Comparación de pacientes con laringectomía total primaria y de rescate

Introduction and objectivesTotal laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival.MethodsThe study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death.ResultsThe mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P = .000) and between fistula and infection (P = .000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P = .038), T4 (P = .026), lymphovascular invasion (P = .019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P = .005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P = .026).ConclusionsAlthough organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.     

Resultados oncológicos de la laringectomía de rescate en pacientes con carcinomas escamosos de laringe

ObjectiveTo analyse the oncological results of a salvage total laryngectomy in patients with a laryngeal carcinoma.Material and methodsRetrospective review of a cohort of 241 patients treated with a salvage laryngectomy after a local recurrence. The initial treatment received by these patients was radiotherapy (n = 201, 83.4%), chemoradiotherapy (n = 19, 7.9%), and partial surgery (n = 21, 8.7%),ResultsTotal laryngectomy as salvage treatment achieved local control of the disease in 81.3% of cases, with a 5-year specific survival of 65.3%. The variables related with specific survival in a univariate analysis were the location of the primary tumour, the local extension of the initial tumour and of the recurrence, the resection margins, and the pathological status of the neck dissections. According to the results of a multivariate analysis, the variables related to specific survival were the status of the resection margins, the presence of simultaneous regional recurrence, and the local extension of the recurrence.ConclusionThe 5-year specific survival of patients treated with a salvage laryngectomy was 65.3%. The variables related with the control of the disease were the status of the resection margins, the presence of simultaneous regional recurrence and the local extension of the recurrence.     

Role of supracricoid partial laryngectomy with cricohyoidoepiglottopexy in glottic carcinoma with anterior commissure involvement

ObjectivesTo analyze oncologic and functional outcomes after supracricoid laryngectomy with cricohyoidoepiglottopexy (SCL-CHEP) in glottic carcinoma with anterior commissure (AC) involvement, to determine predictive factors, and to compare results with those reported for other therapeutic strategies.Material and methodsA retrospective analysis included all patients who underwent SCL-CHEP for glottic squamous cell carcinoma with anterior commissure involvement in our institution, between 2000 and 2014. Swallowing function was evaluated on the DOSS (Dysphagia Outcomes and Severity Scale).ResultsFifty-three patients were included. Three-year overall, cause-specific and recurrence-free survival rates were 86, 95 and 80%, respectively. There were 5 cases of local recurrence (9%), all treated by total laryngectomy. Smoking was the only predictive factor of recurrence-free survival (P = 0.02). Mean DOSS score was 5.5 ± 0.9. DOSS scores ≥ 6 (normal oral feeding) were recovered by 59% of patients. T-stage ≥ 2 was the only predictive factor for DOSS score (P = 0.04).ConclusionIn glottic carcinoma with anterior commissure involvement, SCL with CHEP provided a local control rate of more than 90%, which is higher than reported with endoscopic surgery or external radiotherapy. However, contrary to LSC, salvage of local recurrence can often be obtained by conservative treatments after endoscopic surgery. Therefore, total-laryngectomy-free survival rates after SCL-CHEP and endoscopic surgery are finally comparable.     

Lymph-node metastasis following total laryngectomy and total pharyngolaryngectomy for laryngeal and hypopharyngeal squamous cell carcinoma: Frequency,distribution and risk factors

ObjectivesTo evaluate the prevalence and distribution of lymph-node metastasis after total laryngectomy or total pharyngolaryngectomy.Material and methodsRetrospective single-center series of 136 successive patients undergoing total laryngectomy or total pharyngolaryngectomy with neck dissection for squamous cell carcinoma of the larynx or hypopharynx.ResultsThe primary site was laryngeal in 110 cases and hypopharyngeal in 26. In 63 patients, surgery was first-line treatment; 73 were operated on for recurrence. The lymph-node metastasis rate, confirmed on histology, was 44.8% regardless of primary site. Hypopharyngeal location was a risk factor for lymph-node metastasis (73.1%, P = 0.002) as was the supraglottic subsite (64.3%, P = 0.039). Levels IIa and III were invaded in 28.7% and 25.7% of cases, respectively. Level VIb lymph-node involvement was 23.8% in patients who underwent level VIb neck dissection. Lymph-node recurrence rate was 10.3% in levels II to IV and 13.2% in VIb.ConclusionsWhatever the tumor site, levels IIa and III were most frequently invaded. The high rate of histological involvement of level VIb and of recurrence argues for systematic elective bilateral neck dissection of these territories in some primary sites.     

