We read with interest the case reported by Gooi et al. describing long term oral intake through a salivary bypass tube (SBT) with a chronic pharyngocutaneous fistula (PCF).

We agree that PCF is a significant complication of salvage laryngectomy that has become more problematic with the increased use of organ preserving chemoradiotherapy . The authors use of the SBT for the early management of their patient is entirely appropriate. This clearly corrected the patient’s nutritional status and consequently his general physiological status. However, we consider the use of a SBT for long term management is inappropriate in other than a most exceptional case which this does not appear to be. Our main concern with the proposed management as a long term solution is that the PCF is allowed to persist and as such the inherent problems and risks associated with PCFs remain. Apart from the morbidity and burden of such a wound on the patient and family, there is a mortality risk from major neck vessel erosion and haemorrhage.

To eliminate such sequelae the PCF must be closed. This will not occur with conservative management in a background of a previous radiotherapy field due to radiation-induced fibroatrophy . Well vascularised tissue must be recruited to the area to aid healing in such wounds. We, as other groups, favour free tissue transfer over local flaps in such cases . They have the advantage in allowing one to choose the most appropriate tissue that can be most readily tailored to a defect. This avoids any potential dead space and has better wound edge apposition. This remains our primary choice of management of PCF as it provides a truly long term solution.

In the reported case, the key issue is vascular supply. However, options outside the neck such as the internal mammary vessels are described and allow free tissue transfer . Although not generally considered, we strongly recommend them as an option in vessel depleted necks.