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Prophylactic swallowing exercises (PSE) during head-and-neck cancer (HNC) (chemo)radiotherapy (CRT) have a positive effect on swallowing function and muscle strength. Adherence rates to PSE are, however, moderate to low, undermining these effects. PRESTO already showed that the service-delivery mode (SDM), the way the exercises are offered, can influence adherence. The aim of this study was to investigate the effect of SDM on swallowing function and muscle strength during and post-CRT. In addition, the effect of overall adherence (OA), independent of SDM, was also investigated. A total of 148 HNC patients, treated with CRT, were randomly assigned to one of the three SDM's (paper-supported, app-supported, or therapist-supported PSE) and performed a 4-week PSE program. OA was calculated based on the percentage of completed exercises. Patients were divided into OA levels: the OA75+ and OA75- group performed respectively ≥ 75 and < 75% of the exercises. Swallowing function based on Mann Assessment of Swallowing Ability-Cancer (MASA-C), tongue and suprahyoid muscle strength during and up to 3 months after CRT were compared between the SDM's and OA levels. Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction was used. No significant differences were found between the three SDMs. Significant time effects were found: MASA-C scores decreased and muscle strength increased significantly during CRT. By the end of CRT, the OA75+ showed significantly better swallowing function compared to OA75-. Muscle strength gain was significantly higher in the OA75+ group. SDM had no impact on swallowing function and muscle strength; however, significant effects were shown for OA level. Performing a high level of exercise repetitions is essential to benefit from PSE.Trial registration ISRCTN, ISRCTN98243550. Registered December 21, 2018-retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search., (© 2023. The Author(s).)

Background: Prophylactic swallowing exercises (PSE) during radiotherapy can significantly reduce dysphagia after radiotherapy in head and neck cancer (HNC). However, its positive effects are hampered by low adherence rates during the burdensome therapy period. Hence, the main goal of this multicenter randomized controlled trial (RCT) was to investigate the effect of 3 different service-delivery modes on actual patients' adherence., Methods: A total of 148 oropharyngeal cancer patients treated with primary (chemo)radiotherapy were randomly assigned to a 4 weeks PSE program, either diary-supported (paper group; n = 49), app-supported (app group; n = 49) or therapist-supported (therapist group; n = 50). Participants practiced 5 days/week, daily alternating tongue strengthening exercises with chin tuck against resistance exercises. Adherence was measured as the percentage of completed exercise repetitions per week (%reps). Statistical analysis was performed by means of SPSSv27, using Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction., Results: Adherence and evolution of adherence over time was significantly different between the three groups (p < .001). Adherence rates decreased in all three groups during the 4 training weeks (p < .001). During all 4 weeks, the therapist group achieved the highest adherence rates, whilst the app group showed the lowest adherence rates., Conclusions: PSE adherence decreased during the first 4 radiotherapy weeks regardless of group, but with a significant difference between groups. The therapist group achieved the highest adherence rates with a rather limited decline, therefore, increasing the face-to-face contact with a speech-language therapist can overcome the well-known problem of low adherence to PSE in this population., Trial Registration: Trial registration: ISRCTN, ISRCTN98243550. Registered December 21, 2018 - retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search ., (© 2022. The Author(s).)

We retrospectively evaluated how accurately preoperative imaging localizes parathyroid adenoma in superior versus inferior parathyroids. Over 6 years, 104 patients with primary hyperparathyroidism underwent parathyroid surgery in a single centre. Of these, 103 underwent ultrasound, 97 [ 99m Tc]pertechnetate/MIBI SPECT/CT and 30 [ 18 F]fluorocholine (FCH) PET/CT. One patient with a unilateral double adenoma was excluded from the analysis. Surgical findings with histopathologic confirmation of adenoma were used as the standard. Ultrasound misjudged 5 of 48 detected lower adenomas as upper, but 14 of 29 upper adenomas as lower (error rate 10 vs 48%, p = 0.0002). The corresponding error rates for [ 99m Tc]pertechnetate/MIBI SPECT/CT were 3 versus 55% (p = 0.000014), and for [ 18 F]FCH PET/CT 17 versus 36% (p = 0.26). Our results suggest that about half of the superior parathyroid adenomas which are detected, are erroneously assigned to the inferior position by both ultrasound and SPECT/CT imaging whereas the opposite mistake is significantly less frequent with ultrasound and SPECT/CT., (© 2023. The Author(s).)

