Orocutaneous Fistula

Cancer of the oral cavity accounts for approximately 30% of head and neck carcinomas. Surgical intervention ranges from simple excision with minimal morbidity to composite resection with significant attendant complications. When large resections are necessary and mandibulotomy is required for access, a fistula may ensue. Currently as mandibular osteotomy has become the preferred method of access for the majority of large oral cavity and oropharyngeal tumours, this complication is not infrequent.8,9 Previous investigators have attempted to identify factors that may predispose to mandibulotomy sepsis and fistula formation, although no consensus has been reached as to the precise cause. Preoperative irradiation and type of fixation (wire or plate) does not appear to influence the incidence of sepsis, although most studies have been retrospective in nature.10'11 A failure to achieve a watertight mucosal closure adjacent to the mandibulotomy site, even when using a free flap to reconstruct the defect, is an important factor. Patients who undergo step osteotomy as opposed to linear cuts and those who have a marginal mandibulectomy in combination with the resection are not at an increased risk of infection.

Generally, the management of this complication is similar in principal to that of pharyngocutaneous fistulae. Small fistulae respond to conservative measures with meticulous wound care and antibiotic therapy. Early recognition and intervention are key to the successful management of this complication. Diverting the flow of saliva away from the great vessels and keeping skin flaps viable will result in spontaneous healing of most fistulae. Placement of a Savory tube into the pharynx may be useful to direct saliva away from the neck. Necrotic tissue must be carefully excised, and appropriate antibiotic therapy is guided by culture and sensitivity. Larger fistulae and those extending over the carotid artery require vascularized tissue flaps to avoid carotid artery or jugular vein blowout. When plate exposure is contributing to persistence of the fistula, removal of the plate and reconstruction with an appropriate flap are necessary.

0 0

Post a comment