AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 4 37–4 4 1
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Case reports
Is partial laryngectomy safe forever?☆,☆☆ Kenneth Bagwell, MD⁎, Steven B. Leder, PhD, CCC-SLP, Clarence T. Sasaki, MD, FACS Yale School of Medicine, Department of Surgery, Section of Otolaryngology, New Haven, CT, United States
ARTI CLE I NFO
A BS TRACT
Article history:
Objectives: Over past decades, function-preserving surgery has been oncologically effective
Received 2 November 2014
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 postoperative follow-up. The data encourage a larger sample size. © 2015 Elsevier Inc. All rights reserved.
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 [1,2]. An important
benefit of function-preserving laryngeal surgery, in properly selected patients, is life-long preservation of swallowing and phonation [3]. 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
☆ Contributions: Kenneth Bagwell wrote the manuscript. Steven B. Leder edited the manuscript and contributed literature. Clarence T. Sasaki edited the manuscript and identified patients for inclusion in the series. ☆☆ Grant or financial support: Supported in part by the Virginia Alden Wright Fun. ⁎ Corresponding author at: 800 Howard Avenue, 4th Floor, New Haven, CT 06519, United States. Tel.: +1 203 785 3181. E-mail address: [email protected] (K. Bagwell).
http://dx.doi.org/10.1016/j.amjoto.2014.11.005 0196-0709/© 2015 Elsevier Inc. All rights reserved.
438
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 4 37 –4 4 1
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 [4,5]. Only one longer-term study examining head and neck cancer patients greater than 5 years after treatment solely with chemoradiotherapy has been performed [6]. To date, post-operative safe swallow function has been reported for short-term periods, i.e., 12–36 months [7]. 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.
3.
Results
3.1.
Case 1
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. 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 postoperative 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. 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
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
Table 1 – Summary of patients. Primary malignancy
Patient 1 T2N1 squamous cell cancer of the left epiglottis
Surgical treatment
Open left supraglottic laryngectomy, bilateral modified radical neck dissections Patient 2 T2N0 squamous cell cancer Open right supraglottic of the right false vocal cord laryngectomy, bilateral modified radical neck dissections Patient 3 T2N0 squamous cell cancer Right vertical of the right true vocal cord hemilaryngectomy
Radiation
Timing of first G tube Completion placement laryngectomy documented aspiration
Yes, to 60 Gy
12 years post-op Yes
Yes, 15 years post-op
Yes, to 59.4 Gy
8 years post-op
No
No
Yes
Yes, 11 years post-op
Yes, to 60 Gy for a 8 years post-op previous primary lesion
AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 4 37–4 4 1
439
Fig. 1 – Chest x-ray of patient 1.
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 postoperative 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 postoperative outpatient follow-up. However, three years postoperatively 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
Fig. 2 – Modified barium swallow.
speech-language pathology on supraglottic swallow techniques and her symptoms resolved. By eight years post-operatively her dysphagia to liquids recurred and she developed dysphagia to solids as well. Annual screening chest x-rays, while negative for malignancy, showed progressive scarring of the lower lobes. She began to experience episodes of frank choking with solid foods and lost 11 pounds over a 6 month period. One year later she suffered an episode of aspiration pneumonia requiring hospitalization and treatment with intravenous antibiotics. She continues now, 14 years post-operatively, to report episodes of fever and cough at home treated by her primary physician with oral antibiotics. Modified barium swallow has demonstrated aspiration of pudding-thick liquids which is only inconsistently resolved with supraglottic swallow techniques. She continues to defer gastrostomy tube placement and completion laryngectomy despite the recommendations of her head and neck surgeon.
3.3.
Case 3
Patient 3 is a 77 year old man with a history of left base of tongue squamous cell carcinoma treated successfully with left functional neck dissection, iridium seed implantation to the tongue base, and external beam radiation therapy to a total of 60 Gy who presented 10 years later with new-onset hoarseness. He had a history of COPD and a 50-pack year history of tobacco use with modest alcohol use. On examination an erythematous lesion of the right anterior vocal cord was noted and biopsy revealed invasive squamous cell carcinoma. He was taken to the operating room where direct laryngoscopy revealed an erythematous irregular plaque of the right true vocal cord extending anteriorly with intact passive mobility of both cords. An uncomplicated tracheotomy and a right vertical hemilaryngectomy were performed. His post-operative inpatient course was smooth and he was discharged after 11 days. Final pathology disclosed negative margins. During follow-up appointments physical examinations were without evidence of disease. His left vocal cord was fully mobile and he demonstrated adequate glottal closure with apposition to the right pseudocord. At approximately 7 years post-operatively he was admitted to the hospital with productive cough and fever and was treated successfully for severe acute bronchitis with a two day course of moxifloxacin. One year later, he reported steady weight loss as
440
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 4 37 –4 4 1
Fig. 3 – Chest x-ray for patient 3.
