Management of a Postoperative Orocutaneous Fistula with Transoral Negative Pressure Therapy

Abstract

Orocutaneous fistulas are a common problem in head and neck reconstruction and can be a challenge to manage. They result in persistent wound drainage, poor healing, and delay in adjuvant therapy and may precipitate flap failure. Negative pressure wound therapy offers several benefits, including increasing granulation tissue formation, promoting wound contraction, and removing moisture to promote fistula closure. Its use in head and neck reconstruction has few documented attempts in the literature for managing complicated intraoral wounds. The goal of this study was to establish feasibility and efficacy of an intraoral NPWT for management of post-surgical orocutaneous fistulas.The patient was a 73-year-old female with a history of pT2N0M0 squamous cell carcinoma of the left buccal mucosa who had previously undergone primary resection and reconstruction with a parascapular free flap with adjuvant radiation. Ten years following her original treatment, she developed osteoradionecrosis with an orocutaneous fistula and a pathologic fracture. She underwent a segmental mandibulectomy and reconstruction with an osteocutaneous free flap.She had an uneventful postoperative course and was discharged on day 6. One-week post-discharge, the native oral mucosa overlying the fibula flap had broken down, and a significant orocutaneous salivary leak was present (Figure 1). Given the proximity of the salivary collection to the pedicle, there was concern this would compromise the anastomosis and result in flap loss. Any surgical intervention to correct the problem would require extensive remobilization of the existing inset or elevation of a second soft-tissue flap. Thus, the decision was made to pursue an alternative novel treatment option.Impressions were obtained and a stone model poured to fabricate an acrylic splint that could support the negative pressure device (Figure 2). The stent was relined with polyvinyl siloxane impression material to ensure adequate seal against the mucosa. The intraoral appliance would not initially hold suction because of the air leak from the cutaneous portion of the fistula, so a VAC sponge was adapted and a Y-connector was used to apply negative pressure to both sites simultaneously.The patient was able to tolerate wearing the device around the clock as continuous suction was able to be maintained. She followed up every third day to change the VAC dressing and to make adjustments as needed. She continued to be fed via Dobhoff tube during this period.On follow-up 2 weeks later, the patient had significant granulation tissue formation in her intraoral wound with almost complete closure.At this point, the intraoral device was discontinued, but the VAC dressing on the neck was maintained for an additional 2 weeks until the intraoral component of the fistula had closed completely and was no longer able to be probed (Figure 3).The principle aim of this study was to determine the efficacy and practicality of an intraoral wound VAC device in the management of an orocutaneous fistula. There was a positive benefit to healing of the orocutaneous fistula for this patient, as she had dramatic granulation tissue formation within 2 weeks of using the device. An intraoral wound VAC device seems a viable option for acute management of orocutaneous fistulas in select patients. The use of such a device would require significant patient compliance and commitment as well as technique sensitive dressing application that may not be suitable in all cases.