Utility of the Montgomery salivary tubes for preventing pharyngocutaneous fistula in total laryngectomy.

PURPOSE: To evaluate the prophylactic, protocolized, and standardized use of a Montgomery tube in preventing pharyngocutaneous fistulas after total laryngectomy and neck dissection. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral centre. SUBJECT AND METHODS: A Montgomery salivary bypass tube was placed in 44 patients undergoing total laryngectomy and neck dissection, observing the percentage of fistula appearance and the time of start of deglutition. Comparison was made with a group of 28 patients prior to the implantation of the protocol in whom the tube was not used. RESULTS: There was a statistically significant decrease in the percentage of fistulas and an earlier onset of deglutition in the salivary bypass tube patients compared to those in whom the tube had not been used. CONCLUSION: Prophylactic and standardized use of the Montgomery salivary bypass tube in patients undergoing total laryngectomy and neck dissection might decrease the incidence of pharyngocutaneous fistula and improve the course of one that is already established.

Chimeric Lateral Arm Free Flap to Treat Pharyngocutaneous Fistula After Total Laryngectomy.

Pharyngocutaneous fistula is a major complication after total laryngectomy, leading to a severe adverse impact for the patient and social activity. The reported incidence ranges from 9% to 25% in the last decade. In this paper, the authors present our experience using chimeric lateral arm free flap for reconstruction of the pharyngo-esophageal segment. Eight patients with pharyngocutaneous fistula were treated with this technique. The flap has 2 skin islands, each one supplied by a perforator coming from the main pedicle. One skin island is used as a patch for pharynx closure and the other is used for anterior soft tissue coverage. The follow-up period ranged from 8 months to 3 years. All flaps survived. There was 1 small fistula that was sutured. External skin wound dehiscence was present in 1 case and it was secondary closed by itself. All patients were able to eat by mouth and there were no signs of stricture. The authors preferred this type of flap because both defects are simultaneously closed and each skin paddle is supplied by a perforator coming from the main pedicle. It has a better color match than other free flaps. The skin island is thin and remains thin even after the patients gain weight.

Three Simultaneous Free Flaps to Reconstruct a Complex Frozen Neck and a Large Hypopharyngeal Fistula.

Frozen neck and hypopharyngeal fistula are sometimes present after tumor ablation of the larynx, multiple local surgeries with scar tissue, and radiotherapy and chemotherapy. This multiorgan involvement requires 1 or even 2 flaps. We present a 63-year-old heavy smoker with frozen neck tissue and simultaneous large hypopharyngeal fistula and neck defect. After careful preoperative planning, he was successfully treated with 3 simultaneous free flaps: 2 anterolateral thigh flap (ALT) and 1 lateral arm flap (LAF). One ALT was used as a patch to restore the hypopharynx continuity. A second ALT was used to cover the anterior neck defect and the LAF flap was used to reconstruct the submandibular area. The flaps survived and the patient had a 5 mm proximal fistula which was sutured, and he was able to eat per mouth. By combining multiple free flaps, we were able to restore the function of the hypopharynx and to cover the esthetic units of the neck by avoiding the "turkey neck" appearance.

First Complex Allotransplantation of Neck Organs: Larynx, Trachea, Pharynx, Esophagus, Thyroid, Parathyroid Glands, and Anterior Cervical Wall: A Case Report.

OBJECTIVE: Evaluate the possibility of performing a complex vascular allotransplant of all neck organs including skin. SUMMARY BACKGROUND DATA: There are 2 previous attempts described in the literature, none of them being that complex. The first one is nonfunctional due to chronic rejection, the second one is viable yet considerably limited in complexity (no parathyroids, no skin). METHODS: The allotransplantation was performed simultaneously on 2 adjacent operating rooms, using microsurgical techniques. RESULTS: The patient's voice, breathing through mouth, swallowing, and endocrinal functions have been fully restored. CONCLUSIONS: Achieved results show clearly that such operations performed in selected patients can nearly fully restore functional and aesthetic effects in 1 single procedure.

A Simple Closure Technic for Tracheoesophageal Puncture Failures.

