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Lymph node yield is an important prognostic factor in head and neck squamous cell carcinoma. Variability in neck dissection sampling techniques has not been studied as a determinant of lymph node yield.
This retrospective study used lymph node yield and average nodes per level to compare level-by-level and en bloc neck dissection sampling methods, in primary head and neck squamous cell carcinoma cases operated between March 2017 and February 2020.
From 123 patients, 182 neck dissections were analysed, of which 133 were selective and the rest were comprehensive: 55 had level-by-level sampling and 127 had undergone en bloc dissection. The level-by-level method yielded more nodes in all neck dissections combined (20 vs 17; p = 0.097), but the difference was significant only for the subcohort of selective neck dissection (18.5 vs 15; p = 0.011). However, the gain in average nodes per level achieved by level-by-level sampling was significant in both groups (4.2 vs 3.33 and 4.4 vs 3, respectively; both p < 0.001).
Sampling of cervical lymph nodes level-by-level yields more nodes than the en bloc technique. Further studies could verify whether neck dissection sampling technique has any impact on survival rates.
This study aimed to report the pre- and post-operative laryngeal endoscopic findings in patients referred by non-otolaryngologists who are undergoing thyroid and/or parathyroid surgery, and to determine the number and nature of referrals before and after the release of the clinical practice guideline for improving voice outcomes after thyroid surgery.
This retrospective cohort study, conducted at a tertiary care academic hospital, comprised adult patients referred by the endocrine surgery service for laryngoscopy from 2007 to 2018 (n = 166). Data regarding patient demographics, reason for referral and endoscopic findings were recorded.
The number of referrals increased significantly after the release of the practice guideline. The most common indication for referral pre- and post-operatively was voice change. The most common finding during laryngoscopy was normal examination findings (pre-operatively) and unilateral vocal fold immobility (post-operatively).
Peri-operative thyroid and/or parathyroid patients have laryngoscopic findings other than vocal fold immobility. Laryngoscopy to detect structural and functional pathology is warranted.
Since the start of the coronavirus disease 2019 pandemic, transnasal humidified rapid-insufflation ventilatory exchange (‘THRIVE’) has been classified as a high-risk aerosol-generating procedure and is strongly discouraged, despite a lack of conclusive evidence on its safety.
This study aimed to investigate the safety of transnasal humidified rapid-insufflation ventilatory exchange usage and its impact on staff members. A prospective study was conducted on all transnasal humidified rapid-insufflation ventilatory exchange cases performed in our unit between March and July 2020.
During the study period, 18 patients with a variety of airway pathologies were successfully managed with transnasal humidified rapid-insufflation ventilatory exchange. For each case, 7–10 staff members were present. Appropriate personal protective equipment protocols were strictly implemented and adhered to. None of the staff involved reported symptoms or tested positive for coronavirus disease 2019, up to at least a month following their exposure to transnasal humidified rapid-insufflation ventilatory exchange.
With strictly correct personal protective equipment use, transnasal humidified rapid-insufflation ventilatory exchange can be safely employed for carefully selected patients in the current pandemic, without jeopardising the health and safety of the ENT and anaesthetic workforce.
Wide-ranging outcomes have been reported for surgical and non-surgical management of T3 laryngeal carcinomas. This study compared the outcomes of T3 tumours treated with laryngectomy or (chemo)radiotherapy in the northeast of England.
The outcomes of T3 laryngeal carcinoma treatment at three centres (2007–2016) were retrospectively analysed using descriptive statistics and survival curves.
Of 179 T3 laryngeal carcinomas, 68 were treated with laryngectomies, 57 with chemoradiotherapy and 32 with radiotherapy. There was no significant five-year survival difference between treatment with laryngectomy (34.1 per cent) and chemoradiotherapy (48.6 per cent) (p = 0.184). The five-year overall survival rate for radiotherapy (12.5 per cent) was significantly inferior compared to laryngectomy and chemoradiotherapy (p = 0.003 and p < 0.001, respectively). The recurrence rates were 22.1 per cent for laryngectomy, 17.5 per cent for chemoradiotherapy and 50 per cent for radiotherapy. There were significant differences in recurrence rates when laryngectomy (p = 0.005) and chemoradiotherapy (p = 0.001) were compared to radiotherapy.
Laryngectomy and chemoradiotherapy had significantly higher five-year overall survival and lower recurrence rates compared with radiotherapy alone. Laryngectomy should be considered in patients unsuitable for chemotherapy, as it may convey a significant survival advantage over radiotherapy alone.
Total laryngectomy is often utilised to manage squamous cell carcinoma of the larynx or hypopharynx. This study reports on surgical trends and outcomes over a 10-year period.
