Discussion

A salivary fistula may occur at any time following surgery but most commonly is detected 5 to 10 days postoperatively, though they may occur later in patients who have undergone prior irradiation.18 A late-developing fistula, one that occurs 3 to 4 weeks after surgery, or a few months after complete healing, is considered persistent or an indication of recurrent malignancy until proven otherwise. The patient will develop a low-grade fever 3 to 4 days postoperatively, which will occur a few days before significant induration of the wound is noted, and no other etiology of the elevated temperature is noted. Typically, the wound skin becomes inflamed, and the most dependent fistula drainage point becomes edematous and red. It is prudent to open an area along the suture line to permit drainage of purulent material. This controlled drainage should be made to divert saliva away from the carotid artery. Opening the wound limits the spread of saliva and infected material beneath the skin flaps. Cultures should be sent, even though the results most often exhibit mixed oral flora. Irrigation of the wound with half-strength hydrogen peroxide and packing with plain gauze soaked in 1% povidone-iodine is performed 4 times per day.

Hyperalimentation, most commonly via nasogastric or gas-trostomy tube, is peremptory to assist in providing a caloric load of about 2000 calories/day.

If the suction drains are still in place when a fistula occurs, the drain volumes increase and the character of the drainage changes. Saliva is usually obvious, but the drainage may be frankly purulent, with a volume within the range of 50 to 100 ml/day. If the increased drainage, > 150 ml, is on the left side, a chylous fistula is easily ruled out by placing cream down the feeding tube and observing the drainage at 1 h when it will become obviously milky. Although primarily on the left, a chyle leak may occur on the right by the transection of accessory thoracic ducts. It is best to control the fistula drainage with suction, if necessary, to create a mature fistula tract. This allows the skin flaps to heal to the deep neck tissue and avoids the potential problem of necrosis of a large amount of skin, which exposes underlying structures. It is hoped that, as the fistula heals, granulation tissue will stimulate closure and healing will be exhibited by a reduction in fistula fluid volume.

High-dose intravenous (IV) antibiotics are used until the wound is clean and the drainage clear. Once frankly purulent drainage has ceased and the wound is clean, antibiotics can be given enterally until the fistula is healed, or can potentially be discontinued.

The local management of the fistula depends on its site and size. Fistulae related to the great vessels and the laryngectomy stoma have the highest morbidity. If the skin flaps are intact, the fistula can be managed conservatively with irrigation and packing, since the underlying tissue will not be exposed to the added drying effect of air exposure. In the case of a high-volume fistula, the fistula should be directed medial to the great vessels.3,28 This is done by incising directly over the pharyngeal defect, which is then sutured to the overlying skin. Pressure dressings or suction drains are used to permit healing of the surrounding skin flaps. The resulting mature fistula will require secondary closure with a flap when the wound is clean and granulating.

More problematic is the case of significant tissue necrosis, leaving a large soft tissue defect. In these cases, the wound should be irrigated and dressed regularly to prevent drying and excoriation of the tissues. Necrotic material may be debrided in the operating room and, if the carotid artery is exposed, tissue coverage is required. The choices are a dermal graft or the rotation and suturing of the sternomastoid or levator scapulae muscle over the vessel to the prevertebral fascia. Preferably, these defensive maneuvers would have been performed at surgery. A further option is the early application of a pectoralis major myocutaneous flap. Because a "good" flap will not heal to "bad" tissue, the wound may have to be temporized with defensive maneuvers until it is clean and granulating. Depending on the size of the defect, split skin grafts may need to be applied to the muscle.

In total laryngectomy and laryngopharyngectomy patients, the fistula will often be small, but troublesome, because it is sited directly above the laryngectomy stoma. Left unattended, this can result in continued wound breakdown and severe aspiration. They are best dealt with by insertion of a cuffed tracheotomy tube and placement of a suction catheter to detour the saliva, or a salivary bypass tube inserted endoscopically and packing placed through the fistula. We traditionally wait 2 weeks after the complete closure of the fistula before feeding by mouth, and do not normally perform a barium swallow before oral intake.

In general, our policy is to create a clean granulating fistula wound by local wound care and observation. The patient is supported nutritionally, and any systemic disorders such as diabetes or hypothyroidism are controlled. Small fistulae, in our experience, will close over several weeks. Larger fistulae with significant loss of skin and mucosa are closed with usage of myocutaneous or free flap, after a 4- to 6-week wound cleaning and healing period.

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