well as increasing dysphagia. His examination was without evidence of recurrent disease. A flexible fiberoptic evaluation of swallowing revealed pharyngeal dysphagia with laryngeal penetration with 5 cc or larger clear liquid boluses. He demonstrated successful oral and pharyngeal phases with pureed consistency and solid foods. He was instructed to observe strict aspiration precautions when eating but was otherwise cleared for a regular consistency diet. Nevertheless, he was subsequently hospitalized three times for respiratory difficulty over the next 6 months and was found to be aspirating contrast on modified barium swallow. A follow-up chest radiograph showed basilar scarring (Fig. 3). A gastrostomy tube was placed and he regained some of his weight. Despite being strictly nil per os with gastrostomy tube feeds for nutrition he continued to suffer from recurrent aspiration. At 11 years post-operatively a completion total laryngectomy and cricopharyngeal myotomy was performed. His post-operative course was complicated by formation of a peristomal pharyngocutaneous fistula which was treated with Betadine-soaked gauze packing and eventually healed. After closure of this fistula, he suffered from no further episodes of aspiration pneumonia.
4.
Discussion
This case series follows three patients post-operatively after partial laryngectomy. All received post-operative radiotherapy. While being free of locoregional and distant recurrence, all went on to develop dysphagia and aspiration eight years or more post-operatively. The occurrence of aspiration has been extensively studied in healthy adults [8,9]. Interestingly, the prevalence of aspiration and the likelihood of developing associated sequelae such as pneumonia has been recently challenged. Aspiration has been identified in cohorts of healthy adults and when followed over time remains stable without pulmonary complications [10]. Although healthy individuals with normal anatomy and adequate pulmonary reserve may be at low risk for pulmonary complications, these data may not translate to representative patients with laryngeal cancer.
Patients with laryngeal cancer tend to be both long-standing smokers and older in age. Chronic tobacco exposure induces changes in the mucociliary transport of the upper tracheobronchial tree. Histopathologic studies of the bronchial mucosa of smokers have displayed chronic ultrastructural ciliary changes [11]. Additionally, worse outcomes with regards to deglutition and aspiration after supraglottic laryngectomy were associated with increased pack-years of tobacco use [12]. Increased age has also been associated with decreasing ciliary beat frequency, mucociliary clearance time, and increased ciliary ultrastructural abnormalities [13]. It may be that these changes lead to overall decreased broncho-alveolar clearance and pulmonary reserve in the aging tobacco user resulting in less tolerance of aspiration as compared to the healthy adult. There are three anatomic barriers to aspiration. The glottic closure reflex, anterior rotation and elevation of the larynx, and retroflexion of the epiglottis over the airway work in concert to prevent aspiration during the normal swallow [5]. With respect to dysphagia following supraglottic partial laryngectomy, the literature shows adequate functional outcomes in short-term studies [7]. This cohort of patients remained free of disease and dysphagia for many years postoperatively after partial laryngectomy. However, over time all developed dysphagia, aspiration, and recurrent pneumonia. Therefore, all three were recommended for completion total laryngectomy for definitive treatment. The late onset dysphagia in this series is likely multifactorial with partial laryngectomy serving as only one of many contributing factors. It is likely that conservation laryngeal surgery places patients in a zone of marginal respiratory compensation and they become highly susceptible to agerelated changes, second head and neck primaries and radiation effect. Many patients treated for laryngeal cancer go on to receive post-operative radiotherapy. Radiotherapy to the larynx is a known cause of acute dysphagia whether coupled with surgical treatment or used as a primary modality [14]. Even as a primary modality it can have devastating long-term effects. In a retrospective series
AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 4 37–4 4 1
patients treated primarily with radiotherapy for head and neck cancer and without any surgical resection developed late-onset dysphagia and aspiration 5 years or more after completion [6]. In our series, all patients received surgery; two patients received adjuvant radiotherapy to standard doses of ~ 60 Gy and a third received radiotherapy 10 years prior for an initial tongue base primary lesion. An additional factor in this series may also have contributed to late dysphagia and aspiration. Two of our three patients developed second primary cancers. One patient was treated with brachytherapy, while the other was treated with vertical hemilaryngectomy. Development and re-irradiation of secondary primary head and neck malignancies, either with external beam or brachytherapy, has been associated with gastrostomy tube dependence and aspiration [15]. This again demonstrates the possibility of multiple factors all contributing to late-onset aspiration in this patient cohort. To our knowledge, this is the first case series that describes the occurrence of late dysphagia and aspiration after partial laryngectomy in detail. Information gleaned from this small case series is useful to the head and neck surgeon. It may be prudent to counsel patients pre-operatively regarding the possibility of late onset dysphagia and aspiration after function-preserving partial laryngectomy. These patients should also be followed for more than 5 years after being disease-free to survey for the development of late-onset dysphagia. More research is needed to further characterize this problem.
