Voice and swallowing after partial laryngectomy: Factors influencing outcome

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1 ORIGINAL ARTICLE Voice and swallowing after partial laryngectomy: Factors influencing outcome Matteo Alicandri Ciufelli, MD, Alessia Piccinini, MD, Alberto Grammatica, MD,* Andrea Chiesi, MD, Giuseppe Bergamini, MD, Maria Pia Luppi, SLT, Federica Nizzoli, SLT, Angelo Ghidini, MD, Sauro Tassi, MD, Livio Presutti, MD Otolaryngology Department, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy. Accepted 30 November 2011 Published online 6 February 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI /hed ABSTRACT: Background. The purpose of this study was to assess the factors influencing swallowing and phonatory results after partial laryngectomy. Methods. We carried out a medical chart review of patients who underwent partial laryngectomies between June 2003 and November 2010, focusing on functional outcomes. Results. Thirty-two patients were enrolled. No statistically significant difference was found in the comparison of phonatory outcomes of patients with preservation of both arytenoids; the results of the Yanagihara classification were significantly different (p ¼.015) in patients with an atypical neoglottis; radiotherapy statistically significantly influenced only the mean fundamental frequency (p ¼.035). The type of partial laryngectomy does not seem to affect the deglutition results; radiotherapy statistically significantly affected the dysphagia score (DS; p ¼.03), penetration aspiration (p ¼.02), and MD Anderson Dysphagia Inventory (MDADI; p ¼.02). Conclusion. Horizontal supraglottic laryngectomy and supracricoid partial laryngectomy give the same swallowing results. The presence of both arytenoids does not influence the final outcome compared to patients in whom only 1 arytenoid is preserved. Postoperative radiotherapy only influences the swallowing function. VC 2012 Wiley Periodicals, Inc. Head Neck 35: , 2013 KEY WORDS: partial laryngectomy, voice function, swallowing function, laryngeal cancer, logopedic rehabilitation INTRODUCTION Partial laryngeal surgery causes important alterations to the normal anatomy of the upper digestive tract, particularly in its intersection with the airways. Postoperative sequelae affecting swallowing and phonation are always present, and recovery of adequate function can be difficult to achieve. Despite the fact that these interventions have been used for a number of decades, in the recent English-language literature, there is a paucity of studies investigating the functional outcomes from an endoscopic, acoustic, perceptual, and self-assessment point of view. Moreover, various parameters have been evaluated, lacking definite guidelines in the evaluation of swallowing and phonatory results. 1 Articles present in the literature only focus on single types of laryngectomy from a functional outcome point of view, without comparing different types of partial laryngeal operations. 2 4 Furthermore, single factors influencing the functional outcomes such as some anatomical structure preservation (eg, arytenoid cartilage), postoperative conformation of the neoglottis of patients, or time after surgery were only rarely considered, and the *Corresponding author: A. Grammatica, Otolaryngology Department, University Hospital of Modena, Via del Pozzo 71, Modena, Italy. albertogrammatica@libero.it The authors received no financial support or funding for this study. analysis of single factors influencing the final outcomes were evaluated on a single type of laryngectomy or compared to total laryngectomies. With the advances in radiotherapy and chemotherapy in treating head and neck cancer and consequent organ preservation protocols, the attention of the scientific community will be increasingly focused on the functional results of partial laryngeal surgery. In fact, due to similar survival rates between surgery and radiotherapy in most stages of this pathology, the challenge for surgery will be to demonstrate acceptable functional results in terms of voice and swallowing, so as to maintain and justify a role in the therapy of laryngeal cancer. The purpose of the present study was to assess the main factors influencing swallowing and phonatory results after supracricoid partial laryngectomy and horizontal supraglottic laryngectomy. Knowledge of the factors that most influence the functional outcome could help the surgeon in technique selection and anatomical structure preservation, which should be accurately balanced in every patient with the objective of a radical removal of the neoplasm. MATERIALS AND METHODS Between June 2003 and November 2010, 176 patients underwent partial laryngectomies at the Ear, Nose, and Throat Department of the University Hospital of Modena. In the event of a favorable clinical course and without complications, on the seventh postoperative day, patients 214 HEAD & NECK DOI /HED FEBRUARY 2013

