Analysis on feasibility of functional preservation surgery of T3/T4 head and neck cancer - a pirouette around the cricoarytenoid joint

Analysis on feasibility of functional preservation surgery of T3/T4 head and neck cancer - a pirouette around the cricoarytenoid joint | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis on feasibility of functional preservation surgery of T3/T4 head and neck cancer - a pirouette around the cricoarytenoid joint Todor M Popov, Iglika Stancheva, Venera Dobriyanova, Silviya Valcheva, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7633383/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study evaluates the feasibility, functional outcomes, and survival of surgical laryngeal preservation in advanced T3/T4 head and neck disease, based on the principle that an intact cricoarytenoid joint (CAJ) can provide sufficient functional reserve to compensate for resections involving other key contributors to swallowing. Methods Monocentric, observational study (STROBE compliant). 162 consecutive patients with advanced (T3/T4) laryngeal, hypopharyngeal, oropharyngeal, and tongue carcinomas treated surgically. Definitive surgery with either laryngectomy or laryngeal preservation (stage-matched subgroups), stratified by CAJ involvement and surgical approach (transoral vs. open). Results Of 162 patients, 95 (58%) underwent laryngectomy; 90% had CAJ invasion. Among 76 without CAJ involvement, 67 (88%) were suitable for preservation. Functional outcomes: 95.6% decannulated, 3% PEG, 4.4% tracheostomy dependence. Recurrence-free survival did not differ (85.1% preservation vs. 78.9% laryngectomy; log-rank p = 0.56). Overall survival tended lower in laryngectomy (57.9% vs. 79.1%; p = 0.16), explained by non–cancer mortality. Flap reconstruction was required in 43.4% of open non-laryngeal preservation cases, mostly T4 (p < 0.001). Open surgery showed inferior overall survival compared with transoral (70.0% vs. 92.6%; p = 0.038). Conclusion Functional upper airway preservation is feasible in most advanced head and neck cancers when CAJ is not engaged. An intact CAJ provides sufficient functional reserve to compensate for resections involving other key contributors to swallowing, enabling excellent oncologic outcomes with generally favorable functional recovery. Open preservation surgery carries greater morbidity and higher non–cancer-related mortality. surgical preservation of the larynx advanced squamous cell carcinoma dysphagia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 key messages • Cricoarytenoid joint integrity is the decisive boundary for surgical functional preservation in advanced head and neck cancer. • 88% of patients without CAJ invasion achieved preservation with favorable functional outcomes. • Oncologic outcomes were comparable to stage-matched laryngectomy, but open surgery carried higher morbidity and non–cancer mortality. Highlights Surgical Feasibility of Laryngeal Preservation: Surgical preservation of upper airway continuity was feasible in 88% of advanced T3/T4 cases without cricoarytenoid joint invasion. Functional Feasibility of Laryngeal Preservation: The vast majority of patients with preserved larynx achieved decannulation and adequate swallowing function; only a small minority required permanent PEG or tracheostomy. This suggests that, if the cricoarytenoid joint is preserved, the larynx retains sufficient functional reserve for decannulation and oral alimentation, even after extensive resections of other key contributors to swallowing. Oncologic Outcomes: Recurrence-free survival was equivalent between preservation and laryngectomy, but overall survival tended to be worse in laryngectomy due to non-cancer-related mortality. Flap Reconstruction: Nearly half of non-laryngeal preservation cases required flap reconstruction, predominantly in advanced T4 disease. Functional Recovery (Transoral vs. Open Surgery): Transoral laser surgery accelerated postoperative recovery, although long-term dysphagia outcomes equalized between approaches. Transoral vs. Open Surgery: Survival Outcomes: Recurrence-free survival was similar between approaches, but overall survival was significantly worse after open surgery. 1. Introduction Over the past three decades, treatment strategies for locally advanced squamous cell carcinoma of the head and neck have undergone profound change. Following the advent of non-surgical laryngeal preservation protocols, the therapeutic paradigm gradually shifted away from definitive surgical resection toward approaches emphasizing functional sustainability and quality-of-life conservation. Chemoradiotherapy (CRT) emerged as the leading modality in this regard, often presented as superior in preserving swallowing, breathing, and phonation. However, this pendulum swing remains controversial. Large retrospective, population-based analyses have revealed discrepancies between real-world outcomes and the results reported in landmark clinical trials [ 1 ]. In light of this divergence, the contemporary value of surgery in advanced head and neck cancer deserves reevaluation. Rather than viewing surgery solely as a radical extirpative measure, its potential for maximizing upper airway function preservation should be reconsidered. Functional preservation—defined as maintaining the essential components of swallowing, breathing, and phonation—offers a framework that extends beyond traditional organ-based concepts. Conventionally, surgical decision-making has relied heavily on human-defined anatomical borders (larynx, hypopharynx, oropharynx, tongue). Yet, these borders may not fully capture the structures that determine whether upper airway functions can be sustained. Our preliminary analyses suggest that the status of the cricoarytenoid joint (CAJ), reflected clinically by vocal cord fixation, represents the critical determinant of whether surgical functional preservation is feasible. In this sense, the CAJ can be regarded as a functional “red line.” When uninvolved, preservation of airway functions remains achievable even in tumors extending across conventional anatomical subsites. The present study systematically examines this concept by analyzing a consecutive cohort of 162 patients with advanced (T3/T4) head and neck carcinoma. Our aim was to identify the major factors determining functional preservation of the upper airways, with an emphasis on functional integrity rather than anatomical site designation. Specifically, we sought to assess the role of cricoarytenoid joint (CAJ) status as the decisive boundary for surgical feasibility, while also evaluating oncologic outcomes, quantify long-term dysphagia, and decannulation success. This study evaluates the feasibility, functional outcomes, and survival of surgical laryngeal preservation in advanced T3/T4 disease, based on the principle that an intact cricoarytenoid joint (CAJ) can provide sufficient functional reserve to compensate for resections involving other key contributors to swallowing. 2. Materials and methods Study design and treatment protocols The present study was carried out during a period of three years (2020–2023) as a monocentric, observational, single-surgeon study. The investigated population was formed from all consecutive adult patients with advanced T3/T4 stage squamous cell carcinoma of the larynx, hypopharynx, oropharynx and tongue. Inclusion criteria consisted in enrolling all consecutive operable advanced T-stage squamous cell carcinoma invading the before-mentioned anatomical areas of the head and neck. Exclusion criteria: any chemo or radiotherapy prior to surgery. All enrolled participants finished the study, i.e., there was no attrition. Randomization was not applicable and a formal power calculation was not performed. All female patients were at a post-reproductive age. Surgical treatment included resection with free resection margins and neck dissection ipsilaterally (2–5 levels). In all cases with supraglottic and base of tongue invasion, as well as in all cases of tumors crossing the median line, contralateral neck dissection was also performed (2–5 levels). Additionally, if the tumor extended into the subglottic or retrocricoid region, a full paratracheal lymph node dissection (levels 6–7) was carried out. All patients underwent postoperative radiotherapy or combined chemoradiotherapy according to the protocol, except 6 due to various reasons. The follow-up period was an average of 24 months with a standard deviation of 14 months. Patients were followed-up every month during the first six months after surgery and every three months after this period. Every six months, PET-CT was scheduled for radiological evaluation. Cases were registered as events in recurrence-free survival when recurrence or death due to malignancy was found. Censoring was recorded when death due to other causes not connected to the primary disease existed or follow-up period has finished. When overall survival was calculated, an event was registered in all cases of death, regardless of cause. Ethical committee approved the study – KENIMUS, Protocol-329/08.03.2021. Written informed consent for participation was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki. The study did not interfere with the decision-making process for the treatment of each patient. Dysphagia assessment All patients with larynx preservation surgery were assessed on 6th to 9th month after the surgical intervention. The MD Anderson Dysphagia Inventory (MDADI) and visual analogue scale (VAS) were used for post-operative assessment. Statistical analysis SPSS software v.23.0 for Windows (IBM SPSS, NY, USA) and GraphPad Prism software were used for data analysis. 