Central Annals of Otolaryngology and Rhinology

Cite this article: Martin Villares C, Gonzalez Gimeno MJ, Diez Gonzalez L, San Roman CJ, Dominguez CJ, et al. (2017) Surgical Mini-Pharyngostoma: A Safe Technique for Unsafe Laryngectomy Patients. Ann Otolaryngol Rhinol 4(2): 1162.

*Corresponding author

Martin Villares, Department of Otorhinolaryngology, Hospital El Bierzo, Spain, Email:

Submitted: 24 January 2017

Accepted: 20 February 2017

Published: 21 February 2017

ISSN: 2379-948X

Copyright© 2017 Martin et al.

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Keywords•Head and neck cancer•Pharyngocutaneousfistula•Laryngeal neoplasm•Pharyngostoma

Case Report

Surgical Mini-Pharyngostoma: A Safe Technique for Unsafe Laryngectomy PatientsMartin Villares C1*, Gonzalez Gimeno MJ2, Diez Gonzalez L1, San Roman Carbajo J1, Dominguez Calvo J1, Valor Garcia C3, Arguello de Tomas M1

1Department of Otorhinolaryngology, Hospital El Bierzo, Spain2Department of Otorhinolaryngology, Universidad Complutense de Madrid, Spain3Department of Otorhinolaryngology, Hospital San Sebastian de los Reyes, Spain

Abstract

From the first laryngectomy performed by Billroth, pharyngocutaneous fistula has not been eradicated. Modern reconstructive techniques can solve almost any surgical problem in laryngectomy patients, but morbidity is still high in critical patients. In a effort to minimize morbilitity in unhealthy patients, we used the surgical pharyngostoma technique as conservative approach for complex postlaryngectomy fistulas in selected patients, in which, aggressive surgical interventions were not safe.

INTRODUCTIONThe laryngectomy technique has been established for dec-

ades and has not changed through out the years, but Pharynx recon-struction after laryngectomy remains controversial [1]. Nowa-days, there is no consensus about the best technique to opti-mize pharynx wound healing, so prevention is better than any treat-ment [2]. Current literature supports aggressive reconstruc-tive techniques in patients with complex pharyngocutaneous fis-tulas [3], but sometimes they are associated with unaccept-able high complication rates [4,5]. In a effort to minimize mor-bilitity, some surgeons still recommend the controlled sub-mental pharyngostoma technique as a simple and safe therapeu-tic approach for these complex postlaryngectomy patients [6-9]. We describe our experience with this conservative concept in five  selected  laryngectomy patients. The aim of our  study  is  to revise the elective indication of surgical pharyngostoma for spe-cially selected patients with unsafe wounds, in which, aggressive surgical interventions are not safe.

PATIENTS AND METHODS

General description

This is a retrospective study of a cohort of 100 consecu-tive laryngectomy patients. After laryngectomy, the gen-eral technique of pharyngeal closure was the primary su-ture of pharyngeal defects mucosa was sufficient or with a my-ocutaneous  flap  if  the  pharyngeal  mucosa  was  not  suffi-cient [3]. All the patients had similar postoperative nutri-

tional support and nurse care (nasogastric tube with oral feed-ing on day 7-10, suction drains and antibiotic therapy). We present a case series of  five patients underwent a surgical minipharyn-gostoma to assess the results for these specially cases from a rate of 19% of postlaryngectomy fistulas.

Concepts

1. Postlaryngectomy  fistula [10]: any anomalous path con-necting the pharynx and the skin.

2. Pharyngostoma [10]: direct and unplanned open-ing from the pharynx to the skin with fre-quent skin necrosis.

3. Surgical controlled pharyngostoma [6]: when the sur-geon  creates  an  artificial  and  controlled  fistu-la between pharynx and skin for protecting su-ture  line  and  skin  flaps.  These  surgical  pharyngosto-mas can be:

A) Planned [6,8]:  if surgeon plan the artificial fistula preop-eratively,  before  any  fistula  formation,  as  a  prophylactic  tech-nique

B) Unplanned: when the surgeon create the arti-ficial  fistula  to  solve  an  unplanned  chronic  or  infect-ed  fistula  to  avoid  that  infection  spreads  through  all  tis-sues planes of the neck [7,9].

Classification of surgical pharyngostomas

We created the surgical pharyngostomas in our laryngecto

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Ann Otolaryngol Rhinol 4(2): 1162 (2017) 2/3

my patients in three clinical situations:

a) Intraoperative, after the laryngecto-my, as a Planned Pharyngostoma , before the formation of a un-planned pharyngocutaneous fistula ( prophylactic technique).

b) Along postoperative period, after the forma-tion of a  chronic or an  infected  fistula,  as a Controlled Pharyn-gostoma, in order to protect the remaining pharyngeal su-ture and carotid or jugular exposure. 

c) When  the  fistula began  to bleed during nursing  care be-cause  severe  wound  breakdown.  After  carotid  or  jugular  sys-tem ligation, we made an Emergent Submental Pharyngostoma. 