Tracheosephageal puncture is the one of the most favorable methods, and widely used by physicians for voice reconstruction after total laryngectomy. Intractable leakages from the tracheosephageal punctures are the most common complication, and management of these fistulas is still troublesome for the patients and physicians. Local surgical sutures, rotational flaps, injections are reported previously, but in this report the authors aimed to mention on a very simple method with silicone septal button. Insertion of a temporary silicone septal button may be well tolerated by patients and can help to manage this complication easily on exact indications. The authors discussed indications and long-term results of this method with different patients.

Treatment of tracheopharyngeal and tracheo-oesophageal fistulas following laryngectomy and fistula classification based on individual silicone casts.

Persistent tracheopharyngeal (TPF) and tracheo-oesophageal (TEF) fistulas after laryngectomy create a therapeutic challenge. The current classification of TPFs and TEFs is based on clinical experience without detailed anatomical information. In this study, casts of TPFs/TEFs were obtained from 16 patients; these were the first steps in manufacturing customised prostheses. Fistulas were classified according to the shape and dimension of the tracheopharyngeal and tracheo-oesophageal silicone casts and prostheses as well as on epithetic requirements. Four different types of fistulas were classified: Type A, a fistula with a straight axis between the neopharynx and oesophagus; Type B, a fistula with a stenosis of the neopharynx but a straight axis; Type C, the axis between the neopharynx and oesophagus is flexed anteriorly; and Type D, neighbouring structures are absent creating a large defect. This classification system might improve the manufacturing processes of customised prostheses in individual cases with challenging tracheopharyngeal and tracheo-oesophageal fistulas.

Necrotizing fasciitis of the neck after total laryngectomy.

Necrotizing fasciitis (NF) is an unusual, life threatening, rapidly advancing infection characterized by widespread fascial and subcutaneous tissue necrosis and gangrene of the skin. It most commonly affects the extremities, abdominal wall and perineum, whereas cervical NF is rare. NF of the head and neck is often caused by both aerobic and anaerobic microorganisms found in the upper aerodigestive tract. Usually, cervical NF originates from odontogenic, tonsillar and pharyngeal infection, and it is very rarely a complication of surgical procedure. Without immediate surgical treatment, cervical NF leads to mediastinitis and fatal sepsis. There is only one case of cervical NF after total laryngectomy described in the literature. We report two cases of cervical NF after total laryngectomy, selective neck dissection and primary vocal prosthesis insertion. In both cases, the infection spreads to thoracic region and in one of them NF was associated with Lemierre's syndrome, i.e., thrombosis of the internal jugular vein. In both patients, vocal prosthesis was inserted during the infection and did not influence the healing process.

Surgical site infection in clean-contaminated head and neck cancer surgery: risk factors and prognosis.

Since new treatment strategies, such as chemoradiotherapy, have been introduced for head and neck cancer, a higher number of unknown factors may be involved in surgical site infection in clean-contaminated head and neck cancer surgery. The aim of the present study was to clarify the risk factors of surgical site infection in clean-contaminated surgery for head and neck cancer and the prognosis of patients with surgical site infection. Participants were 277 consecutive patients with head and neck cancer who underwent clean-contaminated surgery for primary lesions at the Aichi Cancer Center over a 60-month period. A total of 22 putative risk factors were recorded in each patient and statistically analyzed to elucidate surgical site infection related factors. Surgical site infection was observed in 92 (32.1 %) of 277 cases. Univariate analysis indicated that alcohol consumption, T classification, neck dissection, reconstructive procedure, and chemoradiotherapy were significantly associated with surgical site infection. Multiple logistic regression analysis identified two independent risk factors for surgical site infection: reconstructive surgery (p = 0.04; odds ratio (OR) 1.77) and chemoradiotherapy (p = 0.01; OR 1.93). In spite of surgical site infection, the five-year overall survival rate of patients with surgical site infection was not significantly different from those without surgical site infection. Although surgical site infection did not impact the overall survival of patients with surgical procedures, head and neck surgeons should pay attention to patients with previous chemoradiotherapy as well as to those with a high risk of surgical site infection requiring reconstructive surgery.

[Indications and complications prevention and management of phaseâ ¡ implantation of Provox Vega voice prosthesis after total laryngectomy].