3. Results 3.1. Clinico-pathological characteristics of the studied cohort The study cohort consisted of 162 cases: 88 (54.2%) with predominantly laryngeal localization, 33 (20.4%) hypopharyngeal, 22 (13.6%) oropharyngeal, and 19 (11.7%) tongue. Regarding tumor stage, 43.2% were classified as pT4a, 8.0% as pT4b, and the remaining 48.8% as pT3 tumors. More than half of the patients (52.5%) had pathologically confirmed metastatic disease. The N-status distribution was: N1 (10.7%), N2a/N2b/N2c (71.5%), and N3 (17.8%). A detailed summary of clinicopathological characteristics is presented in Table 1 . Table 1 Clinicopathological characteristics of the studied patient cohort. Characteristics Number of patients (n = 162) Percentage Age 62 (mean), 21–87 N/A Gender 144 males, 18 females 88.89% vs 11,11% T-stage pT3 79 48,7% pT4a & pT4b 83 51,3% N-stage pN0 76 47.5% pN1 9 5.6% pN2a 9 5.6% pN2b 31 19,4% pN2c 20 12.5% pN3 15 9.4% Metastasis (pN0 vs pN1-3) pN0 77 47.5% pN1-3 85 52.5% Location Larynx 88 54.2% Hypopharynx 33 20.37% Oropharynx 22 13.58% Tongue 19 11.73% 3.2. Surgical Feasibility of Laryngeal Preservation Surgical preservation of upper airway continuity was feasible in 88% of advanced T3/T4 cases without cricoarytenoid joint invasion. Across the cohort of 162 patients, the presence of cricoarytenoid joint (CAJ) invasion—clinically manifested as vocal cord fixation—was the principal determinant of surgical strategy. Of the total cohort, 95 patients (58%) underwent laryngectomy, 86 of whom (90%) had documented CAJ invasion. Among the 76 patients without CAJ involvement, only 9 (12%) were deemed unsuitable for functional preservation (Fig. 1 ). Consequently, 67 patients (88% of those without CAJ invasion) were considered feasible candidates for surgical preservation of the larynx and its upper airway functions (stage-matched cohorts). When stratified by tumor location, the likelihood of laryngeal preservation varied substantially. Patients with laryngeal (75%) and hypopharyngeal (78.8%) tumors predominantly underwent laryngectomy, reflecting the high frequency of CAJ invasion. Nevertheless, approximately one in four patients with advanced T3/T4 laryngeal or hypopharyngeal carcinomas were suitable for functional preservation. By contrast, most base of tongue/oropharyngeal tumors (86.4%) and all oral cavity tumors (100%) were managed without laryngectomy. These findings emphasize that, while CAJ invasion remains the decisive factor, the anatomical site of tumor origin strongly influences the feasibility of preservation (Fig. 1 ). 3.3. Functional Feasibility of Laryngeal Preservation The vast majority of patients with preserved larynx achieved decannulation and adequate swallowing function; only a small minority required permanent PEG or tracheostomy (stage-matched cohorts). In the cohort of patients with surgically preserved larynx (n = 67), functional outcomes were evaluated among those who survived the postoperative period (excluding 2 early postoperative deaths, 3%). In this group, successful decannulation was achieved in 95.6%, with only 3 patients (4.4%) remaining tracheostomy-dependent. Similarly, percutaneous endoscopic gastrostomy (PEG) feeding was required in only 2 patients (3%), reflecting a high rate of functional swallowing recovery. Standardized swallowing assessments confirmed these findings. At 6–9 months after surgery, patients demonstrated moderate-to-good swallowing capacity, with a mean MD Anderson Global Score of 5 points, a Composite Score of 87/100, and a Visual Analog Scale score of 7.5/10. The most important determinant of poor swallowing recovery across the cohort was loss of unilateral tongue mobility, whether resulting from hypoglossal nerve resection, extensive muscle sacrifice, or both. 3.4. Oncologic Outcomes Recurrence-free survival was equivalent between preservation and laryngectomy, but overall survival tended to be worse in laryngectomy due to non-cancer-related mortality. Among patients with advanced T3/T4 disease, surgical preservation of the larynx did not compromise recurrence-free survival compared with stage-matched patients who underwent laryngectomy. Survival analysis showed no significant difference in recurrence-free survival (log-rank, p = 0.56): 78.9% recurrence-free in the laryngectomy group versus 85.1% in the preservation group (Fig. 2 A). Both groups were comparable in T- and N-stage distribution, with a mean follow-up of 24 ± 14 months - stage-matched cohorts. When overall survival was examined, no statistically significant difference was observed (log-rank, p = 0.16). However, a trend toward inferior overall survival among laryngectomees was evident: 57.9% versus 79.1% in the preservation group (Fig. 2 B). Importantly, this divergence was attributable to non–cancer-related mortality. Within the laryngectomy cohort, deaths included 6 cardiovascular events, 1 COVID-related infection, 1 natural death, 2 trauma, and 3 unknown causes. In contrast, the preservation cohort experienced 3 second malignancies, 2 postoperative deaths, and 1 unknown cause, with no cardiovascular, infectious/COVID, or trauma-related deaths. 3.5. Flap Reconstruction Nearly half of laryngeal preservation cases required flap reconstruction, predominantly in advanced T4 disease. Among patients with functional laryngeal preservation (n = 67), a subgroup underwent open surgery for non-laryngeal tumors (pharyngeal and tongue). Within this group, 43.4% (23/53) required reconstruction with a distant flap, while 30/53 (56.6%) were managed with primary closure. Flap reconstruction was strongly associated with advanced disease: the majority of cases were T4a/T4b tumors (χ² = 23.196, p < 0.001), whereas only a small minority of T3 resections required flap coverage. Survival analysis demonstrated a trend toward poorer recurrence-free survival in the flap group compared with the non-flap group (log-rank χ² = 3.36, p = 0.067), though not statistically significant. This difference reflects the more advanced tumor burden in patients requiring flap coverage. The type of flap was dictated by tumor site. The pectoralis major flap was predominantly used for caudally located pharyngolaryngeal tumors, while microvascular free flaps were used for cranially situated pharyngeal and tongue resections, where pliability and precision were required. 3.6. Functional Recovery Transoral laser surgery accelerated postoperative recovery, although long-term dysphagia outcomes equalized between approaches. Within the preservation cohort (n = 67), outcomes were compared between transoral laser surgery and open surgery. As the data were not normally distributed (Kolmogorov–Smirnov and Levene’s tests, p < 0.005), non-parametric Mann–Whitney tests were applied. Early recovery strongly favored the transoral approach: patients required significantly shorter nasogastric feeding (mean rank 7.79 vs. 16.59, U = 116.5, p = 0.001; Fig. 3 A), shorter hospitalization (mean rank 11.00 vs. 22.25, U = 189, p < 0.001; Fig. 3 B), and shorter temporary tracheostomy (mean rank 11.31 vs. 22.5, U = 201.5, p < 0.001; Fig. 3 C). By 6–9 months postoperatively, dysphagia outcomes had equalized. The MD Anderson Global Score (5 vs. 4, p = 0.183; Fig. 4 A), Composite Score (87 vs. 81/100, p = 0.097; Fig. 4 B), and Visual Analog Scale (7.5 vs. 6/10, p = 0.232; Fig. 4 C) showed no significant differences, although scores tended to favor the transoral group. The strongest predictor of persistent dysphagia across both groups was loss of unilateral tongue mobility, due to hypoglossal nerve sacrifice, major muscle resection, or both. In the entire preservation cohort, 2 patients (3%) required permanent PEG feeding and 3 patients (4.4%) remained tracheostomy-dependent. 