REFERENCES
[1] Som ML. Conservation surgery for cancer of the supraglottis. J Laryngol Otol 1970;84:655–78. [2] Lee K, 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.
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[3] Ogura JH, Marks JE, Freeman RB. Results of conservation surgery for cancers of the supraglottis and pyriform sinus. Laryngoscope 1980;90:591–600. [4] Rassekh CH, Driscoll BP, Saikaly H, et al. Preservation of the superior laryngeal nerve in supraglottic and supracricoid partial laryngectomy. Laryngoscope 1998;103:445–7. [5] Sasaki CT, Leder SB, Acton LM, et al. Comparison of glottic closure reflex in traditional “open” versus endoscopic laser supraglottic laryngectomy. Ann Otol Rhinol Laryngol 2006; 115:93–6. [6] Hutcheson KA, Lewin JS, Barringer DA, et al. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer 2012;118:5793–9. [7] Peretti G, Piazza C, Cattaneo A, et al. Comparison of functional outcomes after endoscopic versus open-neck supraglottic laryngectomies. Ann Otol Rhinol Laryngol 2006; 115:827–32. [8] Robbins JA, Coyle J, Rosenbak J, et al. Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia 1999;14: 228–32. [9] Daggett A, Logemann J, Rademaker A, et al. Laryngeal penetration during deglutition in normal subjects of various ages. Dysphagia 2006;21:270–4. [10] Todd JT, Lintzenich CR, Wallin J, et al. Stability of aspiration status in healthy adults. Ann Otol Rhinol Laryngol 2013;122: 289–93. [11] Verra F, Escudier E, Lebargy F, et al. Ciliary abnormalities in bronchial epithelium of smokers, ex-smokers, and nonsmokers. Am J Respir Crit Care Med 1995;151:630–4. [12] Beckhardt RN, Murray JG, Ford CN, et al. Factors influencing functional outcome in supraglottic laryngectomy. Head Neck 1994;16:232–9. [13] Ho JC, Chan KN, Hu WH, et al. The effect of aging on nasal mucociliary clearance, beat frequency, and ultrastructure of respiratory cilia. Am J Respir Crit Care Med 2001;163: 983–8. [14] Chun JY, Kim YH, Choi EC, et al. The oncologic safety and functional preservation of supraglottic partial laryngectomy. Am J Otolaryngol 2010;31:246–51. [15] Kasperts N, Slotman B, Leemans CR, et al. A review on reirradiation for recurrent and second primary head and neck cancer. Oral Oncol 2005;41:225–43.
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Case reports
Is partial laryngectomy safe forever?☆,☆☆ Kenneth Bagwell, MD⁎, Steven B. Leder, PhD, CCC-SLP, Clarence T. Sasaki, MD, FACS Yale School of Medicine, Department of Surgery, Section of Otolaryngology, New Haven, CT, United States
ARTI CLE I NFO
A BS TRACT
Article history:
Objectives: Over past decades, function-preserving surgery has been oncologically effective
Received 2 November 2014
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 postoperative follow-up. The data encourage a larger sample size. © 2015 Elsevier Inc. All rights reserved.