Objective: To explore the indications and management of common postoperative complications of phase II tracheoesophageal puncture (TEP) for Provox Vega voice prosthesis after total laryngectomy. Methods: The clinical data of 20 patients undergoing phase II TEP for Provox Vega voice prosthesis in our hospital between May 2021 and January 2022 were analyzed. Among them, there were 19 males and 1 female, aged from 37 to 76 years, with an average age of (60.0±8.4)years. The surgical indications and the prevention and treatment of common postoperative complications were summarized. Descriptive analysis was used in this research. Results: The basic surgical indications were as following: after total laryngectomy, there was no stenosis of the stoma and esophagus entrance, no scar constitution, no mouth opening restriction, no stiffness and backward restraint of the neck after radiotherapy, and more than half a year apart surgery or radiotherapy. Among the 20 patients, 18 underwent implantation successfuly, 1 failed in the operation, and for 1 patient, the prosthesis was removed due to bleeding 1 week after implantation. The common postoperative complications included TEP fistula infection (2 cases), the TEP fistula bleeding(1 case), deep neck (prevertebral) abscess (1 case), granulation at the inner side of the TEP fistula (1 case), invagination of the prosthesis (2 cases) and leakage around the prosthesis (2 cases). All patients were cured with different interventions. Conclusions: The Provox Vega voice prosthesis is generally safe for phase Ⅱ implantatione, but implantation indications need to be established. Common postoperative complications can be solved through preventive and remedial interventions.

Long-term oral intake through a salivary bypass tube with chronic pharyngocutaneous fistula.

Pharyngocutaneous fistulae (PCFs) are a common complication after total laryngectomy. Patients with persistent PCFs are often kept nil by mouth and are dependent on feedings via a gastric tube. Our patient is a 65-year-old man who presented to our clinic in 2008 having a persistent PCF after a total laryngectomy who failed numerous attempts at reconstruction. We inserted a salivary bypass tube as a method of spanning the PCF and advanced his oral diet. He has been able to tolerate a regular diet 30 months postoperatively with no dysphagia and has gained weight. This is a demonstration of salivary bypass tubes as a useful adjunct to maintain oral intake in the presence of a persistent PCF.

[Speech rehabilitation following a total laryngectomy]. / Spraakrevalidatie na een totale laryngectomie.

In patients with advanced laryngeal or hypopharyngeal cancer, or in cases when the disease recurs after treatment with (chemo)radiation, a total laryngectomy (TLE) is performed. For them to be able to function properly, speech rehabilitation is of the utmost importancefor these patients. For voice rehabilitation, voice prostheses or an electrolarynx can be used. Esophogus-speech can also be applied. In recent decades, voice prostheses in particular have undergone significant development. They can be considered the standard technique for rehabilitation. For dentists, it is important to realise that the anatomy of these patients has changed. In addition, many have a prior history of radiotherapy and thus an increased risk of xerostomia and osteoradionecrosis. In cases where maxillofacial surgery is indicated, the chance of osteoradionecrosis is higher. If extraction is considered, consultation with a head and neck oncology centre is necessary.

Indications and complications of secondary tracheoesophageal puncture in Chinese laryngectomees.

BACKGROUND: Although there are many literatures about secondary tracheoesophageal puncture (TEP) for voice prosthesis. Most of the description of indications is not specific and the description of complications is not so vivid, which is not of great value for novice doctors. OBJECTIVE: To show specific indications and vivid complications of secondary TEP with typical clinical pictures for novice doctors. MATERIAL AND METHODS: The clinical data of 20 patients undergoing secondary TEP for Provox Vega voice prosthesis in our hospital were analyzed. The surgical indications and the prevention and treatment of common perioperative complications were summarized. RESULTS: The surgical indications included: no obvious stenosis of the stoma and the entrance of esophagus; no obvious scar constitution, mouth opening restriction and backward restraint of the neck, etc. The common postoperative complications included: TEP fistula infection (2 cases), bleeding of the fistula (1 case), deep neck abscess (1 case), granulation hyperplasia at the inner side of the fistula (1 case), invagination of the voice prosthesis (2 cases) and leakage (2 cases). CONCLUSIONS AND SIGNIFICANCE: The secondary TEP for Provox Vega voice prosthesis is clinically safe, but certain indications should be mastered. Common postoperative complications can be solved through preventive and remedial treatment schemes.

The end of tracheostomal stenosis? Introducing the fish mouth technique.