3.7. Transoral vs. Open Surgery: Survival Outcomes Recurrence-free survival was similar between approaches, but overall survival was significantly worse after open surgery. Focused survival analysis of the preservation cohort (n = 67) compared transoral and open resection. Recurrence-free survival was not significantly different (88.9% vs. 82.5%, log-rank χ² = 4.30, p = 0.21; Fig. 5 A), although curves diverged slightly in favor of the transoral group. In contrast, overall survival was significantly worse in the open surgery subgroup (70.0% vs. 92.6%, log-rank p = 0.038; Fig. 5 B). Importantly, this difference was not cancer-driven but attributable to non-oncologic deaths: the open subgroup included 2 postoperative deaths, 3 second malignancies, and 1 unknown cause, whereas the transoral group had virtually no non-cancer-related mortality. These findings suggest that the survival advantage of transoral surgery reflects not only oncologic adequacy, but also its association with reduced treatment morbidity. 4. Discussion Numerous articles have been dedicated to the topic of surgical and nonsurgical laryngeal preservation in advanced head and neck carcinoma. A significant share of the surgical literature is based on smaller case series or focused on specific anatomical subsites that allowed partial resections with preservation of upper airway function. For instance, Kadota et al. described 18 patients undergoing base of tongue reconstruction with laryngeal preservation [ 2 ], Makino et al. reported on 100 consecutive cases of cervical esophageal carcinoma treated with the aim of sparing the larynx [ 3 ], and Li et al. emphasized the pyriform sinus as a focal point for preservation strategies [ 4 ]. While such studies illustrate the feasibility of functional preservation in selected subsites, they do not provide a systematic framework for assessing surgical boundaries across tumor sites. The central concept of this study builds upon the classical philosophy of laryngeal-sparing surgery: the cricoarytenoid unit as the “functional heart” of the larynx, responsible for a critical share of breathing, phonation, and airway protection [ 9 , 10 ]. It has long been accepted that invasion of the cricoarytenoid joint, usually manifesting as vocal cord fixation, constitutes a clinical and oncological threshold obligating either primary laryngectomy or nonsurgical preservation strategies [ 11 ]. This axiom defines the traditional surgical “red line.” Our analysis explored surgical possibilities beyond conventional anatomical borders, while consistently centering on the functional integrity of the cricoarytenoid joint and its capacity to compensate for resections involving other key structures in swallowing. We found that surgical preservation of the larynx was feasible in 88% of advanced T3/T4 cases without CAJ involvement, regardless of tumor subsite. Functionally, results were favorable: only 3% required PEG feeding and 4.4% remained tracheostomy-dependent long term. These rates compare well with previously published organ-preservation series reporting PEG dependence between 5–15% and tracheostomy rates up to 10% [ 12 , 13 ]. This suggests that, if the cricoarytenoid joint is preserved, the larynx retains sufficient functional reserve for decannulation and oral alimentation, even after extensive resections of other key contributors to swallowing. Yet, these outcomes come at a price. Patients requiring open preservation surgery—predominantly T4a/b tumors—experienced a far more demanding postoperative course, characterized by prolonged nasogastric feeding and extended tracheostomy dependence, as seen in other reports of open pharyngolaryngectomy reconstructions [ 14 ]. More importantly, overall survival was significantly worse in the open surgery subgroup, despite recurrence-free survival being comparable to the transoral cohort [Figure 5 ]. Non-cancer-related deaths (postoperative complications, second malignancies, other systemic causes) were disproportionately higher in this group. This echoes observations from larger surgical cohorts that functional preservation does not always translate into survival benefit, particularly in frail patients with significant comorbidity [ 15 ]. Still, when these patients successfully navigate the initial months of recovery, they often reach surprisingly satisfactory levels of swallowing and quality of life [Figure 4 ], a finding also reported in long-term functional series after complex reconstructions [ 16 ]. In this context, reconstructive techniques play a pivotal role, as the choice between regional and free flaps directly impacts both early recovery and ultimate functional restoration. The evolution of laryngeal preservation strategies must be viewed in light of the broader treatment landscape. Over the past decades, prospective randomized trials shifted the paradigm of stage III and IV laryngeal cancers toward organ preservation using chemoradiotherapy (CRT), highlighting speech and swallowing outcomes [ 5 , 6 ]. While CRT has demonstrated functional benefits compared to total laryngectomy (TL), survival outcomes remain controversial. Hoffman et al. documented a decline in 5-year survival for laryngeal cancer in the 1980s and 1990s [ 7 ], while Cosetti et al. suggested that this decline was largely attributable to advanced glottic tumors [ 8 ]. Other population-level analyses have echoed this trend, suggesting that real-world CRT outcomes may not mirror those achieved in controlled clinical trials [ 17 ]. These trends, together with the absence of molecularly guided treatment stratification in head and neck carcinoma, remind us that surgery still has a role to play—especially if performed with a systematized focus on functional preservation. The present findings argue for a reinvention of an old paradigm: a systematic surgical approach that places the cricoarytenoid joint at the center of functional assessment and decision-making. This “pirouette” around the cricoarytenoid joint may represent a practical way to balance oncologic radicality with functional outcomes in advanced disease. Finally, one limitation of the present study is the absence of a transoral robotic surgery (TORS) subgroup, which has been increasingly recognized as a valuable minimally invasive option in selected oropharyngeal and supraglottic tumors [ 18 , 19 ]. Future studies incorporating TORS into this framework would provide a more complete view of the surgical preservation spectrum. 5. Conclusion Functional upper airway preservation is feasible in most advanced head and neck cancers when the cricoarytenoid joint (CAJ) is not engaged. An intact CAJ provides sufficient functional reserve to compensate for resections involving other key contributors to swallowing, enabling excellent oncologic outcomes with generally favorable functional recovery. Open preservation surgery carries greater morbidity and higher non–cancer-related mortality, highlighting the need for careful patient selection and tailored reconstructive planning. Declarations Competing interests The authors declare no competing interests. Ethics approval The Ethical Committee of Medical University—Sofia approved the study – KENIMUS, Protocol-329/08.03.2021. Written informed consent for participation in the study was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki. Funding This study is financed by the European Union-NextGenerationEU, through the National Recovery and Resilience Plan of the Republic of Bulgaria, project BG-RRP-2.004-0004-C01“, group 3.1.5 Strategic research and innovation program for development of Medical University - Sofia “. Author Contribution •Popov TM: study design, surgical treatment, sample collection, data analysis, survival analysis, manuscript drafting •Stancheva I, Dobriyanova V, Dimitrov L. Rangachev J: patient follow-up and data aquisition •Skelina S, Valcheva S, Komitova K: dysphagia scoring and data aquistion •Ts. Marinov, Skelina S: study design, data analysis, draft review Acknowledgments All authors provided substantial input into the conceptualization, drafting, and editing of this report. Each has given approval for the publication of the article. Data Availability Raw data were generated at Medical University - Sofia. Derived data supporting the findings of this study are available from the corresponding author [TP] on request. Declaration of Generative AI and AI-Assisted Technologies During the preparation of this work, the authors used ChatGPT (OpenAI) in order to assist with language refinement, structuring of sections, and improvement of clarity in writing . After using this tool, the authors critically reviewed, edited, and verified all content and take full responsibility for the integrity and accuracy of the final manuscript. References Patel SA, Qureshi MM, Dyer MA, Jalisi S, Grillone G, Truong MT. Comparing surgical and nonsurgical larynx-preserving treatments with total laryngectomy for locally advanced laryngeal cancer. Cancer. 