From VA Larynx to the future of chemoselection: Defining the role of induction chemotherapy in larynx cancer.

Organ preservation protocols utilizing induction chemotherapy as a selection agent have played a critical role in the treatment of advanced laryngeal squamous cell carcinoma (LSCC). The selection of patients who will have a good response to chemoradiation allows for organ preservation in a significant group of patients and minimizes the rate of surgical salvage. While there remains debate regarding its utility when compared to surgery or other organ preservation regimens, the data does suggest an important role for induction chemotherapy in LSCC. In addition, there are continued opportunities to identify pretreatment biomarkers for induction chemotherapy, whether genetic, epigenetic or cellular, that could predict response to treatment and select patients to therapy (whether organ preservation or surgery). As our understanding of the biology of larynx cancer advances, induction paradigms have utility for the development and adoption of novel agents and therapeutics. The background of induction chemotherapy as a selection agent and future directions of this approach are discussed.

Robotics in otorhinolaryngology - head and neck surgery.

A look at the past, present and future.

Impacto de la laringectomía total en la situación laboral / Impact of total laryngectomy on return to work

Introducción: La laringectomía total es una de las cirugías oncológicas más mutilantes. No existen estudios específicos que evalúen el retorno laboral después de la misma. Pacientes y métodos: Se realizó un estudio transversal de una muestra de 116 pacientes laringectomizados que se hallaban libres de enfermedad y con un seguimiento mínimo de 2 años desde la laringectomía total. Se les realizó una encuesta dirigida a conocer la situación laboral, tanto previa como posterior. En el momento de la cirugía 62 (53%) estaban activos laboralmente, 40 (35%) estaban jubilados y 14 (12%) tenían una situación de invalidez. Resultados: El 60% tenía profesiones con bajo grado de cualificación, siendo el grupo más numeroso los trabajadores de la construcción. De los 62 pacientes laboralmente activos en el momento de la laringectomía total 29 pasaron a inactivos y 33 (53%) mantuvieron la actividad laboral. Los factores más importantes para mantener la actividad laboral fueron el nivel de cualificación profesional y el método de rehabilitación vocal. El 80% de los pacientes con cualificación alta-intermedia mantuvieron su trabajo, frente al 35% en los de cualificación profesional baja (p < 0,001). El 70% de los pacientes con prótesis fonatoria mantuvo la actividad laboral, frente a un 31% de los pacientes rehabilitados con erigmofonía (p=0,004). La regresión logística confirmó estas variables como independientes para seguir trabajando. Conclusiones: Este es el primer estudio que analiza el impacto de la laringectomía total en la situación laboral. Los factores más importantes para volver a trabajar fueron tener un trabajo cualificado alto-intermedio y la utilización de prótesis fonatoria como método de rehabilitación vocal (AU)

Introduction: Total laryngectomy is one of the most mutilating oncological operations. There are no specific studies evaluating return to work after this surgery. Patients and methods: A cross-sectional study was performed on a sample of 116 laryngectomized patients who were disease- free and had a minimum follow-up of 2 years from total laryngectomy. A survey was conducted to find out their employment situation before and after surgery. At the time of surgery, 62 (53%) were working, 40 (35%) were retired and 14 (12%) were in a disability situation. Results: 60% had professions with low qualification requirements, the largest group being construction workers. Of the 62 patients active at the time of total laryngectomy, 29 became inactive and 33 (53%) maintained their work activity. The most important factors in maintaining work activity were the level of professional qualification and the method of vocal rehabilitation. Eighty percent of the patients with high-intermediate qualification maintained their jobs, compared to 35% of those with low professional qualifications (P < .001). Seventy percent of the patients with voice prostheses maintained their work activity, compared to 31% of the patients rehabilitated with oesophageal voice (P = .004). Logistic regression confirmed these as independent variables for continuing to work. Conclusions: This is the first study that analyzes the impact of total laryngectomy on the work situation. The most important factors for a return to work were having a high-intermediate skilled job and the use of voice prosthesis as a method of vocal rehabilitation (AU)

Trends in treatment, incidence and survival of hypopharynx cancer: a 20-year population-based study in the Netherlands.