2 VOICE AND SWALLOWING AFTER PARTIAL LARYNGECTOMY TABLE 1. Score Dysphagia score. Symptoms 1 No symptoms. 2 Rare cough during liquid food deglutition. 3 Frequent cough during liquid food deglutition. Rare cough during solid food deglutition. 4 Frequent cough during solid and liquid food deglutition. 5 Frequent cough not related to food introduction. Inadequate food intake. 6 Recurrent aspiration pneumonia. were evaluated by a speech therapist before starting phonatory and deglutitory rehabilitation. Rehabilitation therapy ended at the discharge of the patient unless there were complications or delays in adequate functional recovery. For patients who reside in Modena and its province, it was possible to ensure an adequate and continuous follow-up of the phonatory and swallowing performances with a timing not defined in advance, but based on clinical issues and patient performance regarding swallowing and phonation. All patients underwent phoniatric evaluation consisting of: (1) clinical history interview; (2) dysphagia score (DS) evaluation (Table 1), a scale already used and described in an earlier article, 5 consisting of quantifying the patient's dysphagia grade by assigning a score based on symptoms reported; (3) performance status scale for head and neck cancer (PSS-HN) compilation, testing the normalcy of diet and the ability to eat in public, grading on a scale from 0 to 100, 6 and a single result was recorded; (4) MD Anderson Dysphagia Inventory (MDADI): a validated dysphagia-specific quality-of-life questionnaire assessing the emotional, physical, and functional consequences of deglutition impairment 7 ; (5) Voice Handicap Index-10 (VHI) to assess a patient's self-perceived emotional, physical, and functional status relative to their voice dysfunction 8 ; (6) spectroacoustic voice examination (Kay Electrics CSL model 4300B) according to the SIFEL protocol 9 recording a message containing the word "AIUOLE'' and the vowel "a.'' Each spectroacoustic examination was evaluated using Yanagihara's classification of dysphonia (1967). 10 Finally, the fundamental frequency of the vocal signal was established for each patient giving the mean fundamental frequency (MF); (7) the maximum phonatory time (MPT; normal value >10 seconds) of the vowel "a'' was evaluated and assessed for each patient, executing the evaluation 3 consecutive times and recording the maximum result; and (8) instrumental evaluation of the patient, using flexible endoscopic evaluation of phonatory and swallowing (FEES). All of the procedures were executed by the same ENT specialist and a video of each patient was recorded on the same digital support Atmos MediaStroboscope. During FEES, boluses of various consistencies (liquid and gelatinous colored water) were used to evaluate the correct deglutition process or the eventual anatomic and functional alterations. Data were evaluated using a penetration aspiration (PA) scale modified for partial laryngectomy (Table 2), already used and described in an earlier article, 5 and the score was assessed for each patient. In particular, during the FEES for patients undergoing supraglottic horizontal partial laryngectomies, the parameters examined were: vocal fold mobility, anatomic conformation of the residual laryngeal tissue, and vibration of the residual laryngeal structure. For patients undergoing other partial laryngectomies (cricohyoidoepiglottopexy [CHEP], cricohyoidopexy [CHP], and tracheohyoidoepiglottopexy [THEP]), the parameters examined were: presence of 1 or both arytenoids, motility of the cricoarytenoid unit, type of neoglottic competence (ie, typical or atypical), and presence of vibrating structure. A retrospective medical chart review of these patients was constructed for the period between November 2010 and February The inclusion criteria for the present study were: patients operated on by partial laryngectomy, at least 6 months after operation so as to attain adequate achievement and stabilization of vocal performance at the end of speech therapy after surgery, and patients undergoing a full course of speech therapy performed during hospitalization and postoperatively at our department. The exclusion criteria were as follows: patients with pneumopathies with a reduction in vital lung capacity, patients who underwent surgery for Vox implants or laryngeal injection for phonetic and deglutitory rehabilitation purposes, and patients with neurologic events occurring in the postoperative period. The phonatory and swallowing comparisons were performed in the following groups: preservation of 1 arytenoid versus preservation of both arytenoids, typical versus atypical neoglottis, patients undergoing radiotherapy versus patients not undergoing radiotherapy, and horizontal supraglottic partial laryngectomy versus supracricoid/supratracheal partial laryngectomy. Statistical considerations The Mann Whitney test was used to compare the nonparametric variables (DS, PA, PSS, MDADI), a t test was used for parametric variables (MPT, VHI, MF), and Pearson's chi-square test was used to compare the results of Yanagihara's classification. TABLE 2. Score Modified penetration-aspiration scale. Criteria 1 Material does not enter the airway. 