General principles for management of postlaryngec-tomy fistula

The  fundamental  principles  in  the  management  of  fistu-la  after  larygectomy were  described  by  Stell  and  Cooney  [11]. Planned submental pharyngostoma technique had been well de-scribed  in  the  literature  [6-9,  12,  13]. We used  in  our  patients the  classical  technique, with no personal  variations. Guidelines for pharyngostoma  closure were well  described  [3,13].    In  our patients, fasciocutaneous flap (deltopectoral flap of Bakamjiam) and pediculated pectoral major  flap were used  for surgical clo-sure after healing the pharyngostome [14]. 

CASE PRESENTATIONWe made five surgical submental pharyngostomas in our pa-

tients. One of  these surgical pharyngostomes were made  intra-operatory, after the laryngectomy and before fistula formation (a pro-phylactic planned pharyngostoma ) and the other four pharyn-gostomas  along  the  postoperatory  phase,  after  unplanned  fis-tula  formation. We  describe  each  patient who  needed  a  surgi-cal pharyngostoma in our study:

Patient 1

In one patient we created a minipharyngostoma intraopera-tory  after  a  high  risk  salvage  laryngectomy  and  before  fistula formation, as a Planned Prophylactic Pharyngostoma. We could not  use  pectoral  flap  the  laryngectomy due  to  a  previous  non-oncologic surgery in pectoral area. Vascular neck status was very poor because a heavy chemoradiation therapy. After 3 weeks, we closed the pharyngostoma successfully with circular inverted flaps and a submental flap. 

Patients 2,3

Along postoperatory phase, two patients presented an un-planned infected fistula without healing after four weeks with in-tensive nursing and nutritional support. We returned to the op-erating room and, after a meticulous surgical wound debri-dement,  we  created  a  safe  Controlled  Submental  Pharyngos-tome  in  each  two  patient.  We  closed  the  two  pharyngosto-mas three weeks after with a fasciocutaneous deltopecto-ral flap in one patient and with a pediculated myocutaneous pecto-ral flap in the another patient. The surgery was successful.   

Case 4,5

In another two laryngectomy patients,  the  unplanned  fis-tula began to bleed during nursing care in postoperato-ry phase. We had to return immediately to the operation room. Pa-

tient  exhibited  vessel  necrosis  (thyroid  artery  necro-sis in one patient and internal jugular vein rupture in the oth-er  patient).  Urgent  vessels  ligation  and  a  wide  wound  debri-dement were made in the two patients. In the patient with jugu-lar  rupture,  a  myocutaneous  pectoral  flap  was  used  to  cov-er the pharyngeal suture line and to protect the carotid ar-tery.    In  the  two  patients,  we  created  a  controlled  mid-line  pharyngostoma  for  saliva  (an  Emergency  Pharyngos-toma ). The surgery was successful and we closed these pharyn-gostomas four weeks later with a fasciocutaneous deltopecto-ral flap in one patient and with local flaps in the other.   

DISCUSSIONIn spite of the high incidence of fistula formation age of chem-

oradiation  therapy  [1],  no  consensus  exit  about  the  best  tech-nique to optimize pharynx wound healing. So, prevention is bet-ter than any treatment [2]. In effort to minimize wound healing complications in high risk laryngectomy patients, some surgeons recommend the conservative concept of intraoperatory prophy-lactic planned pharyngostoma after laryngectomy [6-12]. Krespy [6]  suggest  to  create  a  pharyngostoma  during  laryngectomy  if we are sure that a complex pharyngostoma will take place dur-ing the postoperatory phase. Sundaram [8], after a rate of 67% of unplanned fistulas after salvage laryngectomy, began to use the controlled pharyngostoma concept in his last 11 salvage larynge-ctomy without regional myocutaneous flaps or free-tissue trans-fers. No fistula formation developed in his patients. We created one surgical pharyngostoma in a salvage-laryngectomy patient with a poor physical health who needed a simple and safe re-construction with low incidence of postoperative complications [5]. The patient had a pervious non-oncologic surgery in pectoral area and microvascular anastomosis was not possible due to the vascular status of neck after chemoradiation [4].

