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Predictable swallowing function after open horizontal supraglottic partial laryngectomy
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ANL-2079; No. of Pages 8 Auris Nasus Larynx xxx (2016) xxx–xxx Contents lists available at ScienceDirect
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Predictable swallowing function after open horizontal supraglottic partial laryngectomy Christine Breunig a, Philipp Benter c, Rainer O. Seidl a, Annekatrin Coordes a,b,* a
Department of Otolaryngology at UKB, Hospital of the University of Berlin, Charite´ Medical School, Berlin, Germany Department of Otorhinolaryngology, Head and Neck Surgery, Charite´ – Universita¨tsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany c Department of Radiology at UKB, Hospital of the University of Berlin, Charite´ Medical School, Berlin, Germany b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 November 2015 Accepted 14 January 2016 Available online xxx
Objective: After horizontal supraglottic partial laryngectomy, patients have an increased risk of dysphagia as they are not able to close the laryngeal entrance during swallowing, especially if the surgical defect of the tongue base has increased. There is no investigation that studies risk factors for impaired swallow function, or that predicts postoperative swallow outcomes based on radiologically determined tumor dimensions. The present study investigated the impact of the tongue base tumor extension (determined by CT scan in patients undergoing partial laryngectomy) on the recovery rate of swallow function. Methods: The retrospective study in a tertiary hospital between 2000 and 2015 included all patients who underwent open horizontal supraglottic partial laryngectomy due to oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration. All clinicopathological data were collected. The dimension of tongue base infiltration was measured using CT scan. Swallow function was recorded by Fiberoptic Endoscopic Evaluation of Swallowing and determined by evaluating both the duration until nasogastric tube removal and changing of the cuffed tracheostomy tube for an uncuffed speech cannula. Results: The study included 26 patients (44–76 years, median 59 years). The clinical tumor (cT) classification included cT2 and cT3, while the pathologic tumor (pT) classification included pT2 and pT3 in 90% and pT1 and pT4 in 10% respectively. The duration until using the speech cannula was not associated with clinicopathological data, including the investigated radiologic tumor dimensions (biggest tumor diameter, tongue base infiltration depth, width, height, area and volume). The duration until nasogastric tube removal was significantly associated with the tongue base infiltration width (p = 0.012), height (p = 0.026) and area (p < 0.0001). The patients were divided into two groups according to the median tongue base infiltration area estimated as 6.20 cm2. In patients <6.20 cm2, 50% of the nasogastric tubes were removed after 4 days (95% CI 0–8.6 days) and in patients 6.20 cm2, 50% were removed after 22 days (95% CI 6.8–37.2 days; p < 0.0001). Conclusion: The postoperative swallow function after open horizontal supraglottic partial laryngectomy depends on the tumor extension of the tongue base. The tongue base infiltration area is a useful tool for surgical planning as it can be used to predict postoperative swallow function. In foreseeably permanent dysphagia, as well as permanent and necessary tracheotomy tube cuffs after organ-preserving surgery, alternative therapy methods should be particularly preferred as the primary chemoradiation. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Horizontal supraglottic partial laryngectomy Swallow function Dysphagia Speech cannula Tracheotomy tube
* Corresponding author at: Department of Otorhinolaryngology, Head and Neck Surgery, Charite´ – Universita¨tsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany. Tel.: +49 30 8445 2431; fax: +49 30 8445 4460. E-mail address: [email protected] (A. Coordes). http://dx.doi.org/10.1016/j.anl.2016.01.003 0385-8146/ß 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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1. Introduction Laryngeal squamous cell carcinoma is the most common cancer in the head and neck area [1]. For intermediate and advanced tumor stages, the two main curative treatment options consist of surgery (partial and total laryngectomy) and/or (chemo)radiation therapy [2–4]. When the cancer is restricted supraglottically or unilaterally, horizontal supraglottic laryngectomy and supracricoid partial laryngectomy have comparable cure rates to total laryngectomy [5,6]. In general, partial laryngectomy techniques differ in the resection of the epiglottic and the preepiglottic space. Organ preservation surgery such as the horizontal supraglottic partial laryngectomy can also be performed if the base of the tongue is involved, including resection of both the epiglottic and the preepiglottic space. The oncological strategy requires a complete surgical resection with adequate safety margins, while functional outcomes and life quality require sufficient swallow function and other laryngeal functions such as voice. These laryngeal dysfunctions can be found both after partial laryngectomy and radiation therapy only [7,8]. After horizontal supraglottic partial laryngectomy, patients have an increased risk for deglutition and aspiration, as they may not be able to put the tongue base over the laryngeal entrance during swallowing, especially if the surgical defect of the tongue base has increased. Therefore, surgical technique is important as are sufficient sutures between remaining parts of the tongue base and the thyroid cartilage [9]. Various studies have been published that determine influences on swallowing outcomes after partial laryngectomy and that identify strategies to compensate for the postoperative loss of oropharyngeal structure [10]. However, there is no investigation that studies risk factors for impaired recovery of swallow function, or predicts postoperative dysphagia outcomes based on radiologic tumor extension. The present study determines the impact of the estimated preoperative tumor extension at the tongue base using CT scan, in order to predict future swallow function in patients who have undergone open horizontal supraglottic laryngectomy. 2. Materials and methods 2.1. Patient inclusion criteria The retrospective clinical study was performed in a tertiary hospital according to the Helsinki declaration guidelines and the institution’s ethic committee. We included all patients in our institution between 2000 and 2015 who underwent open horizontal supraglottic partial laryngectomy due to oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration. The therapeutic strategy was discussed individually for every patient within a multidisciplinary tumor board consisting of head and neck surgeons, medical oncologists, radiotherapists, and head and neck radiologists. Criteria for surgical treatment included the in sano resectability were assessed using clinical and radiological examinations. Nobody underwent neoadjuvant therapy. Postoperatively, all