2 Material enters the airway, contacts the neoglottis, stimulates cough reflex, and is ejected completely. 3 Material enters the airway, contacts the neoglottis, stimulates cough reflex, and is not completely ejected. 4 Material enters the airway, passes below the neoglottis, stimulates cough reflex, and is ejected completely. 5 Material enters the airway, passes below the neoglottis, stimulates cough reflex, and is not completely ejected. 6 Material enters the airway, passes below the neoglottis, and no effort is made to reject. HEAD & NECK DOI /HED FEBRUARY

3 ALICANDRI CIUFELLI ET AL. We also evaluated the correlation between the phonatory and swallowing parameters and the age of the patients and time after surgery; for this correlation, we used Pearson's correlation coefficient. SPSS Statistics software, version 17.0, was used for statistical analyses. RESULTS From the retrospective medical chart review, data for 36 patients were retrieved. Four patients were excluded from the study because they had undergone a previous Vox Implants (Bioplasty BV, Hofkamp 2, 6161 DC Geleen, The Netherlands) injection for rehabilitative purposes. Therefore, 32 patients (31 men and 1 woman) were enrolled in the study (age range, years; mean age, 65 years). The types of laryngectomy were as follows: 9 supraglottic horizontal partial laryngectomies, 21 supracricoid laryngectomies with CHEP, 1 supracricoid laryngectomy with CHP, and 1 supratracheal laryngectomy with THEP. The results of the spectroacoustic analysis conducted on the entire sample gave an average MPT of 9.31 seconds (SD 64.49; range, 3 20 seconds), and the distribution of values was as follows: 19.44% 5 seconds, 41.66% >5 seconds and <10 seconds, and 38.88% 10 seconds. The mean fundamental frequency for the entire sample was Hz (SD Hz; range, Hz). The overall distribution of the patients in Yanagihara's classification was: 44.44% class IV; 19.44% class III; 19.44% class II; and 16.66% class I. The mean VHI was (SD 68.39), with a distribution of 8.33% >27 and <40 (severe); 25% 26 and >13 (moderate); 63.88% 13 and >0 (mild); 2.77% ¼ 0 (normal). From the analysis of swallowing function, the results for the entire sample were as follows: the mean DS was 1.75 (SD 61.05), with a distribution of 8.33% ¼ 4; 19.44% ¼ 3; 11.11% ¼ 2; and 61.11% ¼ 1. The mean value of the Penetration Aspiration Scale was 1.19 (SD 60.52), with a distribution of 5.55% ¼ 3; 8.33% ¼ 2; and 86.11% ¼ 1. Regarding the quality of life, the analysis of the PSS- HN on the whole group gave the following average values: Normal diet ¼ (SD ); Eating public ¼ (SD ); and Understandability of speech ¼ (SD ). The mean values of the subdirectory of MDADI were: global (G) ¼ (SD ); emotional (E) ¼ (SD ); functional (F) ¼ (SD ); and physical (P) ¼ (SD ). The results obtained from statistical analysis performed on the single groups of patients (1 or 2 arytenoids, typical/atypical neoglottis, radiotherapy/no radiotherapy, or supracricoid/supraglottic resection) are summarized in Table 3. DISCUSSION Phonatory outcomes Supracricoid partial laryngectomies result in resection of the glottic and paraglottic space together with the thyroid cartilage. So the neoglottic sphincter is composed of TABLE 3. Results of statistical analysis (p values). MPT* VHI10* MF* YANAGIHARA DS PA PSSHN_nd PSSHN_ep PSSHN_us MDADI_G MDADI_E MDADI_F MDADI_P 1 arytenoid vs 2 arytenoid Atypical vs typical neoglottic competence No RT vs RT Supraglottic laryngectomies vs supracricoid p <.001 p < Age Time from surgery Abbreviations: MPT, maximum phonatory time; VHI 10, Voice Handica Index-10; MF, mean fundamental frequency; DS, Dysphagia score; PA, Penetration Aspiration Scale; PSSHN_nd, performance status scale for head and neck cancer normal diet; PSSHN_ep, performance status scale for head and neck cancer eating in public; PSSHN_us, performance status scale for head and neck cancer understanding sounds; MDADI_G, MD Anderson Dysphagia Inventory_global; MDADI_E, MD Anderson Dysphagia Inventory_emotional; MDADI_F, MD Anderson Dysphagia Inventory_functional; MDADI_P, MD Anderson Dysphagia Inventory_Physical; RT, radiation therapy. * T test (A vs B: superiority comparison). Chi-square of Pearson (A vs B: superiority comparison). Mann Whitney test (A vs B: superiority comparison). Correlation Coefficient of Pearson. Analysis conducted only on supracricoid laryngectomies. Note: Bold face numbers represent the statistical positive value of our findings. 216 HEAD & NECK DOI /HED FEBRUARY 2013

