech Handicap Index in a cohort of head and neck cancer patients.

The aim of this study was to explore post-treatment speech impairments using English version of Speech Handicap Index (SHI) (first speech-specific questionnaire) in a cohort of oral cavity (OC) and oropharyngeal (OP) cancer patients. Sixty-three consecutive OC and OP cancer patients in follow-up participated in this study. Descriptive analyses have been presented as percentages, while Mann-Whitney U-test and Kruskall-Wallis test have been used for the quantitative variables. Statistical Package for Social Science-15 statistical software (SPSS Inc., Chicago, IL) was used for the statistical analyses. Over a third (36.1%) of patients reported their speech as either average or bad. Speech intelligibility and articulation were the main speech concerns for 58.8% and 52.9% OC and 31.6% and 34.2% OP cancer patients, respectively. While feeling of incompetent and being less outgoing were the speech-related psychosocial concerns for 64.7% and 23.5% OC and 15.8% and 18.4% OP cancer patients, respectively. Worse speech outcomes were noted for oral tongue and base of tongue cancers vs. tonsillar cancers, mean (SD) values were 56.7 (31.3) and 52.0 (38.4) vs. 10.9 (14.8) (P<0.001) and late vs. early T stage cancers 65.0 (29.9) vs. 29.3 (32.7) (P<0.005). The English version of the SHI is a reliable, valid and useful tool for the evaluation of speech in HNC patients. Over one-third of OC and OP cancer patients reported speech problems in their day-do-day life. Advanced T-stage tumors affecting the oral tongue or base of tongue are particularly associated with poor speech outcomes.

Evaluation of swallowing by Sydney Swallow Questionnaire (SSQ) in oral and oropharyngeal cancer patients treated with primary surgery.

This work aimed at evaluating patients' swallowing functions by a newly validated swallow-specific questionnaire, the Sydney Swallow Questionnaire (SSQ), in a cohort of oral and oropharyngeal cancer patients. Mean/median SSQ scores were calculated and compared with study variables using the Mann-Whitney U test and Kruskal-Wallis test. The mean composite SSQ scores (SD) for the base of tongue, oral tongue, and tonsillar cancer patients were 663.8 (382.8), 456.2 (407.6), and 283.0 (243.1), respectively (p = 0.005); for advanced vs. early T stage disease they were 918.1 (319.5) vs. 344.8 (292.1) (p ≤ 0.001); for patients <60 years vs. ≥60 years they were 549.3 (415.1) vs. 314.0 (247.3) (p = 0.02); and for patients with reconstruction vs. without reconstruction they were 676.5 (410.5) vs. 331.9 (286.5) (p = 0.002). SSQ is a useful tool for evaluation of swallowing in head and neck cancer patients. Site of cancer, T stage, patient's age, and reconstruction directly affect post-treatment swallow outcome.

Development and validation of first-ever speech-specific perceptual speech evaluation tool for patients with head and neck cancer: the London speech evaluation (LSE) scale.

BACKGROUND: The aim of this study was to develop and validate the first ever speech-specific perceptual speech-evaluation tool for patients with head and neck cancer. METHODS: Five speech parameters (intelligibility, articulation, speech rate, nasality, and asthenia) and overall grade were included and evaluated. Speech samples of 117 subjects were recorded on electroglottograph equipment using a standard protocol and were independently judged and rated by 3 experienced speech and language therapists and re-rated 12 weeks apart. RESULTS: Among patients the Cronbach's alpha (α) coefficients for internal consistency for connected speech were 0.89, whereas for single words the α coefficients ranged between 0.80 and 0.84. The Spearman's correlation coefficients for intra-rater reliability for connected speech and words varied between 0.30 and 0.90 and 0.49 and 0.76, respectively, whereas for inter-rater reliability the coefficients ranged between 0.53 and 0.99 and 0.56 and 0.99, respectively. For construct validity, the Spearman's correlation coefficient ranged between 0.41 and 0.55. CONCLUSIONS: The London Speech Evaluation (LSE) scale demonstrated a high reliability and validity in our cohort of patients with head and neck cancer. surgery.

Evaluation of factors affecting post-treatment quality of life in oral and oropharyngeal cancer patients primarily treated with curative surgery: an exploratory study.

