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.


Hyperalimentation IV Antibiotics

Drains in-situ intact skin flaps

Leave on suction

Drains Out

Pack fistula Irrigation


Leave on suction

Pack fistula Irrigation









Curretage fistula tract

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


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.


Gallagher and Levine—CHAPTER 58

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Fistulae in Head and Neck Surgery

Aongus J. Curran and Patrick J. Gullane


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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