Treatment

Upon detection of a fistula, initial management is to gently open the wound as previously described and to palpate carefully for the extent of infection. Identification of the relationship to vascular structures, microvascular anastomoses, and the trachea can be attempted with conservative, careful exploration of the wound. A cuffed tracheotomy tube should be placed in the stoma to prevent aspiration of infected secretions, and the patient made NPO. Nutritional support can ideally be provided by tube feeds, although parenteral nutrition may be used if enteral feeding is not possible. Cultures of wound drainage should be obtained, with empiric intravenous broad spectrum antibiotics (covering anaerobes and gram-negative organisms) started while awaiting culture and sensitivity results.

After the initial standard management, therapy includes both conservative medical management and different levels of surgical management. The appropriate choice of treatment depends on the size and location of the fistula, prior radiation status, and general medical condition. Generally, in patients with no history of radiotherapy, fistulas under <2 cm close spontaneously within 2 to 4 weeks with proper wound care. Moist gauze packings of the fistula tract are applied 3 times each day. The infected tract is packed with gauze soaked in betadine solution or 0.5% acetic acid. As the infection appears to clear, dressing changes should continue with Dakins gauze to stimulate granulation tissue. When granulation tissue appears, packing may be continued with saline soaked strips alone. Oral 0.5% acetic acid solutions, shown to be bacteriostatic, may also be administered (as swish and swallow) to acidify the upper digestive tract. Sharp debridement of overlying necrotic debris and fibrinous exudate should also be performed at least once a day, with care to avoid underlying structures. In otherwise healthy, nonradiated patients, the fistula tract should improve within 2 to 4 weeks of treatment, and persistence of the tract should raise suspicion for residual tumor or distal outflow obstruction.

For patients with a small fistula who have received prior radiotherapy, similar conservative measures are started with the understanding that wound healing is delayed. If the fistula tract lies over vascular structures or a microvascular anastomosis, more aggressive treatment is warranted. Although some investigators recommend immediate return to the operating room, we usually attempt conservative measures for several days. If the wound appears to be infected, debridement and packing are continued to allow for a noninfected bed of granulation tissue should flap reconstruction be necessary. If the tract is unchanged, appears to have worsened after a few days of conservative treatment, or if there is increasing concern for the underlying vessels or anastomosis, the patient is returned to the operating room, the fistula site is opened, and the extent of infection evaluated with gentle blunt dissection. Copious irrigation with warm bacitracin solution is performed after removal of purulent debris and necrotic tissue. Excessive manipulation of the wound is avoided to minimize injury to underlying structures. If the infection appears relatively contained and does not involve vascular structures, a pharyngos-tome can be created by placement of a passive drain (Penrose, suction drain tubing without application of suction), thus diverting the salivary stream away from the vessels. If the infection is widespread or the skin and vessels tenuous, vascularized tissue should be brought into the wound to hasten healing and to provide protection for the underlying vasculature. Local flaps may be used for coverage if nonirradiated. If the surgical field has been irradiated or epithelial lining is required, the use of the pectoralis myocutaneous flap is a popular choice. First, necrotic edges and nonviable tissue should be removed from the recipient site, and then the pectoralis muscle brought into contact with underlying mucosa and sutured to surrounding tissue. The muscle flap provides a barrier between the vessels and the fistula site. A passive drain should be placed over the muscle flap and advanced over several days, allowing the fistula to close slowly.

Larger pharyngocutaneous fistulae are usually associated with prior radiotherapy and/or a more compromised host. Often there is significant loss of neck skin and wide exposure of underlying structures. The first priority in this type of fistula is protection of the carotid artery and prevention of carotid rupture. If the defect appears infected or is so extensive that local vascularized muscle transfer may not be large enough to provide definitive closure, conservative measures should begin with betadine gauze packing, changed 3 times per day, and debridement twice daily. Adequate nutrition, optimization of cardiopulmonary status, correction of hypothyroidism, and management of any other correctable systemic conditions should also be addressed during this time. Conservative treatment for 1 to 2 weeks usually results in significant decrease in the size of the fistula. Although controversial, hyperbaric oxygen appears to improve wound healing and may be considered for those patients who seem unimproved with other conservative measures. Advocates believe hyperbaric oxygen promotes angiogenesis and helps healing by improving wound oxygenation. Patients who are at risk for carotid artery hemorrhage are followed closely in the hospital. Infected wounds are debrided and packed until gross resolution of infection or a tissue bacterial count of >105 colony-forming units (CFU)/g is reached. At this time, the bacterial count is felt to be low enough to attempt definitive closure.

In choosing a reconstructive method, the patient's general condition, the extent of the defect, and the availability of vessels in the neck for possible microvascular anastomosis should be considered. Many surgical methods of repair have been reported, but the principles of providing both an internal and external lining remain constant. The pectoralis myocutaneous flap remains an excellent option. It is a sturdy, well-vascular-ized source of tissue for support and protection of the repair site. The negative features about the flap include its large and bulky size which may put tension on the suture line or cause it to unfurl away from the wound site. In patients who can tolerate a longer procedure or for those patients in whom a pectoralis flap failed or is unavailable, radial forearm free flaps provide another option. This flap can be constructed either alone, providing both the internal pharyngeal and external skin lining, or in conjunction with a myofascial flap to provide the external lining. Other alternatives include the latissimus dorsi free or pedicled flap, in which the skin paddle replaces the internal pharyngeal lining, with skin graft coverage of the external muscle. This flap provides a large amount of coverage; however, it may be excessively thick and bulky. Other reports in the literature include removal of the fistula site and repair with free jejunal transfer or gastric pullup. These operations have higher potential morbidity, but offer the benefit of not requiring a tubular suture line as with a forearm flap.

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