Sinonasal Disease in Total Laryngectomy Patients
1
Sinonasal Disease in Total Laryngectomy Patients Vijay A. Patel, MD 1 ; Christopher D. Pool, MD 1 ; Mitchell Dunklebarger, BS 1 ; Eric Schaefer, MS 2 ; Neerav Goyal, MD MPH 1 1 Department of Surgery, Division of Otolaryngology – Head and Neck Surgery 2 Department of Surgery, Division of Outcomes, Research & Quality Neerav Goyal, MD MPH Director, Head and Neck Surgery Penn State Milton S. Hershey Medical Center Division of Otolaryngology – Head and Neck Surgery Email: [email protected] Phone: 717-531-8945 Fax: 717-531-6160 Contact References Introduction : Total laryngectomy (TL) results in complete abolition of nasal airflow, with notable pathologic alterations of intranasal mucosa, mucociliary clearance, and nasal cycle. Despite these observed morphological changes, it remains unclear whether this subpopulation experiences clinically significant sinonasal disease. The goal of this study was to identify rhinosinusitis in TL patients using radiographic imaging. Methods : An IRB-approved retrospective review (January 2005—July 2017) identified 50 patients who underwent radiographic imaging before and after TL. The Lund-Mackay Staging System (LM) was applied to 197 surveillance Computed Tomography scans. Simple linear regression was modeled to LM; tests of statistical significance were estimated via the method of Kenwood and Roger. Demographic as well as relevant clinical factors were also analyzed. Results : The mean age was 62.4 years, with a 5:1 male-to-female ratio. A series of abstracted rhinologic associated comorbidities include acid reflux (50%) allergic rhinitis (2%), asthma (8%), chronic rhinosinusitis (10%), radiation therapy (56%), and tobacco use (24%). A median of 3 scans was obtained, 49% within 12 months after TL. For every 1 month after TL, postoperative LM was +0.01-point (p=0.49). Conversely, for every +1-point in preoperative LM, postoperative LM was +1.08-point (p<0.001). Two patients required endoscopic sinus surgery after TL for persistent sinonasal disease. Conclusions : Preoperative sinonasal disease burden likely plays an important role in the development of clinically significant rhinosinusitis in TL patients. Correlating radiographic findings to validated outcome measures remains a critical aspect of determining optimal surgical candidates, this arena is still under investigation in this unique patient cohort. Abstract Introduction A database query was performed on July 25, 2017 to identify 50 patients status post total laryngectomy with and without neck dissection (CPT 31360 and 31635) between January 2002-2018. A separate database query was also performed to concomitantly identify patients who underwent imaging (CPT 70450, 70452, 70460, 70470, 70486-8, 70490- 92, 70496, and 78811-6). Parameters analyzed include age, indication for surgery, gender, ethnicity, smoking history, ethyl alcohol consumption, and TNM stage. Co-morbidities enumerated include a prior history of acid reflux, allergic rhinitis, asthma, chemoradiation, chronic obstructive pulmonary disease, chronic rhinosinusitis, and sinus surgery. Imaging findings were tabulated using Lund-Mackay (LM) scores. To analyze the primary outcome of LM scores, a fitted, mixed model was applied which includes random intercept and slope effects for each patient. Methods and Materials If inadequate nasal airflow is purported to be a potential cause of nasal pathology, one would expect sinonasal disease etiologies such as rhinosinusitis to be associated with TL patients. Our study suggests that of all the analyzed patient clinical factors, preoperative sinonasal disease burden plays the largest role in developing radiographically apparent findings over time. As a result, capturing this important clinical parameter will dictate counseling patients on their symptomatology in future follow- up clinic visits as well as assist in the determination of which patients may require operative intervention for refractory nasal symptoms. Preoperative sinonasal disease burden likely plays an important role in the development of clinically significant rhinosinusitis in TL patients. Correlating radiographic findings to validated outcome measures remains a critical aspect of determining the degree of observed symptomatology and the concomitant need for surgical intervention; this arena is still under active investigation in this unique patient cohort. Conclusions Patients who have undergone TL for malignancy of the aerodigestive tract develop an iatrogenic interruption of the continuity of the nasopharyngeal airway. Alterations of the intranasal mucosa, mucociliary transport, and nasal cycle have all been described as changes due to absence of nasal airflow. This results in microscopic changes within the human respiratory nasal epithelium as the mucociliary system atrophies and mucus production decreases 1-3 . Similarly, symptoms such as severe hyposmia has been reported in two-thirds of TL patients, likely secondary to compromised transport of odorant molecules to olfactory mucosa as well as surgical interference with sensory laryngeal nerves which may alter olfactory function through a complex feedback mechanism 3-6 . In spite of these observed morphological changes, it remains unclear whether TL patients experience clinically significant sinonasal disease. 