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At least 145 records · Page 8Linked to original sources
PubMed1988

New strategies for avoiding total laryngectomy in patients with head and neck cancer.

Cisplatin-based chemotherapy has yielded high response rates in patients with head and neck cancer but has failed to improve the survival rates in randomized studies. Thus, its place in the management of head and neck cancer remains unclear. We have been investigating whether the combination of chemotherapy and radical irradiation as an alternative to morbid surgery in selected patients might yield an improved quality of life without compromising survival. Between January 1983 and December 1985, we treated 32 patients with epidermoid carcinoma arising from the larynx, base of the tongue, or hypopharynx, using an interdisciplinary regimen, with the objective of avoiding total laryngectomy. All of these patients had large primary tumors that could not have been removed without total laryngectomy. Patients who could be treated by conservation laryngeal surgery were excluded, as were patients who presented with clearly unresectable disease. The regimen employed cisplatin-based chemotherapy together with brachytherapy and external radiation therapy, with highly individualized treatment planning. Seven patients had T2 lesions, 19 had T3, and 6 had T4. The follow-up periods ranged from 8 to 38 months (median, 18). The actuarial survival rate at 2 years is 85%, and the laryngectomy-free rate at 2 years is also 85%. None of the 11 patients with laryngeal cancer has relapsed, and none has required laryngectomy. None of the 12 patients with base of the tongue cancer treated by brachytherapy has relapsed above the clavicles and none has required laryngectomy, but 1 patient has died of complications of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1985

Epiglottic reconstruction after supraglottic laryngectomy.

It has been well established that supraglottic laryngectomy is an effective treatment of laryngeal cancer arising above the vocal cords with cure rates equaling total laryngectomy. Although there is preservation of a near normal voice after supraglottic laryngectomy, chronic aspiration occurs in some patients particularly after extended supraglottic laryngectomy or when there is associated compromised pulmonary function. During normal deglutition, the epiglottis serves to divert food to the pyriform fossae and partially covers the inlet to the airway. These important functions can be accomplished after supraglottic laryngectomy by reconstructing a neoepiglottis from an epiglottic remnant whenever one third or more of the epiglottis can be preserved which is microscopically free of tumor. Our results in 14 patients have shown no clinically significant aspiration after epiglottic reconstruction.

Deglutition↗
PubMed1998

Electromyography in near-total laryngectomy.

OBJECTIVE: To investigate the dynamics of speech shunt muscle in patients with Pearson near-total laryngectomy by needle electromyography and correlation of ability to activate shunt muscle with speech production. DESIGN AND SETTINGS: Prospective study of patients with near-total laryngectomy at 2 hospital-based academic tertiary care centers. PARTICIPANTS AND INTERVENTION: Fourteen patients with near-total laryngectomy were subjected to percutaneous needle electromyographic study of the shunt muscle. MAIN OUTCOME MEASURES: Speech ability, electromyographic evidence of viable muscle in shunt wall, and ability to activate shunt muscle were recorded. RESULTS: Twelve of 14 patients had good speech; 11 had evidence of viable shunt muscle; and 9 were able to activate muscle by phonation, swallowing, or deep breathing, indicating preserved innervation. Six of the 12 patients with speech ability and 1 of the 2 patients without speech ability were able to recruit motor units during attempted phonation. CONCLUSIONS: Electromyography demonstrated viable muscle with retained innervation in 64% of the patients with near-total laryngectomy, proving its "dynamic" nature. However, the usefulness of shunt muscle activation in speech and prevention of aspiration needs further confirmation.

Adult↗
PubMed1999

High-speed digital imaging of neoglottic vibration after total laryngectomy.

