Pharyngeal Stenosis and Swallowing Dysfunction Following Laryngectomy: A Scoping Review^†

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This review aimed to clarify the characteristics of pharyngeal stenosis as a sequela of laryngectomy, the incidence of dysphagia requiring dilation, and the frequency and timing of dilation intervention. It also aimed to further understanding of pharyngoesophageal stenosis after laryngectomy, and to make recommendations for optimizing decision-making, surgical planning, and management of the long-term sequelae of laryngectomy and the need for surgical intervention.

 

In the discussion section, there is a need for clarity.  As the discussion text is long, I recommend narrowing down the content. I recommend that you mainly describe the characteristics of pharyngoesophageal stenosis, the incidence of dysphagia requiring dilation, and considerations regarding the frequency and timing of dilation interventions, and then consider the remaining objectives described by the authors in the introduction in a more concise manner. In particular, the authors discuss fistulas and methods for evaluating dysphagia. Although these were not specifically indicated in the results of this survey, the authors write at length about fistulas and methods for evaluating dysphagia, making the content difficult to understand. If the authors are going to include such information in the discussion, it would be easier to understand if the text was divided appropriately and used bullet points and charts.

Comments on the Quality of English Language

No problems 

Author Response

We very much thank Reviewer 1 for their helpful and inciteful review of our work and their constructive criticism.  We have endeavored to incorporate the Reviewers feedback into our revised version.

1.   In the discussion section, there is a need for clarity.  As the discussion text is long, I recommend narrowing down the content. I recommend that you mainly describe the characteristics of pharyngoesophageal stenosis, the incidence of dysphagia requiring dilation, and considerations regarding the frequency and timing of dilation interventions, and then consider the remaining objectives described by the authors in the introduction in a more concise manner. In particular, the authors discuss fistulas and methods for evaluating dysphagia. Although these were not specifically indicated in the results of this survey, the authors write at length about fistulas and methods for evaluating dysphagia, making the content difficult to understand. If the authors are going to include such information in the discussion, it would be easier to understand if the text was divided appropriately and used bullet points and charts.

Response:  We completely agree with the Reviewer that the Discussion is quite long.  We deliberately extended our article in order to comply with the article length/word number requirements of the journal.  In order to make the logic and rationale of the discussion more apparent, we have done several things:

1. We introduced the elements of the discussion in the introduction, so that the flow of the discussion is introduced early to the reader, and hopefully appears more logical in terms of how our data on incidence of stricture formation fits into the overall picture of swallowing dysfunction in the post laryngectomy patient.
2. We liked the concept of dividing out the information in the discussion more clearly and to that end introduced clearly headings that call our the different elements of the discussion more clearly.  We hope that this new format makes the interpretation and rationale of our discussion much clearer.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors, I read your work with interest, I find that the topic of Pharyngeal Stenosis Following Total Laryngectomy is current and worth studying in depth. I believe that the article could have potential after an in-depth analysis of its weaknesses.

The points to clarify and improve are:
1) The methods lack the section of the Quality Assessment of the included studies and the corresponding results in the results section

2) The results are not expressed clearly enough. In a literature review, information on the included studies should be reported, for example type of study (retrospective, other), years of study conduct, etc. Moreover, a more detailed description of the procedures performed on patients and complications in this session is mandatory.

3) The tables are not clear enough. There is also a lack of a table reporting all the included studies, with the name of the first author and year of publication for each study, number of patients undergoing total laryngectomy, number of patients who had dysphagia, number of dilation procedures performed for each individual study, etc.

4) Then adapt the discussion to the requested changes. In general the discussion is too long, as well as the conclusions. Discuss the results obtained without digressing too much and summarize the main results in the conclusions.

Author Response

We wish to thank the reviewer for reviewing our work and for providing very helpful feedback.  We agree completely with the reviewer's suggestions and have attempted to address them point by point. 

1) The methods lack the section of the Quality Assessment of the included studies and the corresponding results in the results section.  We thank the reviewer for pointing this out- we have included this information in the revised version by introducing two new tables (Tables 1 and 3).  We have also described the quality assessment in the Methods section (lines 126-138), the Results sections (lines 152-154).  

2) The results are not expressed clearly enough. In a literature review, information on the included studies should be reported, for example type of study (retrospective, other), years of study conduct, etc. Moreover, a more detailed description of the procedures performed on patients and complications in this session is mandatory.

Thank you for pointing this out.  We have now included Tables 1 and 3 which include the data on all the included studies.

3) The tables are not clear enough. There is also a lack of a table reporting all the included studies, with the name of the first author and year of publication for each study, number of patients undergoing total laryngectomy, number of patients who had dysphagia, number of dilation procedures performed for each individual study, etc.

We apologize for this lapse.  We have included Tables 1 and 3 now in the revised version of the manuscript which includes this important information.

4) Then adapt the discussion to the requested changes. In general the discussion is too long, as well as the conclusions. Discuss the results obtained without digressing too much and summarize the main results in the conclusions.

We agree fully with the reviewer regarding this criticism, which was also raised by the second reviewer.  Because of the article length requirements, our original article including just these points was too short to meet submission requirements.  To that end, we included more information in the discussion than was originally planned.  However, in order to facilitate the flow of the paper, we have separated the discussion sections into themes, introduced by a bulleted statement in order to introduce the concept in the discussion section.  This has also been tied into a concluding statement in the introduction, including information on what will be discussed in the discussion section.  In this way, we hoped to tie together the concepts not only of the incidence of stricture in post laryngectomy patients, but also how stricture occurs, the impact of radiation and mucositis in generating strictures, the impact of fistula on generating strictures, and finally on the inadequacies of other interventional techniques and outcome measures to assess interventions.  If it is felt that the article remains too long with these revisions, we could remove much of the discussion, but may not be able to fulfill the word count required of the article.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The indications provided in the previous review have only been partially followed by the authors. In particular, the discussion and especially the conclusion of the article are too long and heavy for the reader.

Author Response

The indications provided in the previous review have only been partially followed by the authors. In particular, the discussion and especially the conclusion of the article are too long and heavy for the reader.

 

We thank the reviewer once again for their critique of our work, and we wish to apologize to the reviewer that we did not completely resolve the concerns this reviewer had with our work.  Initially, the paper was meant to be a concise review on the rate of post laryngectomy pharyngoesophageal stenosis. However, due to the requirements of this journal, we have endeavored to expand the manuscript into something larger and more comprehensive.  As a result, the paper is indeed longer than we had originally planned.  We are somewhat in a challenging position in trying to resolve the editorial needs of the journal and the reviewers.  In defense of the paper, by expanding its scope to meet the length requirements, we have incorporated our original work into a paper that more comprehensively addresses the swallowing dysfunction seen in the laryngectomized patient, including the limitations of current interventions and evaluations.  As a result, we feel we have created a paper that is better than what we had intended, certainly for someone interested in understanding the complexities of swallowing dysfunction after laryngectomy.  In considering the input from the reviewers and from the Editors, we recommend changing the title of our work to "Pharyngeal stenosis and its role in swallowing dysfunction in the laryngectomized patient:  A scoping review".   In this way, we might more appropriately capture the entirety of the content presented in this manuscript.   We stand ready however, if the Editor so desires, to shorten the manuscript to something less than its current word length.  Thank you again for taking your time in reviewing our paper.