Expresión de E-cadherina y β-catenina en carcinomas de células escamosas de laringe e hipofaringe

Introduction and objectivesDysfunction of the E-cadherin/catenin complex is directly related to carcinogenesis and metastases development.The aim of this paper is to investigate the prognostic significance of E-cadherin and β-catenin expression in surgically treated laryngeal and hypopharyngeal squamous cell carcinomas.Material and methodsTumour tissue samples were obtained from 133 consecutive patients with squamous cell carcinomas of the head and neck: 68 of the larynx and 65 hypopharyngeal carcinomas, who underwent surgical treatment in our hospital between 2000 and 2005.E-cadherin and β-catenin expression was analysed by immunohistochemistry, quantifying the percentage of stained cells and the intensity of staining.ResultsE-cadherin and β-catenin expression was evaluable in 59 laryngeal carcinomas and in 58 cases of hypopharyngeal carcinomas.In the laryngeal tumours, a significant association was found between the low expression of membrane β-catenin with T4 tumours and tumour recurrence. In the hypopharynx there was a significant association between positive expression of nuclear β-catenin and poor histological differentiation (P = .02). In the multivariate analysis, only the presence of lymph node metastases was an independent predictive factor of decreased disease-specific survival in laryngeal squamous cell carcinomas.ConclusionsThe expression of E-cadherin and β-catenin does not show prognostic significance in laryngeal and hypopharyngeal squamous cell carcinomas over the TNM classification.     

Successful 10-year outcomes after supracricoid partial laryngectomy for selected glottic squamous cell carcinoma classified as T3N0M0: A STROBE analysis

PurposeTo evaluate long-term oncological outcome for patients with selected glottic squamous cell carcinoma (SCC) classified as T3N0M0 treated by supracricoid partial laryngectomy (SCPL).Materials and methodsAnalysis of an inception cohort of 46 patients with isolated untreated SCC classified as T3N0M0 and minimum 10-year follow-up, consecutively treated by SCPL between 1982 and 2012 in a French university teaching hospital. The main endpoint was 5- and 10-year actuarial survival and local control estimates. Accessory endpoints comprised cause of death, screening for variables decreasing survival and increasing risk of local recurrence, oncologic consequences of local recurrence, and laryngeal preservation rate.ResultsFive- and 10-year actuarial survival was 78.1%, and 53.3%, respectively. The main causes of death were intercurrent disease and metachronous second primary, each in 33.3% of cases. Postoperative mortality (aspiration pneumonia) was 2.1%. There were no significant correlations between survival and any study variables. Five- and 10-year local control was 90.5%. Overall local recurrence varied significantly (P = 0.003), from 2.3% with negative margins (R0) to 100% with positive margins (R1) and/or dysplasia. Local recurrence was associated with a significantly (P < 0.005) increased risk of nodal failure and distant metastasis, and reduced survival. Overall laryngeal preservation was 89.1%.ConclusionThe present results suggest that SCPL should continue to be taught and that this type of partial laryngeal surgery should be included in the various organ-sparing strategies considered in advanced laryngeal cancer.     