OBJECTIVES: To establish the applicability of digital high-speed imaging in studying neoglottic mucosal vibration after total laryngectomy and to perform a structured evaluation of the recordings using a standardized assessment form to gain insight about the anatomical and morphologic characteristics of the neoglottis. DESIGN: Evaluation of a new clinical tool and description of clinical disorders in a patient survey. SETTING: The Netherlands Cancer Institute, Amsterdam. PATIENTS: Forty-six patients who underwent laryngectomy, 36 who underwent standard total laryngectomy and 10 who underwent a partial or total pharynx reconstruction (ie, myocutaneous pectoralis major flap [n = 4], free radial forearm flap [n = 2], tubed gastric pull-up [n = 3], and full gastric pull-up [n = 1]). INTERVENTION: Digital high-speed imaging, using a 90 degrees rigid laryngoscope, of the neoglottic vibration in prosthetic tracheoesophageal speakers after total laryngectomy. MAIN OUTCOME MEASURES: Digital high-speed imaging might overcome some of the problems of stroboscopy in studying irregular voices and could, therefore, be expected to give more insight into the anatomical and morphologic characteristics of the neoglottis. RESULTS: Digital high-speed recordings could be obtained in 44 of 46 patients. Using a structured evaluation form, a wide variability in anatomical and morphologic features could be established. CONCLUSIONS: Digital high-speed imaging appeared to be a useful tool in studying the irregular vibrations of the neoglottis. Evaluation by the structured evaluation form gives a good idea about the wide variability in anatomical and morphologic features of the neoglottis.

Aged↗
PubMed2002

Swallowing outcomes following laryngectomy and pharyngolaryngectomy.

OBJECTIVES: To determine the incidence of dysphagia (defined as the inability to manage a diet of normal consistencies) at hospital discharge and beyond 1 year postsurgery and examine the impact of persistent dysphagia on levels of disability, handicap, and well-being in patients. DESIGN: Retrospective review and patient contact. SETTING: Adult acute care tertiary hospital. PATIENTS: The study group, consecutively sampled from January 1993 to December 1997, comprised 55 patients who underwent total laryngectomy and 37 patients who underwent pharyngolaryngectomy with free jejunal reconstruction. Follow-up with 36 of 55 laryngectomy and 14 of 37 pharyngolaryngectomy patients was conducted 1 to 6 years postsurgery. MAIN OUTCOME MEASURES: Number of days until the resumption of oral intake; swallowing complications prior to and following discharge; types of diets managed at discharge and follow-up; and ratings of disability, handicap, and distress levels related to swallowing. RESULTS: Fifty four (98%) of the laryngectomy and 37 (100%) of the pharyngolaryngectomy patients experienced dysphagia at discharge. By approximately 3 years postsurgery, 21 (58%) of the laryngectomy and 7 (50%) of the pharyngolaryngectomy patients managed a normal diet. Pharyngolaryngectomy patients experienced increased duration of nasogastric feeding, time to resume oral intake, and incidence of early complications affecting swallowing. Patients experiencing long-term dysphagia identified significantly increased levels of disability, handicap, and distress. Patients without dysphagia also experienced slight levels of handicap and distress resulting from taste changes and increased durations required to complete meals of normal consistency. CONCLUSIONS: The true incidence of patients experiencing a compromise in swallowing following surgery has been underestimated. The significant impact of impaired swallowing on a patient's level of perceived disability, handicap, and distress highlights the importance of providing optimal management of this negative consequence of surgery to maximize the patient's quality of life.

Adult↗
PubMed2006

Screening and rehabilitation of olfaction after total laryngectomy in Swedish patients: results from an intervention study using the Nasal Airflow-Inducing Maneuver.

OBJECTIVES: To examine the olfactory function in patients with laryngectomy and to assess the results of the Nasal Airflow-Inducing Maneuver (NAIM) odor-rehabilitation technique. DESIGN: A prospective intervention study. SETTING: University hospital. PATIENTS: Twenty-four patients, 21 men and 3 women, mean age 68 years, who underwent laryngectomy at least 5 months prior to intervention. INTERVENTION: Speech therapists trained patients in the NAIM technique: simultaneous lowering of the jaw, floor of the mouth, tongue, base of the tongue, and soft palate while the lips are closed. Three interventions were given within 6 weeks. MAIN OUTCOME MEASURE: Olfactory testing with semistructured interview, the Questionnaire on Olfaction, Taste, and Appetite (QOTA), and the Scandinavian Odor-Identification Test (SOIT). Quality of life was measured with European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-H&N35 questionnaires. The patients were categorized as smellers or nonsmellers based on the SOIT results. RESULTS: Before the treatment, 10 patients (42%) were smellers (ie, 6 had normosmia and 4 hyposmia), while 14 patients (58%) were nonsmellers (ie, all had anosmia). Thus, 18 patients had impaired olfaction. Using the NAIM technique, 13 (72%) of 18 patients with impaired olfaction showed improvement. Of the 14 nonsmellers, 7 converted to smellers after only 1 intervention session, giving us a success rate of 50% in anosmic patients after 1 session. CONCLUSIONS: Olfactory impairment is common in patients who underwent laryngectomy. The NAIM method is easy to learn and rapidly improves smell and taste. A single intervention session is sometimes sufficient, but many patients benefit from repeated training. The SOIT test is an effective and simple test for the assessment of olfaction acuity after laryngectomy.