Hypopharynx cancer has the worst prognosis of all head and neck squamous cell cancers. Since the 1990s, a treatment shift has appeared from a total laryngectomy towards organ preservation therapies. Large randomized trials evaluating treatment strategies for hypopharynx cancer, however, remain scarce, and frequently this malignancy is evaluated together with larynx cancer. Therefore, our aim was to determine trends in incidence, treatment and survival of hypopharynx cancer. We performed a population-based cohort study including all patients diagnosed with T1-T4 hypopharynx cancer between 1991 and 2010 in the Netherlands. Patients were recorded by the national cancer registry database and verified by a national pathology database. 2999 patients were identified. The incidence increased significantly with 4.1% per year until 1997 and decreased non-significantly afterwards. For women, the incidence increased with 1.7% per year during the entire study period. Total laryngectomy as primary treatment significantly decreased, whereas radiotherapy and chemoradiation increased. The 5-year overall survival significantly increased from 28% in 1991-2000 to 34% in 2001-2010. Overall survival for T3 was equal for total laryngectomy and (chemo)radiotherapy, but for T4-patients the survival was significantly better after primary total laryngectomy (± adjuvant radiotherapy). This large population-based study demonstrates a shift in treatment preference towards organ preservation therapies. The 5-year overall survival increased significantly in the second decade. The assumed equivalence of organ preservation and laryngectomy may require reconsideration for T4 disease.

Understanding the anatomy of the larynx from the era of Gimbernat to the present day moving towards laryngeal transplantation

Knowledge of the gross anatomy of the larynx in Spain throughout the period when Gimbernat was working as a surgeon and anatomist was considerable; very much comparable to our present understanding. However, the lack of aseptic surgical technique, anaesthesia, and antibiotics limited the ability to undertake complex surgery. Nevertheless, it was during that period when for first time it became possible to diagnose some laryngeal pathologies, thanks to the invention, by a Spanishsinger, Manuel Garcia (1805-1906), of a primitive laryngoscope that made it possible to see the laryngeal interior. Only in 1873 was the first major surgery of the larynx was reported when Billroth undertook the first laryngectomy to treat surgically laryngeal carcinoma. It was more than a hundred years later, before the first laryngeal transplantation was attempted by Strome and his team (1998), and though initially meeting with some success, that transplanted larynx had to be removed 14 years later. Based on our current understanding of laryngeal anatomy and surgical technique, we argue that there are four factors that must be addressed if satisfactory transplantation of the larynx to be achieved: 1) psycho-social and ethicolegal aspects; 2) tissue viability vs. rejection; 3) restoration of a vascular, and 4) selective reinnervation of the larynx has to be achieved. The three first factors are being addressed, however, the selective reinnervation remains challenging because the nerve supply of the larynx is now known to be much more complex than many accounts imply. This is because: 1) each laryngeal muscle may receive a variable number of nerve branches; 2) there are multiple connections between the different laryngeal nerves; 3) many laryngeal nerves and connections are mixed conveying both motor and sensory fibres; and 4) the laryngeal muscles may receive a dual nerve supply, from both the recurrent laryngeal and superior laryngeal nerves (AU)

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One-Lung Ventilation for Lung Lobectomy Using Endobronchial Blocker Through Adjustable Silicon Hyperflex Tracheostomy Tube in Postlaryngectomy Patient.

One-lung ventilation is challenging in patients with difficult airway who require lung surgery. The choice of airway technique remains limited in patients with permanent tracheostomy after total laryngectomy. Conventional airway management techniques and available airway equipment have limited the options for securing airway in such patients, and dedicated airway equipment is not available for the management of such patients. Here, using endobronchial blocker through adult silicon hyperflex tracheostomy tube with an adjustable flange, we report a successful airway management for 1-lung ventilation in a patient with total laryngectomy with permanent tracheostomy.