The aim was to explore the impact of important clinico-demographic factors on the post-treatment quality of life (QOL) in surgically treated oral and oropharyngeal cancer patients. 63 consecutive follow-up oral and oropharyngeal cancer patients treated primarily with surgery were recruited. 55 patients sent the completed questionnaires and finally included in this study. QOL and important sub-domains of the QOL were assessed. Mean QOL scores (SD) were computed, level of significance was set at P < 0.05. The mean composite QOL score and standard deviation (SD) for oral and oropharyngeal cancer patients were 76.6 (15.2) and 73.4 (13.9), respectively. Patients with higher T-stage (T3 and T4) and higher overall-stage (III and IV) had lower mean QOL scores as against early T (T1 and T2) and overall early-stage (I and II); mean scores (SD) 64.3 (13.6) and 72.3 (13.8), and 76.6 (13.6) and 81.7 (14.1), respectively. Younger patients had lower mean scores (SD) than older patients; mean QOL scores (SD) 69.7 (14.0) and 79.6 (SD), respectively. Patients with reconstruction had lower mean QOL scores as compared to those without reconstruction; mean scores (SD) 67.6 (16.0) and 77.4 (12.5), respectively. In conclusion, tumor-stage, overall-stage, age of patients, and reconstruction had a significant direct effect on the post-treatment QOL of oral and oropharyngeal cancer patients.

An exploratory study of the influence of clinico-demographic variables on swallowing and swallowing-related quality of life in a cohort of oral and oropharyngeal cancer patients treated with primary surgery.

There are insufficient data on swallowing and the consequences of its dysfunction in patients with cancers of the oral cavity (OC) and oropharynx (OP) that are treated with primary surgery. The study attempts to explore the effect of important clinico-demographic variables on post-treatment swallowing and related quality of life (QOL) in post-surgical OC and OP cancer patients. Sixty-two consecutive OC and OP cancer patients completed the MD Anderson Dysphagia Inventory (MDADI) questionnaire. Mean scores were computed. Comparison of scores based on mean ranks were performed using Mann-Whitney U test or Kruskal-Wallis test. Level of significance was set at P ≤ 0.02. Adjustments were made for multiple comparisons. Significantly worse mean (SD) QOL scores were observed in late T-stage (T3/T4) versus early T-stage (T1/T2) patients for global domain, physical domain, functional domain and emotional domains [44.4 (21.9) vs. 78.7 (22.7) (P < 0.001); 50.0 (9.4) vs. 75.9 (16.3), (P < 0.0001); 57.8 (20.6) vs. 84.1 (16.7), (P < 0.001) and 55.2 (18.0) vs. 78.5 (16.3), (P < 0.001)], respectively. Patients undergoing reconstruction versus without reconstruction had worse QOL scores; 58.8 (26.9) versus 79.5 (22.8), (P < 0.01); 61.2 (15.1) versus 76.4 (17.5), (P = 0.002); 65.4 (20.5) versus 86.3 (15.9), (P < 0.0001) and 63.3 (18.8) versus 79.8 (16.3), (P < 0.01), respectively, for global, physical, functional and emotional domains. Advanced T-stage, reconstruction, younger age and base of tongue tumours have a negative impact on post-treatment swallow function and related QOL in these patients.

Assessment and management of dysphagia in patients with head and neck cancer who receive radiotherapy in the United Kingdom - a web-based survey.

We undertook a service evaluation to establish how oropharyngeal dysphagia is managed in head and neck cancer patients receiving radiotherapy in the United Kingdom. A web-based survey including 23 open and closed questions was distributed to Speech and Language Therapy (SLT) teams via a national network of Royal College of Speech and Language Therapists (RCSLT) special interest groups with members involved in head and neck cancer care. Forty-six teams responded to the survey and 89% completed the questionnaire fully. Fifty percent (n=21/42) of the SLT teams reported routinely seeing patients prior to commencing radiotherapy. Baseline oromotor assessment (85.7% (n=36/42)), clinical dysphagia assessment (90.5% (n=38/42)) and information provision on the potential treatment effects on swallowing (97.6% (n=41/42)) and communication ability (85.7% (n=36/42)) were the most common components of initial evaluation. In keeping with expert opinion and emerging evidence, prophylactic swallowing exercises were administered by 71.4% (n=30/42) of teams targeting specific aspects of swallowing, although the nature, intensity and duration of programmes varied. A range of measures are used to monitor progress during treatment. Our survey highlighted that resource limitations affect service provision with some teams managing the consequences of treatment rather than proactive multidisciplinary intervention prior to and during treatment. Cancer- and treatment-related dysphagia can impact significantly on a broad range of outcomes following radiotherapy. There is variability in dysphagia service provision to patients before, during and following treatment. Comprehensive evaluation of swallowing function prior to treatment and proactive management can yield benefits for patients, inform multidisciplinary case management and support those involved in clinical trials to accurately determine treatment effects.