4 VOICE AND SWALLOWING AFTER PARTIAL LARYNGECTOMY anatomic structures left after the destructive surgery: anteriorly, the tongue base and the suprahyoid epiglottis (only in CHEP and THEP), and posteriorly, 1 or both cricoarytenoid units. In these patients, phonation is guaranteed by approximation of these structures: 1 or both arytenoids move forward meeting with the tongue base and the suprahyoid epiglottis. In CHP and tracheohyoidopexy, the epiglottis is fully removed, so 1 or both cricoarytenoid units join with the tongue base. On the other hand, in horizontal supraglottic laryngectomy, resection preserves the glottis and phonation occurs through vibration of the vocal folds. Clearly, based on our results, by preserving the vocal folds as in horizontal supraglottic laryngectomy, all of the phonatory outcomes were significantly better and also the statistical analysis has shown a significant difference in a comparison of the results of supraglottic and supracricoid laryngectomies. As we have already explained, in supracricoid laryngectomies, the neoglottic sphincter is composed of anatomical structures preserved after the destructive surgery and phonation is guaranteed by the approximation of the tongue base, the cricoarytenoid units, and, if preserved, the epiglottis. But in some patients in our sample, we have found that neoglottis formation can occur from atypical anatomic features. The results of statistical analysis have shown that the kind of neoglottic competence does not affect the MPT, MF, and VHI. Only the results of Yanagihara's classification are significantly influenced (p ¼.015). In fact, in our sample, we found that the patients with atypical neoglottic competence were distributed mostly within classes 2 and 3 (40% and 60%, respectively), none in class 4, whereas 70.6% of patients with typical neoglottic competence were distributed in class 4. This could be due to anomalous positioning of the epiglottis or involvement of the lateral pharyngeal wall in the sphincteric and vibratory function of the neoglottis. In this way, atypical neoglottis formation seems to guarantee adequate functional outcome in terms of vocal performance. In the literature, there are no studies on the atypical neoglottis. Only 1 study published recently describes the different types of atypical neoglottis in patients undergoing supracricoid laryngectomies. 11 In fact, this article describes how the epiglottis and arytenoids could articulate in various shapes to participate in sphincteric and phonation function. In this study, the phonatory outcomes, in particular, MF, VHI, and MPT (11, 6, and 12, respectively), seem to be comparable with the outcomes of our series. Concerning supracricoid partial laryngectomy, in our analysis, no statistically significant difference was found in the comparison of phonatory outcomes of patients with preservation of 1 or both arytenoids. In fact, based on our results, the preservation of both arytenoids does not significantly impact the voice quality of patients. In cases where there is a doubt about the oncologic radicality of resection, this could be an important decisional factor for the surgeon. Comparing our results with the literature, Weinstein et al 12 have also attempted to compare the phonatory outcomes in patients with 1 or both arytenoids. In fact, in that work, the authors described the videostroboscopic features of the mucosal wave when 1 or both arytenoids were present, but the series was too limited to disclose any statistical correlation with phonatory outcome. In another study, So et al 13 analyzed the phonatory outcomes of supracricoid partial laryngectomies. MPT was not significantly affected by arytenoid removal suggesting well-tolerated recovery of the glottal closure after removal of 1 arytenoid and reconstruction of the neoglottis. As reported in the literature, 14 radiotherapy after supracricoid partial laryngectomy could be associated with a negative influence on functional outcome and a direct correlation has been demonstrated between radiotherapy dose and complication rate after larynx preservation therapy. In the literature, adverse reactions correlated with radiotherapy are certainly well known and may result in unexpected functional disturbance which may cause persistence or worsening of the complaints about phonatory function. 