1. Cvetnic V, Sips D: Clinical and cytomorphological alterations of nasal mucosa in laryngectomized patients. Rhinology 1988; 26: 183–189. 2. Fisher EW, Lund VJ, Rutman A: The human nasal mucosa after deprivation of airflow: a study of laryngectomy patients. Rhinology 1992; 30: 5–10. 3. Pavia J, Garcia A, Abello R, Franch M, de Espana R, Herranz R: Nasal mucociliary transport in laryngectomees. Eur J Nucl Med 1986; 11: 470–473 4. Leon EA, Catalanotto FA, Werning JW. Retronasal and orthonasal olfactory ability after laryngectomy. Arch Otolaryngol Head Neck Surg. 2007;133:32-36. 5. Henkin RI, Gibson WC. Hyposmia following laryngectomy. Lancet. 1968;2:1394. 6. Henkin RI, Hoye RC, Ketcham AS, Gould WJ. Hyposmia following laryngectomy. Lancet. 1968;2:479-481. Preoperatively (LM=2) 24 Months (LM=6) 83 Months (LM=19) 42 Months (LM=8) Radiographic Imaging Results Fifty TL patients (197 LM scores, mean 3.9 CT scans) were included in the analysis. A series of identified rhinologic-associated comorbidities including acid reflux (50%), allergic rhinitis (2%), asthma (8%), and chronic rhinosinusitis (10%) was observed. A modest increase in postoperative LM scores was observed, with a mean and median of 2.7 and 1.0 (range 0-19). The interpretation of the fixed effects of time since surgery and preoperative LM score on postoperative LM scores is for every 1-point increase in preoperative LM score, postoperative LM scores were associated with an increase of 1.08 points (95% CI: 0.73 to 1.42), a significant effect (p<0.001). Please refer to the figure below: Discussion Trend Analysis: Lund - Mackay Scores
Transcript of Sinonasal Disease in Total Laryngectomy Patients
Sinonasal Disease in Total Laryngectomy Patients
Vijay A. Patel, MD1; Christopher D. Pool, MD1; Mitchell Dunklebarger, BS1;
Eric Schaefer, MS2; Neerav Goyal, MD MPH1
1Department of Surgery, Division of Otolaryngology – Head and Neck Surgery2Department of Surgery, Division of Outcomes, Research & Quality
Neerav Goyal, MD MPHDirector, Head and Neck SurgeryPenn State Milton S. Hershey Medical CenterDivision of Otolaryngology – Head and Neck SurgeryEmail: [email protected]: 717-531-8945Fax: 717-531-6160
Contact References
Introduction: Total laryngectomy (TL) results in complete abolition of
nasal airflow, with notable pathologic alterations of intranasal mucosa,
mucociliary clearance, and nasal cycle. Despite these observed
morphological changes, it remains unclear whether this subpopulation
experiences clinically significant sinonasal disease. The goal of this
study was to identify rhinosinusitis in TL patients using radiographic
imaging.
Methods: An IRB-approved retrospective review (January 2005—July
2017) identified 50 patients who underwent radiographic imaging before
and after TL. The Lund-Mackay Staging System (LM) was applied to 197
surveillance Computed Tomography scans. Simple linear regression was
modeled to LM; tests of statistical significance were estimated via the
method of Kenwood and Roger. Demographic as well as relevant clinical
factors were also analyzed.
Results: The mean age was 62.4 years, with a 5:1 male-to-female ratio.
A series of abstracted rhinologic associated comorbidities include acid
reflux (50%) allergic rhinitis (2%), asthma (8%), chronic rhinosinusitis
(10%), radiation therapy (56%), and tobacco use (24%). A median of 3
scans was obtained, 49% within 12 months after TL. For every 1 month
after TL, postoperative LM was +0.01-point (p=0.49). Conversely, for
every +1-point in preoperative LM, postoperative LM was +1.08-point
(p<0.001). Two patients required endoscopic sinus surgery after TL for
persistent sinonasal disease.
Conclusions: Preoperative sinonasal disease burden likely plays an
important role in the development of clinically significant rhinosinusitis in
TL patients. Correlating radiographic findings to validated outcome
measures remains a critical aspect of determining optimal surgical
candidates, this arena is still under investigation in this unique patient
cohort.
