Abstract
Objectives
Over past decades, function-preserving surgery has been oncologically effective for specific types of laryngeal cancer. Although safe short-term swallow function has been reported, swallow safety during long-term survival has received less attention. The purpose of this report is to highlight potential consequences of late dysphagia and chronic aspiration after partial laryngectomy.
Methods
A retrospective case series was performed. The head and neck cancer database from Yale–New Haven Hospital identified 3 patients requiring completion laryngectomy due to chronic aspiration 11–15 years after oncologically successful partial laryngectomy. Demographics, presentation, treatment, and course are included.
Results
Primary treatment was open supraglottic laryngectomy with adjuvant radiation therapy ( n = 2) and vertical hemilaryngectomy ( n = 1). All patients demonstrated locoregional control and preservation of swallow function for > 10 years postoperatively. Due to late dysphagia and chronic aspiration, two patients required completion laryngectomy 11 and 15 years postoperatively and the third patient will require this 14 years postoperatively.
Conclusions
Successful swallowing after function-preserving laryngeal surgery may not last forever despite adequate control of cancer. Three patients presented with aspiration 11–15 years after partial laryngectomy and required definitive completion laryngectomy. This observation may affect preoperative counseling and consideration for longer post-operative follow-up. The data encourage a larger sample size.
1
Introduction
Historically, function-preserving surgery has been oncologically effective for specific types of laryngeal cancer as long-term locoregional control has been reported in the literature for T1, T2, and selected T3 laryngeal cancers . An important benefit of function-preserving laryngeal surgery, in properly selected patients, is life-long preservation of swallowing and phonation . Therefore, benefits of this treatment approach include oncologic control with positive psychosocial outcomes.
Function-preserving surgery, however, also has potential risks. Initially, there was concern that alteration and removal of the supraglottic anatomy would cause dysphagia and aspiration. Specifically, in open supraglottic laryngectomy and vertical hemilaryngectomy the infrahyoid muscles are detached and sections of the laryngeal cartilage and healthy mucosa are removed for the sake of tumor resection. While development of endoscopic laser techniques for supraglottic laryngectomy has obviated the need for external dissection the potential remains to functionally alter the endolaryngeal soft tissues. Both open and endoscopic surgical techniques may damage the superior laryngeal nerve thereby impairing the normal physiology needed for successful swallowing and speaking .
Only one longer-term study examining head and neck cancer patients greater than 5 years after treatment solely with chemoradiotherapy has been performed . To date, post-operative safe swallow function has been reported for short-term periods, i.e., 12–36 months . Concern for late developing dysphagia and aspiration after surgical procedures prompted investigation into long-term functional swallowing outcomes. The purpose of this case series is to highlight potential consequences of late dysphagia and chronic aspiration occurring more than 10 years after function-preserving partial laryngectomy.
2
Methods
A retrospective case series was performed. The head and neck cancer database from Yale–New Haven Hospital identified 3 patients requiring completion laryngectomy due to chronic aspiration 11–15 years after oncologically successful partial laryngectomy. Demographics, presentation, treatment, and course are included.
2
Methods
A retrospective case series was performed. The head and neck cancer database from Yale–New Haven Hospital identified 3 patients requiring completion laryngectomy due to chronic aspiration 11–15 years after oncologically successful partial laryngectomy. Demographics, presentation, treatment, and course are included.
3
Results
3.1
Case 1
Table 1 shows a summary of the patients’ information. Patient 1 is a 57 year old man with COPD, hypothyroidism and a 66 pack-year smoking history who presented with of blood-tinged saliva and voice changes without dysphagia, odynophagia, dyspnea, weight loss, or otalgia. Flexible fiberoptic laryngeal examination disclosed an erythematous mass of the left epiglottis extending toward but not involving the false cords. CT scan of the neck confirmed the presence of a 2.2 × 3.1 × 4.0 cm left ventral epiglottic mass along with a necrotic left level II lymph node. Operative biopsies confirmed the presence of squamous cell cancer. He was staged T2N1 supraglottic laryngeal cancer.
