A Case of Multiple Pharyngocutaneous Fistulae Following Post-Operative Concurrent Chemoradiotherapy for Oropharyngeal Cancer

Pharyngocutaneous fistula is a readily encountered complication that occurs after surgery for laryngopharyngeal cancer. The development of pharyngocutaneous fistula increases hospitalization, delays postoperative adjuvant treatment, and can lead to serious complications such as wound infection and carotid artery rupture. Transoral robotic surgery (TORS) is actively being performed as a standard procedure for surgery of pharyngeal and laryngeal cancers. Many reports verified that TORS is advantageous in terms of perioperative outcomes such as decreased hospitalization and reduced rate of postoperative complications, free flap reconstruction, and tracheostomy or gastrostomy tube dependence relative to open surgery. However, careful selection of patients is mandatory and there are some critical points to consider in optimal treatment outcomes. Recently, we experienced a 47-year-old patient with tonsillar cancer who underwent lateral oropharyngectomy by TORS and radical neck dissection. Unfortunately, multiple pharyngocutaneous fistulae occurred following postoperative concurrent chemoradiotherapy (CCRT). Multiple phrayngocutaneous fistulae following TORS and postoperative CCRT have not been reported in the literature. Therefore, we report this case with a brief discussion supported by a review of the relevant literature.

Surgical emphysema as an early sign for pharyngocutaneous fistula following total laryngectomy: a case report

Background Pharyngocutaneous fistula is the most common and troublesome complication after total laryngectomy. Many factors may be used in laryngectomy patients for the early diagnosis of pharyngocutaneous fistulae such as skin flap edema, neck erythema, salivary leak, postoperative barium swallow, and wound amylase level. Its diagnosis is mainly standing on a clinical basis. Case presentation This report described two cases of laryngeal carcinoma, which presented with a history of persistent hoarseness of voice and mild stridor and were diagnosed with a battery of clinical investigations and managed successfully with total laryngectomy and lateral neck dissection. Both patients suffered from postoperative surgical emphysema before developing pharyngocutaneous fistula. Conclusion Surgical emphysema can precede the occurrence of pharyngocutaneous fistula after total laryngectomy. Further studies are needed to confirm this finding.

Montgomery Salivary Bypass Tube in Head and Neck Cancer: The Experience of Our Otolaryngology Clinic

Introduction: One of the most common complications in the immediate and late postoperative period following total laryngectomy or pharyngolaryngectomy is pharyngocutaneous fistulae (PCF) formation and pharyngoesophageal stenosis (PES), causing significant mortality and morbidity. Since 1978, Montgomery salivary bypass tube (MSBT) has been used to reduce the incidence of PCF and PES. The aim of this retrospective study was to analyze the outcomes of using MSBT both as a tool to prevent PCF and PES and to treat these complications in the postoperative period. Methods: Between January 2013 and December 2019, we inserted 109 MSBT in 87 patients with laryngeal/hypopharyngeal cancer treated in the Unit of Otolaryngology of our University Hospital. Results: Sixty (86.9%) patients healed from complications with primary and secondary placement of MSBT. Seven patients presented a persistence of PCF and 2 presented a recurrence of PES. Secondary placement of MSBT allowed treating successfully 15 (83%) of 18 patients. Only 3 of them presented a PCF at the end of the follow-up period. Conclusion: According to our experience, the MSBT is an affordable, easy to apply and well-tolerated tool. Although it is generally used for PCF treatment, it can also be used intraoperatively for PCF and PES prevention.