resected specimens were examined histologically in order to evaluate the width of the tumor cell free surgical margin and the nodal status. R0 resection was defined as a complete tumor resection with microscopically negative surgical margins for tumor cells 5 mm. The indication for adjuvant radiation included the tumor stage (Union for International Cancer Control (UICC) >II), the R1 surgical margins’ status and the lymph node spread. Additional chemotherapy was performed in patients with R1 resection or extra capsular lymph node spread. 2.2. Patient and treatment assessment All clinicopathological data was collected. Tumor size was recorded both as clinical tumor (cT) classification according to the preoperative CT scan, and pathological tumor (pT) classification after surgery and histological evaluation. Nobody received preoperative swallow therapy. Fiberoptic Endoscopic Evaluation of Swallowing was used to evaluate safe and sufficient swallow function without any signs of aspiration. Thereafter, the cuffed tracheostomy tube was replaced by an uncuffed speech cannula. The nasogastric tube was removed when the patients were able to swallow liquid foods and their calorie intake was sufficient. Thus, we evaluated both the duration until the nasogastric tube was removed and the cuffed tracheostomy tube was changed for a speech cannula. 2.3. Assessment of the tongue base infiltration A 64-channel multidetector CT scan (BrillianceCT-64channel, Philips Medical Systems, Cleveland, OH) was performed to visualize the tumor dimension and iSite Enterprise (Philips) software was used for volumetric image visualization. The isotropic volume dataset was used for multiplanar reconstruction (slice thickness 0.625 mm) to generate images of the maximum extent of the tumor, and the maximum extent of tongue base infiltration in the axial, transverse and sagittal planes. In the sagittal plane, the maximum tongue base infiltration depth was measured at the maximum extent of tongue base infiltration in the ventrodorsal diameter, and the maximum tongue base infiltration height was determined at the maximum extent of tongue base infiltration in the craniocaudal diameter. In the axial plane, the maximum tongue base infiltration width was measured at the maximum extent of tongue base infiltration in the right-left diameter (Fig. 1). The biggest diameter of the tumor extension was determined using the complex 3D volumetric image visualization. Two observers (one radiologist and one otolaryngologist) independently assessed the tumor dimensions. In all cases, the value used was the mean of both measurements. The tongue base infiltration area was calculated as being from multiplication of maximum tongue base infiltration depth and maximum tongue base infiltration width. The tongue base infiltration volume was calculated as from multiplication of the tongue base infiltration area and the maximum tongue base infiltration height.
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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Fig. 1. The maximum tongue base infiltration. The maximum extension of the tongue base infiltration was measured using CT scan. In the first example patient (A–C), the maximum tongue base infiltration was in the right-sided tongue base. Therefore, the maximum tongue base infiltration depth and tongue base infiltration height were determined in (C) and not (B). The maximum tongue base infiltration width was determined in (A). In the second example patient (D–E), the maximum tongue base infiltration depth, height and width are indicated.
2.4. Surgical technique (Fig. 2) In all cases, the open horizontal supraglottic partial laryngectomy [11] was performed by one surgeon. The extent of resection was determined individually. The section plane passed horizontally and included at least one vestibular fold along the floor of the laryngeal ventricle of Morgagni. The arytenoid cartilage remained unchanged. The surgical resection included the hyoid bone, the upper part of the thyroid cartilage
and the laryngeal vestibule. Intraoperatively, frozen sections were performed to evaluate whether the tumor was completely resected and had the tumor cell free surgical margin, otherwise remaining tumor cells were resected. Suture stitches were used for careful readaptation. The remaining larynx (thyroid cartilage) was fixated to the remaining tongue base, so that the tongue base overlapped the thyroid cartilage in order to restore the laryngeal function, despite extensive surgical resections and to improve the swallowing function [12,13].
B
A
C
D
cancer
hyoid bone thyroid cartilage arytenoid cartilage
suture
cricoid cartilage
Fig. 2. Schema of the surgical resection during the horizontal partial laryngectomy by Alonso. The surgical resection included parts of the hyoid bone and the upper part of the thyroid cartilage. The mucosa of the larynx was adapted carefully using suture stitches. The remaining thyroid cartilage was fixated to the remaining tongue base so that the tongue base overlaps the thyroid cartilage.
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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Bilateral neck dissection was always performed concomitantly [14]. 2.5. Statistical analysis Statistical analysis was performed to evaluate various clinicopathological factors which may correlate with the clinical outcome, determined as duration until nasogastric tube removal and duration until changing to a speech cannula. For statistical analysis we used IBM SPSS Statistics 20 [15]. Pearson correlation was used to evaluate possible predicting factors, which measure the degree of linear dependence between two variables. The Pearson coefficient was determined. Mann–Whitney test was used to evaluate the statistical difference of two independent variables. P values 0.05 were significant. The probability of nasogastric tube removal or/and the implementation of a percutaneous endoscopic gastrostomy (PEG) tube was demonstrated using the Kaplan–Meier curve. 3. Results 3.1. Patients’ characteristics and the clinicopathological data The study group included 26 patients who underwent open horizontal partial laryngectomy due to oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration. Patients’ characteristics are indicated in Table 1. Their age ranged from 44 to 76 years (median 59 years). 21 patients (81%) were males and 5 (19%) females. The cT classification included only cT2 and cT3, while the final pT classification included pT2 and pT3 in 90% of the patients and pT1 and pT4 in 10% respectively. Adjuvant radiation was performed in 24 (92.3%) patients, with 8 (30.1%) patients having received additional chemotherapy. One patient required total laryngectomy due to permanent aspiration. The mean overall survival was 63 months (95% confidence interval (CI) 43–85 months) and the mean tumor-specific survival was 78 months (95% CI 56–100 months). The duration until the nasogastric tube was removed ranged from 0 to 24 days (median 8.5 days). Seven patients underwent PEG placement. The duration until changing for speech cannula ranged from 2 to 100 days (median 7.5 days). The multiplanar reconstruction images performed by CT scan were used to determine the maximum extent of the tumor, and the maximum extent of tongue base infiltration in the axial, transverse and sagittal plane. The maximum extent of tongue base infiltration in the ventrodorsal diameter was called the median maximum tongue base infiltration depth and was estimated as 2.08 cm and the maximum tongue base infiltration height in the craniocaudal diameter as 1.92 cm. The maximum tongue base infiltration width in the right-left diameter was 3.30 cm. The tongue base infiltration area and the tongue base infiltration volume were determined as 6.20 cm2 and 10.8 cm3 respectively.