2019;125(19):3367–77. 10.1002/cncr.32292 . Epub 2019 Jun 17. PMID: 31206637. Kadota H et al. Reconstruction after base of tongue carcinoma resection with preserved larynx. Jpn J Clin Oncol. 2010. Makino T et al. Surgical treatment of cervical esophageal carcinoma with laryngeal preservation. Ann Surg Oncol. 2013. Li Y et al. Partial resection of the pyriform sinus for hypopharyngeal carcinoma. Laryngoscope. 2015. Forastiere AA et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003. Lefebvre JL et al. Larynx preservation in advanced laryngeal and hypopharyngeal cancer: EORTC trials. J Clin Oncol. 2009. Hoffman HT et al. Declining survival in laryngeal cancer: SEER data. Otolaryngol Head Neck Surg. 2006. Cosetti M et al. Impact of non-surgical strategies on survival in advanced laryngeal cancer. Cancer. 2008. Laccourreye O et al. Supracricoid partial laryngectomy: functional and oncologic results. Ann Otol Rhinol Laryngol. 1996. Gallo A et al. Cricoarytenoid joint involvement in laryngeal carcinoma: implications for function and treatment. Head Neck. 2000. Steiner W, Ambrosch P. Endoscopic laser surgery of the upper aerodigestive tract: with special emphasis on cancer surgery. Stuttgart: Thieme; 2000. Hutcheson KA et al. Long-term dysphagia after chemoradiation vs surgery. Head Neck. 2013. Ferlito A et al. Functional outcomes after partial laryngectomy: PEG and tracheostomy dependence. Eur Arch Otorhinolaryngol. 2009. Patel RS et al. Morbidity after open conservation surgery for hypopharyngeal cancer. Head Neck. 2014. Olsen KD et al. Functional and survival outcomes after organ-preservation surgery. Laryngoscope. 2012. Lewin JS, et al. Functional outcomes after flap reconstruction for pharyngolaryngectomy. Arch Otolaryngol Head Neck Surg; 2005. Gourin CG et al. Effect of organ preservation on survival in laryngeal cancer: population-based analysis. Laryngoscope. 2010. Weinstein GS et al. Transoral robotic surgery for oropharyngeal carcinoma: oncologic and functional outcomes. Lancet Oncol. 2010. Holsinger FC, et al. Transoral robotic and laser surgery for head and neck cancer: functional perspectives. Curr Opin Otolaryngol Head Neck Surg; 2015. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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08:04:43","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97273,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/387d95509958b2b8f56e7067.png"},{"id":93016300,"identity":"b292cd19-4ae0-4edf-9c44-3a6910e44600","added_by":"auto","created_at":"2025-10-08 08:04:43","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88946,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/7e8dd6c3409d76a2a9ad67d4.png"},{"id":93016302,"identity":"ab71809a-76e4-4731-a180-ab82136fb3e9","added_by":"auto","created_at":"2025-10-08 08:04:43","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":106665,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/580c79d6425c72176c4e1d59.png"},{"id":93016299,"identity":"42c7520f-1fcc-4098-ba36-d843898572e9","added_by":"auto","created_at":"2025-10-08 08:04:43","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69476,"visible":true,"origin":"","legend":"","description":"","filename":"c4c57ad9658341ce80a789ffa6d9ab6c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/461c51132ded7a28dfdf8cfe.xml"},{"id":93016301,"identity":"9111783b-1e78-4611-ba74-2d669a4ae7ab","added_by":"auto","created_at":"2025-10-08 08:04:43","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77872,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/d71680fa98ba8e0ab0908604.html"},{"id":93016287,"identity":"46a28b43-0902-492d-bfeb-33a4c36a100f","added_by":"auto","created_at":"2025-10-08 08:04:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":149332,"visible":true,"origin":"","legend":"\u003cp\u003eFeasibility of laryngeal preservation in advanced T3/T4 head and neck cancer.\u003c/p\u003e\n\u003cp\u003eCONSORT-style flowchart showing the distribution of 162 patients according to cricoarytenoid joint (CAJ) involvement and surgical strategy. Of 95 patients undergoing laryngectomy, 86 (90%) had CAJ invasion, while among 76 patients without CAJ invasion, only 9 (12%) were unsuitable for preservation. Overall, 67 patients (88% of those without CAJ invasion) were feasible for functional preservation. Comparative percentages of larynx preservation and laryngectomy are displayed across tumor locations.\u003c/p\u003e","description":"","filename":"floatimage116.png","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/c488f6ba450fb0e5241f043c.png"},{"id":93017526,"identity":"88b0840a-d483-4c2d-8b44-3f545867c6a3","added_by":"auto","created_at":"2025-10-08 08:12:43","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":224503,"visible":true,"origin":"","legend":"\u003cp\u003eOncologic outcomes: laryngectomy vs. laryngeal preservation.\u003c/p\u003e\n\u003cp\u003e(A) Kaplan–Meier analysis of recurrence-free survival (RFS) in 162 patients with advanced T3/T4 disease, showing no significant difference between laryngectomy and preservation (78.9% vs. 85.1%; log-rank p = 0.56).\u003c/p\u003e\n\u003cp\u003e(B) Kaplan–Meier analysis of overall survival (OS) showing a trend toward worse survival in the laryngectomy group (57.9% vs. 79.1%; log-rank p = 0.16), attributable mainly to non–cancer-related mortality.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/ab8b5e3cdc667b63d962bd5a.jpeg"},{"id":93016294,"identity":"98257359-0d4e-4ab7-92ba-555a0f0f5283","added_by":"auto","created_at":"2025-10-08 08:04:43","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":85554,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative recovery: transoral laser vs. open surgery.\u003c/p\u003e\n\u003cp\u003eBox plots comparing (A) nasogastric tube feeding duration, (B) hospital stay, and (C) duration of temporary tracheostomy in patients with preserved larynx (n = 67). Recovery was significantly faster following transoral laser surgery (all comparisons p \u0026lt; 0.001, Mann–Whitney U test).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/f962e1d2ca7d75ec5d59b2f9.jpeg"},{"id":93016293,"identity":"23056779-381f-4dcb-ad41-bf658a3c270a","added_by":"auto","created_at":"2025-10-08 08:04:43","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":82321,"visible":true,"origin":"","legend":"\u003cp\u003eLong-term swallowing outcomes after larynx preservation surgery.\u003c/p\u003e\n\u003cp\u003eBox plots comparing dysphagia outcomes between transoral and open surgery at 6–9 months follow-up. (A) MD Anderson Global Score, (B) MD Anderson Composite Score, and (C) Visual Analog Scale (VAS). No significant differences were found between approaches, although results tended to favor transoral surgery.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/3ec963503901e3b4f38b34b8.jpeg"},{"id":93017751,"identity":"3decef74-89c8-4ef4-9242-f35bd93d58d8","added_by":"auto","created_at":"2025-10-08 08:20:43","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":187959,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival outcomes: transoral laser vs. open surgery in laryngeal preservation cohort (n = 67).\u003c/p\u003e\n\u003cp\u003e(A) Kaplan–Meier analysis of recurrence-free survival showed no significant difference (88.9% vs. 82.5%; log-rank χ² = 4.30, p = 0.21).\u003c/p\u003e\n\u003cp\u003e(B) Kaplan–Meier analysis of overall survival revealed significantly worse survival in the open surgery subgroup (70.0% vs. 92.6%; log-rank p = 0.038), explained by higher rates of non-cancer-related deaths.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/904c3f7e5ca77c912c5915b7.jpeg"},{"id":98433368,"identity":"1fc4aa49-98fb-421e-819a-017f7201f0c6","added_by":"auto","created_at":"2025-12-17 16:50:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1484767,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7633383/v1/1b865e8c-e65d-48d1-a058-9741f235b750.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis on feasibility of functional preservation surgery of T3/T4 head and neck cancer - a pirouette around the cricoarytenoid joint","fulltext":[{"header":"key messages","content":"\u003cp\u003e\u0026bull; Cricoarytenoid joint integrity is the decisive boundary for surgical functional preservation in advanced head and neck cancer.\u003c/p\u003e\u003cp\u003e\u0026bull; 88% of patients without CAJ invasion achieved preservation with favorable functional outcomes.\u003c/p\u003e\u003cp\u003e\u0026bull; Oncologic outcomes were comparable to stage-matched laryngectomy, but open surgery carried higher morbidity and non\u0026ndash;cancer mortality.