Transoral Laser-Assisted Total Laryngectomy: Expanding the TLM’s World

Introduction. The introduction of laryngeal transoral procedures has created a shift in the treatment of laryngeal cancers towards the primary surgical management of patients. In this study, we aimed to evaluate the safety, efficacy, and feasibility of the transoral laser-assisted total laryngectomy (TLM-TL) in advanced laryngeal cancer. Case presentation. In this case report, we describe a case of a 50-year-old male patient presented to the otorhinolaryngology clinic with a history of hoarseness and odynophagia since 6 months. Based on the pathological and imaging findings, the diagnosis of stage IVa laryngeal squamous cell carcinoma with the involvement of the base, tongue, and left palatine tonsil was made for the patient, and transoral total laryngectomy with partial glossectomy via the TLM technique was planned. Result. The tumor was successfully resected by TLM-TL with clear surgical margins. No complication was observed after the surgery. Good functional recovery was obtained regarding swallowing and speech. The patient’s oncologic and functional outcomes were evaluated for 2 years. Everything was satisfactory with good long-term cosmetic and laryngopharyngeal functional outcome and no sign of tumor recurrence. Conclusions. TLM-TL is a minimally invasive and cost-benefit endoscopic surgical procedure feasible in advanced laryngeal cancer with good long-term oncological and functional outcome. It could limit postoperative complications, mainly the incidence of pharyngocutaneous fistulae. It is also associated with better satisfaction after TL due to cosmetic benefits.

Efficacy of small-volume gastrografin videofluoroscopic screening for detecting pharyngeal leaks following total laryngectomy

ObjectivesPharyngocutaneous fistulae are dreaded complications following total laryngectomy. This paper presents our experience using 3–5 ml gastrografin to detect pharyngeal leaks following total laryngectomy, and compares post-operative videofluoroscopy with clinical follow-up findings in the detection of pharyngocutaneous fistulae.MethodsA retrospective case–control study was conducted of total laryngectomy patients. The control group (n = 85) was assessed clinically for development of pharyngocutaneous fistulae, while the study group (n = 52) underwent small-volume (3–5 ml) post-operative gastrografin videofluoroscopy.ResultsIn the control group, 24 of 85 patients (28 per cent) developed pharyngocutaneous fistulae, with 6 requiring surgical correction. In the study group, 24 of 52 patients (46 per cent) had videofluoroscopy-detected pharyngeal leaks; 4 patients (8 per cent) developed pharyngocutaneous fistulae, but all cases resolved following non-surgical management. Patients who underwent videofluoroscopy had a significantly lower risk of developing pharyngocutaneous fistulae; sensitivity and specificity in the detection of pharyngocutaneous fistulae were 58 per cent and 100 per cent respectively.ConclusionSmall-volume gastrografin videofluoroscopy reliably identified small pharyngeal leaks. Routine use in total laryngectomy combined with withholding feeds in cases of early leaks may prevent the development of pharyngocutaneous fistulae.

Complications and predisposing factors from a decade of total laryngectomy

BackgroundTotal laryngectomy is often utilised to manage squamous cell carcinoma of the larynx or hypopharynx. This study reports on surgical trends and outcomes over a 10-year period.MethodA retrospective review of patients undergoing total laryngectomy for squamous cell carcinoma was performed (n = 173), dividing patients into primary and salvage total laryngectomy cohorts.ResultsA shift towards organ-sparing management was observed. Primary total laryngectomy was performed for locoregionally advanced disease and utilised reconstruction less than salvage total laryngectomy. Overall, 11 per cent of patients developed pharyngocutaneous fistulae (primary: 6 per cent; salvage: 20 per cent) and 11 per cent neopharyngeal stenosis (primary: 9 per cent; salvage: 15 per cent). Pharyngocutaneous fistulae rates were higher in the reconstructed primary total laryngectomy group (24 per cent; 4 of 17), compared with primary closure (3 per cent; 3 of 90) (p = 0.02). Patients were significantly more likely to develop neopharyngeal stenosis following pharyngocutaneous fistulae in salvage total laryngectomy (p = 0.01) and reconstruction in primary total laryngectomy (p = 0.02). Pre-operative haemoglobin level and adjuvant treatment failed to predict pharyngocutaneous fistulae development.ConclusionComplications remain hard to predict and there are continuing causes of morbidity. Additionally, prior treatment continues to affect surgical outcomes.