A retrospective review of patients undergoing total laryngectomy for squamous cell carcinoma was performed (n = 173), dividing patients into primary and salvage total laryngectomy cohorts.
A shift towards organ-sparing management was observed. Primary total laryngectomy was performed for locoregionally advanced disease and utilised reconstruction less than salvage total laryngectomy. Overall, 11 per cent of patients developed pharyngocutaneous fistulae (primary: 6 per cent; salvage: 20 per cent) and 11 per cent neopharyngeal stenosis (primary: 9 per cent; salvage: 15 per cent). Pharyngocutaneous fistulae rates were higher in the reconstructed primary total laryngectomy group (24 per cent; 4 of 17), compared with primary closure (3 per cent; 3 of 90) (p = 0.02). Patients were significantly more likely to develop neopharyngeal stenosis following pharyngocutaneous fistulae in salvage total laryngectomy (p = 0.01) and reconstruction in primary total laryngectomy (p = 0.02). Pre-operative haemoglobin level and adjuvant treatment failed to predict pharyngocutaneous fistulae development.
Complications remain hard to predict and there are continuing causes of morbidity. Additionally, prior treatment continues to affect surgical outcomes.
To retrospectively study the primary laryngeal lymphoma cases in China reported in Chinese-language literature.
Chinese-language literature was searched for papers on primary laryngeal lymphoma published in the last 25 years.
The selected papers comprised a total of 115 cases. The male-to-female ratio was 3.4:1. Non-Hodgkin's lymphoma was the exclusive pathological type. The estimated 3-year, 5-year and 10-year survival rates were 70.9 ± 6.4 per cent, 63.4 ± 7.6 per cent and 56.4 ± 9.5 per cent respectively, as determined by Kaplan–Meier analysis. B-cell non-Hodgkin's lymphoma patients had a better prognosis than T-cell non-Hodgkin's lymphoma patients (p = 0.032). Patients with lymph node involvement at diagnosis had a poorer prognosis (p < 0.01).
Primary laryngeal lymphoma is a rare disease with no specific clinical features. More than one biopsy might be needed to obtain the correct diagnosis. Proper treatment could lead to promising outcomes. The T-cell subtype and lymph node involvement at diagnosis might indicate worse prognosis.
The National Institute for Health and Care Excellence referral guidelines prompting urgent two-week referrals were updated in 2015. Additional symptoms with a lower threshold of 3 per cent positive predictive values were integrated. This study aimed to examine whether current pan-London urgent referral guidelines for suspected head and neck cancer lead to efficient and accurate referrals by assessing frequency of presenting symptoms and risk factors, and examining their correlation with positive cancer diagnoses.
The risk factors and symptoms of 984 consecutive patients (over a six-month period in 2016) were collected retrospectively from urgent referral letters to University College London Hospital for suspected head and neck cancer.
Only 37 referrals (3.76 per cent) resulted in a head and neck cancer diagnosis. Four of the 23 recommended symptoms demonstrated statistically significant results. Nine of the 23 symptoms had a positive predictive value of over 3 per cent.
The findings indicate that the current referral guidelines are not effective at detecting patients with cancer. Detection rates have decreased from 10–15 per cent to 3.76 per cent. A review of the current head and neck cancer referral guidelines is recommended, along with further data collection for comparison.
Laryngeal voice quality classifications and ‘states of the larynx’ are reviewed and expanded. Supplementary notes accompanying the text describe the video, audio, and text materials in the online companion site that accompanies the book to illustrate and explain the articulatory production of each laryngeal voice quality. Constricted phonation types exploit degrees of laryngeal articulator tightening with concomitant lingual and larynx-height settings. A new continuum of laryngeal stricture, from open to closed, is introduced. Glottal, ventricular, and epiglottal stop are illustrated. Breathiness vs. whisperiness is redefined. Creaky voice and varieties of harsh voice are investigated, including ventricular production and trilling of the aryepiglottic folds. New drawings and laryngoscopic photographs capture the extent of open and constricted postures. Breathy states with and without voicing are compared side by side with whispery states. The concept of vocal tract tension is reattributed to constrictive settings of the laryngeal articulator mechanism. The aim is to paint an auditory portrait of the articulatory configurations of the vocal tract.
Chapter 8 summarizes the ramifications of the Laryngeal Articular Model for the phonetic description of voice quality and investigates its place in phonetic theory. Predispositions for background voice qualities to underlie different vowel qualities are identified. It is argued that there is a parallel between the coarticulatory path that infants follow in their earliest speech development and elements in the process of phonetic sound change. The laryngeal articulator as an enabler of sound change is explored. Theories of ontogenetic speech development are reviewed (concepts of ‘speechlikeness,’ autogeneration, frame/content, cyclicity, reduplication, variegation) and reinterpreted to reflect the scope of laryngeal behaviour outlined in this volume. The discussion evaluates the implications of the revised view of laryngeal phonetic behaviour for the phylogeny of human speech. The physiology of the larynx is shown to permit a wider range of speech production than formerly assumed and to accommodate, on phonetic grounds, an earlier time period for the appearance of speech in human ancestors, as hypothesized in recent anthropological and genetic research.