Treatment and Survival Trends in Glottic Carcinoma in Situ and Stage I Cancer From 1988 to 2012.

OBJECTIVE: To identify trends in treatment and survival for patients with stage I glottic cancer and glottic carcinoma in situ (CIS). METHODS: The 18-registry SEER data were analyzed for CIS and stage I glottic cancer. Treatment variables and observed and relative survival were assessed separately for stage I and glottic CIS. RESULTS: Among 14 025 cases of stage I glottic cancer identified from 1988 to 2012, radiation was the most common treatment for all eras. An increase in surgical treatment occurred with a decline in combination therapy. There were 3169 cases of glottic CIS, with surgery the most common initial treatment but with radiotherapy increasing across the years. Relative survival was similar for treatment type and era of diagnosis. Among the 3738 patients with glottic CIS, 5.4% went on to develop invasive glottic carcinoma of any stage, with invasive cancer more common in patients treated by surgery alone compared to radiation or surgery with radiation. CONCLUSIONS: Despite changes in treatment modalities for CIS and stage I glottic cancer, there have not been significant changes in survival for CIS, with slightly improved survival for treatment with surgery alone. Patients treated with surgery alone had an increased rate of subsequent invasive cancer.

Subtotal supracricoid laryngectomy: changing in indications, surgical techniques and use of new surgical devices.

PURPOSE: The aim of this study is to evaluate the evolution of supracricoid partial laryngectomy (SCPL) in indications, surgical techniques and outcomes through last decades. MATERIALS AND METHODS: A retrospective analysis of 146 patients affected by laryngeal cancer treated with SCPL was carried on. We defined: (1) group A, 100 patients treated by cold instruments between 1995 and 2004; (2) group B, 46 patients treated by harmonic scalpel between 2005 and 2010. Complications rate, and functional and oncological results were documented and a comparison between the two groups was made; histopathological analysis of surgical margins was evaluated and correlated with local incidence of recurrence. RESULTS: Significant differences in age mean-value (p=0.02), T classification (p=0.007), and in indication for more advanced-staged patients were found in group B (p=0.001). Surgical procedure was shorter in group B (p<0.001), with shorter swallowing recovery (p=0.003). Oncological outcomes did not report any significant differences. Group B showed a higher incidence of post- operative arytenoid edema (p=0.03) associated with a lower rate of pneumonia (p=0.038). Despite a higher rate of close or positive-margins found in group B no higher incidence of local-recurrence was reported (p=0.02) compared to group A. CONCLUSIONS: We documented changing in indications and surgical technique for SCPL because of the development of modern diagnostic techniques and the introduction of low-thermal injury device allowing a more challenging tumor excision as well as with a shorter swallowing recovery in our series.

The changing landscape of total laryngectomy surgery.

OBJECTIVE: To determine if the number of total laryngectomies (TL) performed in California has changed over a 15-year period from 1996 to 2010. We also sought to investigate if the location of surgery, length of stay, use of rotational/free flaps, cost, and complications changed over this period. STUDY DESIGN: Cross-sectional. SETTING: California Hospital Inpatient Discharge Data sets. SUBJECTS AND METHODS: All patient records enlisting International Classification of Diseases, Ninth Revision, Clinical Modification procedural codes for total/radical laryngectomy were extracted from 1996 to 2010 data sets. Patients' demographics were evaluated. Hospitals were coded as university medical centers (UMCs) vs others. Population-adjusted surgery rates, percentage of surgeries with rotational/free flap and/or percutaneous endoscopic gastrostomy (PEG), length of stay, total charges, and disposition status were then analyzed and compared between UMCs and non-UMCs. RESULTS: A total of 4145 TLs were performed in California during 1996 to 2010. The overall number of surgeries declined from 1.3 to 0.6 per 100,000 California residents (P < .001). The number of surgeries performed in non-UMCs dropped by 70% during this period (P < .001). The median length of stay increased from 10 to 12 days, and the median total charges increased from $45,000 to $192,000 over the 15-year period. The use of rotational/free flaps more than doubled, and the use of PEG tubes increased 7-fold. CONCLUSION: The total number of TLs in California has declined and surgeries are currently being performed equally at UMCs and non-UMCs. The use of rotational/free flaps, costs, hospital stay length, and complications have increased over the past 15 years.