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 [1,2]. An important
benefit of function-preserving laryngeal surgery, in properly selected patients, is life-long preservation of swallowing and phonation [3]. 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
☆ Contributions: Kenneth Bagwell wrote the manuscript. Steven B. Leder edited the manuscript and contributed literature. Clarence T. Sasaki edited the manuscript and identified patients for inclusion in the series. ☆☆ Grant or financial support: Supported in part by the Virginia Alden Wright Fun. ⁎ Corresponding author at: 800 Howard Avenue, 4th Floor, New Haven, CT 06519, United States. Tel.: +1 203 785 3181. E-mail address: [email protected] (K. Bagwell).
http://dx.doi.org/10.1016/j.amjoto.2014.11.005 0196-0709/© 2015 Elsevier Inc. All rights reserved.
438
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 4 37 –4 4 1
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 [4,5]. Only one longer-term study examining head and neck cancer patients greater than 5 years after treatment solely with chemoradiotherapy has been performed [6]. To date, post-operative safe swallow function has been reported for short-term periods, i.e., 12–36 months [7]. 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.
3.
Results
3.1.
Case 1
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. 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 postoperative 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. 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
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
Table 1 – Summary of patients. Primary malignancy
Patient 1 T2N1 squamous cell cancer of the left epiglottis
Surgical treatment
Open left supraglottic laryngectomy, bilateral modified radical neck dissections Patient 2 T2N0 squamous cell cancer Open right supraglottic of the right false vocal cord laryngectomy, bilateral modified radical neck dissections Patient 3 T2N0 squamous cell cancer Right vertical of the right true vocal cord hemilaryngectomy
Radiation
Timing of first G tube Completion placement laryngectomy documented aspiration
Yes, to 60 Gy
12 years post-op Yes
Yes, 15 years post-op
Yes, to 59.4 Gy
8 years post-op
No
No
Yes
Yes, 11 years post-op
Yes, to 60 Gy for a 8 years post-op previous primary lesion
AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 4 37–4 4 1
439
Fig. 1 – Chest x-ray of patient 1.
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 postoperative 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 postoperative outpatient follow-up. However, three years postoperatively 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
Fig. 2 – Modified barium swallow.
speech-language pathology on supraglottic swallow techniques and her symptoms resolved. By eight years post-operatively her dysphagia to liquids recurred and she developed dysphagia to solids as well. Annual screening chest x-rays, while negative for malignancy, showed progressive scarring of the lower lobes. She began to experience episodes of frank choking with solid foods and lost 11 pounds over a 6 month period. One year later she suffered an episode of aspiration pneumonia requiring hospitalization and treatment with intravenous antibiotics. She continues now, 14 years post-operatively, to report episodes of fever and cough at home treated by her primary physician with oral antibiotics. Modified barium swallow has demonstrated aspiration of pudding-thick liquids which is only inconsistently resolved with supraglottic swallow techniques. She continues to defer gastrostomy tube placement and completion laryngectomy despite the recommendations of her head and neck surgeon.
3.3.
Case 3
Patient 3 is a 77 year old man with a history of left base of tongue squamous cell carcinoma treated successfully with left functional neck dissection, iridium seed implantation to the tongue base, and external beam radiation therapy to a total of 60 Gy who presented 10 years later with new-onset hoarseness. He had a history of COPD and a 50-pack year history of tobacco use with modest alcohol use. On examination an erythematous lesion of the right anterior vocal cord was noted and biopsy revealed invasive squamous cell carcinoma. He was taken to the operating room where direct laryngoscopy revealed an erythematous irregular plaque of the right true vocal cord extending anteriorly with intact passive mobility of both cords. An uncomplicated tracheotomy and a right vertical hemilaryngectomy were performed. His post-operative inpatient course was smooth and he was discharged after 11 days. Final pathology disclosed negative margins. During follow-up appointments physical examinations were without evidence of disease. His left vocal cord was fully mobile and he demonstrated adequate glottal closure with apposition to the right pseudocord. At approximately 7 years post-operatively he was admitted to the hospital with productive cough and fever and was treated successfully for severe acute bronchitis with a two day course of moxifloxacin. One year later, he reported steady weight loss as
440
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 4 37 –4 4 1
Fig. 3 – Chest x-ray for patient 3.
well as increasing dysphagia. His examination was without evidence of recurrent disease. A flexible fiberoptic evaluation of swallowing revealed pharyngeal dysphagia with laryngeal penetration with 5 cc or larger clear liquid boluses. He demonstrated successful oral and pharyngeal phases with pureed consistency and solid foods. He was instructed to observe strict aspiration precautions when eating but was otherwise cleared for a regular consistency diet. Nevertheless, he was subsequently hospitalized three times for respiratory difficulty over the next 6 months and was found to be aspirating contrast on modified barium swallow. A follow-up chest radiograph showed basilar scarring (Fig. 3). A gastrostomy tube was placed and he regained some of his weight. Despite being strictly nil per os with gastrostomy tube feeds for nutrition he continued to suffer from recurrent aspiration. At 11 years post-operatively a completion total laryngectomy and cricopharyngeal myotomy was performed. His post-operative course was complicated by formation of a peristomal pharyngocutaneous fistula which was treated with Betadine-soaked gauze packing and eventually healed. After closure of this fistula, he suffered from no further episodes of aspiration pneumonia.