Abstract
Introduction
A database query was performed on July 25, 2017 to identify 50 patients
status post total laryngectomy with and without neck dissection (CPT
31360 and 31635) between January 2002-2018. A separate database
query was also performed to concomitantly identify patients who
underwent imaging (CPT 70450, 70452, 70460, 70470, 70486-8, 70490-
92, 70496, and 78811-6). Parameters analyzed include age, indication
for surgery, gender, ethnicity, smoking history, ethyl alcohol consumption,
and TNM stage. Co-morbidities enumerated include a prior history of
acid reflux, allergic rhinitis, asthma, chemoradiation, chronic obstructive
pulmonary disease, chronic rhinosinusitis, and sinus surgery. Imaging
findings were tabulated using Lund-Mackay (LM) scores. To analyze the
primary outcome of LM scores, a fitted, mixed model was applied which
includes random intercept and slope effects for each patient.
Methods and Materials
If inadequate nasal airflow is purported to be a potential cause of nasal
pathology, one would expect sinonasal disease etiologies such as
rhinosinusitis to be associated with TL patients. Our study suggests that
of all the analyzed patient clinical factors, preoperative sinonasal disease
burden plays the largest role in developing radiographically apparent
findings over time. As a result, capturing this important clinical parameter
will dictate counseling patients on their symptomatology in future follow-
up clinic visits as well as assist in the determination of which patients
may require operative intervention for refractory nasal symptoms.
Preoperative sinonasal disease burden likely plays an important role in
the development of clinically significant rhinosinusitis in TL patients.
Correlating radiographic findings to validated outcome measures
remains a critical aspect of determining the degree of observed
symptomatology and the concomitant need for surgical intervention; this
arena is still under active investigation in this unique patient cohort.
Conclusions
Patients who have undergone TL for malignancy of the aerodigestive
tract develop an iatrogenic interruption of the continuity of the
nasopharyngeal airway. Alterations of the intranasal mucosa, mucociliary
transport, and nasal cycle have all been described as changes due to
absence of nasal airflow. This results in microscopic changes within the
human respiratory nasal epithelium as the mucociliary system atrophies
and mucus production decreases1-3. Similarly, symptoms such as severe
hyposmia has been reported in two-thirds of TL patients, likely secondary
to compromised transport of odorant molecules to olfactory mucosa as
well as surgical interference with sensory laryngeal nerves which may
alter olfactory function through a complex feedback mechanism3-6. In
spite of these observed morphological changes, it remains unclear
whether TL patients experience clinically significant sinonasal disease.
1. Cvetnic V, Sips D: Clinical and cytomorphological alterations of nasal mucosa in laryngectomized patients. Rhinology 1988; 26: 183–189.
2. Fisher EW, Lund VJ, Rutman A: The human nasal mucosa after deprivation of airflow: a study of laryngectomy patients. Rhinology 1992; 30: 5–10.
3. Pavia J, Garcia A, Abello R, Franch M, de Espana R, Herranz R: Nasal mucociliary transport in laryngectomees. Eur J Nucl Med 1986; 11: 470–473
4. Leon EA, Catalanotto FA, Werning JW. Retronasal and orthonasal olfactory ability after laryngectomy. Arch Otolaryngol Head Neck Surg. 2007;133:32-36.
5. Henkin RI, Gibson WC. Hyposmia following laryngectomy. Lancet. 1968;2:1394.6. Henkin RI, Hoye RC, Ketcham AS, Gould WJ. Hyposmia following laryngectomy. Lancet. 1968;2:479-481.
Preoperatively (LM=2) 24 Months (LM=6)
83 Months (LM=19)42 Months (LM=8)
Radiographic Imaging
ResultsFifty TL patients (197 LM scores, mean 3.9 CT scans) were included in
the analysis. A series of identified rhinologic-associated comorbidities
including acid reflux (50%), allergic rhinitis (2%), asthma (8%), and
chronic rhinosinusitis (10%) was observed. A modest increase in
postoperative LM scores was observed, with a mean and median of 2.7
and 1.0 (range 0-19).
The interpretation of the fixed effects of time since surgery and
preoperative LM score on postoperative LM scores is for every 1-point
increase in preoperative LM score, postoperative LM scores were
associated with an increase of 1.08 points (95% CI: 0.73 to 1.42), a
significant effect (p<0.001). Please refer to the figure below:
Discussion
Trend Analysis: Lund-Mackay Scores