Table 1 Demographic data and clinical data. Gender Male (%) Female (%) Patient age at initial diagnosis Median (y) Range (y) Pathologic tumor (pT) classification pT1 (%) pT2 (%) pT3 (%) pT4 (%) Clinical tumor (cT) classification cT1 (%) cT2 (%) cT3 (%) cT4 (%) Adjuvant therapy Radiation (%) Chemotherapy/immunotherapy (%) Total laryngectomy (%) Tongue base infiltration depth Mean SD (cm) Tongue base infiltration width Mean SD (cm) Tongue base infiltration height Mean SD (cm) Biggest diameter of the tumor Mean SD (cm) Tongue base infiltration area Mean SD (cm2) Tongue base infiltration volume Mean SD (cm3) Duration until changing to a speech cannula Median (d) Range (d) Duration until nasogastric tube removal Median (d) Range (d) Duration until PEG implementation No of patients with PEG Median (d) Range (d)
21 (80.8) 5 (19.2) 59 44–76 2 (7.8) 14 (53.8) 9 (34.6) 1 (3.8) 0 (0) 8 (30.8) 18 (69.2) 0 (0) 24 (92.3) 8 (30.1) 1 (3.8) 2.08 0.79 3.11 1.01 2.04 1.06 3.89 1.39 6.16 2.78 11.82 6.77 7.5 2–100 8.5 0–24 7 0 0–210
Abbreviations: PEG, percutaneous endoscopic gastrostomy.
3.2. Predicting factors for clinical outcome We performed a Pearson correlation to determine predicting factors for clinical outcome. The results are demonstrated in Table 2. None of the investigated patient data (including biggest tumor diameter, maximum tongue base infiltration depth, width, height, area or volume) was significantly associated with the duration until changing for speech cannula. However, the duration until nasogastric tube removal had a highly significant association with the tongue base infiltration width (p = 0.012), height (p = 0.026) and area (p < 0.0001). Correlation coefficients were 0.565, 0.522 and 0.749, respectively (Fig. 3A). Also, there was no correlation between the duration until nasogastric tube removal and the time until changing for speech cannula. There was also no significant difference between both time periods according to the clinical or pathological tumor stage. Patient age was not significantly associated with the duration between nasogastric tube removal
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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Table 2 Predicting factors for clinical outcome. Statistical correlation between clinicopathological parameters and the duration until changing to a speech cannula and nasogastric tube removal respectively. Statistical significant data are indicated including the Pearson correlation coefficient. (a) The measurement of the degree of linear dependence between two variables investigated using the Pearson correlation. Statistical significant data are indicated including the Pearson correlation coefficient. Duration until changing to a speech cannula
Duration time until nasogastric tube removal
Patient age Tongue base infiltration depth Tongue base infiltration width
n.s. n.s. n.s.
Tongue base infiltration height
n.s.
Biggest diameter of the tumor Tongue base infiltration area
n.s. n.s.
Tongue base infiltration volume Duration until changing to a speech cannula Time until nasogastric tube removal Duration until PEG implementation
n.s.
n.s. n.s. r = 0.543 p = 0.016 r = 0.482 p = 0.036 n.s. r = .793 p < 0.0001 n.s. n.s.
n.s. n.s.
n.s.
(b) The statistical results of two independent variables determined using the Mann–Whitney test. Duration until changing to a speech cannula Patient age <60 years versus 60 years Patient age <65 years versus 65 years Clinical tumor (cT) classification: cT2 versus cT3 Pathologic tumor (pT) classification: pT1-2 versus pT3-4
Duration until nasogastric tube removal
n.s. n.s. n.s.
n.s. n.s. n.s.
n.s.
n.s.
Abbreviations: PEG, percutaneous endoscopic gastrostomy, n.s., not significant.
or changing for speech cannula. The subdivision according to 60 or 65 years did not provide a statistical correlation. The probability of nasogastric tube removal or/and the implementation of a PEG tube was demonstrated using the Kaplan–Meier curve (Fig. 3B). After 13 days, 50% of the nasogastric tubes were removed, and the 95% confidence
interval (CI) ranged from 3.7 to 22.2 days. To demonstrate the impact of tongue base infiltration, we divided the patients into two groups according to the median tongue base infiltration area, which was estimated as 6.20 cm2 (Fig. 3C). Thereby, in the patient group with the tongue base infiltration area <6.20 cm2, 50% of the nasogastric tubes were removed after
Fig. 3. Correlation between the time until nasogastric tube removal and tongue base infiltration area. (A) Correlation between the duration time until nasogastric tube removal and tongue base infiltration area. (B) The probability of nasogastric tube removal or/and the implementation of a PEG tube. (C) The impact of the tongue base infiltration on the probability of nasogastric tube removal. According to the median tongue base infiltration area estimated as 6.2 cm2, the patients were divided in two groups.
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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4 days (95% CI 0–8.6 days). In patients with the tongue base infiltration area 6.20 cm2, 50% of the nasogastric tubes were removed after 22 days (95% CI 6.8–37.2 days). Both curves had highly significant differences (p < 0.0001). In patients with the tongue base infiltration area <6.20 cm2, 2 patients required a PEG tube, while in the group with 6.20 cm2, 5 patients required a PEG tube. Thus, the extension of tongue base infiltration and surgically required resection significantly increases the risk of a permanent swallowing disorder and the probability of dependency on a PEG system for nutrition. 4. Discussion Horizontal partial laryngectomy enables organ preservation in supraglottic laryngeal cancer with tongue base infiltration, or oropharyngeal cancer of the tongue base. However, the oncological strategy requires a complete surgical resection with adequate safety margins and adjuvant (chemo-) radiation therapy depending on the tumor stage. In this study, 92% of the patients underwent adjuvant (chemo-) radiation therapy. The tumor-specific and overall survival rates were consistent with survival reported previously in literature [16,17]. The functional outcome and quality of life require both sufficient swallowing, including oral intake ability, and speech function, including decannulation. Speech pathologists have evaluated functional therapy programs in postoperative rehabilitation [18]. The tumor size is expected to have an impact on the swallowing function after partial laryngectomy. However, there is no study investigating risk factors for impaired recovery of swallowing function or predicting postoperative deglutition outcome based on radiologic tumor extension. Therefore, the present study investigated whether the extension of the surgical resection at the tongue base in patients undergoing open horizontal supraglottic partial laryngectomy affects the recovery rate of swallow function. The tongue base infiltration determined by CT scan was used to estimate the maximum tongue base infiltration depth, width, height, area, volume and the biggest diameter of the tumor (Fig. 1). The duration until changing for speech cannula was not significantly associated with the radiologic tumor dimensions investigated. This time period did not prove to be a useful parameter in studying swallow function. In principle, however, patients can only learn swallowing and coughing when air is able to pass the larynx. Patients therefore need to have an uncuffed speech cannula or to have been decannulated [19]. Thus, the duration until using the speech cannula depends on the regression of postoperative swelling. The tracheostomy is kept during adjuvant radiation therapy due to the expected postradiogenic edema. Decannulation is thus not a reliable marker for swallow function assessment. In contrast, the duration until nasogastric tube removal was significantly associated with the tongue base infiltration width, height and area, although maximum tongue base infiltration depth and maximum tongue base infiltration volume were not significant. The probability of nasogastric tube removal depending on the tongue base infiltration area was demonstrated (Fig. 3B). After subdivision into two groups, the nasogastric
tube was removed significantly earlier in patients with a lesser tongue base infiltration area (Fig. 3C). In the group with the lower extension of the tongue base infiltration area, 2 patients required a PEG tube while in the group with the larger infiltration area, 5 patients required a PEG tube. This important aspect needs to be considered prior to tumor surgery. In patients with an increased risk of a permanent swallowing disorder and permanently necessary tracheal cannula after organ-preserving surgery, alternative therapy methods should be particularly preferred as the primary chemoradiation. To our knowledge, there is no study investigating the impact of tongue base infiltration determined by CT scan on the postoperative swallowing function. Studies have investigated the differences in reconstruction techniques. Most studies found that cricohyoidoepiglottopexy after supracricoid laryngectomy allows better swallow function than cricohyoidopexy [20–24], while other groups were not able to show a significant difference [25–27]. Another important aspect is preserving one or two arytenoids, which improves the swallow function [22,28–31]. In our study, the arytenoid cartilage was not resected in all cases to improve postoperative swallowing function. In a possible tumor infiltration, a different treatment strategy was planned. However, Alicandri-Ciufelli et al. found comparable swallow function in patients undergoing horizontal supraglottic laryngectomy and supracricoid partial laryngectomy [32]. Most studies describe the swallow function depending on the duration of nasogastric tube removal. Further measurements to study swallow function are Fiberoptic Endoscopic Evaluation of Swallowing [25,28,30,33,34], videofluoroscopic of swallow [26,29,30,33,34], quality of life questionnaires [27–29,35], dysphagia severity score [22,33,34,36–40], Functional Outcome Swallowing Scale [41], permanent gastrostomy or complementary total laryngectomy for persistent aspiration [34]. The effect of radiation on postoperative swallowing is controversial. In this study, 92.3% received adjuvant radiation or chemoradiation. Some authors describe that the dysphagia occur independently of radiotherapy [22,26,27,38,42,43], while other authors have found a significant radiation influence [23,28,32,35]. In our study, swallowing was not influenced by the patient’s age. Some studies have found that being over 65 or 70 years old impacts the functional outcome [27,44,45], while other studies could not find such a correlation statistically [22,46]. The T classification is an important prognostic marker [17]. However, for predicting postoperative swallowing function, the radiological determination of the tumor dimension is important. For an open horizontal supraglottic partial laryngectomy, the tumor infiltration height and width of the tumor dimension are critical regarding swallowing function. The tumor infiltration depth has a low influence on the surgical resection in an open partial laryngectomy in contrast with other surgical techniques such as transoral laser microsurgery. In earlier tumor stages, transoral laser and robotic surgery [47,48] are preferred. With increasing tumor size, the tongue base infiltration increases, which is immobile and cannot support the swallowing function. However, Rich et al. [47] reported
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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sufficient swallowing function after laser microsurgery in adjuvant therapy for advanced stage oropharyngeal cancer. The limitations of the study include the retrospective study design. In a prospective study, the study may be completed by investigating the quality of life using questionnaires. Calculating the maximum tumor infiltration area is an artificial measure. Greater patient numbers may significantly highlight the influence of other tumor dimension measurements (e.g. tongue base infiltration depth). All patients received open horizontal partial laryngectomy and 92.3% adjuvant (chemo)radiation. For further investigation on the impact of tongue base infiltration in patients with oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration, the comparison with a patient group undergoing transoral laser microsurgery and primary chemoradiation therapy might be interesting. Through this, we may be able to predict post therapeutic swallow function depending on tumor size and different tumor therapies, such as transoral laser surgery, open supraglottic partial laryngectomy and chemoradiation therapy. 5. Conclusion The postoperative swallow function after open horizontal partial laryngectomy depends on the extension of the tongue base infiltration. The radiologically determined tongue base infiltration height, width and area are useful tools for surgical planning as they can be used to predict postoperative swallow function. Conflict of interest The authors report no conflicts of interest relevant to this article and no financial support or funding. References [1] Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74–108. [2] Lee NK, Goepfert H, Wendt CD. Supraglottic laryngectomy for intermediate-stage cancer: U.T. M.D. Anderson Cancer Center experience with combined therapy. Laryngoscope 1990;100:831–6. [3] Timmermans AJ, de Gooijer CJ, Hamming-Vrieze O, Hilgers FJ, van den Brekel MW. T3-T4 laryngeal cancer in The Netherlands Cancer Institute; 10-year results of the consistent application of an organpreserving/-sacrificing protocol. Head Neck 2014. [4] Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091–8. [5] Chawla S, Carney AS. Organ preservation surgery for laryngeal cancer. Head Neck Oncol 2009;1:12. [6] Comert E, Tuncel U, Sencan Z. Analysis of multicentricity in supraglottic laryngeal carcinoma treated with partial laryngeal surgery. Eur Arch Otorhinolaryngol 2013;270:635–9. [7] Theunissen EA, Timmermans AJ, Zuur CL, Hamming-Vrieze O, Paul de Boer J, Hilgers FJ, et al. Total laryngectomy for a dysfunctional larynx after (chemo)radiotherapy. Arch Otolaryngol Head Neck Surg 2012;138:548–55. [8] Kronenberger MB, Meyers AD. Dysphagia following head and neck cancer surgery. Dysphagia 1994;9:236–44. [9] Moritsch E. [Wiresutures for improvement of swallowing after Alonsooperation (author’s transl)]. Laryngol Rhinol Otol 1977;56:665–8.
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Predictable swallowing function after open horizontal supraglottic partial laryngectomy Christine Breunig a, Philipp Benter c, Rainer O. Seidl a, Annekatrin Coordes a,b,* a
Department of Otolaryngology at UKB, Hospital of the University of Berlin, Charite´ Medical School, Berlin, Germany Department of Otorhinolaryngology, Head and Neck Surgery, Charite´ – Universita¨tsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany c Department of Radiology at UKB, Hospital of the University of Berlin, Charite´ Medical School, Berlin, Germany b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 November 2015 Accepted 14 January 2016 Available online xxx
Objective: After horizontal supraglottic partial laryngectomy, patients have an increased risk of dysphagia as they are not able to close the laryngeal entrance during swallowing, especially if the surgical defect of the tongue base has increased. There is no investigation that studies risk factors for impaired swallow function, or that predicts postoperative swallow outcomes based on radiologically determined tumor dimensions. The present study investigated the impact of the tongue base tumor extension (determined by CT scan in patients undergoing partial laryngectomy) on the recovery rate of swallow function. Methods: The retrospective study in a tertiary hospital between 2000 and 2015 included all patients who underwent open horizontal supraglottic partial laryngectomy due to oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration. All clinicopathological data were collected. The dimension of tongue base infiltration was measured using CT scan. Swallow function was recorded by Fiberoptic Endoscopic Evaluation of Swallowing and determined by evaluating both the duration until nasogastric tube removal and changing of the cuffed tracheostomy tube for an uncuffed speech cannula. Results: The study included 26 patients (44–76 years, median 59 years). The clinical tumor (cT) classification included cT2 and cT3, while the pathologic tumor (pT) classification included pT2 and pT3 in 90% and pT1 and pT4 in 10% respectively. The duration until using the speech cannula was not associated with clinicopathological data, including the investigated radiologic tumor dimensions (biggest tumor diameter, tongue base infiltration depth, width, height, area and volume). The duration until nasogastric tube removal was significantly associated with the tongue base infiltration width (p = 0.012), height (p = 0.026) and area (p < 0.0001). The patients were divided into two groups according to the median tongue base infiltration area estimated as 6.20 cm2. In patients <6.20 cm2, 50% of the nasogastric tubes were removed after 4 days (95% CI 0–8.6 days) and in patients 6.20 cm2, 50% were removed after 22 days (95% CI 6.8–37.2 days; p < 0.0001). Conclusion: The postoperative swallow function after open horizontal supraglottic partial laryngectomy depends on the tumor extension of the tongue base. The tongue base infiltration area is a useful tool for surgical planning as it can be used to predict postoperative swallow function. In foreseeably permanent dysphagia, as well as permanent and necessary tracheotomy tube cuffs after organ-preserving surgery, alternative therapy methods should be particularly preferred as the primary chemoradiation. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Horizontal supraglottic partial laryngectomy Swallow function Dysphagia Speech cannula Tracheotomy tube
* Corresponding author at: Department of Otorhinolaryngology, Head and Neck Surgery, Charite´ – Universita¨tsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany. Tel.: +49 30 8445 2431; fax: +49 30 8445 4460. E-mail address: [email protected] (A. Coordes). http://dx.doi.org/10.1016/j.anl.2016.01.003 0385-8146/ß 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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1. Introduction Laryngeal squamous cell carcinoma is the most common cancer in the head and neck area [1]. For intermediate and advanced tumor stages, the two main curative treatment options consist of surgery (partial and total laryngectomy) and/or (chemo)radiation therapy [2–4]. When the cancer is restricted supraglottically or unilaterally, horizontal supraglottic laryngectomy and supracricoid partial laryngectomy have comparable cure rates to total laryngectomy [5,6]. In general, partial laryngectomy techniques differ in the resection of the epiglottic and the preepiglottic space. Organ preservation surgery such as the horizontal supraglottic partial laryngectomy can also be performed if the base of the tongue is involved, including resection of both the epiglottic and the preepiglottic space. The oncological strategy requires a complete surgical resection with adequate safety margins, while functional outcomes and life quality require sufficient swallow function and other laryngeal functions such as voice. These laryngeal dysfunctions can be found both after partial laryngectomy and radiation therapy only [7,8]. After horizontal supraglottic partial laryngectomy, patients have an increased risk for deglutition and aspiration, as they may not be able to put the tongue base over the laryngeal entrance during swallowing, especially if the surgical defect of the tongue base has increased. Therefore, surgical technique is important as are sufficient sutures between remaining parts of the tongue base and the thyroid cartilage [9]. Various studies have been published that determine influences on swallowing outcomes after partial laryngectomy and that identify strategies to compensate for the postoperative loss of oropharyngeal structure [10]. However, there is no investigation that studies risk factors for impaired recovery of swallow function, or predicts postoperative dysphagia outcomes based on radiologic tumor extension. The present study determines the impact of the estimated preoperative tumor extension at the tongue base using CT scan, in order to predict future swallow function in patients who have undergone open horizontal supraglottic laryngectomy. 2. Materials and methods 2.1. Patient inclusion criteria The retrospective clinical study was performed in a tertiary hospital according to the Helsinki declaration guidelines and the institution’s ethic committee. We included all patients in our institution between 2000 and 2015 who underwent open horizontal supraglottic partial laryngectomy due to oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration. The therapeutic strategy was discussed individually for every patient within a multidisciplinary tumor board consisting of head and neck surgeons, medical oncologists, radiotherapists, and head and neck radiologists. Criteria for surgical treatment included the in sano resectability were assessed using clinical and radiological examinations. Nobody underwent neoadjuvant therapy. Postoperatively, all
resected specimens were examined histologically in order to evaluate the width of the tumor cell free surgical margin and the nodal status. R0 resection was defined as a complete tumor resection with microscopically negative surgical margins for tumor cells 5 mm. The indication for adjuvant radiation included the tumor stage (Union for International Cancer Control (UICC) >II), the R1 surgical margins’ status and the lymph node spread. Additional chemotherapy was performed in patients with R1 resection or extra capsular lymph node spread. 2.2. Patient and treatment assessment All clinicopathological data was collected. Tumor size was recorded both as clinical tumor (cT) classification according to the preoperative CT scan, and pathological tumor (pT) classification after surgery and histological evaluation. Nobody received preoperative swallow therapy. Fiberoptic Endoscopic Evaluation of Swallowing was used to evaluate safe and sufficient swallow function without any signs of aspiration. Thereafter, the cuffed tracheostomy tube was replaced by an uncuffed speech cannula. The nasogastric tube was removed when the patients were able to swallow liquid foods and their calorie intake was sufficient. Thus, we evaluated both the duration until the nasogastric tube was removed and the cuffed tracheostomy tube was changed for a speech cannula. 2.3. Assessment of the tongue base infiltration A 64-channel multidetector CT scan (BrillianceCT-64channel, Philips Medical Systems, Cleveland, OH) was performed to visualize the tumor dimension and iSite Enterprise (Philips) software was used for volumetric image visualization. The isotropic volume dataset was used for multiplanar reconstruction (slice thickness 0.625 mm) to generate images of the maximum extent of the tumor, and the maximum extent of tongue base infiltration in the axial, transverse and sagittal planes. In the sagittal plane, the maximum tongue base infiltration depth was measured at the maximum extent of tongue base infiltration in the ventrodorsal diameter, and the maximum tongue base infiltration height was determined at the maximum extent of tongue base infiltration in the craniocaudal diameter. In the axial plane, the maximum tongue base infiltration width was measured at the maximum extent of tongue base infiltration in the right-left diameter (Fig. 1). The biggest diameter of the tumor extension was determined using the complex 3D volumetric image visualization. Two observers (one radiologist and one otolaryngologist) independently assessed the tumor dimensions. In all cases, the value used was the mean of both measurements. The tongue base infiltration area was calculated as being from multiplication of maximum tongue base infiltration depth and maximum tongue base infiltration width. The tongue base infiltration volume was calculated as from multiplication of the tongue base infiltration area and the maximum tongue base infiltration height.
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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Fig. 1. The maximum tongue base infiltration. The maximum extension of the tongue base infiltration was measured using CT scan. In the first example patient (A–C), the maximum tongue base infiltration was in the right-sided tongue base. Therefore, the maximum tongue base infiltration depth and tongue base infiltration height were determined in (C) and not (B). The maximum tongue base infiltration width was determined in (A). In the second example patient (D–E), the maximum tongue base infiltration depth, height and width are indicated.
2.4. Surgical technique (Fig. 2) In all cases, the open horizontal supraglottic partial laryngectomy [11] was performed by one surgeon. The extent of resection was determined individually. The section plane passed horizontally and included at least one vestibular fold along the floor of the laryngeal ventricle of Morgagni. The arytenoid cartilage remained unchanged. The surgical resection included the hyoid bone, the upper part of the thyroid cartilage
and the laryngeal vestibule. Intraoperatively, frozen sections were performed to evaluate whether the tumor was completely resected and had the tumor cell free surgical margin, otherwise remaining tumor cells were resected. Suture stitches were used for careful readaptation. The remaining larynx (thyroid cartilage) was fixated to the remaining tongue base, so that the tongue base overlapped the thyroid cartilage in order to restore the laryngeal function, despite extensive surgical resections and to improve the swallowing function [12,13].
B
A
C
D
cancer
hyoid bone thyroid cartilage arytenoid cartilage
suture
cricoid cartilage
Fig. 2. Schema of the surgical resection during the horizontal partial laryngectomy by Alonso. The surgical resection included parts of the hyoid bone and the upper part of the thyroid cartilage. The mucosa of the larynx was adapted carefully using suture stitches. The remaining thyroid cartilage was fixated to the remaining tongue base so that the tongue base overlaps the thyroid cartilage.
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Bilateral neck dissection was always performed concomitantly [14]. 2.5. Statistical analysis Statistical analysis was performed to evaluate various clinicopathological factors which may correlate with the clinical outcome, determined as duration until nasogastric tube removal and duration until changing to a speech cannula. For statistical analysis we used IBM SPSS Statistics 20 [15]. Pearson correlation was used to evaluate possible predicting factors, which measure the degree of linear dependence between two variables. The Pearson coefficient was determined. Mann–Whitney test was used to evaluate the statistical difference of two independent variables. P values 0.05 were significant. The probability of nasogastric tube removal or/and the implementation of a percutaneous endoscopic gastrostomy (PEG) tube was demonstrated using the Kaplan–Meier curve. 3. Results 3.1. Patients’ characteristics and the clinicopathological data The study group included 26 patients who underwent open horizontal partial laryngectomy due to oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration. Patients’ characteristics are indicated in Table 1. Their age ranged from 44 to 76 years (median 59 years). 21 patients (81%) were males and 5 (19%) females. The cT classification included only cT2 and cT3, while the final pT classification included pT2 and pT3 in 90% of the patients and pT1 and pT4 in 10% respectively. Adjuvant radiation was performed in 24 (92.3%) patients, with 8 (30.1%) patients having received additional chemotherapy. One patient required total laryngectomy due to permanent aspiration. The mean overall survival was 63 months (95% confidence interval (CI) 43–85 months) and the mean tumor-specific survival was 78 months (95% CI 56–100 months). The duration until the nasogastric tube was removed ranged from 0 to 24 days (median 8.5 days). Seven patients underwent PEG placement. The duration until changing for speech cannula ranged from 2 to 100 days (median 7.5 days). The multiplanar reconstruction images performed by CT scan were used to determine the maximum extent of the tumor, and the maximum extent of tongue base infiltration in the axial, transverse and sagittal plane. The maximum extent of tongue base infiltration in the ventrodorsal diameter was called the median maximum tongue base infiltration depth and was estimated as 2.08 cm and the maximum tongue base infiltration height in the craniocaudal diameter as 1.92 cm. The maximum tongue base infiltration width in the right-left diameter was 3.30 cm. The tongue base infiltration area and the tongue base infiltration volume were determined as 6.20 cm2 and 10.8 cm3 respectively.
Table 1 Demographic data and clinical data. Gender Male (%) Female (%) Patient age at initial diagnosis Median (y) Range (y) Pathologic tumor (pT) classification pT1 (%) pT2 (%) pT3 (%) pT4 (%) Clinical tumor (cT) classification cT1 (%) cT2 (%) cT3 (%) cT4 (%) Adjuvant therapy Radiation (%) Chemotherapy/immunotherapy (%) Total laryngectomy (%) Tongue base infiltration depth Mean SD (cm) Tongue base infiltration width Mean SD (cm) Tongue base infiltration height Mean SD (cm) Biggest diameter of the tumor Mean SD (cm) Tongue base infiltration area Mean SD (cm2) Tongue base infiltration volume Mean SD (cm3) Duration until changing to a speech cannula Median (d) Range (d) Duration until nasogastric tube removal Median (d) Range (d) Duration until PEG implementation No of patients with PEG Median (d) Range (d)
21 (80.8) 5 (19.2) 59 44–76 2 (7.8) 14 (53.8) 9 (34.6) 1 (3.8) 0 (0) 8 (30.8) 18 (69.2) 0 (0) 24 (92.3) 8 (30.1) 1 (3.8) 2.08 0.79 3.11 1.01 2.04 1.06 3.89 1.39 6.16 2.78 11.82 6.77 7.5 2–100 8.5 0–24 7 0 0–210
Abbreviations: PEG, percutaneous endoscopic gastrostomy.
3.2. Predicting factors for clinical outcome We performed a Pearson correlation to determine predicting factors for clinical outcome. The results are demonstrated in Table 2. None of the investigated patient data (including biggest tumor diameter, maximum tongue base infiltration depth, width, height, area or volume) was significantly associated with the duration until changing for speech cannula. However, the duration until nasogastric tube removal had a highly significant association with the tongue base infiltration width (p = 0.012), height (p = 0.026) and area (p < 0.0001). Correlation coefficients were 0.565, 0.522 and 0.749, respectively (Fig. 3A). Also, there was no correlation between the duration until nasogastric tube removal and the time until changing for speech cannula. There was also no significant difference between both time periods according to the clinical or pathological tumor stage. Patient age was not significantly associated with the duration between nasogastric tube removal
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Table 2 Predicting factors for clinical outcome. Statistical correlation between clinicopathological parameters and the duration until changing to a speech cannula and nasogastric tube removal respectively. Statistical significant data are indicated including the Pearson correlation coefficient. (a) The measurement of the degree of linear dependence between two variables investigated using the Pearson correlation. Statistical significant data are indicated including the Pearson correlation coefficient. Duration until changing to a speech cannula
Duration time until nasogastric tube removal
Patient age Tongue base infiltration depth Tongue base infiltration width
n.s. n.s. n.s.
Tongue base infiltration height
n.s.
Biggest diameter of the tumor Tongue base infiltration area
n.s. n.s.
Tongue base infiltration volume Duration until changing to a speech cannula Time until nasogastric tube removal Duration until PEG implementation
n.s.
n.s. n.s. r = 0.543 p = 0.016 r = 0.482 p = 0.036 n.s. r = .793 p < 0.0001 n.s. n.s.
n.s. n.s.
n.s.
(b) The statistical results of two independent variables determined using the Mann–Whitney test. Duration until changing to a speech cannula Patient age <60 years versus 60 years Patient age <65 years versus 65 years Clinical tumor (cT) classification: cT2 versus cT3 Pathologic tumor (pT) classification: pT1-2 versus pT3-4
Duration until nasogastric tube removal
n.s. n.s. n.s.
n.s. n.s. n.s.
n.s.
n.s.
Abbreviations: PEG, percutaneous endoscopic gastrostomy, n.s., not significant.
or changing for speech cannula. The subdivision according to 60 or 65 years did not provide a statistical correlation. The probability of nasogastric tube removal or/and the implementation of a PEG tube was demonstrated using the Kaplan–Meier curve (Fig. 3B). After 13 days, 50% of the nasogastric tubes were removed, and the 95% confidence
interval (CI) ranged from 3.7 to 22.2 days. To demonstrate the impact of tongue base infiltration, we divided the patients into two groups according to the median tongue base infiltration area, which was estimated as 6.20 cm2 (Fig. 3C). Thereby, in the patient group with the tongue base infiltration area <6.20 cm2, 50% of the nasogastric tubes were removed after
Fig. 3. Correlation between the time until nasogastric tube removal and tongue base infiltration area. (A) Correlation between the duration time until nasogastric tube removal and tongue base infiltration area. (B) The probability of nasogastric tube removal or/and the implementation of a PEG tube. (C) The impact of the tongue base infiltration on the probability of nasogastric tube removal. According to the median tongue base infiltration area estimated as 6.2 cm2, the patients were divided in two groups.
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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4 days (95% CI 0–8.6 days). In patients with the tongue base infiltration area 6.20 cm2, 50% of the nasogastric tubes were removed after 22 days (95% CI 6.8–37.2 days). Both curves had highly significant differences (p < 0.0001). In patients with the tongue base infiltration area <6.20 cm2, 2 patients required a PEG tube, while in the group with 6.20 cm2, 5 patients required a PEG tube. Thus, the extension of tongue base infiltration and surgically required resection significantly increases the risk of a permanent swallowing disorder and the probability of dependency on a PEG system for nutrition. 4. Discussion Horizontal partial laryngectomy enables organ preservation in supraglottic laryngeal cancer with tongue base infiltration, or oropharyngeal cancer of the tongue base. However, the oncological strategy requires a complete surgical resection with adequate safety margins and adjuvant (chemo-) radiation therapy depending on the tumor stage. In this study, 92% of the patients underwent adjuvant (chemo-) radiation therapy. The tumor-specific and overall survival rates were consistent with survival reported previously in literature [16,17]. The functional outcome and quality of life require both sufficient swallowing, including oral intake ability, and speech function, including decannulation. Speech pathologists have evaluated functional therapy programs in postoperative rehabilitation [18]. The tumor size is expected to have an impact on the swallowing function after partial laryngectomy. However, there is no study investigating risk factors for impaired recovery of swallowing function or predicting postoperative deglutition outcome based on radiologic tumor extension. Therefore, the present study investigated whether the extension of the surgical resection at the tongue base in patients undergoing open horizontal supraglottic partial laryngectomy affects the recovery rate of swallow function. The tongue base infiltration determined by CT scan was used to estimate the maximum tongue base infiltration depth, width, height, area, volume and the biggest diameter of the tumor (Fig. 1). The duration until changing for speech cannula was not significantly associated with the radiologic tumor dimensions investigated. This time period did not prove to be a useful parameter in studying swallow function. In principle, however, patients can only learn swallowing and coughing when air is able to pass the larynx. Patients therefore need to have an uncuffed speech cannula or to have been decannulated [19]. Thus, the duration until using the speech cannula depends on the regression of postoperative swelling. The tracheostomy is kept during adjuvant radiation therapy due to the expected postradiogenic edema. Decannulation is thus not a reliable marker for swallow function assessment. In contrast, the duration until nasogastric tube removal was significantly associated with the tongue base infiltration width, height and area, although maximum tongue base infiltration depth and maximum tongue base infiltration volume were not significant. The probability of nasogastric tube removal depending on the tongue base infiltration area was demonstrated (Fig. 3B). After subdivision into two groups, the nasogastric
tube was removed significantly earlier in patients with a lesser tongue base infiltration area (Fig. 3C). In the group with the lower extension of the tongue base infiltration area, 2 patients required a PEG tube while in the group with the larger infiltration area, 5 patients required a PEG tube. This important aspect needs to be considered prior to tumor surgery. In patients with an increased risk of a permanent swallowing disorder and permanently necessary tracheal cannula after organ-preserving surgery, alternative therapy methods should be particularly preferred as the primary chemoradiation. To our knowledge, there is no study investigating the impact of tongue base infiltration determined by CT scan on the postoperative swallowing function. Studies have investigated the differences in reconstruction techniques. Most studies found that cricohyoidoepiglottopexy after supracricoid laryngectomy allows better swallow function than cricohyoidopexy [20–24], while other groups were not able to show a significant difference [25–27]. Another important aspect is preserving one or two arytenoids, which improves the swallow function [22,28–31]. In our study, the arytenoid cartilage was not resected in all cases to improve postoperative swallowing function. In a possible tumor infiltration, a different treatment strategy was planned. However, Alicandri-Ciufelli et al. found comparable swallow function in patients undergoing horizontal supraglottic laryngectomy and supracricoid partial laryngectomy [32]. Most studies describe the swallow function depending on the duration of nasogastric tube removal. Further measurements to study swallow function are Fiberoptic Endoscopic Evaluation of Swallowing [25,28,30,33,34], videofluoroscopic of swallow [26,29,30,33,34], quality of life questionnaires [27–29,35], dysphagia severity score [22,33,34,36–40], Functional Outcome Swallowing Scale [41], permanent gastrostomy or complementary total laryngectomy for persistent aspiration [34]. The effect of radiation on postoperative swallowing is controversial. In this study, 92.3% received adjuvant radiation or chemoradiation. Some authors describe that the dysphagia occur independently of radiotherapy [22,26,27,38,42,43], while other authors have found a significant radiation influence [23,28,32,35]. In our study, swallowing was not influenced by the patient’s age. Some studies have found that being over 65 or 70 years old impacts the functional outcome [27,44,45], while other studies could not find such a correlation statistically [22,46]. The T classification is an important prognostic marker [17]. However, for predicting postoperative swallowing function, the radiological determination of the tumor dimension is important. For an open horizontal supraglottic partial laryngectomy, the tumor infiltration height and width of the tumor dimension are critical regarding swallowing function. The tumor infiltration depth has a low influence on the surgical resection in an open partial laryngectomy in contrast with other surgical techniques such as transoral laser microsurgery. In earlier tumor stages, transoral laser and robotic surgery [47,48] are preferred. With increasing tumor size, the tongue base infiltration increases, which is immobile and cannot support the swallowing function. However, Rich et al. [47] reported
Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003
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sufficient swallowing function after laser microsurgery in adjuvant therapy for advanced stage oropharyngeal cancer. The limitations of the study include the retrospective study design. In a prospective study, the study may be completed by investigating the quality of life using questionnaires. Calculating the maximum tumor infiltration area is an artificial measure. Greater patient numbers may significantly highlight the influence of other tumor dimension measurements (e.g. tongue base infiltration depth). All patients received open horizontal partial laryngectomy and 92.3% adjuvant (chemo)radiation. For further investigation on the impact of tongue base infiltration in patients with oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration, the comparison with a patient group undergoing transoral laser microsurgery and primary chemoradiation therapy might be interesting. Through this, we may be able to predict post therapeutic swallow function depending on tumor size and different tumor therapies, such as transoral laser surgery, open supraglottic partial laryngectomy and chemoradiation therapy. 5. Conclusion The postoperative swallow function after open horizontal partial laryngectomy depends on the extension of the tongue base infiltration. The radiologically determined tongue base infiltration height, width and area are useful tools for surgical planning as they can be used to predict postoperative swallow function. Conflict of interest The authors report no conflicts of interest relevant to this article and no financial support or funding. References [1] Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74–108. [2] Lee NK, Goepfert H, Wendt CD. Supraglottic laryngectomy for intermediate-stage cancer: U.T. M.D. Anderson Cancer Center experience with combined therapy. Laryngoscope 1990;100:831–6. [3] Timmermans AJ, de Gooijer CJ, Hamming-Vrieze O, Hilgers FJ, van den Brekel MW. T3-T4 laryngeal cancer in The Netherlands Cancer Institute; 10-year results of the consistent application of an organpreserving/-sacrificing protocol. Head Neck 2014. [4] Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091–8. [5] Chawla S, Carney AS. Organ preservation surgery for laryngeal cancer. Head Neck Oncol 2009;1:12. [6] Comert E, Tuncel U, Sencan Z. Analysis of multicentricity in supraglottic laryngeal carcinoma treated with partial laryngeal surgery. Eur Arch Otorhinolaryngol 2013;270:635–9. [7] Theunissen EA, Timmermans AJ, Zuur CL, Hamming-Vrieze O, Paul de Boer J, Hilgers FJ, et al. Total laryngectomy for a dysfunctional larynx after (chemo)radiotherapy. Arch Otolaryngol Head Neck Surg 2012;138:548–55. [8] Kronenberger MB, Meyers AD. Dysphagia following head and neck cancer surgery. Dysphagia 1994;9:236–44. [9] Moritsch E. [Wiresutures for improvement of swallowing after Alonsooperation (author’s transl)]. Laryngol Rhinol Otol 1977;56:665–8.
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Please cite this article in press as: Breunig C, et al. Predictable swallowing function after open horizontal supraglottic partial laryngectomy. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.01.003