\u003c/p\u003e"},{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003eSurgical Feasibility of Laryngeal Preservation: Surgical preservation of upper airway continuity was feasible in 88% of advanced T3/T4 cases without cricoarytenoid joint invasion.\u003c/li\u003e\n \u003cli\u003eFunctional Feasibility of Laryngeal Preservation: The vast majority of patients with preserved larynx achieved decannulation and adequate swallowing function; only a small minority required permanent PEG or tracheostomy. This suggests that, if the cricoarytenoid joint is preserved, the larynx retains sufficient functional reserve for decannulation and oral alimentation, even after extensive resections of other\u0026nbsp;key contributors to swallowing.\u003c/li\u003e\n \u003cli\u003eOncologic Outcomes: Recurrence-free survival was equivalent between preservation and laryngectomy, but overall survival tended to be worse in laryngectomy due to non-cancer-related mortality.\u003c/li\u003e\n \u003cli\u003eFlap Reconstruction: Nearly half of non-laryngeal preservation cases required flap reconstruction, predominantly in advanced T4 disease.\u003c/li\u003e\n \u003cli\u003eFunctional Recovery (Transoral vs. Open Surgery): Transoral laser surgery accelerated postoperative recovery, although long-term dysphagia outcomes equalized between approaches.\u003c/li\u003e\n \u003cli\u003eTransoral vs. Open Surgery: Survival Outcomes: Recurrence-free survival was similar between approaches, but overall survival was significantly worse after open surgery.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eOver the past three decades, treatment strategies for locally advanced squamous cell carcinoma of the head and neck have undergone profound change. Following the advent of non-surgical laryngeal preservation protocols, the therapeutic paradigm gradually shifted away from definitive surgical resection toward approaches emphasizing functional sustainability and quality-of-life conservation. Chemoradiotherapy (CRT) emerged as the leading modality in this regard, often presented as superior in preserving swallowing, breathing, and phonation. However, this pendulum swing remains controversial. Large retrospective, population-based analyses have revealed discrepancies between real-world outcomes and the results reported in landmark clinical trials [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn light of this divergence, the contemporary value of surgery in advanced head and neck cancer deserves reevaluation. Rather than viewing surgery solely as a radical extirpative measure, its potential for maximizing upper airway function preservation should be reconsidered. Functional preservation\u0026mdash;defined as maintaining the essential components of swallowing, breathing, and phonation\u0026mdash;offers a framework that extends beyond traditional organ-based concepts.\u003c/p\u003e\u003cp\u003eConventionally, surgical decision-making has relied heavily on human-defined anatomical borders (larynx, hypopharynx, oropharynx, tongue). Yet, these borders may not fully capture the structures that determine whether upper airway functions can be sustained. Our preliminary analyses suggest that the status of the cricoarytenoid joint (CAJ), reflected clinically by vocal cord fixation, represents the critical determinant of whether surgical functional preservation is feasible. In this sense, the CAJ can be regarded as a functional \u0026ldquo;red line.\u0026rdquo; When uninvolved, preservation of airway functions remains achievable even in tumors extending across conventional anatomical subsites.\u003c/p\u003e\u003cp\u003eThe present study systematically examines this concept by analyzing a consecutive cohort of 162 patients with advanced (T3/T4) head and neck carcinoma. Our aim was to identify the major factors determining functional preservation of the upper airways, with an emphasis on functional integrity rather than anatomical site designation. Specifically, we sought to assess the role of cricoarytenoid joint (CAJ) status as the decisive boundary for surgical feasibility, while also evaluating oncologic outcomes, quantify long-term dysphagia, and decannulation success. This study evaluates the feasibility, functional outcomes, and survival of surgical laryngeal preservation in advanced T3/T4 disease, based on the principle that an intact cricoarytenoid joint (CAJ) can provide sufficient functional reserve to compensate for resections involving other key contributors to swallowing.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003e\u003cb\u003eStudy design and treatment protocols\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe present study was carried out during a period of three years (2020\u0026ndash;2023) as a monocentric, observational, single-surgeon study. The investigated population was formed from all consecutive adult patients with advanced T3/T4 stage squamous cell carcinoma of the larynx, hypopharynx, oropharynx and tongue. Inclusion criteria consisted in enrolling all consecutive operable advanced T-stage squamous cell carcinoma invading the before-mentioned anatomical areas of the head and neck. Exclusion criteria: any chemo or radiotherapy prior to surgery. All enrolled participants finished the study, i.e., there was no attrition. Randomization was not applicable and a formal power calculation was not performed. All female patients were at a post-reproductive age.\u003c/p\u003e\u003cp\u003eSurgical treatment included resection with free resection margins and neck dissection ipsilaterally (2\u0026ndash;5 levels). In all cases with supraglottic and base of tongue invasion, as well as in all cases of tumors crossing the median line, contralateral neck dissection was also performed (2\u0026ndash;5 levels). Additionally, if the tumor extended into the subglottic or retrocricoid region, a full paratracheal lymph node dissection (levels 6\u0026ndash;7) was carried out. All patients underwent postoperative radiotherapy or combined chemoradiotherapy according to the protocol, except 6 due to various reasons.\u003c/p\u003e\u003cp\u003eThe follow-up period was an average of 24 months with a standard deviation of 14 months. Patients were followed-up every month during the first six months after surgery and every three months after this period. Every six months, PET-CT was scheduled for radiological evaluation. Cases were registered as events in recurrence-free survival when recurrence or death due to malignancy was found. Censoring was recorded when death due to other causes not connected to the primary disease existed or follow-up period has finished. When overall survival was calculated, an event was registered in all cases of death, regardless of cause.\u003c/p\u003e\u003cp\u003eEthical committee approved the study \u0026ndash; KENIMUS, Protocol-329/08.03.2021. Written informed consent for participation was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki. The study did not interfere with the decision-making process for the treatment of each patient.\u003c/p\u003e\n\u003ch3\u003eDysphagia assessment\u003c/h3\u003e\n\u003cp\u003eAll patients with larynx preservation surgery were assessed on 6th to 9th month after the surgical intervention. The MD Anderson Dysphagia Inventory (MDADI) and visual analogue scale (VAS) were used for post-operative assessment.\u003c/p\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eSPSS software v.23.0 for Windows (IBM SPSS, NY, USA) and GraphPad Prism software were used for data analysis.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Clinico-pathological characteristics of the studied cohort\u003c/h2\u003e\u003cp\u003eThe study cohort consisted of 162 cases: 88 (54.2%) with predominantly laryngeal localization, 33 (20.4%) hypopharyngeal, 22 (13.6%) oropharyngeal, and 19 (11.7%) tongue. Regarding tumor stage, 43.2% were classified as pT4a, 8.0% as pT4b, and the remaining 48.8% as pT3 tumors. More than half of the patients (52.5%) had pathologically confirmed metastatic disease. The N-status distribution was: N1 (10.7%), N2a/N2b/N2c (71.5%), and N3 (17.8%). A detailed summary of clinicopathological characteristics is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinicopathological characteristics of the studied patient cohort.