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.

Treatment of large pharyngotracheal fistulas after laryngectomy by a novel customized pharyngeal stent.

Persisting tracheoesophageal (TEF) and/or tracheopharyngeal (TPF) fistulas after laryngectomy are incessant problems that can lead to a tremendous loss of quality of life among patients. As soon as surgical options for closing fistulas become impractical, then alternative approaches to stent the fistulas gain significant value. Conventional stents seldom seal the entire fistula, might dislocate and tend to induce tissue proliferation and cause discomfort to the patient. On the basis of these side effects a novel customized pharyngeal stent has been developed to completely seal the fistula without dislocation and discomfort. The anatomic dimensions of the neopharynx in two patients were obtained by a silicone cast of the respective neopharynx and the stent was manufactured according to this anatomical model. The soft silicone edges of the stent match the pharyngeal anatomic structures and follow the changes of the base of the tongue during the process of swallowing. Nevertheless, the stents are rigid enough to remain in place. The reported two patients were able to subsist by themselves orally most of the time without any signs of leakage at all. One stent had to be explanted after 7 months due to an enlargement of the fistula. The second stent is still in place for 10 months up to now without any side effects.