To assess published reports of oncological surgical success rates in patients who underwent transoral laser supraglottic surgery and robotic surgery for supraglottic cancer.
A systematic review of the literature was conducted and a meta-analysis of published data was performed. PubMed, Sage, Medline and Cochrane data sources were investigated. Overall survival rates, disease-specific survival rates, additional treatments and recurrence rates were investigated to determine the success of the surgical procedures.
The meta-analysis included 24 studies; 1617 studies were excluded. There were no statistically significant differences between the transoral laser supraglottic surgery and transoral robotic supraglottic surgery groups in terms of overall survival (77.0 per cent and 82.4 per cent respectively) and disease-specific survival (75.8 per cent and 87.0 per cent respectively). There was recurrence in 164 out of 832 patients (19.7 per cent) in the transoral laser supraglottic surgery group and in only 6 out of 66 patients (9 per cent) in the transoral robotic supraglottic surgery group.
Transoral laser surgery and robotic surgery appear to have comparable and acceptable oncological success rates.
To study the cluster of differentiation 8 population in the laryngeal mucosa of patients with laryngeal carcinoma. To our knowledge this is the first paper to address this issue.
The study group included 40 patients with known laryngeal cancer who were scheduled for laryngectomy. The control groups included 10 smokers and 10 non-smokers who were scheduled for microlaryngeal surgery. Specimens from the three groups were processed for histopathological and histochemical evaluation.
In patients without cancer of the larynx, the number of cluster of differentiation 8 lymphocytes was greater in smokers than non-smokers. The number of cluster of differentiation 8 lymphocytes was greatest in smokers with laryngeal cancer, and the difference between this group and the two control groups was statistically significant.
The study showed that smoking increased the number of cluster of differentiation 8 T-lymphocytes in the laryngeal mucosa. The increase was greatest in patients who had developed laryngeal cancer.
In order to improve a large posterior glottal gap and/or aspiration, injections of augmentation substances should not only be administered at the mid-membranous vocal fold in the thyroarytenoid muscle, but also at the cartilaginous portion of the vocal fold to make adduction arytenopexy possible.
Ten adult human larynges were investigated using the whole-organ serial section technique.
Vertical thickness of the posterior aspect of the thyroarytenoid muscle was relatively thin (3.4 ± 0.4 mm), especially in females (3.2 ± 0.3 mm). Consequently, care should be taken to ensure the correct depth of needle placement. If the needle is placed too deep, augmentation substances are injected into the lateral cricoarytenoid muscle, located beneath the thyroarytenoid muscle, or into the paraglottic space, located inferolateral to the thyroarytenoid muscle.
The injection location and the amount of injected material should be modified based on the pathological conditions of the voice disorder and aspiration.
Mules and other equine species have been used in warfare for thousands of years to transport goods and supplies. Mules are known for ‘braying’, which is disadvantageous in warfare operations. This article explores the fascinating development of surgical techniques to stop military mules from braying, with particular emphasis on the key role played by the otolaryngologist Arthur James Moffett in devoicing the mules of the second Chindit expedition of World War II.
The PubMed database (1900–2017) and Google search engine were used to identify articles related to devoicing mules in the medical and veterinary literature, along with information and images on the Chindit expedition.
This paper reviews the surgical techniques aimed at treating braying in mules, ranging from ventriculectomy and arytenoidectomy to Moffett's approach of vocal cordectomy.
Moffett's technique of vocal cordectomy provided a quick, reproducible and safe solution for devoicing mules. It proved to be advantageous on the battlefield and demonstrated his achievements outside the field of medicine.
Lipoid proteinosis is a rare autosomal recessive disorder caused by mutations in the extracellular matrix protein 1 gene. It is characterised by deposition of hyaline material in the skin and mucous membranes. This paper describes the management of two cases with laryngopharyngeal disease.
Two patients with a biopsy diagnosis of lipoid proteinosis were identified from the surgical pathology archive covering the period 2004–2016. Their notes were reviewed.
An adult male and an adult female were identified. Both had dysphonia and laryngopharyngeal lesions. The patients underwent interval laser microlaryngoscopy to debulk disease but minimise mucosal injury and scarring, using a ‘pepper pot’ technique. Both had adequate symptom control.
Lipoid proteinosis is a rare genetic condition, which typically presents in infancy with dysphonia and subsequent skin involvement. Two cases are presented to demonstrate that laryngotracheal symptoms can be controlled with interval laser debulking and the ‘pepper pot’ technique without causing stenosis.