Aged↗
PubMed2007

Retronasal and orthonasal olfactory ability after laryngectomy.

OBJECTIVE: To characterize orthonasal and retronasal olfactory ability in patients who have had a total laryngectomy (TL). DESIGN: Prospective psychophysical evaluation of orthonasal and retronasal olfactory function. SETTING: Academic center outpatient clinic. PATIENTS: Volunteer sample of 36 subjects who underwent laryngectomy 0.5 to 25.0 years after TL (median, 3.5 years) and 36 age-, sex-, and smoking history-matched controls. MAIN OUTCOME MEASURES: Scores on established psychophysical tests of orthonasal and retronasal olfaction and self-rating scores of smell assessed with a visual analog scale. RESULTS: Assessment of orthonasal olfactory ability yielded a mean composite score of 4.3 (maximum score, 7) for the TL group and 5.3 for the control group (P = .002). Evaluation of retronasal olfactory ability resulted in a mean score of 11.0 (maximum score, 20) for the TL group vs 14.3 for the control group (P<.001). The mean self-rating scores of smell were 2.9 and 6.6 (maximum score, 10) for the TL and control groups, respectively (P<.001). Self-ratings of smell positively correlated with orthonasal (r(S) = 0.42; P<.001) and retronasal (r(S) = 0.50; P<.001) olfactory ability. CONCLUSIONS: Laryngectomy is associated with measurable decreases in olfactory function that are also subjectively perceived. Quantification of decrements in orthonasal and retronasal olfactory function can be used to characterize the severity of hyposmia and to assess the potential for, and efficacy of, olfactory rehabilitation. Although self-assessment with a simple visual analog scale successfully identifies many laryngectomy patients who have objective evidence of olfactory dysfunction, further investigation is necessary to evaluate and compare its validity and reliability with other available survey instruments that purport to measure olfaction.

Aged↗
PubMed1985

Feasibility of subtotal laryngectomy based on whole-organ examination.

Subtotal (near-total) laryngectomy has recently been advocated to eradicate large laryngeal tumors. The operation, which preserves the cricoarytenoid joint and adjacent vocal fold, is based on the premise that many T3 and T4 tumors can be resected without complete sacrifice of the phonatory mechanism. The purpose of this study was to verify or disprove the assumption by examining sections of whole-organ laryngeal specimens. Twenty-four of the 64 specimens analyzed were determined to be resectable by subtotal laryngectomy. Twenty-two other specimens could have been resected by a more conventional conservation technique such as hemilaryngectomy or supraglottic laryngectomy. This study supports the concept of subtotal laryngectomy for selected large tumors. Guidelines for determining the suitability of the technique are suggested.

Epiglottis↗
PubMed1993

Impact of bilateral neck dissection on recovery following supraglottic laryngectomy.

Previously reported data from our institution has led us to perform bilateral neck dissections for therapeutic as well as staging advantages for horizontal supraglottic laryngectomies. Concern over the possibility of increased morbidity associated with simultaneous bilateral neck dissection prompted this retrospective review of patients with supraglottic laryngectomy who were treated with either unilateral (46 patients) or bilateral (23 patients) neck dissection. No significant differences were found in morbidity when patients were evaluated for transfusion rate, cervical wound drainage, need for tracheotomy, oral diet, or duration of hospitalization. Significant differences were noted in surgical operating time, eg, it took 100 minutes longer to perform bilateral dissections, and slight increases were noted in estimated blood loss and fluids given intravenously. No significant differences were noted in the percentage or type of postoperative complications. It seems that bilateral neck dissection in conjunction with supraglottic laryngectomy does not increase postoperative surgical morbidity and may actually avoid complications associated with postoperative radiation therapy in patients with supraglottic laryngectomy.