A comprehensive review of literature showed different and controversial results about the management after postlaryngec-tomy fistula formation. Until know, no study proposed a standard clinical guideline or rule for surgical management and closure of these unplanned chronic fistulas. Many surgeons published their techniques to manage the post-laryngectomy fistulas [6-11] but sometimes, modern reconstructive  techniques are very aggres-sive operations for a our unhealthy patients [1,4,5].  After unfavo-rable results with a postlaryngectomy fistula with intensive nurs-ing and nutritional support, we managed theses complex pharyn-gostomes with conservative principles, in order to conversion an unsafe wound in a safe wound in a high-risk laryngectomy pa-tient.  Aggressive modern  reconstructive  techniques  sometimes are  not  indicated  in  these  patients  [1,4,5  ].  Some  authors  still recommending considering the creation of a controlled pharyn-gostoma to minimized the risk of major wound complications in high risk patients [6-11]. We present our successfully experience with this conservative approach in two chronic and infected fis-tulas after four weeks of intense nutritional and nurse support.   Neumann [7] treats these postlaryngecotmy fistulas the sooner after  diagnosis  of  fistula was  archived, with  his  “early  surgical pharyngostoma” concept: the unsafe fistula was modified by an early and safe artificial pharyngostoma. A very complex pharyn-gocutaneous fistula following a large oncologic resection with a gastric transposition was solved by Stew [9] with an easy surgical pharyngostome in a T4 hypopharyngeal carcinoma.  

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FINAL CONSIDERATIONSFrom the review the literature and from our limited surgical

experience about five patients, we suggest some possible indica-tions for surgical mini-pharyngostoma in very selected patients as a low-morbidity surgical alternative to aggressive modern re-construction techniques. Further studies and experiences will be required to confirm these surgical indications. 

CONFLICT OF INTERESTThis research is part of a communication in accept-proc-

ess at IFOS2017.   

REFERENCES1.  Hanasono M, Lin D, Wax MK, Rosenthal EL. Closure of laryngectomy 

defects  in  the age of chemoradiation  therapy. Head Neck. 2012; 34: 580-588.

2.    Patel UA, Moore BA, Wax M, Rosenthal E,  Sweeny L, Militsakh ON, et al. Impact of pharyngeal closure technique on fistula after salvage laryngectomy.  JAMA Otolaryngol Head Neck Surg. 2013; 139: 1156-1162.

3.  Ragbir M, Brown JS, Mehanna H. Recostructive considerations in head and neck surgical oncology. J Laryngol Otol . 2016; 130: 191-197.

4.  Grundmann  T,  Kehrl  W.  Therapy  of  iatrogenic  pharyngocutaneous fistulas-Possibilities of surgical treatment. Laryngootologie 2003; 82: 358-63.

5.  Cordova A, Corradino B, Pirrello R, Di Lorenzo S, Dispenza C, Moschel-

la F. Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyper-baric oxygen therapy. Acta Otolaryngol. 2005; 125: 759-764.

6.  Krespi JP. Pharyngocutaneous Fistula.  In Complications in Head and Neck Surgery. Krespi JP and Ossof RH. WB Saunders Company 1993: 29-34.

7.  Neumann A, Schultz-Coulon HJ. Early surgical pharyngostoma in ther-apy of postoperative pharyngeal fistulas. Laryngorhinootologie. 2001; 80: 269-274.

8.  Sundaram K, Wasserman  JM. Prevention of unplanned pharyngocu-taneous fistula in salvage laryngectomy. Otolaryngol Head Neck Surg. 2009; 141: 645-647.

9.  Stew B, Dafydd C, Berry S, Howard D. A novel surgical method of man-aging a high output pharyngostome. Ann R Coll Surg Engl. 2014; 96: 1-2.

10. Zbar RIS, Funk GF. Pharyngocutaneous fistula in Current Therapy in Otolaryngology-Head  and Neck  Surgery.  Pharyngocutaneous  fistula. 1988; 20: 314-319.

11. Stell  PM, Cooney TC.   Management of  fistulae of  the head and neck after radical surgery. J Laryngol Otol. 1974; 88: 819-34.

12. Chepeha BD. Reconstruction of  the hypopharynx  and esophagus.  In Cummings Otolaryngology Head and Neck Surgery, fifth edition, 2010: 1458-1459.

13. Mallet Y, Kara A. Surgery of orostomas and pharyngostomas. In EMQ Otorhinolaryngology and Cervicofacial Surgery. 2008: 46-305.

14. Mazzola  RF,  Sambataro  G.  Guidelines  for  pharyngostome  closure. Plast Reconstr Surg. 1987; 80: 366-373.

Martin Villares C, Gonzalez Gimeno MJ, Diez Gonzalez L, San Roman CJ, Dominguez CJ, et al. (2017) Surgical Mini-Pharyngostoma: A Safe Technique for Unsafe Laryngectomy Patients. Ann Otolaryngol Rhinol 4(2): 1162.

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