BACKGROUND: Post-laryngectomy tracheostomal stenosis is common and often results in an inadequate airway. Several techniques have been described to minimise tracheostomal stenosis. The star technique involves an 'X' incision with four flaps sutured into the trachea. The petal technique involves two inferior flaps on either side being sutured into the trachea. The authors combined the star and petal techniques, resulting in an innovative fish mouth technique. METHODS AND RESULTS: This innovation involves two lateral skin flaps being sutured into an incision on either side of the lateral wall of the trachea. This results in an elongated, broadened and elliptical tracheostoma, mimicking that of a fish mouth. CONCLUSION: Benefits of the fish mouth technique include adequate stoma size for respiration, easier clearing of secretions, self-sufficiency without a stent, easier cleaning of a tracheoesophageal voice prosthesis, and stoma occlusion for voice production. The fish mouth technique is easily reproducible and suitable for those with a voice prosthesis.

An automatic water-occluding device to enable laryngectomee participation in water activities.

Individuals with a laryngectomy face a host of challenges ranging from restricted vocal communication to significant lifestyle modifications associated with breathing through a stoma. Although there are significant mental and physical health benefits achieved by returning to recreational pursuits that were enjoyed pre-surgery, there can be significant obstacles in doing so. One particular challenge arises during participation in water activities (e.g, fishing, boating, etc.) where accidental submersion poses a significant risk of drowning. This manuscript describes a proof-of-concept device that protects the airway from accidental incursion of water into the airway during unanticipated submersion in water, thereby allowing laryngectomees to return to participation in water activities. The device is designed to be worn comfortably for long periods of time, while not interfering with the common methods of replacement speech that are utilized post-laryngectomy.

High pharyngoesophageal strictures after laryngopharyngectomy can also be treated by self-expandable plastic stents.

BACKGROUND: Permanent dysphagia occurring after laryngectomy or laryngopharyngectomy can usually be treated by periodic dilation. Occasionally, however, conservative treatment is insufficient, and patients require long-term tube feeding. We describe 4 cases with stricture after laryngopharyngectomy who underwent insertion of self-expandable plastic stents (SEPSs) across the stricture for treatment of dysphagia. OBJECTIVE: The aim of this study was to evaluate the role of SEPSs in postlaryngopharyngectomy strictures. DESIGN: An interventional study of management of 4 patients of dysphagia after laryngopharyngectomy with SEPSs. SETTING: Medical gastroenterology unit in a tertiary care hospital. PATIENTS: Four patients with dysphagia after laryngopharyngectomy. INTERVENTIONS: SEPS placement and removal after 3 months. MAIN OUTCOME MEASUREMENTS: Improvement in dysphagia. METHODS: Four patients with dysphagia after laryngopharyngectomy underwent dilation of stricture followed by SEPS placement for 3 months. RESULTS: Three patients had grade IV, and 1 grade III dysphagia. Endoscopy showed stricture at 10 to 14 cm from the incisors. Stricture was dilated up to 15 mm on 3 occasions, 2 weeks apart. A silicone Polyflex stent was placed across the stricture and removed after 3 months. No dysphagia recurred after 2 months. No significant complications were noted. LIMITATIONS: Small sample size. CONCLUSIONS: SEPSs dilate postlaryngopharyngectomy strictures and prevent restenosis even after removal.

Endoscopic Sealing With a Polyglycolic Acid Sheet for Restoration of Vocal Fold Mucosa in Dogs.

OBJECTIVES/HYPOTHESIS: Voice outcomes of cordectomy for early glottic cancer are often poor due to vocal fold scarring and tissue defects. Improvements in this aspect could make cordectomy a more acceptable treatment option than radiotherapy. We hypothesized that a polyglycolic acid (PGA) sheet could be used to cover vocal fold defects. The present study aimed to prevent vocal fold scarring after cordectomy using the PGA sheet. STUDY DESIGN: Animal experiment. METHODS: Nine male beagles were divided into three groups including a control group (n = 3). Following cordectomy, the vocal fold defect was covered with the PGA sheet plus fibrin glue (PGA group; n = 3) or with the PGA sheet plus fibrin glue containing basic fibroblast growth factor (bFGF; the PGA-bFGF group, n = 3). Vocal folds were chronologically observed, and larynges were removed 6 months after surgery. Mucosal amplitude was measured using a high-speed camera, and histological analysis was performed. RESULTS: The re-epithelialization process was delayed in the PGA and PGA-bFGF groups compared with the control group. The mucosal amplitude was significantly more normalized and the thickness ratio significantly higher in the PGA and PGA-bFGF groups compared with the control group. The PGA-bFGF group had the highest elastic fiber density, followed by the PGA group and then the control group, with a significant difference between the PGA-bFGF and control groups. CONCLUSIONS: The PGA sheet plus fibrin glue could serve as an effective regenerative scaffold for reconstructing vocal fold morphology and function after cordectomy, with the potential benefit of establishing an endoscopic sealing method for vocal fold defects. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E436-E443, 2020.

