What management is possible for small pharyngocutaneous fistulas (PCFs) in patients with limited survival chance who are not candidates for surgery?
Background: Some of the most common complications following total laryngectomy are PCFs. While a standard protocol for PCF management does not exist, the first approach is conservative management with wound care and tube feeding. When this fails, surgical closure is indicated but the approach is difficult, especially in a previously radiated field.
Study design: Case report
Setting: Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute
Synopsis: In a 61-year-old male who required total laryngopharyngectomy for hypopharynx carcinoma, a small PCF developed one week after surgery. After two weeks of conservative management with wound care, there were no signs of decrease in PCF size.
With the help of a pectoralis major myocutaneous flap (PMMF), surgeons pursued reconstruction, but after three weeks the patient developed a PCF at the same location. Six weeks of conservative management were unsuccessful, and an epithelialized fistula developed. Taking into account the patient’s limited life expectancy and tissue healing problems, as well as the complications with earlier flap reconstructions, physicians sealed the defect with a 6 mm-long Provox 2, which stopped drainage from the fistula and eventually allowed the patient to speak and eat. He died about four months after his hospital discharge.
The authors noted that if the PCF has well-defined and epithelialized edges, anterograde insertion with the special inserter should be preferred. If the defect is too small for voice prosthesis, this can be dilated to accommodate a voice prosthesis. If the defect is not well defined, retrograde insertion may be preferred.
Bottom line: In a patient with a small fistula and limited life expectancy, a voice prosthesis can be used instead of surgical intervention to relieve the patient.
Reference: Karakullukcu MB, Lohuis PJ, van den Brekel MW, et al. Sealing of small postlaryngectomy pharyngocutaneous fistulas with voice prosthesis. Laryngoscope. 2010;120(10):1971-1973.
—Reviewed by Sue Pondrom