Lymph Node Density in Node-Positive Laryngeal Carcinoma: Analysis of Prognostic Value for Survival.

OBJECTIVE: We investigated the value of lymph node density (LND) as a predictor of survival in patients with laryngeal squamous cell carcinoma (SCC) and positive neck node (pN+) after laryngectomy. STUDY DESIGN: Case series with chart review. SETTING: Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey. SUBJECTS AND METHODS: We reviewed the records of 289 patients with newly diagnosed primary laryngeal carcinomas who underwent partial or total laryngectomy and combined neck dissection at a tertiary referral center between June 2006 and December 2014. Patients with pN+ laryngeal SCC (n = 101) were included in the study. Overall survival (OS) and disease-free survival (DFS) were used to evaluate the prognostic significance of LND. RESULTS: In 101 patients with pN+ laryngeal SCC, LND ≥0.09 and number of metastatic lymph nodes >4 were significantly associated with OS and DFS but not the overall tumor, node, and metastasis stage. Forward stepwise Cox regression analysis revealed that LND ≥0.09 was the only independent predictor of both DFS and OS. Furthermore, the odds ratio of LND ≥0.09 was 10 times higher in patients with regional recurrence when compared patients without regional recurrence. CONCLUSIONS: LND was the only independent prognostic predictor of OS and DFS in patients with pN+ laryngeal SCC. Moreover, patients with LND ≥0.09 were significantly associated with high risk of regional recurrence. Thus, patients with LND ≥0.09 are at high risk of regional recurrence and death and may be considered for adjuvant chemoradiation.

Measurements of the facial recess anatomy: implications for sparing the facial nerve and chorda tympani during posterior tympanotomy.

Posterior tympanotomy is commonly performed through the facial recess to facilitate cochlear implantation. A rare but serious complication of this procedure is paralysis of the facial nerve and/or the chorda tympani. These complications generally occur because of a limited understanding of the anatomy of the facial recess. To help further define this area, we used computer-aided design software to measure (1) the angle between the facial nerve and the chorda tympani nerve and (2) the distance between the takeoff point of the chorda tympani and the posteriormost prominent point of the short process of the incus in 30 cadaveric adult temporal bones. The mean angle was 23.58° (±6.84), and the mean distance was 7.78 mm (±2.68). Our most important finding was that there was a correlation between the two measurements in that the distance tended to be greater when the angle was less than the mean and vice versa. This trend approached but did not quite reach statistical significance (r = -0.248, p = 0.059).

Preoperative clinical prediction of difficult laryngeal exposure in suspension laryngoscopy.

We investigated general and physical predictors of difficult laryngeal exposure in patients undergoing suspension laryngoscopy; 93 patients were included in this prospective study. The patients were classified as difficult laryngeal exposure group or non-difficult laryngeal exposure group based on the laryngeal view in suspension laryngoscopy. Twelve parameters (age, sex, body mass index, neck circumference, full mouth opening, modified mallampati index, hyoid-mental, thyroid-mental, horizontal thyroid-mental, vertical thyroid-mental, sternum-mental distance) that could predict difficult laryngeal exposure were evaluated. Of 93 patients, 22 had difficult laryngeal exposure. Cormack-Lehane score, neck circumference, body mass index, modified mallampati index, hyoid-mental, thyroid-mental, vertical thyroid-mental, and sternum-mental distance showed significant correlation with difficult laryngeal exposure. Based on the multivariate analysis, neck circumference superior to 40 cm, hyoid-mental and sternum-mental distance with respectively a value less than 6.05 and 13.9 cm were independently associated with difficult laryngeal exposure. Muscular neck, hyoid-mental and sterno-mental distance should be considered clinical predictors of difficult laryngeal exposure. Measurements of physical variables at full extension position of the neck are more useful and reliable predictors than neutral position for the risk of difficult laryngeal exposure.

Pharyngocutaneous fistula after total laryngectomy: emphasis on lymph node metastases as a new predisposing factor.

OBJECTIVE: We investigated patient-related and local risk factors for pharyngocutaneous fistula developing after total laryngectomy. DESIGN: Retrospective clinical study. SETTING: Tertiary medical centre. METHOD: The study included 255 patients who underwent total laryngectomy and concurrent neck dissection between July 2001 and February 2006 for laryngeal cancer. MAIN OUTCOME MEASURES: The association of fistula and patient-related (age, sex, hemoglobin and albumin levels, diabetes mellitus, chronic obstructive pulmonary disease, chronic congestive heart disease, hypertension) and local risk factors (T stage of the tumour and localization, previous radiotherapy, preoperative tracheostomy, lymph node metastases, surgical margin) was analyzed using the chi-square and independent-sample t-tests. RESULTS: Pharyngocutaneous fistulae were found in 18.4% of the patients. Lymph node metastases, chronic congestive heart disease, and postoperative hemoglobin and albumin levels lower than 10.84 +/- 1.2 g/dL and 3.06 +/- 0.5 g/dL, respectively, were found to be statistically significant risk factors in fistula formation. The logistic regression model was carried out on these risk factors. CONCLUSION: Pharyngocutaneous fistula remains the most frequent complication of total laryngectomy despite improved preoperative assessment and postoperative care. Lymph node metastases emerged for the first time as a risk factor for fistula formation. Our experience confirmed that meticulous postoperative care should be paid to the patients who have contributing risk factors and lymph node metastases.

Predictors of extracapsular spread in lymph node metastasis.

We investigated effect of clinical and pathologic parameters on extracapsular spread (ECS) in patients with lymph node metastasis in laryngeal and hypopharyngeal cancer. About 186 patients and 342 neck dissection were included in this study. Relationship between ECS and tumor location, T stage, pathologic N stage, tumor differentiation, number of metastatic lymph nodes, diameter of metastatic lymph node and impact of presence ECS on contralateral neck metastasis (CNM) were evaluated; 76 of the 186 patients had lymph node metastasis. Of the 76 patients, 31 (40.7%) had ECS. Tumor location, pathologic N stage of the tumor, number of metastatic lymph nodes, diameter of metastatic lymph node and the presence of CNM were significantly associated with ECS (P < 0.05). Only number of (>or=3) lymph node metastasis emerged as significant independent predictor of ECS (P < 0.05; OR:11.6). In conclusion, the number of metastatic lymph nodes (>or=3) should be used as predictor of ECS. Furthermore, contralateral neck dissection should be performed in patients with ipsilateral lymph node metastasis with ECS.