Total laryngectomy: national and regional case volume trends 1998-2008.

OBJECTIVE: The management of advanced laryngeal cancer is evolving, with increasing use of chemoradiation as initial treatment. Recent reports confirm a decline in total laryngectomies (TLs) in the United States. A study was undertaken to evaluate national and regional trends in TLs performed over the most recent decade for which data were available and to use multivariate analysis to characterize these trends in more detail. STUDY DESIGN: Population-based cohort study. SETTING: Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1998 to 2008. SUBJECTS AND METHODS: All patients underwent radical or complete laryngectomy. Descriptive statistics and linear and multivariate regressions were performed on both raw case volumes and nationally extrapolated figures. RESULTS: In this nationally representative sample, 8288 TL cases met inclusion criteria between 1998 and 2008. The TL case volumes decreased by 27.3 per year (P = .005) and showed increasing trends in high-volume centers. The number of hospitals performing TLs decreased by 12.3 per year (P < .0005). The South and Midwest showed higher case volumes even after controlling for multiple covariates. CONCLUSION: Total laryngectomy cases are decreasing and concentrating into high-volume centers. This study demonstrated unexplained regional variation in case volumes. These findings may affect patients, otolaryngology residency training, surgeons, and reimbursement.

Trends in total laryngectomy in the era of organ preservation: a population-based study.

OBJECTIVE: To describe time trends in total laryngectomy health services utilization across the United States, such as rates of surgery, cost, length of stay, and insurance payer, and to compare this to important milestones in recommendations for laryngeal cancer treatment. STUDY DESIGN: Population-based cohort study. SETTING: Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) 1997-2008: stratified sample of all US hospital discharges. SUBJECTS AND METHODS: All patients with the principal procedure of complete laryngectomy. The unit of analysis was the discharge. RESULTS: Between 1997 and 2008, the number of laryngectomies done in the United States decreased by 48%. New cases of laryngeal cancer decreased 33% during the same time. The proportion of patients older than 65 years decreased from 48% to 43%. Mortality for the procedure was 1.4% in 1997 and 1.1% in 2008. Mean length of stay over the study period increased from 13 days to 14 days. Mean hospital charges rose from $58,000 in 1997 to $109,000 in 2008, consistent with the overall rise in US health care costs. Medicare was the dominant insurer throughout. Home health was ordered in 50% of 2008 discharges but only 32% in 1997. CONCLUSIONS: The rate of total laryngectomy has dropped more than the incidence of laryngeal cancer has dropped, consistent with the trend toward nonsurgical treatment. Lower surgical volumes and/or salvage laryngectomy surgeries are hypothesized to play a role in longer length of stay, stable mortality rates despite younger patient age, and increased need for home services after discharge.

National trends in laryngeal cancer surgery and the effect of surgeon and hospital volume on short-term outcomes and cost of care.