Peritumoral infiltrate in the prognosis of epidermoid carcinoma of the oral cavity

IntroductionPatients with squamous cell carcinoma of the oral cavity present deficits in their cellular immunity that contribute to neoplastic growth. Thus, the inflammatory activity, such as the immunological response to the tumor, can be used as a prognostic factor.ObjectivesTo evaluate the correlation between peritumoral inflammation and clinical characteristics of the patients, survival, and the disease-free interval.MethodsThe study sample consisted of a retrospective hospital-based cohort of patients undergoing surgery for resection of oral cavity tumor. The inflammatory infiltrate on the slides was evaluated semi-quantitatively, and were divided into minor and major inflammatory processes.ResultsThis study included 57 tumor samples, with infiltration of lymphocytes, plasma cells, and histiocytes. The log-rank test showed no significance for the survival curves and recurrence of the “minor inflammatory” and “major inflammatory” processes, with p = 0.14 and p = 0.24, respectively. A direct association between age and inflammation (p = 0.04) was observed, as well as an indirect association between the degree of tumor differentiation and inflammation (p = 0.01).ConclusionAlthough associated with histological differentiation, the peritumoral inflammatory process cannot be considered a prognostic factor in squamous cell carcinoma of the oral cavity, as it is not related to survival and disease-free interval.     

Helicobacter pylori is associated with poor prognosis of laryngeal precancerous lesion

ObjectivesPrevious evidence suggested Helicobacter pylori (H. pylori) promoted tumorigenesis by inducing inflammation in gastric premalignant disease. Whether this organism affected the development of head and neck precancerous lesion remains unknown. We performed this study to assess the prognostic impact of H. pylori infection on patients with laryngeal precancerous lesion.MethodsIn this prospective study, 41 enrolled patients with laryngeal precancerous lesion were arranged into H. pylori-positive group (n = 16) and H. pylori-negative group (n = 25). Two poor outcomes were recurrence and malignant transformation. Prognostic impact of H. pylori infection was analyzed using the Univariate Cox proportional hazard model and Cochran–Mantel–Haenszel test. We also analyzed the prognostic value of systemic inflammation-based markers.ResultsDuring a median follow-up of 32.9 months, recurrence developed in 8 patients in the H. pylori positive group and 5 patients in the H. pylori negative group (50.0% vs. 20.0%, P = 0.026, Log-rank test). Malignant transformation developed in 4 patients in the H. pylori positive group and no patients in the H. pylori negative group (25.0% vs. 0.0%, P = 0.005, Log-rank test). H. pylori positive group had a significant higher malignant transformation rate after stratifying on the observed covariates. There was no significant difference of recurrence rate in two groups stratified with laryngopharyngeal reflux, size of lesion, and pathological type (Cochran–Mantel–Haenszel test). The basal levels of lymphocyte counts and neutrophils to lymphocytes ratio were significantly different in patients with H. pylori infection. Moreover, the receiver operating characteristic curve analysis revealed a predictive value of lymphocyte counts and neutrophils to lymphocytes ratio for poor outcomes (areas under the curve, 0.658 and 0.651, respectively).ConclusionThe data demonstrate a malignant transformation-relevant role of H. pylori in laryngeal precancerous lesion. H. pylori infection combined with laryngopharyngeal reflux, size of lesion, and pathological type might relate to recurrence of laryngeal precancerous lesion. And changes of lymphocyte counts and neutrophils to lymphocytes ratio associated with H. pylori infection might deserve as predictive indicators for poor prognosis of laryngeal precancerous lesion.     

Transoral-transcervical oropharyngectomy without mandibulotomy,associated to fasciocutaneous radial forearm free-flap reconstruction,for oropharyngeal cancer: Postoperative course,oncologic and functional results,and prognostic factors

ObjectiveTo analyze postoperative course, oncologic and functional results and prognostic factors of transoral-transcervical oropharyngeal cancer surgery without mandibulotomy, associated to radial forearm free-flap reconstruction.Material and methodsRetrospective analysis of computerized medical records of all patients who underwent this type of surgery in our institution between 2004 and 2014. Predictive factors of oncologic and functional results were investigated on univariate and multivariate analyses.ResultsForty-four patients (37 male, 7 female; mean age, 62.3 ± 9.3 years) were included. Three-year overall, disease-specific and recurrence-free survival was 90%, 92% and 79%, respectively. Functional scores were satisfactory (normal or slight impairment) for feeding, speech and oral opening functions in 86%, 93% and 100% of cases, respectively. ASA score ≥ III had significantly negative impact on overall survival (P = 0.005) and on feeding (P = 0.01) and speech (P = 0.01).ConclusionTransoral-transcervical oropharyngeal cancer surgery without mandibulotomy provided excellent oncologic and functional outcomes; it is an advantageous alternative to the conventional conservative transmandibular oropharyngectomy.     

