This may be conservative or surgical and is dictated by size and location of the fistula. Small fistulas often heal spontaneously with meticulous wound care, consisting of antiseptic dressings, minimal debridement, and antibiotics. The patient is fed by nasogas-

tric/gastrostomy tube or parenterally with careful monitoring of nutritional and biochemical status. With this form of management, most fistulae heal by secondary intention. Every attempt is made to divert the flow of saliva medial to the carotid artery, usually with the aid of a carefully placed Penrose drain and to minimize tracheal aspiration. Oral feeding is commenced once the integrity of the upper aerodigestive tract is ensured by contrast medium or Methylene Blue dye swallow. Small fistulae may take up to 1 month or more to close by such a conservative approach.

Massive fistulas are associated with extensive overlying skin loss and mucosal dehiscence. Initial management consists of controlled exteriorization after surgical debridement. Residual or recurrent disease must be considered a possibility when a large fistula fails to close by secondary intention. The conservative measures described above for smaller fistulae also apply to this group of patients; once clean/fresh granulation tissue appears, the wound is usually ready for closure. The exception is the patient with major vessel exposure where urgent cover with vascularized tissue is needed to prevent carotid artery or internal jugular vein blow-out. Local, pedicled, and free flaps may be employed to cover exposed vascular structures. The most commonly used flaps are pectoralis major myocutaneous and free radial forearm flaps for this purpose. The goal is to ensure that mucosal continuity is maintained and adequate skin cover is established. One flap may suffice to provide skin cover when enough local tissue is available to close the mucosal defect. Occasionally, extensive loss of mucosa combined with skin may require two flaps. A free radial forearm flap is a good choice to ensure mucosal continuity is maintained and a pectoralis major myocutaneous flap provides bulk to cover vital vascular structures and skin cover. Various flaps may be utilized alone or in combination, and this will depend on the surgeon's preference and previous experience.

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