15 Analyzing our sample, the results of MPT and VHI in patients undergoing radiotherapy were comparable with the results for patients in whom no radiotherapy was performed and no statistically significant difference was found between the 2 groups (p ¼.962; p ¼.772). On the other hand, the increase in MF found in patients undergoing radiotherapy was statistically significant (p ¼.035) (180 Hz vs 148 Hz in patients in whom no postoperative radiotherapy was performed). This result could be explained by increased rigidity of the structure as a result of fibrosis after radiotherapy causing a loss of elasticity of the mucosa and, therefore, an increase in the fundamental frequency. In a recent study, Pellini et al 16 compared a group of patients with untreated laryngeal cancer versus a group with laryngeal recurrence after radiotherapy and both groups were treated by supracricoid partial laryngectomy. No statistically significant difference in phonatory function was reported, and the mean MPT in the group of patients undergoing partial laryngectomy for untreated laryngeal cancer was 7.7 versus 8.2 in the group of patients with recurrence after radiotherapy. Moreover, our analysis revealed that the correlation between phonatory outcome and the age of the patient and time after surgery was not statistically significant. Concerning the time after surgery, our results are also confirmed by a study 3 in which the purpose was to compare the evolution of the perceptual and acoustic parameters at 6 and 18 months postoperatively. Those authors did not find a statistically significant modification of either the perceptual or the acoustic parameters between 6 and 18 months postoperatively. This might be related to the fact that voice improvement might have stabilized at 6 months after surgery, resulting in no further improvement after the sixth postoperative month. Swallowing outcomes Swallowing is a fundamental outcome for quality of life in patients undergoing supracricoid partial laryngectomy and its postoperative impairment is the most common short-term and long-term complication. When considering patients operated by partial open laryngectomy, we must consider an anatomy that is completely changed and that can react to the surgical modifications in various ways therefore affecting postoperative outcome. In the literature, as with the phonatory results, there is a great variability in swallowing outcomes from good to poor and this could also be influenced by the mode of investigation by each institution. 2 4 Most authors, particularly in the past, measured swallowing function by calculating the HEAD & NECK DOI /HED FEBRUARY

5 ALICANDRI CIUFELLI ET AL. nasogastric feeding tube removal timing and/or permanent gastrostomy rate, and some authors adopted the PSS- HN cancer questionnaire to test the quality of life of patients. 17,20 Only recently has videofluoroscopic examination been adopted as a tool for the study of swallowing disorders by analyzing bolus transit and, to our knowledge, only 2 articles have discussed this technique. 4,15 In our study, we investigated the swallowing outcome based on fibrolaryngoscopic and FEES evaluation, testing the premature spillage of food, laryngeal motility and laryngeal aspiration of each patient, and with the compilation of various questionnaires investigating the objective (PA and DS) and subjective (PSS-HN and MDADI) swallowing competence. Compared to videofluoroscopy, FEES has advantages in terms of safety in the case of high risk of inhalation. It guarantees visual feedback for the patient, it can be performed on an outpatient basis even in patients who cannot be transferred to a radiology center, and, moreover, it ensures the absence of repeated exposure to radiation. The disadvantages are the problematic evaluation of bolus management in the oral cavity, the challenging visualization during the act of deglutition, close to the base of tongue and on the rear wall of the pharynx, and the difficult evaluation of microaspiration or food penetration close to the act of deglutition. Statistical analysis did not find any correlation for DS, PA, and MDADI, and the swallowing part of PSS-HN between the group in which both arytenoids were preserved versus the group with preservation of only 1 arytenoid; so preservation of both arytenoids does not improve the final outcome of a partial laryngectomy as was observed by Bron et al 17 in a series of 17 patients undergoing supracricoid partial laryngectomy in which arytenoid resection statistically did not diminish the restoration of swallowing. Zacharech et al 19 reported a complete restoration of swallowing function after supracricoid partial laryngectomy in all 10 patients studied (in 4 of 10 patients, both arytenoids were spared). Although the number of patients examined was small and no statistical analysis was performed between the number of arytenoids and the swallowing postoperative performance, the authors stress how a good swallowing function was reached in 100% of cases. These findings contradict those of Laccourreye et al 21 who stressed the importance of preservation of both arytenoids to guarantee a better postoperative functional result and avoid complications. In addition, Lima et al 22 stated how the incidence of complications after supracricoid partial laryngectomy is higher with arytenoid resection observing a longer time to tracheostomy and PEG tube removal compared to patients in whom both arytenoids were spared. Regarding the anatomic type of the glottis, we did not find a statistically significant correlation between the type of neoglottis (atypical or typical) and any of the swallowing parameters considered. As has previously been explained regarding phonatory outcome, an atypical or typical neoglottis could also function normally for deglutition parameters, ensuring an optimal sphincteric valve and avoiding aspiration pneumonia or premature food spillage. 