OBJECTIVES/HYPOTHESIS: The past 2 decades have witnessed an increase in the use of chemoradiation in the treatment of laryngeal cancer. We sought to characterize contemporary patterns of laryngeal cancer surgical care and the effect of volume status on surgical care and short-term outcomes. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Using the Nationwide Inpatient Sample database, temporal trends in laryngeal cancer surgical care were evaluated in 78,478 cases performed in 1993 to 2008. Relationships between volume and mortality, complications, length of stay, and costs were evaluated in 24,856 cases performed in 2003 to 2008 using regression analysis, with adjustment for patient and provider characteristics. RESULTS: Laryngeal cancer surgery in 2001 to 2008 was associated with increased utilization of high-volume hospitals (odds ratio [OR]=2.0, P=.039), a decrease in partial and total laryngectomy procedures (OR=0.7, P<.001), an increase in flap reconstruction (OR=1.6, P<.001), prior radiation (OR=2.2, P<.001), comorbidity (OR=1.6, P<.001), and wound complications (OR=4.0, P<.001), compared to 1993 to 2000. High-volume hospitals were significantly associated with partial laryngectomy (OR=1.8, P=.026) and flap reconstruction (OR=1.8, P=.027). High-volume surgeons were associated with partial laryngectomy (OR=1.7, P=.048), flap reconstruction (OR=1.6, P=.029), prior radiation (OR=2.2, P=.013), and comorbidity (OR=0.4, P=.008). After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and length of hospitalization, and surgery by a high-volume surgeon was associated with even greater reductions in length of hospitalization as well as lower hospital-related costs. CONCLUSIONS: These data reflect changing trends in the primary management of laryngeal cancer, with meaningful differences in the type of surgical care provided by high-volume providers.

Rehabilitación olfativa tras la laringectomía total / Olfactory rehabilitation after total laringectomy

Objetivos: Examinar la función olfatoria en pacientes laringectomizados y evaluar los resultados de la aplicación de la maniobra de inducción de flujo aéreo nasal. Material y métodos: Se realizó un estudio prospectivo de intervención con 41 pacientes laringectomizados, 39 hombres y 2 mujeres. Tras la comprobación de ausencia de alteraciones anatómicas, los participantes fueron sometidos a un test olfatométrico que los dividía en pacientes con olfato y pacientes sin olfato. Todos fueron sometidos a la rehabilitación del olfato mediante la técnica de inducción de flujo aéreo nasal y, posteriormente, a un segundo test olfatométrico para comparar los resultados con el primero. La valoración del sentido del gusto y del olfato de los pacientes se realizó a través de una entrevista semiestructurada en la que se tuvo en cuenta la opinión de cada uno de ellos. Resultados: De los 41 pacientes incluidos en el estudio, 9 tenían capacidad olfativa previa a la rehabilitación según el primer test olfatométrico. La realización de la rehabilitación supuso la recuperación o mejoría de la capacidad olfativa para el 90,24% de los pacientes. Conclusiones: La inducción de flujo aéreo nasal es una técnica que permite la recuperación del olfato y mejora del gusto a personas laringectomizadas. Es de fácil aprendizaje y realización. No precisa de medios técnicos costosos. La recuperación del olfato y el gusto mejoran la calidad de vida del paciente, por lo que esta técnica debería incluirse en los protocolos de rehabilitación integral del paciente laringectomizado (AU)

Objectives: To analyze the olfactory function in patients after total laryngectomy and evaluate the outcomes of the use of the induced nasal airflow manoeuvre. Material and methods: A prospective clinical intervention study was carried out with 41 patients who had undergone total laryngectomy, of which 39 were male and 2 female. After verifying that there were no anatomical disorders, the patients were given an olfaction test that classified them into two groups, those with olfactory perception and those without. All underwent rehabilitation using the induced nasal airflow technique and, subsequently, the olfaction test was repeated to enable a comparison with the first results obtained. A semi-structured interview was held to evaluate the senses of taste and smell of the participants, also taking into account their own opinion. Results: Out of the 41 patients included in the study, 9 had olfactory perception before rehabilitation, according to the first olfaction test. The use of the nasal airflow maneuver meant the recovery or improvement of the olfactory capacity in 90.24% of the patients. Conclusions: The induced nasal airflow technique enables an important recovery of olfaction and improvement of taste after total laryngectomy. This technique is easy to learn and to repeat. It does not require expensive materials. The recovery of olfaction and taste implies an improvement in quality of life for the patient, so this technique should be included in all protocols of comprehensive rehabilitation after total laryngectomy (AU)

National laryngopharyngectomy and reconstructive surgery survey.

