1. Quality of Life after Total Laryngectomy Cyprus experience
Dr Giannis Thrasyvoulou, MD, PG Cert MEd
A. Aspris, G. Vassiliou, Y. Kyamides
Nicosia General Hospital , Cyprus

2. Background Cyprus has a population of around 1 million
Very high percentage of smokers
39% males
14% females
Nicosia General Hospital is the island’s tertiary referral center for advanced laryngeal tumours (approximately laryngectomy cases per year)

3. Methods
Questionnaire packs requested from laryngectomy patients at their follow- up visits at Nicosia General Hospital.
MD Anderson Dysphagia Inventory (MDDADI)
University of Washington Quality of Life Questionnaire (UW-QOL)
The method of pharyngeal closure was also documented as there was a change of practice in recent years (vertical versus horizontal closure)

4. MD Anderson Dysphagia Inventory (MDDADI)
Rigorously validated in head and neck cancer patients
20 statements related to dysphagia in 4 subscales:
Global :impact of swallowing on daily routine
Emotional :patient’s affective response to dysphagia
Functional :impact on daily activities
Physical : reflects how patients perceive their swallowing ability
5 possible responses , total score : 20 to 100

5. University of Washington Quality of Life Questionnaire (UW-QOL)
First part: 12 domains
pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder function, taste, saliva, mood and anxiety
Second part: Asks to choose which 3 of the 12 domains have been the most important in the last 7 days
Third part: Asks to compare current quality of life with perceived quality of life one month before diagnosis and document overall quality of life in the last 7 days

6. Aims
Is quality of life or dysphagia after total laryngectomy affected by:
Treatment modality
Age (above or below 65)
Type of pharyngeal closure (horizontal or vertical closure)

7. Results
26 laryngectomy patients returned completed questionnaires (70 % response rate)
24 men and 2 women (M:F ratio 12:1)
Median age: 63 (range 52-89)

8. Results 6 patients treated by primary laryngectomy alone
6 patients received postoperative radiotherapy
14 patients treated by salvage laryngectomy after failure of organ preservation
Only one patient (2%) underwent flap reconstruction
14 patients (52%) underwent vertical closure and 12 patients (48%) horizontal closure

9. Most problematic domains in the last 7 days

10. Less important domains in the last 7 days

11. Quality of Life Outcomes-Treatment Modality
We have obtained a mean quality of life for each patient and categorised them into the three groups. Then we assign ranks to each value with the lowest value receiving the rank 1 and the highest value rank 26. Hence we obtain the following :
Modality
Number of patients
Score
Total Laryngectomy alone 6 92
Total Laryngectomy followed by RT 69
Salvage Total Laryngectomy 14
190

12. Quality of Life Outcomes
The mean of quality of life of patients in ”Laryngectomy alone" group is slighly higher than that of patients in ”Salvage Laryngectomy” and “Total Laryngectomy followed by radiotherapy” group. (Kruskal –Wallis test)
There is no significant evidence to suggest that either group is better.
A larger dataset is required 

13. Swallowing Outcomes-Treatment Modality
Number of patients
Score
Total Laryngectomy alone 6
83.5
Total Laryngectomy followed by RT 99
Salvage Laryngectomy 14
166.5
We conclude that there is no significant evidence to suggest that there is a difference in dysphagia inventory based on the three different modalities.

14. Quality of Life and dysphagia outcomes Are they age dependent?
We compared QOL indicators as well as MD Anderson Dysphagia Index for patients having laryngectomy before and after the age of 65. (two tailed t- test)
We concluded that there is no significant evidence to suggest that patients under 65 have a different quality of life indicator or worse dysphagia than those over 65.

15. Horizontal pharyngeal closure versus Vertical pharyngeal closure

16. Horizontal versus Vertical closure
two sample t-test using 5% significance level
Comparing MD Anderson Dysphagia Index for each type of closure
Horizontal
closure
100 90 97 98 65 78 99 96
Vertical Closure 72 74 73 58 61 25 50 80 49 54

17. Advantage of horizontal closure versus vertical
We conclude that there is strong significant evidence to suggest that Horizontal leads to a higher MD Anderson Dysphagia Inventory value (P<0.01)
Horizontal closure provides better swallowing outcomes and we perform this type of closure whenever it’s possible.

18. Conclusion
Measuring the functional outcome and quality of life of patients with cancer is a very important process.
This will guide especially patients with T3 laryngeal cancer on the likelihood of success of organ preservation and the functional outcome that may be expected from nonorgan preserving modalities.
A prospective and multicenter clinical audit should be organized as clearly a larger number of patients is needed to reach statistically significant conclusions.

19. Special Thanks
Assistant Professor ENT Christos Themelis (Aristotle University of Thessaloniki)
Mr Nick Violaris, FRCS (Consultant Head & Neck Surgeon, Eastbourne and Brighton Hospitals Trust)
For supporting our ENT Department in Head & Neck cases in the previous years