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of patients (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62 (mean), 21\u0026ndash;87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e144 males, 18 females\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.89% vs 11,11%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT-stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48,7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epT4a \u0026amp; pT4b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51,3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN-stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN2a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN2b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19,4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN2c\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetastasis (pN0 vs pN1-3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN1-3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLarynx\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypopharynx\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.37%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOropharynx\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.58%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTongue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.73%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Surgical Feasibility of Laryngeal Preservation\u003c/h2\u003e\u003cp\u003e\u003cem\u003eSurgical preservation of upper airway continuity was feasible in 88% of advanced T3/T4 cases without cricoarytenoid joint invasion.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAcross the cohort of 162 patients, the presence of cricoarytenoid joint (CAJ) invasion\u0026mdash;clinically manifested as vocal cord fixation\u0026mdash;was the principal determinant of surgical strategy. Of the total cohort, 95 patients (58%) underwent laryngectomy, 86 of whom (90%) had documented CAJ invasion. Among the 76 patients without CAJ involvement, only 9 (12%) were deemed unsuitable for functional preservation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Consequently, 67 patients (88% of those without CAJ invasion) were considered feasible candidates for surgical preservation of the larynx and its upper airway functions (stage-matched cohorts).\u003c/p\u003e\u003cp\u003eWhen stratified by tumor location, the likelihood of laryngeal preservation varied substantially. Patients with laryngeal (75%) and hypopharyngeal (78.8%) tumors predominantly underwent laryngectomy, reflecting the high frequency of CAJ invasion. Nevertheless, approximately one in four patients with advanced T3/T4 laryngeal or hypopharyngeal carcinomas were suitable for functional preservation. By contrast, most base of tongue/oropharyngeal tumors (86.4%) and all oral cavity tumors (100%) were managed without laryngectomy. These findings emphasize that, while CAJ invasion remains the decisive factor, the anatomical site of tumor origin strongly influences the feasibility of preservation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Functional Feasibility of Laryngeal Preservation\u003c/h2\u003e\u003cp\u003e\u003cem\u003eThe vast majority of patients with preserved larynx achieved decannulation and adequate swallowing function; only a small minority required permanent PEG or tracheostomy (stage-matched cohorts).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn the cohort of patients with surgically preserved larynx (n\u0026thinsp;=\u0026thinsp;67), functional outcomes were evaluated among those who survived the postoperative period (excluding 2 early postoperative deaths, 3%). In this group, successful decannulation was achieved in 95.6%, with only 3 patients (4.4%) remaining tracheostomy-dependent. Similarly, percutaneous endoscopic gastrostomy (PEG) feeding was required in only 2 patients (3%), reflecting a high rate of functional swallowing recovery.\u003c/p\u003e\u003cp\u003eStandardized swallowing assessments confirmed these findings. At 6\u0026ndash;9 months after surgery, patients demonstrated moderate-to-good swallowing capacity, with a mean MD Anderson Global Score of 5 points, a Composite Score of 87/100, and a Visual Analog Scale score of 7.5/10. The most important determinant of poor swallowing recovery across the cohort was loss of unilateral tongue mobility, whether resulting from hypoglossal nerve resection, extensive muscle sacrifice, or both.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.4. Oncologic Outcomes\u003c/h2\u003e\u003cp\u003e\u003cem\u003eRecurrence-free survival was equivalent between preservation and laryngectomy, but overall survival tended to be worse in laryngectomy due to non-cancer-related mortality.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAmong patients with advanced T3/T4 disease, surgical preservation of the larynx did not compromise recurrence-free survival compared with stage-matched patients who underwent laryngectomy. Survival analysis showed no significant difference in recurrence-free survival (log-rank, p\u0026thinsp;=\u0026thinsp;0.56): 78.9% recurrence-free in the laryngectomy group versus 85.1% in the preservation group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Both groups were comparable in T- and N-stage distribution, with a mean follow-up of 24\u0026thinsp;\u0026plusmn;\u0026thinsp;14 months - stage-matched cohorts.\u003c/p\u003e\u003cp\u003eWhen overall survival was examined, no statistically significant difference was observed (log-rank, p\u0026thinsp;=\u0026thinsp;0.16). However, a trend toward inferior overall survival among laryngectomees was evident: 57.9% versus 79.1% in the preservation group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Importantly, this divergence was attributable to non\u0026ndash;cancer-related mortality. Within the laryngectomy cohort, deaths included 6 cardiovascular events, 1 COVID-related infection, 1 natural death, 2 trauma, and 3 unknown causes. In contrast, the preservation cohort experienced 3 second malignancies, 2 postoperative deaths, and 1 unknown cause, with no cardiovascular, infectious/COVID, or trauma-related deaths.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.5. Flap Reconstruction\u003c/h2\u003e\u003cp\u003e\u003cem\u003eNearly half of laryngeal preservation cases required flap reconstruction, predominantly in advanced T4 disease.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAmong patients with functional laryngeal preservation (n\u0026thinsp;=\u0026thinsp;67), a subgroup underwent open surgery for non-laryngeal tumors (pharyngeal and tongue). Within this group, 43.4% (23/53) required reconstruction with a distant flap, while 30/53 (56.6%) were managed with primary closure. Flap reconstruction was strongly associated with advanced disease: the majority of cases were T4a/T4b tumors (χ\u0026sup2; = 23.196, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas only a small minority of T3 resections required flap coverage.\u003c/p\u003e\u003cp\u003eSurvival analysis demonstrated a trend toward poorer recurrence-free survival in the flap group compared with the non-flap group (log-rank χ\u0026sup2; = 3.36, p\u0026thinsp;=\u0026thinsp;0.067), though not statistically significant. This difference reflects the more advanced tumor burden in patients requiring flap coverage.\u003c/p\u003e\u003cp\u003eThe type of flap was dictated by tumor site. The pectoralis major flap was predominantly used for caudally located pharyngolaryngeal tumors, while microvascular free flaps were used for cranially situated pharyngeal and tongue resections, where pliability and precision were required.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.6. Functional Recovery\u003c/h2\u003e\u003cp\u003e\u003cem\u003eTransoral laser surgery accelerated postoperative recovery, although long-term dysphagia outcomes equalized between approaches.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWithin the preservation cohort (n\u0026thinsp;=\u0026thinsp;67), outcomes were compared between transoral laser surgery and open surgery. As the data were not normally distributed (Kolmogorov\u0026ndash;Smirnov and Levene\u0026rsquo;s tests, p\u0026thinsp;\u0026lt;\u0026thinsp;0.005), non-parametric Mann\u0026ndash;Whitney tests were applied.\u003c/p\u003e\u003cp\u003eEarly recovery strongly favored the transoral approach: patients required significantly shorter nasogastric feeding (mean rank 7.79 vs. 16.59, U\u0026thinsp;=\u0026thinsp;116.5, p\u0026thinsp;=\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eA), shorter hospitalization (mean rank 11.00 vs. 22.25, U\u0026thinsp;=\u0026thinsp;189, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eB), and shorter temporary tracheostomy (mean rank 11.31 vs. 22.5, U\u0026thinsp;=\u0026thinsp;201.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eC).\u003c/p\u003e\u003cp\u003eBy 6\u0026ndash;9 months postoperatively, dysphagia outcomes had equalized. The MD Anderson Global Score (5 vs. 4, p\u0026thinsp;=\u0026thinsp;0.183; Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003eA), Composite Score (87 vs. 81/100, p\u0026thinsp;=\u0026thinsp;0.097; Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003eB), and Visual Analog Scale (7.5 vs. 6/10, p\u0026thinsp;=\u0026thinsp;0.232; Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003eC) showed no significant differences, although scores tended to favor the transoral group.