OBJECTIVES/HYPOTHESIS: To understand the various methods available to reconstruct total laryngopharyngectomy defects and to understand which, and to what degree, various factors influence the surgeon in choosing a particular reconstructive method. METHODS: Otolaryngologists and plastic surgeons who perform head and neck reconstruction were surveyed regarding preference of laryngopharyngectomy reconstruction. Numerical and rank-order data was analyzed using T statistics and Fisher exact test. RESULTS: Two hundred surveys were mailed and 72 physicians (36% response rate) provided data, with otolaryngologists comprising 54% of the respondents. Otolaryngologists were more likely to consider voice (P = .003) and swallowing (P = .02) outcomes compared to plastic surgeons. In contrast, plastic surgeons more often included cosmesis (P = .05) among those factors influencing their reconstructive choice. However, rank-order analysis demonstrated no statistical difference between plastic surgeons and otolaryngologists with respect to each factor. CONCLUSIONS: Our study sought to examine what motivates surgeons from several specialties to choose one reconstructive method over another for laryngopharyngeal defects. Otolaryngologists were more likely to consider voice and swallowing function in contrast to plastic surgeons, who more frequently included cosmesis as a factor. However, when physicians were asked to rank the importance of each of the eight factors from most to least important in influencing their reconstructive option, there was no statistical difference between plastic surgeons and otolaryngologists with respect to each factor. Further research is necessary to provide an evidence base for which reconstructive method offers the optimal functional restoration.

[Adjuvants in operative laryngology: corticosteroids, fibrin adhesives, Mitomycin C]. / Adjuvanzien in der operativen Laryngologie : Kortikosteroide, Fibrinkleber, Mitomycin C.

Medicinal adjuvants are often used in operative laryngology but their value is judged very differently. The scientific evidence is unsatisfactory for most of these substances. For corticosteroids it is proven that in pediatric intensive care they reduce stridor following extubation. Routine prophylactic use for intubation does not seem to be justified and methylprednisolone and dexamethasone are the preferred preparations. Fibrin adhesives are well tolerated and low in side-effects. The indications for their use should be primarily limited due to the cost factor. Their use in laryngology remains a decision on an individual case-to-case basis. Mitomycin C is used because of its antiproliferative effect on fibroblasts in order to reduce scar tissue formation. Many positive effects have been attributed to the topical application but there are large differences in dosage and exposure time.

Cánula de plata en bronquio principal derecho / Silver cannula in main right bronchus

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Swing of the surgical pendulum: a return to surgery for treatment of head and neck cancer in the 21st century?

Treatment for head and neck cancer has evolved significantly during the past 100 years. Beginning with Bilroth's total laryngectomy on New Year's Day in 1873, "radical" surgery remained the only accepted treatment for head and neck cancer when optimal local and regional control was the goal. Bigger was still better when it came to managing the primary tumor and the neck. The "commando" procedure and radical neck dissection were the hallmarks of this first generation of treatments of head-and-neck cancer. With the advent of microvascular reconstructive techniques, larger and more comprehensive resections could be performed. Despite these large resections and their "mutilating" sequelae, overall survival did not improve. Even for intermediate-stage disease in head-and-neck cancer, the 5-year survival rate did not improve >50%. Many concluded that more than the scalpel was needed for optimal local and regional control, especially for intermediate- and advanced-stage disease. Most important, the multidisciplinary teams must identify and correlate biomarkers in the tumor and host that predict for a response to therapy and for optimal functional recovery. As the pendulum swings back, a scientific approach using tissue biomarkers for the response to treatment in the setting of multidisciplinary trials must emerge as the new paradigm. In the postgenomic era, treatment decisions should be made based on functional and oncologic parameters-not just to avoid perceived morbidity.