Carcinoma, Squamous Cell↗
PubMed1996

Using botulinum toxin A to improve speech and swallowing function following total laryngectomy.

OBJECTIVE: To evaluate a technique to reduce dysfunctional spasm in the pharyngoesophageal segment (PES) in patients after laryngectomy. DESIGN: Pharyngoesophageal segment function related to voice and/or swallowing in patients who had undergone a laryngectomy was evaluated before and after the injection of botulinum toxin A. SETTING: Academic referral medical center. PATIENTS: Eight outpatients with voice and/or swallowing complaints after undergoing a total laryngectomy. INTERVENTIONS: Videofluoroscopic contrast examination was completed to identify stricture vs spasm in the PES in patients with voice and/or swallowing complaints after undergoing a laryngectomy. Lidocaine hydrochloride injection under fluoroscopic guidance was completed to facilitate immediate relaxation of spasm. After positive results with lidocaine, botulinum toxin was injected into the same area to facilitate longer-lasting benefit. MAIN OUTCOME MEASURE: Patient report of benefit and videofluoroscopic evaluation of PES function. RESULTS: Six of 8 patients demonstrated improved function within the PES after lidocaine injection. Five of these 6 received transcutaneous injection of botulinum toxin. Four of the 5 patients demonstrated improved swallowing and/or voice function, and 3 of these 4 received subsequent injections of botulinum. No serious complications were encountered. CONCLUSIONS: Transcutaneous injection of botulinum toxin in the PES under videofluoroscopic guidance provides improvement in voice and/or swallowing function without significant complications. Additional clinical study will be required to evaluate dose and technique influences on degree and duration of benefit and complications.

Administration, Cutaneous↗
PubMed1997

Early speech results with the Provox prosthesis after laryngectomy.

OBJECTIVES: To assess our initial success using the Provox (Atos Medical AB, Horby, Sweden, and Entermad BV, Woerden, the Netherlands) tracheoesophageal speaking valve as the primary prosthesis to rehabilitate patients after total laryngectomy and to compare our success and complication rates with those previously reported. DESIGN: A retrospective analysis of all the patients who had a Provox prosthesis placed from November 1994 to November 1995. PATIENTS AND METHODS: Medical charts were reviewed for success or failure of the prosthesis as determined by the quality of speech and the utility of the device. In addition, complications, whether the patient had a pharyngeal myotomy and/or radiation, and the reasons and timing for replacement were assessed. Twenty-one patients had a Provox prosthesis placed either primarily at the time of their total laryngectomy (n = 8), delayed (n = 5), or as a replacement for another type of prosthesis (n = 8). Follow-up ranged from 2 to 17 months. RESULTS: The initial success rate was 84%, and the long-term success rate was 74%. Of note, 3 patients had substantially improved speech and none were worse when changed from another type of prosthesis. The mean interval to prosthesis change was 166 days. Reasons for failure included infection, radiation fibrosis, manual incoordination, cerebrovascular accident, and combination of total laryngectomy and total glossectomy. The most common complication (in 2 patients) was retraction of the prosthesis into the esophagus that was successfully managed by replacement with a longer device. CONCLUSION: Our early results confirm the effectiveness, longevity, and safety of the Provox prosthesis for speech rehabilitation following total laryngectomy.

Adult↗
PubMed1998

Partial laryngectomy as salvage surgery for radiation failures in T1-T2 laryngeal cancer.