Objective: We aimed to analyze oncologic outcomes and identify patterns of failure and negative prognostic factors in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx., Methods: This was a retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018 for residual/recurrent/second primary SCC in the larynx or hypopharynx after initial (chemo)radiation. Prognostic factors for oncologic outcomes were identified using univariable and multivariable analysis., Results: A total of 405 patients were included in the final analysis. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and locoregional relapse-free survival (LRFS) estimates were 47.7% (95% confidence interval [CI] 42.0-53.2%), 68.7% (95% CI 63.7-73.7%), 42.1% (95% CI 36.7-47.4%), and 44.3% (95% CI 38.8-49.7%), respectively. In a multivariable model, increasing clinical tumor stage of the residual/recurrent/second primary tumor, increasing number of metastatic cervical lymph nodes retrieved during neck dissection, hypopharyngeal and supraglottic tumor location, positive section margin status and perineural invasion were independent negative prognostic variables for OS, DSS, DFS, and LRFS. The type of second tumor was identified as an additional independent prognosticator for DSS, with local recurrences and second primary tumors having a better prognosis than residual tumor., Conclusions and Relevance: Favorable oncologic outcomes are reported after STL. Increasing clinical tumor stage, increasing number of metastatic cervical lymph nodes, hypopharyngeal and supraglottic tumor location, positive section margins, and perineural invasion are identified as independent negative prognosticators for all oncologic outcome measures.

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation. Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis. Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins. Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL., (Copyright © 2020 Meulemans, Demarsin, Debacker, Batailde, Mennes, Laenen, Goeleven, Neyt, Vanclooster, Vauterin, Delaere, Huvenne and Vander Poorten.)

Background: Dysphagia is a common and serious complication after (chemo)radiotherapy (CRT) for head-and-neck cancer (HNC) patients. Prophylactic swallowing exercises (PSE) can have a significantly positive effect on post-treatment swallowing function. However, low adherence rates are a key issue in undermining this positive effect. This current randomized trial will investigate the effect of adherence-improving measures on patients' swallowing function, adherence and quality of life (QOL)., Methods: This ongoing trial will explore the difference in adherence and swallowing-related outcome variables during and after PSE in HNC patients performing the same therapy schedule, receiving different delivery methods. One hundred and fifty patients treated in various hospitals will be divided into three groups. Group 1 performs PSE at home, group 2 practices at home with continuous counseling through an app and group 3 receives face-to-face therapy by a speech and language pathologist. The exercises consist of tongue-strengthening exercises and chin-tuck against resistance with effortful swallow. The Iowa Oral Performance Instrument and the Swallowing Exercise Aid are used for practicing. Patients are evaluated before, during and after treatment by means of strength measurements, swallowing and QOL questionnaires., Discussion: Since low adherence rates undermine the positive impact of PSE on post-treatment swallowing function, there is need to develop an efficient PSE protocol maximizing adherence rates., Trial Registration: ISRCTN, ID: ISRCTN98243550. Registered retrospectively on 21 December 2018.

Obstructive sleep apnoea-hypopnoea (OSAH) syndrome constitutes a major health care problem. Surgical modalities for the treatment of OSAH are regaining momentum in view of the increasing prevalence of OSAH and the low compliance rates associated with continuous positive airway pressure. There are several investigations to complement clinical examination in accurately determining the level of airway collapse to ensure correct patient selection and a targeted surgical approach. The most commonly employed include drug-induced sleep endoscopy and imaging with the tongue base and epiglottis often revealed as the major sites of airway narrowing during sleep. In the continuing search for the optimal approach to address these areas, transoral robotic surgery (TORS) has been successfully used for tongue base reduction and epiglottoplasty. With sufficient experience, this technique is safe and well tolerated. Meticulous work-up and careful patient selection are crucial. Multiple studies have demonstrated very good short-term results of TORS for OSAH, with significant reduction in both the Apnoea-Hypopnea Index (AHI) and Epworth Sleepiness Score (ESS). With the appropriate infrastructure, proctoring, and access to robotic surgical technology, it is possible for these results to be reproduced more widely. Further prospective long-term clinical evaluation will ultimately determine the exact role of TORS in the treatment of OSAH., (© 2018 S. Karger AG, Basel.)