Rehabilitation following total laryngectomy: Oncologic,functional, socio-occupational and psychological aspects

GoalTo review rehabilitation following total laryngectomy by an analysis of epidemiological, oncologic and functional data.Materials and methodsThis retrospective observational study focused on patients having undergone total laryngectomy or pharyngolaryngectomy between January 1, 2005 and December 31, 2016. Oncologic data notably comprised survival and relapse and predictive factors. The impact of the procedure on quality of life and the voice was analyzed by self-administered questionnaires (EORTC QLQ-C30 and H&N35, VHI 30). A satisfaction questionnaire was also sent to patients.ResultsOne hundred and thirty three patients were included. Overall specific 5-year survival was 65%. The relapse rate was 32%. Factors influencing survival were WHO performance status ≥ 2 (P < 0.05), tumor location (P = 0.07), metastatic lymphadenopathy (P = 0.017) and positive resection margins (P = 0.01). Quality of life was moderately degraded (global EORTC QLQ-C30 status: 61.4 ± 23.9). Type of rehabilitation (P = 0.03), tube feeding (P = 0.03) and relapse (P < 0.01) influenced quality of life. There were no differences in voice quality according to rehabilitation method, and no predictive factors for failure of voice rehabilitation. More than 90% of patients were satisfied with their hospital stay; 43%, however, were not satisfied with community caregiver training for laryngectomy patients.ConclusionRehabilitation of laryngectomized patients is a current therapeutic challenge. A therapeutic education tool was designed to better meet patient expectations.     

Otorhinolaryngologists’ personal treatment preferences (total laryngectomy or laryngeal preservation) when faced with advanced stage laryngeal cancer

ObjectiveTo analyse the treatment options that otorhinolaryngologists would consider if faced with advanced stage laryngeal cancer amenable to total laryngectomy or an organ preservation protocol.Material and methodsProspective study conducted in a French Teaching Hospital based on questionnaires filled in by 163 otorhinolaryngologists in 2012, studying the percentage chance of cure that they would be prepared to trade-off to preserve their larynx, defining the additional information that they would like to receive and identifying any statistical associations between these parameters and various medical and socioeconomic variables.ResultsA total of 42.3% of otorhinolaryngologists would not consider the slightest trade-off to preserve their larynx and preferred to undergo total laryngectomy. In the group of otorhinolaryngologists who would consider a larynx preservation protocol (57.6%), the percentage chance of cure that they would be willing to trade-off to preserve their larynx ranged between 5 to 100% (median: 15%) and 4.2% of them were willing to trade-off all chances of cure (100%) to avoid total laryngectomy. The percentage of otorhinolaryngologists who would not consider trading off the slightest chance of survival to preserve their larynx increased from 29.3 to 49.5% (P = 0.01) when they participated in multidisciplinary consultation meetings. In the group of otorhinolaryngologists who would consider a larynx preservation protocol, the median percentage survival trade-off that they would consider in order to preserve their larynx (i) decreased from 20 to 10% (P = 0.004) when they participated in multidisciplinary consultation meetings and (ii) increased regularly with their number of years of practice (P = 0.03) and their age (P = 0.025). Finally, 25.1% of otorhinolaryngologists wanted to receive additional information, although none of the variables analysed affected this desire for more information.ConclusionTreatment options considered by otorhinolaryngologists faced with advanced stage laryngeal cancer were almost equally divided between total laryngectomy and larynx preservation. Number of years of practice and regular participation in head and neck cancer multidisciplinary consultation meetings were variables that significantly influenced this choice.     