11 Interestingly, in our cohort, the type of partial laryngectomy did not seem to affect the deglutition results; in fact, swallowing outcomes for DS, PA, MDADI, and PSS-HN are quite similar when comparing horizontal supraglottic laryngectomy with supracricoid/supratracheal laryngectomies and no statistically significant differences were found between the 2 groups. From the English-language literature consulted, the authors did not find any articles in which the various types of laryngectomy were studied, only articles focusing on 1 type of laryngectomy or comparing supracricoid partial laryngectomy versus total laryngectomy. 15 So, to the best of our knowledge, this seems to be the first article to evaluate and compare various types of partial laryngectomy (horizontal supraglottic laryngectomy, supracricoid partial laryngectomy) from a functional point of view. In our study, the only factor that negatively influences swallowing function seems to be radiotherapy. Radiotherapy statistically significantly affects the DS (p ¼.03), PA (p ¼.02), and MDADI (p ¼.02). In patients undergoing radiotherapy, often fibrosis, scarring, mucositis, edema, erythema, and tenderness of target tissues are present as well as neighboring healthy tissue. These adverse reactions may result in unexpected functional disturbances of involved muscular, mucosal, and neurovascular tissue that can cause a severe impairment of the swallowing mechanism. Radiotherapy after supracricoid partial laryngectomy has been reported to be associated with a negative effect on the functional outcome and a direct correlation has been demonstrated between radiotherapy dose and complication rate after larynx-preservation therapy. 14 More recently, in a study comparing a group of patients with untreated laryngeal cancer versus a group with laryngeal recurrence after radiotherapy and with both groups treated by supracricoid partial laryngectomy, Pellini et al 16 reported no statistically significant difference in swallowing function with a definitive restoration of satisfactory deglutition in 89% of patients who did not receive radiotherapy and in 82% of patients irradiated. In our study, a statistically significant correlation was not seen between the age of patients and the DS (p ¼.86), PA (p ¼.83), or MDADI global questionnaire (p ¼ 0.05) except for the eating in public component of the PSS-HN. This could be explained by a lower compliance of elderly patients to participate in social life because of their age and also the stigma caused by the operation and probably because of worries over swallowing in public places. Functional swallowing outcomes after supracricoid partial laryngectomy associated with the age of patients (over 65 years) have already been investigated in previous studies by Alajmo et al, 23 who reported a high rate of aspiration pneumonia and swallowing dysfunction, stating that supracricoid partial laryngectomies are not advisable for elderly patients. Naudo et al 24 reported temporary grades 1 to 2 of aspiration, according to the scale adopted by Leipzig, 25 of 1 to 4 months duration in 23.4% (44 of 188 patients operated by supracricoid partial laryngectomy) with a statistically significant correlation with increased age. Moreover, grade 3 aspiration (pneumonia with aspiration) occurred in 8.5% of patients and, in this case, a correlation with increased age was also seen. On the other hand, in the past, Laccourreye et al 26 reported 21.7% of aspiration pneumonia after supracricoid partial laryngectomy, stating that age on its own should not be 218 HEAD & NECK DOI /HED FEBRUARY 2013

6 VOICE AND SWALLOWING AFTER PARTIAL LARYNGECTOMY considered as a deterrent for supracricoid partial laryngectomy completion, and more recently, this was confirmed by Schindler et al 27 in a study which showed that age did not significantly impact swallowing function. Finally, our analysis did not find any correlation between the results of PA, DS, PSS-HN, and MDADI questionnaires and time after surgery, showing that the postoperative time from the sixth month onward does not affect swallowing function. CONCLUSION The present investigation shows how horizontal supraglottic laryngectomy and supracricoid partial laryngectomy give the same swallowing results, obviously differing in terms of phonatory results. The presence of both arytenoids compared to patients in whom only 1 arytenoid was preserved does not seem to influence the final outcome. 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