Our aim was to evaluate the long-term objective and subjective results of a modified expansion sphincter pharyngoplasty (ESP) technique in patients with sleep-disordered breathing. Single center prospective study of 35 patients underwent an ESP as a primary surgical treatment between June 2012 and September 2015 at the hospital AZ Sint-Jan Bruges-Ostend. Patients were divided into non-OSAS and OSAS (AHI >5). Primary outcome parameters were the Epworth Sleeping Scale (ESS, reduction and score less then 10) and the Visual Analogue Score of snoring (VAS, assessed by partner) evaluated at 3 months and 1 year. In addition, the OSAS group underwent a polysomnography after 6 months to calculate the Apneu-Hypopneu Index (AHI) change. Secondary outcome parameters were possible complications and morbidity rate. The overall Epworth Sleepiness Scale showed a steady total reduction of, respectively, 42 and 48% at the two timepoints. All patients had a post-operative score of less than ten points. The Visual Analogue Score improved in 92% of the patients; of these, the snoring was reduced in 86% and disappeared in 6%. In the OSAS group, we noticed a reduction in AHI of more than 50 in 53% of the patients. A considerable reduction was found in the severe OSAS group, where we found a mean pre-operative average AHI of 41.3/h that was reduced 6 months after the operation to 17.4/h. There were no severe complications or increased morbidity rate observed. This first long-term study shows that the modified ESP seems to be a safe and promising technique in palatal surgery for patients with sleep-disordered breathing. Surgical effectiveness is sustained after 1 year, both in OSAS as in snoring pathology. The technique seems as approachable for the basic ENT surgeon as the uvulopalatopharynoplasty.

Introduction/aim: We analyzed the functional and oncologic outcomes of primary and salvage transoral robotic surgery (TORS) procedures, performed in three Belgian institutions with a similar philosophy., Patients and Methods: A total of 86 patients who underwent TORS between 24-12-2009 and 25-09-2015 were retrospectively reviewed. Descriptive statistics, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS; Kaplan-Meier), and the variation of these outcomes according to whether patients had primary or salvage TORS were evaluated (univariate log-rank analysis)., Results: Of 86 patients, 56 (65.1%) underwent TORS as a primary treatment and 30 (34.9%) as a salvage procedure for recurrent or second primary cancer. Tumor location was mainly oropharynx ( N  = 63; 73.3%) followed by supraglottic larynx ( N  = 11; 12.8%), hypopharynx ( N  = 11; 12.8%), and glottic larynx ( N  = 1; 1.2%). In the up-front TORS group, most tumors were classified as cT1 ( N  = 23; 41.1%)/pT1 ( N  = 24; 42.9%) or cT2 ( N  = 27; 48.2%)/pT2 ( N  = 27; 48.2%) and cN0 ( N  = 18; 32.1%), cN1 ( N  = 13; 23.2%), or cN2 ( N  = 25; 44.6%). In the salvage TORS group, most tumors were cT1-rT1 ( N  = 18; 60.0%)/pT1-rpT1 ( N  = 18; 60.0%) or cT2-rT2 ( N  = 12; 40.0%)/pT2-rpT2 ( N  = 7; 23.3%) and cN0 ( N  = 25; 83.3%). Neck dissection was performed in 87.5% of primary cases and 30.0% of salvage cases. In the up-front TORS group, patients were postoperatively submitted to follow-up ( N  = 13; 23.2%) or received adjuvant radiotherapy, either as single modality ( N  = 26; 46.4%) or with concomitant cisplatin ( N  = 15; 26.8%). On the other hand, most salvage TORS patients did not receive any adjuvant therapy ( N  = 19; 63.3%). Mean and median follow-up was 23.1 and 21.2 months, respectively. Functional results were excellent (no definitive tracheostomy, long-term tube feeding in 1.8% of primary cases, and 20% of salvage cases). In the up-front TORS group, estimated 2-year OS was 88.5% (SE = 5.0%), 2-year DSS was 91.8% (SE = 4.6%) and 2-year DFS was 86.1% (SE = 5.3%). In the salvage TORS group, estimated 2-year OS was 73.5% (SE = 10.9%), 2-year DSS was 93.3% (SE = 6.4%), and 2-year DFS was 75.8% (SE = 9.7%). Comparing outcome of primarily treated patients to salvage patients, a non-statistically significant trend toward better OS ( p  = 0.262) and DFS ( p  = 0.139) was observed., Conclusion: This retrospective study confirms favorable oncologic and functional outcomes of TORS for selected head and neck malignancies, both in the primary and in the salvage setting.