BACKGROUND: Radiotherapy is the treatment of choice for early glottic carcinoma. Thirteen percent to 24% of patients require salvage surgery. To evaluate time of recurrence, site, and locoregional control, we retrospectively reviewed 29 patients treated from 1981 to 1996. METHODS: There were 28 men and 1 woman. Mean age was 63 years. Twenty were T1 (69%) and 9 were T2 (31%). Median time of recurrence was 14.5 months. In 14 patients (52%), a partial laryngectomy was done, and 13 patients had a total laryngectomy. Two refused surgery. RESULTS: One patient relapsed after salvage surgery. Five-year survival after salvage surgery was 92%, with no difference between partial and total laryngectomy (p = 0.2). CONCLUSIONS: Recurrences after failure to radiotherapy in T1-T2 glottic carcinoma could be salvaged with partial laryngectomy in 52% of patients, preserving laryngeal function, with adequate tumor control and acceptable morbidity. The selection of the surgical procedure is based on the tumor extension.

Adult↗
PubMed2000

The effectiveness of a "critical pathway" in the management of laryngectomy patients.

BACKGROUND: This is a retrospective review of medical and financial records to test the hypothesis that the use of a critical pathway specifically designed for the management of laryngectomy patients will result in improved patient care, decreased length of hospitalization, and optimal allocation of resources. METHODS: Thirty patients undergoing laryngectomy before the implementation of the laryngectomy critical pathway were compared with 30 patients after implementation of the pathway. Clinical outcomes, length of hospitalization, and cost analyses were performed. RESULTS: Adjusting for two outliers, the average length of stay for pathway patients was 7.3 days vs 12 days for prepathway patients. A total estimated cost-savings of $204,000 was ultimately achieved. CONCLUSIONS: Our laryngectomy critical pathway has resulted in improved patient care and optimized allocation of medical resources.

Adult↗
PubMed2002

Supracricoid partial laryngectomy as salvage surgery after radiation failure.

BACKGROUND: Radiotherapy is often chosen as the definitive treatment for early stage laryngeal carcinoma. Total laryngectomy is the main procedure for failures. Endoscopic treatment of recurrences by CO(2) laser has found limited application. Partial laryngectomy through an external approach has been proposed as salvage surgery, and the vertical partial laryngectomy (VPL) is the most mentioned surgical technique in the literature, although there are, to date, very few reports regarding the use of the supracricoid partial laryngectomy (SCPL) as salvage surgery after radiation failure. OBJECTIVES: The aim of the study is to check the feasibility of SCPL with cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP) in patients with laryngeal recurrence after radiation failure and to evaluate the oncologic results, morbidity, and functional outcome. METHODS: Fifteen consecutive patients were treated with salvage intent by SCPL from January 1992 to December 1998. CHEP and CHP were performed in 11 and 4 patients, respectively. Five patients underwent homolateral surgical neck dissection, and one underwent bilateral neck dissection. All patients had a temporary tracheostomy, and two patients required percutaneous endoscopic gastrostomy (PEG) to ensure feeding. Functional rehabilitation started 2 weeks after the operation. RESULTS: The results have been evaluated in terms of oncologic outcome and functional preservation. Twelve patients are alive with a minimum follow-up of 36 months and 3 patients died after 36 days, 6 and 14 months after surgery, the first and second patient from heart failure and the third from lung metastasis. Respiratory function was recovered in all cases. Oral intake began 12 days after surgery, and in 14 cases satisfactory swallowing was recovered 30 days after surgery. An acceptable quality of the voice was achieved by most patients, and a high rate of local immediate complications was solved in all cases. CONCLUSIONS: SCPL represents an effective technique as salvage treatment of laryngeal cancer after exclusive radiotherapy; there is a good functional recovery with acceptable morbidity and good oncologic long-term control.

Aged↗
PubMed2003

Comparison of pharyngoesophageal segment pressure in total laryngectomy patients with and without pharyngeal neurectomy.

BACKGROUND: To compare pharyngoesophageal segment (PES) pressure values in total laryngectomy patients with and without pharyngeal neurectomy (PN) in the early postoperative period. METHODS: Forty-five previously untreated laryngeal carcinoma patients were enrolled into this prospective randomized study. Twenty of them underwent total laryngectomy with PN, and 25 underwent total laryngectomy without PN. PES pressures were measured on the tenth postoperative day with a four-channel catheter. RESULTS: Average PES pressures in patients with and without pharyngeal neurectomy were 12.82 +/- 6.11 mmHg and 17.40 +/-.72 mmHg respectively (p <.05). When compared with the critical point of 20 mmHg that is closely related to voice attainment in the group without pharyngeal neurectomy, 10 (40%) patients had pressure levels greater than 20 mmHg and in the other group only 1 (5%) patient had a pressure level greater than 20 mmHg. The difference between the groups with pressure levels greater than 20 mmHg was found to be statistically significant (p <.05). CONCLUSIONS: Pharyngeal neurectomy results in a statistically significant decrease of PES pressures in total laryngectomy patients.

