Early surgical pharyngostoma in therapy of postoperative pharyngeal fistulas

Abstract

Postoperative salivary fistulas after laryngectomy occur in 2-65% of cases according to the literature. They are not only inconvenient but also dangerous, as the permanent leakage of saliva prevents wound healing and may cause a life threatening arrosion hemorrhage from the jugular vein or carotid artery. Spontaneous closure of such fistulas is unlikely unless the leakage of saliva can be reduced sufficiently by suction and wound compression. However, about 50% of these patients develop a mucocutaneous pharyngostome after several weeks or even months, then requiring extensive flap reconstruction. In order to shorten this long rehabilitation process and to protect the patient from the danger of hemorrhage the commonly recommended therapeutic concept was modified in that the saliva was completely drained from the wound by creation of a submental epithelialized pharyngostome. In this paper our 10 year experience with this concept is reported. During the period from 1991 to 1999 postoperative salivary fistulas were seen in 9 of 94 consecutive patients after total laryngectomy. Right after diagnosis a meticulous surgical wound debridement was performed and a submental pharyngostome was created in each case. After healing of the mucocutaneous lining the pharyngostome itself was closed with regional skin flaps. In 7 of the 9 patients a quick and permanent closure of the fistula was achieved by the treatment described. The sooner after diagnosis of the fistula the pharyngostome was created, the earlier the closure of the fistula was obtained. In 1 patient the pharyngeal reconstruction was complicated by nosocomial infections, 1 patient died in the course of treatment due to non fistula related concomitant disease. In case of postoperative salivary fistulas following laryngectomy the immediate creation of a mucocutaneous pharyngostome can reduce the duration of treatment and at the same time protect the patient from the danger of vascular arrosion.