Objectives: The parapharyngeal space (PPS) is an anatomically complex space in the vicinity of vital structures. With the introduction of the daVinci robot in head and neck surgery, the surgical robotic system is now being used to gain direct access to the parapharyngeal space and to excise the tumors endoscopically. This study evaluates the outcomes of four patients with benign PPS tumors treated with a transoral robotic surgery approach in a single centre., Material and Methods: All patients with benign tumors of the PPS who underwent transoral resection (between January 2012 and June 2014) using the robot were included in this retrospective study., Results: The study population comprised of two males and two females with a mean age of 52 (range 34-66 years). The parapharyngeal mass was successfully transorally removed in all cases. Overall, mean length of stay was 3.25 days with mean time to oral diet of one day. No intraoperative, perioperative or postoperative complications were encountered. The histological diagnosis was pleomorphic adenoma in two cases (50%). The other two cases were: schwannoma and angioma. There were no recurrences on radiological investigations during a mean follow-up of 14.5 months. MRI scan showed a stable residual fibrotic lesion in case of the angioma. The preoperative complaints of mucus in the throat, painless swelling of the soft palate or throat burden of all patients resolved after surgery., Conclusion: With the assistance of the surgical robotic system, benign tumors within the PPS can be excised safely without neck incisions. Further long-term evaluation is needed to define patient selection and the role of TORS for PPS neoplasms.

Background: In search for less invasive operative techniques, the da Vinci Robot System was introduced in thyroid surgery. Previous studies have reported on safety, effectiveness and improved cosmetics of transaxillary endoscopic thyroidectomy procedures in selected cases., Methods: We report on the first 50 patients that have been treated with a gasless transaxillary robot-assisted thyroidectomy in a Belgian institution. We describe the implementation, the operative technique and results of robotic thyroid surgery., Results: 48 hemithyroidectomy and 2 total thyroidectomy procedures were performed. The mean ultrasound dimensions of the nodules were 3.4 ± 1.0 cm (range 1.0-8.0 cm). The mean operative time was significantly longer than with a conventional open approach: 215 min ± 55 min (range 133 min-347 min). No major complications were observed. All patients were "satisfied" about the cosmetic outcome., Conclusion: Transaxillary robotic thyroid surgery is demanding, but feasible. Selected patients can benefit from this technique with an optimal cosmetic outcome. Ideal indication in the hand of our team is a hemithyroidectomy for benign nodules ranging up to 5 cm.

Background: Congenital laryngeal cysts are a rare, but potentially fatal, cause of airway obstruction in infants and children. Most laryngeal cysts are acquired. Here, we describe a congenital laryngeal cyst, its treatment, and its presentation immediately after birth., Case Report: A newborn child developed stridor very shortly after birth, due to a large, congenital saccular cyst. The diagnosis was based on a laryngoscopy and imaging studies, which detected an extralaryngeal extension through the cricothyroid membrane. The cyst was removed with an endoscopic procedure and a CO2-laser. Afterwards, the cyst recurred, but was successfully removed with an external approach., Conclusion: Clinical manifestations of laryngeal cysts in neonates shortly after birth are rare. Here, we present an interesting clinical case. We also concisely reviewed the literature on the epidemiology, clinical presentation, diagnosis, classification, and therapy for laryngeal cysts.

Background: Patients with chronic rhinosinusitis with/without nasal polyps (CRSwNP/CRSsNP) benefit from endoscopic sinus surgery (ESS), with an estimated success rate of 80%. At present, the influence on clinical outcome after ESS of eosinophils, eosinophilic mucin (EM), and fungal hyphae (FH) in secretions remains unclear. By delineating CRS groups and subgroups based on the finding of eosinophils, EM, and FH, differences in recurrence after ESS were investigated., Methods: A prospective monocenter study including 221 CRS patients who were unresponsive to medical treatment and underwent ESS was performed. All tissue and sinonasal secretions were microscopically examined for the presence of eosinophils, EM, and FH. Patients were followed for 3 years after surgery. Recurrence was defined according to the European position paper on rhinosinusitis and nasal polyps., Results: In total, 96 CRSwNP and 125 CRSsNP patients were included. Tissue eosinophils were found in 78% of CRSwNP patients compared with 42% in CRSsNP patients. EM was observed in 52% of the CRSwNP group versus 20% of the CRSsNP group. Furthermore, secretion analysis revealed FH in 7% of CRS. Recurrence in the total group was 22% over 3 years. CRSwNP patients with tissue eosinophilic involvement showed a recurrence rate of 48%, and those with additional EM showed recurrence in 56%., Conclusion: The presence of eosinophils in tissue or airway secretions greatly increases the risk of recurrent disease in CRSwNP patients. The finding of tissue eosinophilia and EM provides valuable information regarding the increased likelihood of CRS recurrence after ESS, whereas the finding of FH does not.

