Open Partial Laryngeal Surgery. Survival outcomes, prognostic factors and neck management: a single institutional analysis

Laryngeal cancer represents the fifth to sixth most common malignancy in men in Europe and USA. In 2002, the World Health Organization estimated 600,000 new head and neck cancer cases and 300,000 deaths worldwide and the larynx accounts for approximately 160,000 cases per year, with higher incidence in males (2.5% of all tumours) than in females (0.5%). Most patients present laryngeal carcinoma in the glottic or supraglottic region, and 55-75% are diagnosed with early cancers, with a favourable prognosis. In these scenario, the goals of the therapy, together with the achievement of a high rate of local control, is a possible preservation of function. Such results can be achieved by different approaches, including primary (or adjuvant) external beam radiotherapy, transoral laser microsurgery (TLM), open partial laryngeal surgery and, more recently, robotic transoral surgery. Each of these modalities has specific advantages and limitations, and the treatment option performed is based on the evaluation of many issues such as tumour extension, need for functional reconstruction, physician technical skill, adequate resources, and ultimately patient choice. Currently, radiotherapy and TLM appear to be widely used treatment modalities, particularly for early glottic carcinomas, but conservative laryngeal open surgery remains a mainstay against laryngeal cancer in a wide spectrum of patients. During the years, the indication to treat advanced lesions (T3-T4) with conservative approaches is growing. In fact, partial laryngectomies, either by TLM or open approach, not only allow for a radical oncologic control but also permit, through the conservation of a cricoarytenoid unit, the creation of a neolarynx adequate for swallowing as well as for speaking. It has to be underscored that OPLS must compared total laryngectomy and its oncological results of total laryngectomy and for this reason the optimal balance between survival chances and the avoidance of mutilating surgery remains one of the most challenging tasks for the otolaryngologist. The aim of the present thesis is to explore the different issues of OPLS in the current management of LC. We analysed our institutional dataset in order to critically discuss oncological outcomes, prognostic factors, postoperative complications and functional sequelae. In addition, we wanted to study the problem of elective neck dissection in this setting given that it appears to be a neglected topic in the literature. We also proposed a practical set of nomograms that can aid to tailor the single patient’s strategy when this peculiar and fascinating surgery becomes an option

The Role of Elective Neck Treatment in the Management of Sinonasal Carcinomas: A Systematic Review of the Literature and a Meta-Analysis

The impact of elective neck treatment (ENT), whether by irradiation or dissection, on the prognosis of patients with cN0 sinonasal carcinomas (SNCs) remains an understudied issue. METHODS: A systematic review and meta-analysis of the literature were performed according to PRISMA guidelines in order to assess regional nodal relapse rate after ENT compared to observation in cN0 SNCs patients. Twenty-six articles for a total of 1178 clinically N0 patients were analyzed. Globally, the 5-year overall survival was 52%; 34.6% of patients underwent ENT and 140 regional recurrences were registered (5.9% in the ENT cohort and 15% in the observation group). ENT appears to confer a lower risk of regional recurrence compared to observation alone, with a cumulative OR of 0.38 (95% CI 0.25–0.58). Our meta-analysis supports the efficacy of ENT for reducing the risk of regional recurrence, but its overall impact on survival remains uncertain

Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas

Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6 days, and nasogastric tube 14.3 ± 6.9 days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases

Barbed reposition pharyngoplasty (BRP) in obstructive sleep apnea treatment: State of the art

Purpose: In this paper, we perform a systematic review that discusses the state of the art and evolution on the barbed reposition pharyngoplasty (BRP) in the velo-pharyngeal surgery. Clinical evidence and published outcomes of this surgical technique are reported and discussed. Materials and methods: We performed a systematic review of the current literature through the analysis of the last 10 years of literature on barbed palate surgery. Study design, number of patients enrolled, inclusion criteria, pre- and posttreatment outcomes (AHI, ODI), surgical success rate, follow-up time and complication has been collected and reported. Results: 15 studies for a total of 1531 patients, out of which 1061 underwent barbed reposition pharyngoplasty. Five trials were uncontrolled prospective studies (215 patients, 14% of total), nine were retrospective studies (1266 patients, 82,6% of total), and one randomized prospective clinical trial (RCT) (50 patients, 3,32% of total). All analyzed studies reported good outcomes after BRP surgery. Average preoperative values of AHI and ODI reduced in all studies considered with a significative statistical difference between preoperative and postoperative values (p < 0.05 in all cases). The postoperative surgical success rate ranged between 65.4 and 93% of cases. There were no significant intra-operative or post-operative complications in all studies considered in this systematic review. Conclusions: Barbed reposition pharyngoplasty has proven to be an easy to learn, quick, safe and effective new palatopharyngeal procedure, that can be used in a single level surgery or as a part of multilevel procedures

Neurocognitive performance improvement after obstructive sleep apnea treatment: State of the art