Evaluation of robotic surgery for transoral resection of T1-2 squamous cell carcinoma of the tonsillar fossa

GoalTo evaluate transoral robotic surgery (TORS) for isolated previously untreated squamous cell carcinoma (SCC) of the tonsillar fossa classified as T1-2.MethodRetrospective analysis of two cohorts of isolated untreated T1-2 tonsillar fossa SCC consecutively operated on by a transoral approach, with (R = 21) and without (NR = 24) robotic assistance, in the period 2006–2014. Three main (survival, local control, and operative morbidity) and three secondary (pathologic data, incidence and duration of tracheotomy and nasogastric intubation, and hospital stay) endpoints were compared between groups. The significance threshold was set at P <  .005.ResultsThree- and five-year actuarial survival estimates were 80.2% and 74.5% respectively in group R, and 91.5% and 82.5% respectively in group NR (NS: P = .34). Three- and five-year actuarial local control estimates were 90% and 90% respectively in group R, and 95.8% and 91% respectively in group NR (NS: P = .81). There were no significant differences in morbidity, tracheotomy/nasogastric intubation time, or hospital stay. Positive resection margins (R1) were noted in 38.1% and 16.7% in groups R and NR, respectively (NS: P = .05) without significant impact on 5-year actuarial local control (P = 0.78).ConclusionRobotic assistance in transoral lateral oropharyngectomy for T1-2 tonsillar fossa SCC did not significantly impact oncologic or functional outcome.     

Efectividad del colgajo de músculo pectoral mayor miofascial en la reducción de fístulas salivares tras laringectomía total de rescate

Introduction

Pharyngocutaneous fistula is the most frequent complication after total laryngectomy. Its incidence varies between 9%-25% in post primary total laryngectomy patients, to 14%-57% in salvage laryngectomy post radiotherapy or post chemotherapy + radiotherapy. The pectoralis major myofascial flap (PMMF)is postulated as a useful tool to decrease the incidence of this complication.

Which risk factors are associated with stomal recurrence after total laryngectomy for laryngeal cancer? A meta-analysis of the last 30 years

IntroductionStomal recurrence is a troublesome complication after total laryngectomy. Despite a large number of studies having been performed, there is still controversy about which risk factors are most significant for the development of stomal recurrence.ObjectiveThe objective of the present meta-analysis was to analyze the potential factors leading to stomal recurrence after total laryngectomy.MethodsPubMed, Web of Science, Cochrane Library, and Ovid databases were systematically searched using multiple search terms. Eighteen studies with 6462 patients were identified. The quality of evidence was assessed by The National Institute for Health and Clinical Excellence.ResultsThe results showed that, tumor subsite (supraglottic vs. subglottic, RR = 0.292, 95% CI 0.142–0.600, p = 0.001; glottic vs. subglottic, RR = 0.344, 95% CI 0.175–0.676, p = 0.002), T stage (RR = 0.461, 95% CI 0.286–0.742, p = 0.001), preoperative tracheotomy (RR = 1.959, 95% CI 1.500–2.558, p < 0.001) were the high-risk factors associated with the development of stomal recurrence.ConclusionFrom the results of our study, tumor subsite, T stage and preoperative tracheotomy were the significant risk factors for stomal recurrence. Methodologically high-quality comparative investigations are needed for further evaluation.     

Pepsin deteriorates prognosis of children with otitis media with effusion who undergo myringotomy or tympanostomy tube insertion

