Fistula formation after head and neck surgery is a serious complication as it leads to prolonged hospitalization and increased patient morbidity. The overall reported incidence varies considerably in the literature, although generally one-third of people who undergo major ablative surgery for oral, pharyngeal, hypopharyngeal, and laryngeal cancers will develop a fistula.1, 2 Despite this frequency, there is considerable debate among surgeons as to the most important risk factors and how best to prevent fistula formation. Any factor that impairs wound healing, such as poor nutritional status and preoperative radiotherapy, is likely to contribute to the formation of a fistula.^{3, 4} Synchronous neck dissection, low postoperative hemoglobin, type of pharyngeal closure (T versus linear), and residual disease are other factors that may predispose to this complication.^{5, 6} Technical factors, such as gentle atraumatic handling of the soft tissues, achieving a watertight anastomosis, ensuring complete hemostasis, and using closed suction drains to eliminate dead space, are key factors in its prevention. In our institution, the rate of postlaryngectomy pharyngocutaneous fistulae and its association with age, gender, preoperative radiation, TNM staging, and a number of other clinical and therapeutic parameters, was investigated.⁷ The overall fistula rate was 22% and no association was found between any of the above clinical or treatment parameters and the likelihood of developing a fistula. The development of a fistula post head and neck surgery remains a common and poorly understood problem. This chapter focuses on the main types of fistulae and how they are best managed.

Pharyngocutaneous Fistula

Pharyngocutaneous fistulae usually follows oncologic resection of oropharyngeal, hypopharyngeal, or laryngeal tumors. Once this occurs, saliva pours into the neck and this may lead to skin breakdown, flap necrosis, vessel exposure, and/or rupture. Initially erythema and tenderness in the lower neck incision or skin flap are present, which leads to the development of a fistula. There may be an associated pyrexia and leukocytosis. The extent of the fistula will become apparent over a number of days and is primarily dependent on the degree of mucosal separation at the site of closure. With massive fistulae, the entire neck skin may slough, exposing major neural and vascular structures.

Management

This may be conservative or surgical and is dictated by size and location of the fistula. Small fistulas often heal spontaneously with meticulous wound care, consisting of antiseptic dressings, minimal debridement, and antibiotics. The patient is fed by nasogastric/gastrostomy tube or parenterally with careful monitoring of nutritional and biochemical status. With this form of management, most fistulae heal by secondary intention. Every attempt is made to divert the flow of saliva medial to the carotid artery, usually with the aid of a carefully placed Penrose drain and to minimize tracheal aspiration. Oral feeding is commenced once the integrity of the upper aerodigestive tract is ensured by contrast medium or Methylene Blue dye swallow. Small fistulae may take up to 1 month or more to close by such a conservative approach.

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