Abstract
Introduction
PCF is the most common major complication after salvage total laryngectomy (TL), especially for previously irradiated patients with laryngeal or hypopharyngeal cancer.
Methods/results
A 65-year-old woman presented with recurrent bilateral supraglottic SCC requiring salvage TL 5.5 years after initial T1N0M0 epiglottic SCC resection. Her post-operative course was complicated by PCF development one month post-operatively and surgical fistula closure was delayed for adjuvant chemoradiotherapy. The fistula persisted despite local wound therapy, several primary closures, pectoralis flap reconstruction with multiple revisions, and extensive hyperbaric oxygen treatments. Given her prior history, she underwent a staged right temporoparietal fascial flap reconstruction for persistent complex fistula, with second-stage flap takedown and complete inset of the TPFF skin island into the PCF.
Conclusion
This case demonstrates the utility of staged TPFF in complex PCF repair, with minimal morbidity, especially in a patient with prior irradiation and flap use that complicates tissue availability.
1
Introduction
We report a case of successful persistent and complex pharyngocutaneous fistula (PCF) closure using a staged temporoparietal free flap (TPFF). PCF is the most common major complication after salvage total laryngectomy (TL), especially for previously irradiated patients with laryngeal or hypopharyngeal cancer. The PCF rate after laryngectomy is approximately 31% , but varies significantly based on institution. There are several treatment options for PCF repair, including non-surgical management, primary closure, local or regional flaps, and free flaps. Successful fistula closure following TL has been accomplished most frequently with the pectoralis major myofascial flap . However, this approach may not always be suitable due to existing tissue damage, desire to preserve tissue for future reconstruction, prior flap use, or large bulk that may be inappropriate for small fistulas near the tracheal stoma. For these reasons, identification of other flaps can be helpful for complex PCF closure. PCF repair using a TPFF has previously been reported in a single case where the pedicle was incorporated into the neck skin ; however, this case highlights the successful use of a staged TPFF reconstruction in a previously heavily re-irradiated bed.
2
Report of a case
A 65-year-old woman presented with T1N0M0 squamous cell carcinoma of the epiglottis. She was treated with radiotherapy, but 5.5 years later had recurrent laryngeal disease with a large bilateral supraglottic mass requiring salvage TL and bilateral selective level II-IV neck dissections. Her post-operative course was complicated by PCF development one month post-operatively, resulting in multiple wound care admissions. Surgical fistula closure was delayed given need for adjuvant chemoradiotherapy. The fistula persisted despite local wound therapy, several primary closures, pectoralis flap reconstruction with multiple revisions, and extensive hyperbaric oxygen treatments at an outside institution ( Fig. 1 ). Tracheoesophageal prosthesis placement into the fistula site was also attempted but subsequently failed. Approximately two years after salvage TL, she presented to our institution for additional PCF closure options. Given her prior history, she underwent a staged right temporoparietal fascial flap reconstruction for persistent complex fistula, with second-stage flap takedown and complete inset of the TPFF skin island into the PCF ( Fig. 2 and Supplemental Video ). Four months post-operatively, the flap fully healed within the prior fistula tract, without drainage evidence ( Fig. 3 ). The patient resumed an oral diet without complication.