\u003c/p\u003e\u003cp\u003eThe strongest predictor of persistent dysphagia across both groups was loss of unilateral tongue mobility, due to hypoglossal nerve sacrifice, major muscle resection, or both. In the entire preservation cohort, 2 patients (3%) required permanent PEG feeding and 3 patients (4.4%) remained tracheostomy-dependent.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.7. Transoral vs. Open Surgery: Survival Outcomes\u003c/h2\u003e\u003cp\u003e\u003cem\u003eRecurrence-free survival was similar between approaches, but overall survival was significantly worse after open surgery.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFocused survival analysis of the preservation cohort (n\u0026thinsp;=\u0026thinsp;67) compared transoral and open resection. Recurrence-free survival was not significantly different (88.9% vs. 82.5%, log-rank χ\u0026sup2; = 4.30, p\u0026thinsp;=\u0026thinsp;0.21; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e5\u003c/span\u003eA), although curves diverged slightly in favor of the transoral group.\u003c/p\u003e\u003cp\u003eIn contrast, overall survival was significantly worse in the open surgery subgroup (70.0% vs. 92.6%, log-rank p\u0026thinsp;=\u0026thinsp;0.038; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e5\u003c/span\u003eB). Importantly, this difference was not cancer-driven but attributable to non-oncologic deaths: the open subgroup included 2 postoperative deaths, 3 second malignancies, and 1 unknown cause, whereas the transoral group had virtually no non-cancer-related mortality. These findings suggest that the survival advantage of transoral surgery reflects not only oncologic adequacy, but also its association with reduced treatment morbidity.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eNumerous articles have been dedicated to the topic of surgical and nonsurgical laryngeal preservation in advanced head and neck carcinoma. A significant share of the surgical literature is based on smaller case series or focused on specific anatomical subsites that allowed partial resections with preservation of upper airway function. For instance, Kadota et al. described 18 patients undergoing base of tongue reconstruction with laryngeal preservation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], Makino et al. reported on 100 consecutive cases of cervical esophageal carcinoma treated with the aim of sparing the larynx [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and Li et al. emphasized the pyriform sinus as a focal point for preservation strategies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While such studies illustrate the feasibility of functional preservation in selected subsites, they do not provide a systematic framework for assessing surgical boundaries across tumor sites.\u003c/p\u003e\u003cp\u003eThe central concept of this study builds upon the classical philosophy of laryngeal-sparing surgery: the cricoarytenoid unit as the \u0026ldquo;functional heart\u0026rdquo; of the larynx, responsible for a critical share of breathing, phonation, and airway protection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. It has long been accepted that invasion of the cricoarytenoid joint, usually manifesting as vocal cord fixation, constitutes a clinical and oncological threshold obligating either primary laryngectomy or nonsurgical preservation strategies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This axiom defines the traditional surgical \u0026ldquo;red line.\u0026rdquo; Our analysis explored surgical possibilities beyond conventional anatomical borders, while consistently centering on the functional integrity of the cricoarytenoid joint and its capacity to compensate for resections involving other key structures in swallowing.\u003c/p\u003e\u003cp\u003eWe found that surgical preservation of the larynx was feasible in 88% of advanced T3/T4 cases without CAJ involvement, regardless of tumor subsite. Functionally, results were favorable: only 3% required PEG feeding and 4.4% remained tracheostomy-dependent long term. These rates compare well with previously published organ-preservation series reporting PEG dependence between 5\u0026ndash;15% and tracheostomy rates up to 10% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This suggests that, if the cricoarytenoid joint is preserved, the larynx retains sufficient functional reserve for decannulation and oral alimentation, even after extensive resections of other key contributors to swallowing.\u003c/p\u003e\u003cp\u003eYet, these outcomes come at a price. Patients requiring open preservation surgery\u0026mdash;predominantly T4a/b tumors\u0026mdash;experienced a far more demanding postoperative course, characterized by prolonged nasogastric feeding and extended tracheostomy dependence, as seen in other reports of open pharyngolaryngectomy reconstructions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. More importantly, overall survival was significantly worse in the open surgery subgroup, despite recurrence-free survival being comparable to the transoral cohort [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e5\u003c/span\u003e]. Non-cancer-related deaths (postoperative complications, second malignancies, other systemic causes) were disproportionately higher in this group. This echoes observations from larger surgical cohorts that functional preservation does not always translate into survival benefit, particularly in frail patients with significant comorbidity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Still, when these patients successfully navigate the initial months of recovery, they often reach surprisingly satisfactory levels of swallowing and quality of life [Figure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e], a finding also reported in long-term functional series after complex reconstructions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In this context, reconstructive techniques play a pivotal role, as the choice between regional and free flaps directly impacts both early recovery and ultimate functional restoration.\u003c/p\u003e\u003cp\u003eThe evolution of laryngeal preservation strategies must be viewed in light of the broader treatment landscape. Over the past decades, prospective randomized trials shifted the paradigm of stage III and IV laryngeal cancers toward organ preservation using chemoradiotherapy (CRT), highlighting speech and swallowing outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While CRT has demonstrated functional benefits compared to total laryngectomy (TL), survival outcomes remain controversial. Hoffman et al. documented a decline in 5-year survival for laryngeal cancer in the 1980s and 1990s [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], while Cosetti et al. suggested that this decline was largely attributable to advanced glottic tumors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Other population-level analyses have echoed this trend, suggesting that real-world CRT outcomes may not mirror those achieved in controlled clinical trials [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These trends, together with the absence of molecularly guided treatment stratification in head and neck carcinoma, remind us that surgery still has a role to play\u0026mdash;especially if performed with a systematized focus on functional preservation.\u003c/p\u003e\u003cp\u003eThe present findings argue for a reinvention of an old paradigm: a systematic surgical approach that places the cricoarytenoid joint at the center of functional assessment and decision-making. This \u0026ldquo;pirouette\u0026rdquo; around the cricoarytenoid joint may represent a practical way to balance oncologic radicality with functional outcomes in advanced disease.\u003c/p\u003e\u003cp\u003eFinally, one limitation of the present study is the absence of a transoral robotic surgery (TORS) subgroup, which has been increasingly recognized as a valuable minimally invasive option in selected oropharyngeal and supraglottic tumors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Future studies incorporating TORS into this framework would provide a more complete view of the surgical preservation spectrum.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eFunctional upper airway preservation is feasible in most advanced head and neck cancers when the cricoarytenoid joint (CAJ) is not engaged. An intact CAJ provides sufficient functional reserve to compensate for resections involving other key contributors to swallowing, enabling excellent oncologic outcomes with generally favorable functional recovery. Open preservation surgery carries greater morbidity and higher non\u0026ndash;cancer-related mortality, highlighting the need for careful patient selection and tailored reconstructive planning.