This review aimed to critically analyse data pertaining to the clinical presentation and treatment of neuroendocrine carcinomas of the larynx.
A PubMed search was performed using the term ‘neuroendocrine carcinoma’. English-language articles on neuroendocrine carcinoma of the larynx were reviewed in detail.
Results and conclusion
While many historical classifications have been proposed, in contemporary practice these tumours are sub-classified into four subtypes: carcinoid, atypical carcinoid, small cell neuroendocrine carcinoma and large cell neuroendocrine carcinoma. These tumours exhibit a wide range of biological behaviour, ranging from the extremely aggressive nature of small and large cell neuroendocrine carcinomas, which usually have a fatal prognosis, to the less aggressive course of carcinoid tumours. In small and large cell neuroendocrine carcinomas, a combination of irradiation and chemotherapy is indicated, while carcinoid and atypical carcinoid tumour management entails conservation surgery.
Advanced hypopharyngeal carcinoma has a dismal prognosis. The optimal treatment for these patients remains under debate. This systematic review aimed to compare survival following surgical and non-surgical treatments.
A systematic review was conducted of randomised studies, with a descriptive analysis of retrospective observational studies.
Two randomised trials and 11 observational studies were included in the review. A meta-analysis of randomised trials reported a hazard ratio of 0.89 for overall survival in favour of surgical treatment (p = 0.44). Neither treatment was favoured in terms of overall survival. Observational studies did not report a survival advantage with either treatment. The five-year larynx preservation rates for non-surgically treated patients were between 38 and 58 percent.
Chemoradiotherapy offers similar survivorship compared to surgery in advanced disease, while also making larynx preservation feasible. It can be used as a treatment in all patients as an alternative to surgery.
This study aimed to evaluate the impact of an onlay pectoralis major flap in reducing the incidence of pharyngocutaneous fistula after salvage total laryngectomy and determine the complications of pectoralis major flap reconstruction.
A retrospective study was conducted of consecutive patients who underwent salvage total laryngectomy between 1995 and 2016. The pharyngeal defects were primarily closed with or without the pectoralis major flap.
Of 64 patients, 34 had primary pharyngeal closure alone (control group) and 30 received an onlay pectoralis major flap (pectoralis major flap group). The overall fistula rate was 15.6 per cent, with 17.6 per cent occurring in the control group and 13.3 per cent in the pectoralis major flap group (p = 0.74). The incidence rates of voice failure (p = 0.02) and shoulder disability (p < 0.001) were significantly higher in the pectoralis major flap group.
The pectoralis major flap in salvage total laryngectomy did not decrease the pharyngocutaneous fistula rate, and the incidence of flap-related complications was high. Appropriate surgical technique and post-operative care may reduce the incidence of pharyngocutaneous fistula.
Laryngeal injury after blunt trauma is uncommon, but can cause catastrophic airway obstruction and significant morbidity in voice and airway function. This paper aims to discuss a case series of sports-related blunt laryngeal trauma patients and describe the results of a thorough literature review.
Retrospective case-based analysis of laryngeal trauma referrals over six years to a tertiary laryngology centre.
Twenty-eight patients were identified; 13 (46 per cent) sustained sports-related trauma. Most were young males, presenting with dysphonia, some with airway compromise (62 per cent). Nine patients were diagnosed with a laryngeal fracture. Four patients were managed conservatively and nine underwent surgery. Post-treatment, the majority of patients achieved good voice outcomes (83 per cent) and all had normal airway function.
Sports-related neck trauma can cause significant injury to the laryngeal framework and endolaryngeal soft tissues, and most cases require surgical intervention. Clinical presentation may be subtle; a systematic approach along with a high index of suspicion is essential, as early diagnosis and treatment have been reported to improve airway and voice outcome.
Laryngeal amyloidosis represents approximately 1 per cent of all benign laryngeal lesions, and can cause variable symptoms depending on anatomical location and size. Treatment ranges from observation through to endoscopic microsurgery, laser excision and laryngectomy.
To highlight the diversity of presentations, increase awareness of paediatric amyloidosis and update the reader on current management.
Five cases are illustrated. Four adult patients were female, and the one child, the second youngest in the literature, was male. Amyloid deposits were identified in all laryngeal areas, including the supraglottis, glottis and subglottis. Treatment consisted of balloon dilatation, endoscopic excision, laser cruciate incision, and resection with carbon dioxide laser, a microdebrider and coblation wands.
Laryngeal amyloidosis remains a rare and clinically challenging condition. Diagnosis should be considered for unusual appearing submucosal laryngeal lesions. Treatment of this disease needs to be evaluated on a case-by-case basis and managed within an appropriate multidisciplinary team.