ObjectiveTo investigate the concentrations of pepsin and pepsinogen within the middle ear cavity and determine whether pepsin and pepsinogen affect the prognosis of children with otitis media with effusion (OME).MethodsAll middle-ear lavage fluid from patients with OME undergoing myringotomy (M subgroup) or tympanostomy tube insertion (T subgroup) was collected and pepsin and pepsinogen were detected using enzyme-linked immunosorbent assay. After close follow-up over 2 years, the effects of pepsin and pepsinogen on the prognosis of the patients with OME in the M and T subgroups were analyzed.ResultsThe average pepsin and pepsinogen concentrations were significantly lower in the M subgroup (n = 54; 24.38 ± 16.10 mg/mL and 286.49 ± 91.95 mg/mL, respectively) than in the T subgroup (n = 55; 45.56 ± 16.60 mg/mL and 664.92 ± 107.06 mg/mL; t = 2.484, P = 0.018 and t = 2.670, P = 0.011, respectively). In the M subgroup, the average time to tympanic membrane healing and tympanic pressure restoration to normal was much longer in pepsin(+) patients (17.0 ± 2.0 days and 26.0 ± 2.5 days, respectively) than in pepsin(−) patients (14.0 ± 1.1 days and 22.0 ± 1.0 days; t = 3.871, P = 0.001 and t = 5.734, P = 0.000, respectively), and the hearing level of pepsin(+) patients with OME ascended to 13.08 ± 1.19 dB, which was much lower than that of pepsin(−) patients (18.29 ± 1.27 dB; t = 11.001, P = 0.000). In the T subgroup, the complication rate including otorrhea and myringosclerosis was much higher in patients with high pepsin concentrations than in those with low pepsin concentrations (P < 0.05). Finally, in both subgroups, the recurrence rates of OME in pepsin(+) or patients with high pepsin concentrations (34.6% [9/26] and 28.6% [10/35]) were significantly higher than those in pepsin(−) or low pepsin concentrations (10.7% [3/28] and 5.0% [1/20]; χ² = 4.456, P = 0.035 and χ² = 4.420, P = 0.036). However, pepsinogen had no significant effect on OME prognosis or recurrence.ConclusionPepsin but not pepsinogen could postpone tympanic membrane healing and pressure restoration in children with OME undergoing myringotomy and increase the incidence of recurrence and complications including otorrhea and myringosclerosis for those undergoing tympanostomy tube insertion. Therefore, pepsin could be considered a poor prognostic factor for OME, further emphasizing the important role of pepsin in OME pathogenesis.     

Impact of cochlear implantation on peripheral vestibular function in adults

ObjectiveCochlear implantation may have a detrimental effect on vestibular function and residual hearing. Our goal was to investigate the impact of cochlear implantation on peripheral vestibular function and the symptomatology that ensues.Material and methodsA prospective observational study included all adults undergoing cochlear implantation by the same operator between July 2014 and December 2015, with pre- and postoperative (4 months) neurovestibular balance examination comprising a questionnaire and clinical tests [head impulse test (HIT), head-shaking test (HST), skull vibration test (SVT)] and instrumental tests [caloric test of the lateral semicircular canal and cervical vestibular-evoked myogenic potentials (cVEMP)].ResultsTwenty-two patients were included, with a mean age of 62 years and sex-ratio of 1.2. Before implantation, 50% of subjects (n = 11) reported at least one episode of vertigo associated with balance disorder during their life. After implantation, there were 11 cases of vertigo but only one patient described persistent discomfort related to vertigo 4 months after surgery. Patients with impaired vestibular function after 4 months, taking all symptoms together, were all aged more than 75 years. HIT was abnormal in 18% of cases before implantation and in 59% after (P = NS). HST showed nystagmus in one patient both before and after surgery. Only 18% of patients showed nystagmus induced by SVT before surgery, increasing to one-third after surgery (P = NS). Caloric test of the lateral canal showed hypofunction in 50% of cases before surgery, including 10% of cases with areflexia. This rate increased after surgery to 58%, with 18% areflexia (P = NS). cVEMPs were not detected in 68% of cases before implantation and this rate increased to 86% after surgery (P = NS). There were no significant associations (P > 0.05) between test results and symptoms.ConclusionsIn the medium term, although older subjects more frequently presented vestibular disorder, cochlear implantation induced little vertigo or balance disorder, sometimes even improving vestibular function. However, vestibular disorders were frequent preoperatively and increased postoperatively. We tested vestibular function on different stimulation frequencies and yet found no correlation between postoperative test results and postoperative vertigo.     