International audienceBackground: Obstructive Sleep Apnea (OSA) syndrome is a respiratory sleep disorder characterized by partial or complete episodes of upper airway collapse with reduction or complete cessation of airflow. Although the connection remains debated, several mechanisms such as intermittent hypoxemia, sleep deprivation, hypercapnia disruption of the hypothalamic–pituitary–adrenal axis have been associated with poor neurocognitive performance. Different treatments have been proposed to treat OSAS patients as continuous positive airway pressure (CPAP), mandibular advancement devices (MAD), surgery; however, the effect on neurocognitive functions is still debated. This article presents the effect of OSAS treatments on neurocognitive performance by reviewing the literature. Methods: We performed a comprehensive review of the English language over the past 20 years using the following keywords: neurocognitive performance and sleep apnea, neurocognitive improvement and CPAP, OSAS, and cognitive dysfunction. We included in the analysis papers that correlated OSA treatment with neurocognitive performance improvement. All validated tests used to measure different neurocognitive performance improvements were considered. Results: Seventy papers reported neurocognitive Performance improvement in OSA patients after CPAP therapy. Eighty percent of studies found improved executive functions such as verbal fluency or working memory, with partial neural recovery at long-term follow-up. One article compared the effect of MAD, CPAP treatment on cognitive disorders, reporting better improvement of CPAP and MAD than placebo in cognitive function. Conclusions: CPAP treatment seems to improve cognitive defects associated with OSA. Limited studies have evaluated the effects of the other therapies on cognitive function

Head-Of-Bed Elevation (HOBE) for Improving Positional Obstructive Sleep Apnea (POSA): An Experimental Study

Purpose: Evaluate the effectiveness of the head-of-bed elevation position (HOBE) with a 30° elevation of the head and trunk, in improving obstruction of the upper airways in obstructive sleep apnea (OSA) patients. A prospective trial simultaneously performing drug-induced sleep endoscopy (DISE) and polysomnography (PSG) tests was performed. Methods: Forty-five patients were included in the prospective study protocol. All patients enrolled in the study and underwent the following evaluations: (1) a drug-induced sleep endoscopy, with an evaluation of obstructions and collapse of the upper airways at 0° and in a HOBE position, with head and trunk elevation of 30°; (2) an overnight PSG assessment in the hospital with head and trunk elevation from 0° to 30° during the night; (3) a questionnaire to evaluate the feedback of patients to sleeping with head-of-bed elevation. Results: Velum (V) and oropharynx lateral wall (O) collapses were reduced in the 30° up position. There were no statistical differences that emerged in the obstruction of the tongue base and epiglottis between the 0° position and the 30° up position (p > 0.05). The average AHI score changed from 23.8 ± 13.3 (0° supine position) to 17.7 ± 12.4 (HOBE position), with a statistical difference (p = 0.03); the same statistical difference emerged in the percentage of apneas that decreased from 55 ± 28.1 to 44 ± 25.8 (p = 0.05). Conclusions: By adopting the HOBE position with 30° elevation of the head and trunk, it is possible to obtain a reduction of upper airways collapses and an improvement of apnea/hypopnea events and nightly respiratory outcomes

Machine Learning Identification of Obstructive Sleep Apnea Severity through the Patient Clinical Features: A Retrospective Study

International audienceObjectives: To evaluate the role of clinical scores assessing the risk of disease severity in patients with clinical suspicion of obstructive sleep apnea syndrome (OSA). The hypothesis was tested by applying artificial intelligence (AI) to demonstrate its effectiveness in distinguishing between mild–moderate OSA and severe OSA risk. Methods: A support vector machine model (SVM) was developed from the samples included in the analysis (N = 498), and they were split into 75% for training (N = 373) with the remaining for testing (N = 125). Two diagnostic thresholds were selected for OSA severity: mild to moderate (apnea–hypopnea index (AHI) ≥ 5 events/h and AHI < 30 events/h) and severe (AHI ≥ 30 events/h). The algorithms were trained and tested to predict OSA patient severity. Results: The sensitivity and specificity for the SVM model were 0.93 and 0.80 with an accuracy of 0.86; instead, the logistic regression full mode reported a value of 0.74 and 0.63, respectively, with an accuracy of 0.68. After backward stepwise elimination for features selection, the reduced logistic regression model demonstrated a sensitivity and specificity of 0.79 and 0.56, respectively, and an accuracy of 0.67. Conclusion: Artificial intelligence could be applied to patients with symptoms related to OSA to identify individuals with a severe OSA risk with clinical-based algorithms in the OSA framework

The Effects of Barbed Repositioning Pharyngoplasty in Positional and Non-Positional OSA Patients: A Retrospective Analysis

PURPOSE: The aim of our retrospective study is evaluating the effectiveness of barbed repositioning pharyngoplasty (BRP) in a consecutive cohort of patients and assessing its impact on positional indexes in order to potentially identify specific obstructive sleep apnea (OSA) phenotypes for patients who might benefit more significantly from this intervention. METHODS: A single-center retrospective study with baseline and follow-up type III sleep tests evaluating the Apnea Hypopnea Index (AHI), supine AHI, non-supine AHI, oxygen desaturation index (ODI), mean SaO2, percentage of time spent at SaO2 below 90% (CT90), and lowest oxygen saturation (LOS) were performed. The patients were then divided into groups according to Sher&rsquo;s criteria and Amsterdam Positional OSA Classification (APOC). Parametric and non-parametric tests and univariate and multivariate analyses were conducted. RESULTS: The study finally included 47 patients. The statistical analysis showed significant improvement in AHI, supine AHI, non-supine AHI, and ODI after surgery. The linear regression showed that high values of baseline AHI, AHI supine, and AHI non supine predict more significant postoperative reductions in AHI, AHI supine, and AHI non supine, respectively. Therapeutic success was achieved in 22 patients out of 47. The logistic regression did not find any independent risk factors for success. The most significant reduction in AHI, supine AHI, and non-supine AHI was observed in the APOC 3 group while the APOC 1 patients experience a substantially lower improvement. CONCLUSIONS: BRP appears to be an effective surgical procedure for the treatment of OSA. The non-positional patients might benefit more from BRP in comparison with positional patients. Moreover, OSA severity should not be considered an absolute contra-indication for this surgical procedure