Quality of life in patients treated with PDMS injection for swallowing disorders.

OBJECTIVE: To document the efficacy of polydimethylsiloxane (PDMS) injections in patients with swallowing disorders after partial supracricoid laryngectomy; to assess the importance of quality-of-life (QOL) outcome in oncologic patients. SUBJECTS AND METHODS: The study included 11 patients with swallowing disorders after partial laryngectomy and appropriate rehabilitation. They were treated with endoscopic injection of PDMS; QOL was investigated with four questionnaires (M.D. Anderson Dysphagia Inventory, Performance Status Scale for Head and Neck Cancer, Performance Karnofsky Scale, and Voice Handicap Index-10) before and after surgical treatment and further rehabilitation. RESULTS: A significant improvement in QOL of all 11 patients was seen after endoscopic injection. The impact of this treatment on the social life of patients was considerable. CONCLUSION: Swallowing disorders and speech problems are quite common complications of partial laryngectomy. QOL in oncologic patients is a mandatory outcome measure. PDMS injection showed an improvement in the everyday life of selected patients.

[Tracheal stenting in patients treated due to carcinoma of the larynx]. / Protezowanie tchawicy za pomoca stentów u chorych leczonych z powodu raka krtani.

INTRODUCTION: Stenosis of the trachea and main bronchia can occur in patients with lung, larynx, thyroid gland, esophagus, in metastatic tumors, can be also caused by trauma and foreign bodies. Treatment in this condition can be difficult. Tracheal stenosis in patients after total removal of the larynx is relatively rare. It can be caused by recidiv tumor and inflammation processes. AIM OF THE STUDY: Was to evaluate usefulness of stents in patient with stenosis of the trachea after total laryngectomy due to squamous cell carcinoma. MATERIAL AND METHODS: Authors described two cases of patient after total laryngectomy. Nitinol, expandable, tracheal stents were used in both cases. Placement of the stent into the trachea was relatively simple. Patients have undergone this procedure in short general anesthesia. RESULTS: After stenting patients exhibited dramatic improvement in their respiratory symptoms and quality of life. CONCLUSIONS: Stents are useful in cases of tracheal stenosis and the effect is related to the reason of stenosis.

A thin tracheal silicone washer to solve periprosthetic leakage in laryngectomies: direct results and long-term clinical effects.

OBJECTIVES: Assessment of the immediate results and long-term clinical effects of a thin silicone washer placed behind the tracheal flange of voice prostheses to treat periprosthetic leakage. PATIENTS AND METHODS: Three year retrospective analysis of 32 laryngectomized patients with 107 periprosthetic leakage events (PLEs). Custom-made silicone washers (outer diameter 18 mm, inner diameter 7.5 mm, thickness 0.5 mm) were placed behind the tracheal flange either in combination with prosthesis replacement or later. RESULTS: There was immediate resolution of periprosthetic leakage in 88 PLEs (median, 38 d; mean, 53 d; range, 8-330 d) and in 6 PLEs with the washer still in situ at the date of analysis (median, 75; mean, 97 d; range, 38-240 d). There was no resolution for periprosthetic leakage in 13 PLEs. Thus, in total, 94 of 107 PLEs (88%) were successfully resolved. In 29 of 32 (91%) patients, the washer resolved the problem at least in one PLE successfully. Twelve of 32 patients, including all 3 with washer failures, also required other interventions to ultimately solve the problem. The vast majority of patients (80%) did not consider placement of the washer to be inconvenient. CONCLUSIONS: In consideration of the high success rate and limited inconvenience for patients, this simple thin silicon washer application provides a good first option for the treatment of periprosthetic leakage.