| Primary malignancy | Surgical treatment | Radiation | Timing of first documented aspiration | G tube placement | Completion laryngectomy | |
|---|---|---|---|---|---|---|
| Patient 1 | T2N1 squamous cell cancer of the left epiglottis | Open left supraglottic laryngectomy, bilateral modified radical neck dissections | Yes, to 60 Gy | 12 years post-op | Yes | Yes, 15 years post-op |
| Patient 2 | T2N0 squamous cell cancer of the right false vocal cord | Open right supraglottic laryngectomy, bilateral modified radical neck dissections | Yes, to 59.4 Gy | 8 years post-op | No | No |
| Patient 3 | T2N0 squamous cell cancer of the right true vocal cord | Right vertical hemilaryngectomy | Yes, to 60 Gy for a previous primary lesion | 8 years post-op | Yes | Yes, 11 years post-op |
He was taken to the operating room where an open supraglottic laryngectomy, bilateral functional neck dissections, and tracheotomy were performed. The epiglottis, a portion of the left ventricle, and the left aryepiglottic fold superior to the arytenoid cartilage were resected. The procedure and his post-operative course were uneventful and decannulation occurred prior to discharge. Post-operatively, he received a course of adjuvant external beam radiation therapy in 2 Gy fractions to a total of 60 Gy, experiencing transient xerostomia and mucositis over the ensuing months following completion of therapy.
In follow-up he remained without evidence of disease. However, 10 years post-operatively, a screening chest x-ray showed bronchial wall thickening consistent with bronchitis. Two years subsequently, plain films revealed streaky opacities of the left lower and right middle lobes concerning for aspiration ( Fig. 1 ).
At 14 years post-operatively, he was consistently losing weight and had been hospitalized for aspiration pneumonia. A fiberoptic endoscopic evaluation of swallowing revealed mild aspiration. Despite recommendations, the patient deferred gastrostomy tube placement.
Over the following year, he continued to lose weight and suffered two further episodes of aspiration pneumonia. He developed a second primary adenocarcinoma of the soft palate that was treated successfully with transoral palladium seed implantation. A feeding gastrostomy tube was placed and he was transitioned to bolus tube feeds.
At 15 years post-operatively he suffered from a more severe episode of aspiration pneumonia despite gastrostomy tube feeds. Decision for definitive surgery was made and he subsequently returned to the operating room undergoing completion total laryngectomy and cricopharyngeal myotomy. His post-operative course was smooth. He resumed adequate oral nutrition and his gastrostomy tube was removed. Final pathology of the specimens removed was negative for malignancy. During post-operative outpatient follow-up, he regained his weight and was breathing comfortably without further episodes of aspiration and continued to be without evidence of disease.
3.2
Case 2
Patient 2 is 46 year old school teacher with a 30 pack-year history of tobacco use and no past history of alcohol abuse who presented with 1 year of progressive odynophagia and hoarseness and an associated 8 pound weight loss over a two month period. An ulcerating lesion of right false cord involving the lingual surface of the epiglottis and the right aryepiglottic fold posteriorly was noted on flexible fiberoptic laryngoscopy. It appeared to spare the arytenoid cartilages and true vocal folds. Biopsy revealed squamous cell carcinoma.
She was taken to the operating room and an open supraglottic laryngectomy was performed. Resection included the epiglottis, right false cord, right aryepiglottic fold, and a portion of the right arytenoid cartilage. The internal branches of the superior laryngeal nerve were identified and spared bilaterally. Her post-operative course was smooth. She was decannulated and discharged from the hospital.
Her immediate outpatient course after discharge was complicated by a superficial wound infection of her apron neck flap which was successfully treated with oral antibiotics. She subsequently underwent adjuvant external beam radiation therapy, for a total of 59.4 Gy, separated into 33 fractions without side effects or complications.
She remained without evidence of disease through post-operative outpatient follow-up. However, three years post-operatively she began to notice mild dysphagia to liquids. Modified barium swallow showed penetration and aspiration of contrast ( Fig. 2 ). She was asymptomatic without evidence of pneumonia and pneumonitis. She resumed working with speech-language pathology on supraglottic swallow techniques and her symptoms resolved.