Adult↗
PubMedDate not supplied

Recovery of postoperative swallowing in patients undergoing partial laryngectomy.

This study assessed the achievement of postoperative swallowing in patients undergoing partial laryngectomy surgery. Oropharyngeal swallow efficiency was used to predict time to achievement of outcome. Fifty-five patients were followed for up to 1 year in two hemilaryngectomy and four supraglottic laryngectomy groups. Within 10 days of healing, a videofluoroscopic evaluation enabled the measurement of swallowing efficiency. Times to achievement of oral intake, removal of feeding tube, preoperative diet, and normal swallow were analyzed using actuarial curves. Patients with hemilaryngectomies achieved swallowing rehabilitation sooner than patients with nonextended supraglottic laryngectomies (p < .05) who, in turn, achieved swallowing function sooner than did patients undergoing supraglottic laryngectomies with tongue base resection (p < .05). Median time to attainment of preoperative diet in these three groups was 28 days, 91 days, and > 335 days, respectively. Higher early postoperative oropharyngeal swallow efficiency was related to earlier achievement of oral food intake and of preoperative diet (p < .05). Results show that the time course for swallowing rehabilitation covers an extended postoperative period. In some surgical groups, functional swallowing and eating may be achieved within 3 months of surgery while for other types, significant impairment remains up to 9 months postoperatively Early radiographic assessments of swallowing function are useful in predicting the time to swallow recovery. Recovery of swallowing ability may be delayed in patients who have not achieved oral intake before radiotherapy is started.

Cineradiography↗
PubMedDate not supplied

Prognosis of recurrent laryngeal carcinoma after laryngectomy.

BACKGROUND: Recurrence is common after total laryngectomy for advanced laryngeal carcinoma. The aim of the present study was to review the prognosis of recurrent laryngeal carcinoma after total laryngectomy. METHODS: The records of 165 patients who developed recurrences after total laryngectomy for laryngeal squamous cell carcinoma between January 1971 and December 1990 were reviewed. RESULTS: Of the 165 patients who developed recurrences, 34 (21%) patients had surgical salvage. The sites of recurrence of these 34 operable patients included 11 pharyngeal, 3 tracheostomal, 15 nodal, 2 pharyngeal with nodal, and 3 pulmonary metastasis. Pharyngeal recurrence had the highest salvage rate, followed by nodal and pulmonary recurrence. All patients with tracheostomal had recurrence after salvage surgery. After the surgical salvage, the tumor recurrence rate was 44% and the 5-year actuarial survival rate was 42%. Of the other 131 patients who had palliative treatment without surgical salvage, the 5-year actuarial survival rate was 2%. CONCLUSIONS: The present study showed that patients who had surgical salvage for recurrent tumor after total laryngectomy had satisfactory prognosis. Close follow-up of patients after initial operation is essential to detect recurrence early, while surgical salvage is still feasible.

Actuarial Analysis↗
PubMedDate not supplied

Complications following laryngectomy.

The complications following 100 consecutive laryngectomies performed at our hospital during a recent 18-month period are reviewed. The complication rates for total laryngectomy (63 patients) and extended laryngectomy (37 patients) were 19% and 49%, respectively, while the fistula rates were 8% and 27%, respectively. These rates were influenced primarily by the extent of surgery and the type of reconstruction, which during this interval included primary closure, pectoralis major myocutaneous flap, or gastric transposition. In comparison to our previous study, when the deltopectoral flap was used for patching the pharynx, the fistula rate for extended laryngectomy has decreased as a result of our use of myocutaneous flaps and greater experience with gastric transposition. Currently, we use the pectoralis major myocutaneous flap for pharyngeal repair if the mucosa would otherwise be closed under tension. All circumferential defects are repaired with a gastric transposition.

Adult↗