Implications of understanding cancer stem cell (CSC) biology in head and neck squamous cell cancer.

Head and neck squamous cell cancer (HNSCC) is the sixth most common cancer in the world. Effective therapeutic modalities such as surgery, radiation, chemotherapy and combinations of each are used in the management of this disease. Efforts are ongoing throughout the world to improve early detection and prevention of HNSCCs. Often, treatment fails to obtain total cancer cure and this is more likely with advanced stage disease. In recent years it appears that one of the key determinants of treatment failure may be the presence of cancer stem cells (CSC) that 'escape' currently available therapies. CSCs form a minute portion of the total tumour burden but may play a disproportionately important role in determining outcomes. Molecular mechanisms which underlie the genesis of CSCs are yet not fully understood and their detection within the total tumour bulk remains a challenge. Specific markers like Aldehyde dehydrogenase 1 (ALDH1), CD44 and Bmi-1 have shown early promising results both in CSC detection and in guiding treatment protocols. CSCs have been shown to be relatively resistant to standard treatment modalities. It is hoped that developing robust in vitro and in vivo experimental models of CSCs might provide a means of devising more effective therapeutic strategies.

MAPK and PI3K signalling differentially regulate angiogenic and lymphangiogenic cytokine secretion in squamous cell carcinoma of the head and neck.

Vascular endothelial growth factors (VEGF-C and VEGF-A) play important roles in tumour-induced lymphangiogenesis and angiogenesis, respectively, key processes implicated in promoting tumour growth and metastatic spread. Previous work from our laboratory has shown that EGFR overexpression in squamous carcinomas of the head and neck (SCCHN) is linked to high levels of VEGF-A and VEGF-C (but low levels of VEGF-D) and is associated with poor prognosis. The present study explored the signalling pathways regulating the induction of VEGF-C and VEGF-A in the SCCHN cell lines CAL 27 and Detroit 562. The addition of exogenous EGF induced the expression of VEGF-C and VEGF-A in a concentration-dependent manner and this was blocked by a selective EGFR inhibitor, gefitinib. In both cell lines stimulated with endogenous or exogenous ligand, inhibition of MEK1/2 (with U0126 or PD98059) or PI3K (with PI-103 or LY294002) resulted in a marked reduction of EGFR-induced VEGF-A expression, whereas exogenous EGF-induced VEGF-C upregulation was blocked by inhibitors of MEK but not PI3K. Inhibition of p38 MAPK suppressed EGF-induced VEGF-C upregulation in CAL 27 cells, but inhibited EGF-induced VEGF-A upregulation in Detroit 562. Taken together, our evidence suggests that both endogenous and exogenous EGFR activation induces VEGF-A expression requiring both PI3K and MAPK signalling whereas VEGF-C expression is dependent on MAPK, but not the PI3K or mTOR pathways in SCCHN cell lines. p38 MAPK appears to be differentially linked to either VEGF-A or VEGF-C regulation in different cellular contexts.

First report on the reliability and validity of speech handicap index in native English-speaking patients with head and neck cancer.

BACKGROUND: Posttreatment speech problems are seen in nearly half of patients with head and neck cancer. Although there are many voice-specific scales, surprisingly there is no speech-specific questionnaire for English-speaking patients with head and neck cancer. The aim of this study was to validate the Speech Handicap Index (SHI) as the first speech-specific questionnaire in the English language. METHOD: In all, 55 consecutive patients in follow-up for oral and oropharyngeal cancer completed the SHI and University of Washington Quality of Life Questionnaire (UWQOL V.04). Thirty-two patients completed both questionnaires again 4 weeks later to address test-retest reliability. RESULTS: Internal consistency, test-retest reliability, construct validity, and group validity of the SHI were found to be highly significant (p < .01) using Cronbach's alpha, Spearman's correlation coefficient (r), and Mann-Whitney U tests. CONCLUSIONS: The SHI is a precise, highly reliable, and valid speech assessment tool for patients with head and neck cancer. Further dedicated studies using the SHI in patients with head and neck cancer would be useful.

Anatomic distribution of cervical lymph node spread in parotid carcinoma.