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eEthics approval\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe Ethical Committee of Medical University\u0026mdash;Sofia approved the study \u0026ndash; KENIMUS, Protocol-329/08.03.2021. Written informed consent for participation in the study was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study is financed by the European Union-NextGenerationEU, through the National Recovery and Resilience Plan of the Republic of Bulgaria, project BG-RRP-2.004-0004-C01\u0026ldquo;, group 3.1.5 Strategic research and innovation program for development of Medical University - Sofia \u0026ldquo;.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003e\u0026bull;Popov TM: study design, surgical treatment, sample collection, data analysis, survival analysis, manuscript drafting\u003cbr\u003e\u0026bull;Stancheva I, Dobriyanova V, Dimitrov L. Rangachev J: patient follow-up and data aquisition\u003cbr\u003e\u0026bull;Skelina S, Valcheva S, Komitova K: dysphagia scoring and data aquistion\u003cbr\u003e\u0026bull;Ts. Marinov, Skelina S: study design, data analysis, draft review\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eAll authors provided substantial input into the conceptualization, drafting, and editing of this report. Each has given approval for the publication of the article.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eRaw data were generated at Medical University - Sofia. Derived data supporting the findings of this study are available from the corresponding author [TP] on request.\u003c/p\u003e\n\u003ch3\u003eDeclaration of Generative AI and AI-Assisted Technologies\u003c/h3\u003e\n\u003cp\u003eDuring the preparation of this work, the authors used \u003cstrong\u003eChatGPT (OpenAI)\u003c/strong\u003e in order to assist with \u003cstrong\u003elanguage refinement, structuring of sections, and improvement of clarity in writing\u003c/strong\u003e. After using this tool, the authors \u003cstrong\u003ecritically reviewed, edited, and verified all content\u003c/strong\u003e and take full responsibility for the integrity and accuracy of the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePatel SA, Qureshi MM, Dyer MA, Jalisi S, Grillone G, Truong MT. Comparing surgical and nonsurgical larynx-preserving treatments with total laryngectomy for locally advanced laryngeal cancer. Cancer. 2019;125(19):3367\u0026ndash;77. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cncr.32292\u003c/span\u003e\u003cspan address=\"10.1002/cncr.32292\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Jun 17. PMID: 31206637.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKadota H et al. Reconstruction after base of tongue carcinoma resection with preserved larynx. Jpn J Clin Oncol. 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMakino T et al. Surgical treatment of cervical esophageal carcinoma with laryngeal preservation. Ann Surg Oncol. 2013.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Y et al. Partial resection of the pyriform sinus for hypopharyngeal carcinoma. Laryngoscope. 2015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eForastiere AA et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLefebvre JL et al. Larynx preservation in advanced laryngeal and hypopharyngeal cancer: EORTC trials. J Clin Oncol. 2009.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoffman HT et al. Declining survival in laryngeal cancer: SEER data. Otolaryngol Head Neck Surg. 2006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCosetti M et al. Impact of non-surgical strategies on survival in advanced laryngeal cancer. Cancer. 2008.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLaccourreye O et al. Supracricoid partial laryngectomy: functional and oncologic results. Ann Otol Rhinol Laryngol. 1996.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGallo A et al. Cricoarytenoid joint involvement in laryngeal carcinoma: implications for function and treatment. Head Neck. 2000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSteiner W, Ambrosch P. Endoscopic laser surgery of the upper aerodigestive tract: with special emphasis on cancer surgery. Stuttgart: Thieme; 2000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHutcheson KA et al. Long-term dysphagia after chemoradiation vs surgery. Head Neck. 2013.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerlito A et al. Functional outcomes after partial laryngectomy: PEG and tracheostomy dependence. Eur Arch Otorhinolaryngol. 2009.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel RS et al. Morbidity after open conservation surgery for hypopharyngeal cancer. Head Neck. 2014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlsen KD et al. Functional and survival outcomes after organ-preservation surgery. Laryngoscope. 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLewin JS, et al. Functional outcomes after flap reconstruction for pharyngolaryngectomy. Arch Otolaryngol Head Neck Surg; 2005.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGourin CG et al. Effect of organ preservation on survival in laryngeal cancer: population-based analysis. Laryngoscope. 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeinstein GS et al. Transoral robotic surgery for oropharyngeal carcinoma: oncologic and functional outcomes. Lancet Oncol. 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolsinger FC, et al. Transoral robotic and laser surgery for head and neck cancer: functional perspectives. Curr Opin Otolaryngol Head Neck Surg; 2015.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"surgical preservation of the larynx, advanced squamous cell carcinoma, dysphagia","lastPublishedDoi":"10.21203/rs.3.rs-7633383/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7633383/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThis study evaluates the feasibility, functional outcomes, and survival of surgical laryngeal preservation in advanced T3/T4 head and neck disease, based on the principle that an intact cricoarytenoid joint (CAJ) can provide sufficient functional reserve to compensate for resections involving other key contributors to swallowing.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eMonocentric, observational study (STROBE compliant). 162 consecutive patients with advanced (T3/T4) laryngeal, hypopharyngeal, oropharyngeal, and tongue carcinomas treated surgically. Definitive surgery with either laryngectomy or laryngeal preservation (stage-matched subgroups), stratified by CAJ involvement and surgical approach (transoral vs. open).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 162 patients, 95 (58%) underwent laryngectomy; 90% had CAJ invasion. Among 76 without CAJ involvement, 67 (88%) were suitable for preservation. Functional outcomes: 95.6% decannulated, 3% PEG, 4.4% tracheostomy dependence. Recurrence-free survival did not differ (85.1% preservation vs. 78.9% laryngectomy; log-rank p\u0026thinsp;=\u0026thinsp;0.56). Overall survival tended lower in laryngectomy (57.9% vs. 79.1%; p\u0026thinsp;=\u0026thinsp;0.16), explained by non\u0026ndash;cancer mortality. Flap reconstruction was required in 43.4% of open non-laryngeal preservation cases, mostly T4 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Open surgery showed inferior overall survival compared with transoral (70.0% vs. 92.6%; p\u0026thinsp;=\u0026thinsp;0.038).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eFunctional upper airway preservation is feasible in most advanced head and neck cancers when CAJ is not engaged. An intact CAJ provides sufficient functional reserve to compensate for resections involving other key contributors to swallowing, enabling excellent oncologic outcomes with generally favorable functional recovery. Open preservation surgery carries greater morbidity and higher non\u0026ndash;cancer-related mortality.\u003c/p\u003e","manuscriptTitle":"Analysis on feasibility of functional preservation surgery of T3/T4 head and neck cancer - a pirouette around the cricoarytenoid joint","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 08:04:38","doi":"10.21203/rs.3.rs-7633383/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f320fcf-062a-4377-8cf0-cceefc9e30db","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T09:25:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 08:04:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7633383","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7633383","identity":"rs-7633383","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}