1

Introduction

A 65-year-old man presented to us in late 2008 after a salvage total laryngectomy, bilateral neck dissection, and bilateral sternocleidomastoid myofascial advancement flaps at an outside institution for a T3N1M0 supraglottic squamous cell carcinoma that persisted after radiation. He had a complicated postoperative course with 2 episodes of hemorrhage and a pharyngocutaneous fistula (PCF) that failed multiple attempts at repair with skin grafts, bilateral pectoralis major, and deltopectoral myocutaneous flaps. At time of presentation, he had a persistent PCF of 7 months duration and was dependent on a gastric feeding tube. Surgical exploration of his neck revealed no suitable vessels for free tissue transfer. A salivary bypass tube (SBT) was placed with the funnel resting on the base of tongue and the distal tube in the esophagus ( Fig ). In this manner, the SBT spanned the PCF. He obtained control of his oral secretions via his SBT, and we then advanced him to a clear liquid diet. This was gradually advanced, and within 4 months, he was tolerating a regular diet through the SBT. We then upsized his SBT to further optimize his oral intake. No solid or liquid food passed external to the SBT on deglutition, and he has not had any episodes of aspiration or pneumonia. He continues to maintain a regular diet 30 months postoperatively and has no dysphagia and no further need for G-tube supplementation. There have been no episodes of oropharyngeal bleeding, base-of-tongue erosion, or enlargement of the PCF since the SBT was placed. He remains without local recurrence.

Salivary bypass tube in place in our patient with persistent PCF.

2

Discussion

Pharyngocutaneous fistulae are a common complication after total laryngectomy, with documented incidences ranging from 3% to 65% . Preoperative radiotherapy followed by salvage laryngectomy has been widely recognized to be the most significant risk factor contributing to the development of this complication . Patients undergoing preoperative radiotherapy such as ours have been shown to develop fistulae earlier, have larger fistulae that persist for longer periods, and have an increase requirement for surgical closure of their PCFs compared with patients who did not receive preoperative radiotherapy .

The treatment of PCFs can escalate to be quite complex, thereby increasing the morbidity of patients already subjected to the significant stress of major surgery. Nutritional support remains a significant concern while these patients are kept on a nil-by-mouth status, which often necessitates nasogastric or G-tube feeding. Small PCFs in nonirradiated patients have been shown to respond well to local wound care with spontaneous closure rates in the literature approaching 70% . In fistulae larger than 1 cm in diameter and in patients who had previously received preoperative radiotherapy, surgical closure is often necessary with either primary closure, local flaps, or free tissue transfer. Despite these interventions, however, a small proportion of PCFs continue to persist. In this select group of patients, long-term nutritional support and management to ensure that these PCFs do not increase in severity remains a challenge.

Montgomery and Montgomery, in 1955, described the use of a polyethylene tube that was used to span the distance between the pharyngostomy and esophagogastrostomy in a patient who had a laryngoesophagectomy before reconstruction of the cervical esophagus . We inserted the SBT in our patient to divert salivary flow and facilitate wound healing. Because the SBT was tolerated so well in this patient, we encouraged feeding through it and were pleasantly surprised that he was able to advance to a solid diet including chicken and fish.

Long-term oral intake meeting nutritional needs through an SBT in a total laryngectomy patient with a persistent PCF has not previously been described. The importance of maintaining adequate nutrition is a factor in quality of life measurements in head and neck cancer patients, with malnutrition having an adverse effect . The method of nutritional intake additionally is an important factor because head and neck cancer patients who are dependent on feeding tubes report lower quality of life scores . The patient presented here demonstrates that SBTs are a useful adjunct in the maintenance of oral nutrition in the setting of persistent PCFs who have failed multiple reconstructive attempts.