Conclusion

Salivary fistulae are a troubling complication in surgery of the upper aerodigestive tract. Their prevention is based on sound surgical technique and decision making. Attention to mucosal closure without tension and great vessel protection are the most important factors. If a fistula occurs, the initial management is conservative and supportive unless the carotid artery or jugular vein is exposed. Nutrition should be maximized and hypothyroidism and diabetes corrected. Saliva should be diverted away from the great vessels and protection of the carotid artery provided (Fig. 58-1). If the fistula fails to close after a 4- to 6-week period, surgical closure will be required. The main principle is to close both mucosal and skin defects with well-vascularized tissue, as a single procedure.

Fistula

Hyperalimentation IV Antibiotics

Drains in-situ intact skin flaps

Leave on suction

Drains Out

Pack fistula Irrigation

Healed

Leave on suction

Pack fistula Irrigation

Healed

Healed

Small

Medium

Large

Healed

Small

Medium

Curretage fistula tract

Local flap (if not irradiated) Healed Not healing Healed Not healing

Large

Pect. major flap Free flap

Local excision and closure

Deltopectoral flap Pect. major flap

Figure 58-1 Algorithm of treatment choices (options) for postoperative salivary fistulae.

REFERENCES

Gallagher and Levine—CHAPTER 58

1. Cantrell R. Pharyngeal fistula: prevention and treatment. Laryngoscope 1978;88:1204-1208

2. Soylu I, Kiroglu M, Aydogan B, et al. Pharyngocutaneous fistula following laryngectomy. Head Neck 1998;20:22-25

3. Myers E. The management of pharyngocutaneous fistula. Arch Otolaryngol 1972;95:10-17

4. Dedo D, Alonso W, Ogura J. Incidence, predisposing factors and outcome of pharyngocutaneous fistulas complicating head and neck cancer surgery. Ann Otol Rhinol Laryngol 1975; 84:833-840

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6. Boyce S, Meyers A. Oral feeding after total laryngectomy. Head Neck 1989;11:269-273

7. Thawley S. Complications of combined radiotherapy and surgery for carcinoma of the larynx and inferior hypopharynx. Laryngoscope 1981;91;677-700

8. Bastian R, Park A. Suction drain management of salivary fistulas. Laryngoscope 1995;105:1337-1341

9. Freeland A, Rogers J. The vascular supply of the cervical skin with reference to incision planning. Laryngoscope 1975;85:714-724

10. Burke J. The effective period of preventative antibiotic action in experimental incisions and dermal lesions. Surgery 1961;50: 161-168

11. Newman RK, Weiland FL, Johnson JT, et al. Salivary scan after major ablative head and neck surgery with prediction of postoperative fistulization. Ann Otol Rhinol Laryngol 1983;92:366

12. Hill G. Surgical metabolism and nutrition. In: Marshall V, Ludbrook J, eds. Clinical Science for Surgeons. Boston: Butterworths; 1988:103-121

13. Lavelle R, Maw A. The aetiology of post-laryngectomy pharyngo-cutaneous fistulae. J Laryngol Otol 1972:785-793

14. Wei W, Lam K, Wong J, Ong G. Pharyngocutaneous fistula complicating total laryngectomy. Aust NZ J Surg 1980;50: 366-369

15. Frederickson J, Haight J. Prevention of pharyngeal fistulae. In: Snow JB, ed. Controversy in Otolaryngology. Philadelphia, PA: WB Saunders; 1980:371-378

16. Walter J, Israel M. General Pathology. 6th Ed. New York: Churchill Livingstone; 1987:117-129

17. McCombe A, Jones A. Radiotherapy and complications of laryngectomy. J Laryngol Otol 1993;107:130-132

18. Cummings C, Johnson J, Chung C, Sageman R. Complications of laryngectomy and neck dissection following planned preoperative radiotherapy. Ann Otol Rhinol Laryngol 1977; 86:745-750

19. Maw A, Lavelle R. The management of post-operative pharyngo-cutaneous pharyngeal fistulae. J Laryngol Otol 1972; 86:795-805

20. Papazoglou G, Doundoulakis G, Terzakis G, Dokianakis G. Pharyngocutaneous fistula after total laryngectomy: incidence, cause, and treatment. Ann Otol Rhinol Laryngol 1994;103: 801-805

21. Stell P, Cooney T. Management of fistulae of the head and neck after radical surgery. J Laryngol Otol 1974:819-834

22. Cohen M, Marschall M, Greager J. Early, aggressive management of postoperative oropharyngocutaneous fistulas. Plast Reconstr Surg 1992;89:56-61

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Fistulae in Head and Neck Surgery

Aongus J. Curran and Patrick J. Gullane

CHAPTER 59

Fistula formation after head and neck surgery is a serious complication as it leads to prolonged hospitalization and increased patient morbidity. The overall reported incidence varies considerably in the literature, although generally one-third of people who undergo major ablative surgery for oral, pharyngeal, hypopharyngeal, and laryngeal cancers will develop a fistula.1'2 Despite this frequency, there is considerable debate among surgeons as to the most important risk factors and how best to prevent fistula formation. Any factor that impairs wound healing, such as poor nutritional status and preoperative radiotherapy, is likely to contribute to the formation of a fistula.3,4 Synchronous neck dissection, low postoperative hemoglobin, type of pharyngeal closure (T versus linear), and residual disease are other factors that may predispose to this complication.5,6 Technical factors, such as gentle atraumatic handling of the soft tissues, achieving a watertight anastomosis, ensuring complete hemo-stasis, and using closed suction drains to eliminate dead space, are key factors in its prevention. In our institution, the rate of postlaryngectomy pharyngocutaneous fistulae and its association with age, gender, preoperative radiation, TNM staging, and a number of other clinical and therapeutic parameters, was investigated.7 The overall fistula rate was 22% and no association was found between any of the above clinical or treatment parameters and the likelihood of developing a fistula. The development of a fistula post head and neck surgery remains a common and poorly understood problem. This chapter focuses on the main types of fistulae and how they are best managed.

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