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

PurposeThe 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 methodsA 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.ResultsSignificant 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.ConclusionsWe 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.     

Routine feasibility of postoperative chemoradiotherapy in head and neck squamous cell carcinoma at high risk of recurrence

ObjectiveTo assess the feasibility in routine practice of postoperative chemoradiotherapy in head and neck squamous cell carcinoma (HNSCC) at high risk of recurrence.MethodA single-center retrospective study recruited all patients receiving postoperative cisplatin chemoradiotherapy for HNSCC at high risk of recurrence. The main endpoints were the rate of complete postoperative chemoradiotherapy and the impact of various clinical factors. Secondary endpoints comprised the impact of completion of therapy on survival and on acute and late toxicity.ResultsOne hundred and six patients were included. 24.5% showed severe comorbidity. Chemoradiotherapy was complete in 61 patients (57.5%). Radiation therapy was interrupted for > 3 days in 16 patients (15.1%). The 3^rd concomitant cisplatin course could not be implemented in 34 patients (32.1%). Low pre-treatment glomerular filtration rate was significantly associated (p = 0.003) with treatment interruption; > 5% weight-loss during treatment showed suggestive association (p = 0.026). Completion of treatment was not associated with any significant difference in overall survival (p = 0.441) or progression-free survival (p = 0.81). 14.9% of patients showed post-treatment kidney failure; there were 10 cases of osteoradionecrosis (9.4%).ConclusionThe rate of complete postoperative chemoradiotherapy was comparable to that reported in clinical trials, despite frequent comorbidity and poor nutritional status. Early nutritional support is a key factor for treatment under optimal conditions.     

Colesteatoma: influencia de la técnica quirúrgica y el estadio EAONO/JOS en los resultados audiológicos

Introduction and objectiveThe treatment of cholesteatoma is surgical in most cases. When it is indicated, it is preferable to choose a reconstructive surgical technique with the dual purpose of eradicating the disease and preserving or improving the patient's hearing. In 2017, the European Academy of Otology and Neuro-Otology/Japanese Otological Society (EAONO/JOS) published a new cholesteatoma classification. The aims of this study are to determine the influence of the surgical technique use and this classification on patient's hearing outcomes.MethodsA retrospective study that include patients who underwent reconstructive surgery of cholesteatoma between 2012 and 2017 is carried out. Based on pre-surgical computed tomography (CT) images, disease is staged according to the EAONO/JOS classification. Hearing outcomes obtained by pre and postoperative pure tone audiometry are analysed according to the surgical technique used and according to the stage of the disease.Results143 patients with no statistically significant differences in hearing thresholds before surgery are included. One year after surgery, all the patients’ airbone pure tone average (PTA) and mean differential auditory threshold have improved significantly (P = .01 and P = .001). Those patients who undergo tympanoplasty with two-stage canal wall up mastoidectomy presente better postsurgical air PTA and postsurgical mean differential auditory threshold outcomes (P = .007 and P = .014) than those patients who underwent tympanoplasty with canal wall down mastoidectomy. Moreover, the patients who underwent tympanoplasty with two-stage canal wall up mastoidectomy had improved airbone PTA and mean differential auditory threshold one year after the surgery with statistical significance (P = .001 and P = .013). The mean differential auditory threshold is also better (P = .008) in the patients who undergo tympanoplasty with canal wall down mastoidectomy one year after the procedure.ConclusionsReconstructive surgical techniques improve hearing one year after surgery. In our study, this improvement is significantly greater with tympanoplasty with two-stage canal wall up mastoidectomy.     

Salvage total laryngectomy: is a flap necessary?

IntroductionPharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with or without chemotherapy.ObjectiveOur purpose is to review the fistula rate in radiated patients undergoing salvage total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors.MethodsWe made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed.ResultsWe identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p = 0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p = 0.03) and large pharyngostomes (64.3% versus 0%, p = 0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p = 0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p = 0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes.ConclusionsProphylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy.