Objectives/Hypothesis
We aimed to identify the risk factors for iatrogenic unilateral vocal fold paralysis (UVFP) caused by thyroid surgery, to allow the identification of patients requiring ...nerve‐protection procedures and monitoring technologies.
Study Design
Retrospective case study in a medical center.
Methods
Patients who underwent thyroid surgery from April 2011 to February 2016 and who were diagnosed with UVFP by laryngoscopy and laryngeal electromyography were included. Patient demographics, types of surgery, and characteristics of the thyroid lesions were analyzed.
Results
Sixty (2.1%) of 2,815 patients who received thyroid surgery developed UVFP. The risk of UVFP was higher in patients over 60 years old (odds ratio, 1.89; 95% confidence interval, 1.01‐3.26; P = .01). Involvement of the external branch of superior laryngeal nerve (EBSLN) occurred in 19 (31.7%) of the 60 UVFP patients, and was more likely to occurr in patients with diabetes mellitus (odds ratio, 14.19; 95% confidence interval, 3.80‐52.94; P < .001). The incidence of UVFP and involvement of the EBSLN differed among surgery types, and was the highest among patients undergoing total thyroidectomy with neck dissection (TTND) (10/158, 6.3% and 5/158, 3.2%, respectively).
Conclusions
The risk of thyroid surgery–related UVFP is higher in older patients. EBSLN involvement is more likely in patients with diabetes mellitus. TTND is associated with higher risks of UVFP and EBSLN injury than other types of surgery, implying the need of intraoperative nerve monitoring in these high‐risk characteristics.
Level of Evidence
4 Laryngoscope, 129:275–283, 2019
Objective
Total laryngectomy (TL) is a life‐saving procedure for individuals with advanced laryngeal cancer and those suffering from recurrence after initial treatment. The present study aimed to ...evaluate the differences between stapler closure (SC) and manual closure (MC) of the pharynx during TL for patients with laryngeal cancer.
Design/Setting
A systematic literature search was performed using the PubMed, EMBASE and Cochrane Library databases. The data were analysed using Comprehensive Meta‐Analysis software (Version 3; Biostat). Dichotomous data were calculated as odds ratios (ORs), and continuous data were calculated as mean differences (MD) with 95% confidence intervals (CI).
Main Outcome/Results
A total of seven studies (535 patients) were included in this meta‐analysis. Pooled analysis showed that the operative time of TL was significantly reduced in the SC group (MD, −63.2; 95% CI, −106.0 to −20.4). Moreover, the SC group had a lower incidence of pharyngocutaneous fistula (OR = 0.38; 95% CI, 0.18 to 0.83; P = .016) and hospital stay (MD, −2.9; 95% CI, −5.6 to −0.1). The incidence of postoperative surgical site infection (OR = 0.41; 95% CI, 0.02 to 8.73; P = .565) was comparable between the two groups.
Conclusion
Based on these results, SC may be a useful option for patients who need TL.
Objectives/Hypothesis
Wide variation in postinjury functional recovery is a hallmark of unilateral vocal fold paralysis (UVFP), ranging from zero to full recovery. The present study examined the ...impact of cricothyroid (CT) muscle involvement on recovery using quantitative laryngeal electromyography (LEMG) of the thyroarytenoid–lateral cricoarytenoid (TA‐LCA) muscle complex at multiple times postinjury.
Study Design
Prospective cohort study in a medical center.
Methods
Eighty‐one patients with UVFP (37 males and 44 females) received an initial assessment of quantitative LEMG, stroboscope, acoustic voice analysis and 36‐Item Short Form Survey quality‐of‐life questionnaire at 3 to 6 months after UVFP onset and a follow‐up assessment at 12 months after UVFP onset.
Results
The initial and follow‐up assessments were performed at 4.3 ± 1.9 and 12.5 ± 1.3 months after UVFP onset, respectively. The peak turn frequency of the TA‐LCA muscle complex on the lesion side was improved at the follow‐up (470 ± 294 Hz) compared with the initial assessment (300 ± 204 Hz) (P < .001). Patients were also divided into two groups with (n = 27) and without (n = 54) CT involvement, respectively. TA‐LCA muscle complex turn frequency improved in patients without CT involvement (from 277 ± 198 to 511 ± 301 Hz; P < .001), but not in those with CT involvement (from 345 ± 211 to 386 ± 265 Hz; P = .46). Seventy‐one of all patients received early intervention with intracordal hyaluronate injection, showing similar therapeutic effects in those with and without CT involvement.
Conclusions
Acute UVFP with combined TA‐LCA muscle complex and CT muscle involvement has a poor prognosis, with poorer recovery of TA‐LCA muscle complex recruitment. Early interventions should be considered in patients with UVFP with CT involvement.
Level of Evidence
2 Laryngoscope, 130:139–145, 2020
The prognostic significance of the relapse interval in patients with resected oral cavity squamous cell carcinoma (OCSCC) is a matter of ongoing debate. In this large-scale, registry-based, ...nationwide study, we examined whether the time interval between surgery and the first disease relapse may affect survival outcomes in Taiwanese patients with OCSCC.
Data made available by the Taiwan Health Promotion Administration as of 2004 were obtained. The study cohort consisted of patients who were included in the registry between 2011 and 2017. Disease staging was performed according to the American Joint Committee on Cancer (AJCC) Staging Manual, Eight Edition. We retrospectively reviewed the clinical records of 13,789 patients with OCSCC who received surgical treatment. A total of 2327 (16.9%) patients experienced a first disease relapse. The optimal cutoff value for the relapse interval was 330 days when both 5-year disease-specific survival (DSS) and overall survival (OS) (≤ 330/>330 days, n = 1630/697) were taken into account. In addition, we undertook a propensity score (PS)-matched analysis of patients (n = 654 each) with early (≤ 330 days) versus late (> 330 days) relapse.
The median follow-up time in the entire study cohort was 702 days (433 and 2001 days in the early and late relapse groups, respectively). Compared with patients who experienced late relapse, those with early relapse showed a higher prevalence of the following adverse prognostic factors: pT4, pN3, pStage IV, poor differentiation, depth of invasion ≥ 10 mm, and extra-nodal extension. Multivariable analysis revealed that early relapse was an independent adverse prognostic factor for both 5-year DSS and OS (average hazard ratios AHRs: 3.24 and 3.91, respectively). In the PS-matched cohort, patients who experienced early relapse showed less favorable 5-year DSS: 58% versus 30%, p < 0.0001 (AHR: 3.10 2.69 - 3.57) and OS: 49% versus 22%, p < 0.0001 (AHR: 3.32 2.89 - 3.81).
After adjustment for potential confounders and PS matching, early relapse was an adverse prognostic factor for survival outcomes in patients with OCSCC. Our findings may have significant implications for risk stratification.
Objective
Traditionally, after total laryngopharyngectomy (TLP), patients cannot speak without a prosthesis or an artificial larynx. In Taiwan, most patients use a commercialized pneumatic laryngeal ...device (PLD). Phonatory tube reconstruction with the anterolateral thigh (ALT) flap is a novel, modified version of synchronous digestive and phonatory reconstruction involving a free muscular cutaneous flap. This study reviewed and compared speech performance between patients who underwent novel flap reconstruction and conventional PLD users.
Method
We retrospectively reviewed patients with laryngeal or hypopharyngeal cancer who underwent TLP from August 2017 to September 2019. The voice handicap index (VHI), speech intelligibility, acoustic and aerodynamic analysis results, and speech range profile (SRP) were compared between patients who underwent ALT phonatory tube reconstruction (ALT group) and those using PLDs (PLD group).
Results
Twenty patients were included; 13 patients were included in the ALT group, and 7 patients were included in the PLD group. Compared to the PLD group, the ALT group had a better fundamental frequency range (P < .001) and semitone range (P < .001) during speech but showed worse jitter, shimmer, and harmonic‐to‐noise ratios. The two groups showed comparable VHI and speech intelligibility performance.
Conclusions
The ALT phonatory tube, a novel flap for reconstruction, can restore digestive and voice functions simultaneously. Compared with PLD use, ALT phonatory tube reconstruction yields an improved speech range and comparable levels of voice handicap and speech intelligibility, suggesting that the technique is a good alternative for patients after TLP.
Level of Evidence
4 Laryngoscope, 131:1349–1357, 2021
To investigate the risk factors of postoperative elevated blood pressure (BP) in children with childhood obstructive sleep apnea syndrome (OSAS) after adenotonsillectomy (AT).
Case series with ...planned data collection.
Tertiary referral center.
Two hundred forty-five consecutive children (180 boys and 65 girls, median age 6.6 years) with polysomnography-diagnosed OSAS who underwent AT between January 2010 and August 2019. Clinical, polysomnographic, and evening BP data were assessed preoperatively and postoperatively (≥3 months after AT). Changes in the variables before and after AT and between individuals with and without hypertension were compared.
Postoperatively, the median (interquartile range) apnea-hypopnea index significantly decreased from 10.4 (5.3-22.6) to 2.2 (1.0-3.8) events/h. In addition, the mean (standard deviation) evening diastolic BP z-score significantly decreased from 0.7 (0.94) to 0.5 (0.81) in the overall cohort, and both systolic (2.1 0.94-1.0 1.31) and diastolic BP z-scores (1.6 0.98-0.7 0.85) significantly decreased in the preoperative elevated BP subgroup. Multivariate logistic regression analysis showed that preoperative obesity (adjusted odds ratio = 4.36, 95% confidence interval = 2.24-8.49) and mean peripheral oxygen saturation <95% during sleep (adjusted odds ratio = 2.73, 95% confidence interval = 1.29-5.79) were independently associated with postoperative elevated BP.
Preoperative obesity and mean peripheral oxygen saturation <95% during sleep were significantly associated with postoperative elevated BP in the children with OSAS, further indicating the importance of careful BP monitoring in this subgroup despite AT treatment.
Objectives/Hypothesis
To elucidate the associations among the immunohistochemical expression of tumor markers, clinicopathological variables, and disease‐free survival (DFS) in patients with ...early‐stage glottic squamous cell carcinoma (SCC) who underwent transoral laser microsurgery (TLM) as the primary treatment.
Study Design
Retrospective chart review.
Methods
The records of consecutive patients with Tis‒T2N0 glottic SCC who underwent TLM between August 1, 2012 and October 31, 2015 were reviewed. Expression of Bcl‐2, pRB, p16INK4A, p53, c‐Myc, E‐cadherin, and EGFR was examined using tissue microarrays containing tumor specimens through immunohistochemistry. Three‐year DFS rates were calculated.
Results
A total of 65 consecutive patients were identified, of which 28 were excluded due to insufficient tissue (n = 22) and low biomarker quality (n = 6). Therefore, 37 patients with complete records were included. The included patients were significantly older and had a more advanced type of cordectomy than did the excluded patients (P = .015 and .009, respectively). According to the findings of univariate analysis, age, betel quid chewing, type of cordectomy, BCL‐2 expression, and pRB expression significantly predicted 3‐year DFS. According to the findings of multivariate analysis, age (adjusted hazard ratio: 0.94, 95% CI: 0.88‐1.00), betel quid chewing (adjusted hazard ratio: 5.07, 95% CI: 1.32‐19.44), and pRB expression (adjusted hazard ratio: 0.02, 95% CI: 0.00‐0.28) were independent predictors of 3‐year DFS.
Conclusions
Low pRB expression is a potential biomarker for predicting disease relapse after primary TLM for early‐stage glottic SCC and may help to identify high‐risk patients who can subsequently undergo intensive management.
Level of Evidence
4
Laryngoscope, 129:E220–E226, 2019
Objective
Increasing evidence supports that auditory feedback of one's own voice closely relates to real‐time adjustments of vocal control. Previous studies highlighted that the low‐frequency ...modulations of below 3 Hz (LFM) embedded in vocal fundamental frequency (F0) showed a reflex‐like response to altered auditory inputs. However, the auditory feedback control of different vocal disorders remains unclear.
Design
A cross‐sectional, case‐controlled study.
Setting
A tertiary medical centre.
Participants
Sustained vocalisations of vowel/a/ from adult healthy controls and patients with vocal fold nodules, vocal fold polyps and vocal fold cysts, respectively. The vocalisations were made at a comfortable pitch and at the intensity of 70 ~ 80 dBC under the following four auditory conditions: natural hearing, 90‐dBC speech noise, 10‐dBC enhanced feedback of self‐produced voice and both the noise and voice feedback.
Main outcome measures
Power spectral analysis of F0 contour of sustained vowel.
Results
Patients with vocal fold nodules presented with different audio‐vocal feedback behaviour and audio‐vocal response to speech noise from the other two vocal pathologies of vocal fold polyp and vocal fold cyst as well as the healthy controls (P < .001, one‐way ANOVA).
Conclusion
The vocal fold nodules may be not only a vocal fold disease but also a disease caused by abnormal audio‐vocal feedback. Moreover, the distinct audio‐vocal feedback of vocal fold nodules could be revealed by power spectral analysis of vocal fundamental frequencies. Although further investigations are necessary, adjustments of audio‐vocal feedback behaviour may provide a new insight and benefit to the treatment of vocal fold nodules in the future.
The aim of this study was to assess associations between fat pad areas at various anatomic levels and the sites of lateral wall collapse and disease severity in adult patients with obstructive sleep ...apnea (OSA). Forty-one patients with OSA who prospectively underwent drug-induced sleep computed tomography were included. Areas of parapharyngeal fat pads and degrees of lateral wall collapse at three representative anatomic levels (nasopharynx, oropharynx, and subglosso-supraglottis), and apnea-hypopnea index (AHI) were measured. In the subglosso-supraglottic region, the parapharyngeal fat pad area in 17 (41%) patients with complete lateral wall collapse was significantly larger than that in 24 (59%) patients without complete collapse (median, 236.0 mm
vs 153.0 mm
; P = 0.02). In multivariate regression analysis, the parapharyngeal fat pad area at the subglosso-supraglottic level (β = 0.02; P = 0.01) and body mass index (β = 3.24; P = 0.01) were independently associated with AHI. Our preliminary results supported that parapharyngeal fat pads at the subglosso-supraglottic level may be involved in the development of lateral wall collapse and then determine the severity of OSA. Further studies are warranted to investigate the effect of reducing parapharyngeal fat pads in the treatment of OSA.
Methods
We sought to compare the prognostic impact of tumor differentiation with respect to adverse risk factors (RFs) identified by the National Comprehensive Cancer Network (NCCN) ...guidelines––including extranodal extension (ENE), positive/close margins, perineural invasion, lymphatic invasion, and vascular invasion––in patients with locally advanced oral cavity squamous cell carcinoma (OCSCC).
Results
Between 1996 and 2018, 1179 consecutive patients with first primary pT3–4 OCSCC were included. A three‐level grading system was adopted––in which the final classification was assigned according to the most prevalent tumor grade. We identified 382/669/128 patients with well/moderately/poorly differentiated tumors, respectively. Compared with well/moderately differentiated tumors, poorly differentiated OCSCC had a higher prevalence of the following variables: female sex (4%/6%/11%), ENE, (14%/36%/61%), positive margins (0.5%/2%/4%), close margins (10%/14%/22%), perineural invasion (22%/50%/63%), lymphatic invasion (2%/9%/17%), vascular invasion (1%/4%/10%), and adjuvant therapy (64%/80%/87%). The 5‐year rates of patients with well/moderately/poorly differentiated OCSCC were as follows: local control (LC, 85%/82%/84%, p = 0.439), neck control (NC, 91%/83%/70%, p < 0.001), distant metastases (DM, 6%/18%/40%, p < 0.001), disease‐free survival (DFS, 78%/63%/46%, p < 0.001), disease‐specific survival (DSS, 85%/71%/49%, p < 0.001), and overall survival (OS, 68%/55%/39%, p < 0.001). Multivariable analysis identified the following variables as independent prognosticators for 5‐year outcomes: ENE (LC/NC/DM/DFS/DSS/OS), poorly differentiated tumors (NC/DM/DFS/DSS/OS), positive margins (LC/DFS), lymphatic invasion (DFS/DSS/OS), perineural invasion (DM), and age ≥65 years (OS).
Conclusions
In addition to ENE, poor tumor differentiation was identified as the second most relevant adverse RF for patients with pT3–4 OCSCC. We suggest that the NCCN guidelines should include poor tumor differentiation as an adverse RF to refine and tailor clinical management.
Final tumor grading of oral cavity squamous cell carcinoma (OCSCC) is assigned according to the most prevalent grade. Relapses of poorly differentiated OCSCC tended to occur regionally and distantly. Poor tumor differentiation was the second most relevant adverse risk factor after extranodal extension. The NCCN guidelines should include poor differentiation as an adverse risk factor.
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