4.
Discussion
This case series follows three patients post-operatively after partial laryngectomy. All received post-operative radiotherapy. While being free of locoregional and distant recurrence, all went on to develop dysphagia and aspiration eight years or more post-operatively. The occurrence of aspiration has been extensively studied in healthy adults [8,9]. Interestingly, the prevalence of aspiration and the likelihood of developing associated sequelae such as pneumonia has been recently challenged. Aspiration has been identified in cohorts of healthy adults and when followed over time remains stable without pulmonary complications [10]. Although healthy individuals with normal anatomy and adequate pulmonary reserve may be at low risk for pulmonary complications, these data may not translate to representative patients with laryngeal cancer.
Patients with laryngeal cancer tend to be both long-standing smokers and older in age. Chronic tobacco exposure induces changes in the mucociliary transport of the upper tracheobronchial tree. Histopathologic studies of the bronchial mucosa of smokers have displayed chronic ultrastructural ciliary changes [11]. Additionally, worse outcomes with regards to deglutition and aspiration after supraglottic laryngectomy were associated with increased pack-years of tobacco use [12]. Increased age has also been associated with decreasing ciliary beat frequency, mucociliary clearance time, and increased ciliary ultrastructural abnormalities [13]. It may be that these changes lead to overall decreased broncho-alveolar clearance and pulmonary reserve in the aging tobacco user resulting in less tolerance of aspiration as compared to the healthy adult. There are three anatomic barriers to aspiration. The glottic closure reflex, anterior rotation and elevation of the larynx, and retroflexion of the epiglottis over the airway work in concert to prevent aspiration during the normal swallow [5]. With respect to dysphagia following supraglottic partial laryngectomy, the literature shows adequate functional outcomes in short-term studies [7]. This cohort of patients remained free of disease and dysphagia for many years postoperatively after partial laryngectomy. However, over time all developed dysphagia, aspiration, and recurrent pneumonia. Therefore, all three were recommended for completion total laryngectomy for definitive treatment. The late onset dysphagia in this series is likely multifactorial with partial laryngectomy serving as only one of many contributing factors. It is likely that conservation laryngeal surgery places patients in a zone of marginal respiratory compensation and they become highly susceptible to agerelated changes, second head and neck primaries and radiation effect. Many patients treated for laryngeal cancer go on to receive post-operative radiotherapy. Radiotherapy to the larynx is a known cause of acute dysphagia whether coupled with surgical treatment or used as a primary modality [14]. Even as a primary modality it can have devastating long-term effects. In a retrospective series
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patients treated primarily with radiotherapy for head and neck cancer and without any surgical resection developed late-onset dysphagia and aspiration 5 years or more after completion [6]. In our series, all patients received surgery; two patients received adjuvant radiotherapy to standard doses of ~ 60 Gy and a third received radiotherapy 10 years prior for an initial tongue base primary lesion. An additional factor in this series may also have contributed to late dysphagia and aspiration. Two of our three patients developed second primary cancers. One patient was treated with brachytherapy, while the other was treated with vertical hemilaryngectomy. Development and re-irradiation of secondary primary head and neck malignancies, either with external beam or brachytherapy, has been associated with gastrostomy tube dependence and aspiration [15]. This again demonstrates the possibility of multiple factors all contributing to late-onset aspiration in this patient cohort. To our knowledge, this is the first case series that describes the occurrence of late dysphagia and aspiration after partial laryngectomy in detail. Information gleaned from this small case series is useful to the head and neck surgeon. It may be prudent to counsel patients pre-operatively regarding the possibility of late onset dysphagia and aspiration after function-preserving partial laryngectomy. These patients should also be followed for more than 5 years after being disease-free to survey for the development of late-onset dysphagia. More research is needed to further characterize this problem.
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