BACKGROUND: The pattern of distribution of cervical nodal involvement from primary parotid carcinomas has not been extensively described. METHODS: All cases of parotid carcinoma over a 10-year period treated at our institution were reviewed. Data from the patients with cervical metastases were analyzed. These findings were pooled with previously published data on topography of cervical lymph nodes from parotid carcinomas. RESULTS: Of 80 cases, 15 had cervical metastases (N+) in our series. When pooled with the data from all other reports, a total of 66 N+ cases were available for analysis. Twenty-eight percent of cases had involvement of level I, 59% had level II, 52% had level III, 38% had level IV, and 41% had level V. There were frequent skip metastases to level V but all were ipsilateral. CONCLUSION: The diffuse distribution of cervical nodal metastases does not support a high echelon neck dissection or radiotherapy fields limited to the upper chain in the management of cervical nodal disease.

Carcinoma arising from pharyngeal diverticula.

BACKGROUND: Pharyngeal diverticulum or Zenker's diverticulum carcinoma is a rare malignancy with a poor prognosis. Carcinoma arising in a recurrent pharyngeal diverticulum is even rarer, with only 1 such case reported in the English-language literature. We report 2 patients with pharyngeal diverticulum carcinoma exhibiting an unusual presentation and good long-term, disease-free survival with normal speech and swallowing. METHODS: A 70-year-old man with a carcinoma in a recurrent pharyngeal diverticulum excised 20 years previously and a 65-year-old man with a neck mass as the only presentation of pharyngeal diverticulum carcinoma. RESULTS: Our patients were treated with open resection, laryngeal preservation, and postoperative radiotherapy (PORT), resulting in long-term tumor control and disease-free survival of 5 and 15 years (longest reported), respectively. CONCLUSION: One-stage diverticulectomy with or without radiotherapy is the treatment of choice and can provide long-term control and survival.

Swallowing outcomes following Intensity Modulated Radiation Therapy (IMRT) for head & neck cancer - a systematic review.

PURPOSE: A systematic review to establish what evidence is available for swallowing outcomes following IMRT for head and neck cancer. METHODS: Online electronic databases were searched to identify papers published in English from January 1998 to December 2009. Papers were independently appraised by two reviewers for methodological quality, method of swallowing evaluation and categorized according to the World Health Organisation's International Classification of Health Functions. The impact of radiation dose to dysphagia aspiration risk structures (DARS) was also evaluated. RESULTS: Sixteen papers met the inclusion criteria. The literature suggests that limiting the radiation dose to certain structures may result in favourable swallowing outcomes. Methodological limitations included variable assessment methods and outcome measures and heterogeneity of patients. There are only limited prospective data, especially where pre-treatment measures have been taken and compared to serial post-treatment assessment. CONCLUSIONS: Few studies have investigated the impact of IMRT on swallow function and the impact on everyday life. Initial studies have reported potential benefits but are limited in terms of study design and outcome data. Further well designed, prospective, longitudinal swallowing studies including multidimensional evaluation methods are required to enable a more comprehensive understanding of dysphagia complications and inform pre-treatment counselling and rehabilitation planning.

Robotic surgery in head and neck cancer: a review.

The invasion of robotic technology in surgical fields cannot be ignored. Its success in various surgical disciplines especially in urology, cardiology, and gynaecology has set its own benchmarks. Extrapolation of similar results in head and neck is still in experimental stages and long term results are still eagerly awaited to truly establish its efficacy beyond awe and reality. Nonetheless, its future role in this area is inevitable given the encouraging results obtained so far. This article covers the inception to current application to speculation of robotic technology in complex area of head and neck surgery.

Validation of the Sydney Swallow Questionnaire (SSQ) in a cohort of head and neck cancer patients.

Impairment of swallowing function is a common multidimensional symptom complex seen in 50-75% of head and neck cancer (HNC) survivors. Although there are a number of validated swallowing-specific questionnaires, much of their focus is on the evaluation of swallowing-related quality of life (QOL) rather than swallowing as a specific function. The aim of this study was to validate the Sydney Swallow Questionnaire (SSQ) as a swallowing-specific instrument in HNC patients. Fifty-four consecutive patients in follow-up for oral and oropharyngeal cancer completed the SSQ and MD Anderson Dysphagia Inventory (MDADI). Thirty-one patients completed both questionnaires again four weeks later to address test-retest reliability. Internal consistency and test-retest reliability was assessed using Cronbach's alpha and Spearman's correlation coefficient, respectively. Construct validity (including group validity) and criterion validity were determined using Spearman's correlation coefficient and Mann-Whitney U-test. Internal consistency, test-retest reliability, construct validity, group validity and criterion validity of the SSQ was found to be significant (P<0.01). We were able to demonstrate the reliability and validity of the SSQ in HNC patients. The SSQ is a precise, reliable and valid tool for assessing swallow in this patient group.