The introduction of recombinant human TSH and neck ultrasonography has refined the management of differentiated thyroid cancer, leading to the publication of new guidelines by the American Thyroid Association (ATA) and a consensus report by the European Thyroid Association (ETA) in 2006. In this paper, we give an overview of the current medical management of differentiated thyroid cancer (pre-surgical, post-surgical), of how the advances have been integrated into the recent 2006 ATA guidelines and ETA consensus and finally, of the impact on the surgical management (first surgery, treatment of cervical lymph nodes) of differentiated thyroid cancer.

Unlabelled: Comparing the microdebrider and standard instruments in endoscopic sinus surgery: a double-blind randomised study., Objective: It is frequently stated that microdebriders provide better mucosal preservation in endoscopic sinus surgery (ESS), and therefore better and faster healing, when compared to the standard Blakesley instruments. However, evidence from comparative prospective studies is lacking. In this study, we compared the results of microdebriders with traditional surgical instruments for ESS., Methods: A prospective, randomised, comparative, double-blind study in 50 patients undergoing bilateral ESS. Each patient was operated on with both instruments: one side of the nose with the microdebrider only, and the other side with standard instruments. The outcome of surgery was measured by using a symptom score and an endoscopic score at five time points during the first six postoperative months., Results: Both instruments resulted in symptom improvement and in endoscopically visible healing over time, but no significant difference was found between the two techniques. In endoscopic evaluation, only the total score at 3 weeks after surgery was significantly better in the microdebrider group. No significant difference was found at any other time point. Synechia formation, patency of middle meatal antrostomy, and open access to the ethmoid were the same in both groups., Conclusion: In this study of endoscopic sinus surgery the use of the microdebrider does not offer major advantages compared to the standard instruments.

Background: At present, some authors prefer cutting forceps to conventional non-cutting forceps in Endoscopic Sinus Surgery, based on the assumption of superior wound healing due to mucosal preservation, without any proof of better clinical outcome. The purpose of this study was to elaborate our previously reported short-term results, by evaluating the long-term outcome., Methods: One hundred consecutive patients, who underwent a bilateral Endoscopic Sinus Surgery procedure, received follow-up in a prospective, double-blinded way. Cutting forceps had been randomly used on one side and non-cutting forceps on the other side. Lateralised symptoms (headache, maxillary pressure, nasal obstruction and secretions) and endoscopic findings (secretion, pus, blood, crusts, oedema, polyps and adhesions) were evaluated on both sides 1 year postoperatively., Results: Both types of instruments gave satisfactory healing situations. Similar to the short-term follow-up results, no significant difference in the global symptom and endoscopic score between the 2 types of instruments was found. The analysis of individual symptoms and endoscopic parameters also showed no difference., Conclusion: Cutting forceps do not result in a better subjective or endoscopic healing evaluation after one year, compared to non-cutting forceps.

We report on a 9-year-old boy with neurofibromatosis type 2 and a progressive proptosis of the left eye. Imaging studies revealed a pneumosinus dilatans of the left ethmoidal and frontal sinuses and an adjacent left orbital mass. Incision biopsy of the orbital mass showed a meningiothelial meningioma. Orbital and intracranial meningiomas are frequently associated with pneumosinus dilatans. This report illustrates the relationship of pneumosinus dilatans, intra-orbital meningioma and neurofibromatosis type 2.

Twenty years of Functional Endoscopic Sinus Surgery have brought about a large amount of innovations and a variety of instruments, all claiming to result in better endoscopic procedures and/or better postoperative outcome. An example of such an innovation is the cutting forceps, which has been claimed to result in better wound healing. However, like several other instruments, it has never been proven to be superior to conventional non-cutting forceps techniques. A prospective, randomised double-blind study in 100 consecutive patients, undergoing bilateral FESS, compared the short term clinical outcome of surgery using cutting instruments to that of non-cutting instruments. Symptoms and endoscopic findings were evaluated at four time points during the first three postoperative weeks. Both types of surgery resulted in reduction of symptoms and in endoscopically visible healing over time, but no significant difference between the two methods was found, neither in symptom relief, nor in endoscopic impression of improvement. In conclusion, endoscopic sinus surgery with cutting instruments can be considered effective in resolving sinus disease. However, these instruments do not generate a better healing process than non-cutting instruments in the first weeks postoperatively.