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Pharyngocutaneous fistula is a critical complication of head and neck cancer reconstruction and it is often difficult to manage. We herein report two cases of pharyngocutaneous fistulas that developed after oropharyngeal reconstruction and were successfully treated with negative pressure wound therapy with instillation and dwell time (NPWTi-d), an advanced form of traditional NPWT. NPWTi-d may be a useful nonsurgical treatment for pharyngocutaneous fistula. Laryngoscope, 134:4573-4576, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: We evaluated vessel counts in the pharyngeal mucosal margins of patients who underwent salvage laryngectomy to establish whether mucosal vascularity might predict fistula risk., Study Design: Retrospective cohort., Setting: Tertiary Medical Center., Methods: Patients who underwent salvage total laryngectomy at our institution between 1999 and 2015 were identified. Pharyngeal mucosal margins from laryngectomy specimens were evaluated histologically for each patient, and vessel counts were performed on 5 ×10 images. The primary outcome measure was fistula within 30 days of surgery and mean vessel counts were assessed as the principle explanatory variable., Results: Seventy patients were included and 40% developed a postoperative fistula. There was a large difference in the mean vessel count in patients who did develop fistula (48.6 vessels/×10 field) compared to those who did not (34.7 vessels/×10 field). A receiver operative characteristic curve found that a cutoff value of 33.9 vessels/×10 field provided a sensitivity of 75% and specificity of 62% to predict the likelihood of fistula occurrence (area under the curve = 0.71, 95% confidence interval [CI]: 0.59-0.83). In a binary logistic regression, patients with vessel counts greater than 33.9 had a 5-fold increased risk of developing fistula (95% CI: 1.8-16.45). Histologically, vessels in the pharyngeal mucosa of patients who developed fistulas were more disorganized., Conclusion: After salvage laryngectomy, patients with higher mean mucosal margin vessel counts are at increased risk of fistula. The mechanism is unknown, but the disorganization of the vasculature may contribute to poor wound healing. Vessel counting may allow for fistula risk stratification and guide postoperative care., (© 2024 The Author(s). Otolaryngology–Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objectives: The aim of the current study was to evaluate the functional outcomes of stapler pharyngeal closure after total laryngectomy by the incidence of PCT and assessment of swallowing after surgery. In addition, the study aimed to evaluate the oncological outcomes in terms of patients' survival rates., Methods: This randomized clinical trial was conducted on 58 patients with advanced laryngeal carcinoma who underwent total laryngectomy. Patients were randomly assigned to two groups according to the method of pharyngeal repair after laryngectomy: manual closure group (n = 28), and stapler group (n = 30). Functional and oncological outcomes were assessed and compared., Results: The incidence of pharyngocutaneous fistula was significantly less in the stapler group. Additionally, operative time was significantly shorter and swallowing function was better in the stapler group compared to the manual group. There was no statistically significant difference between groups regarding survival rates., Conclusion: The stapler is a reliable method for pharyngeal closure after total laryngectomy if the limits of its indications regarding the primary tumor are considered. Stapler closure decreases the incidence of PCF and decreases the surgical time. Good swallowing outcomes are achieved without compromising the oncological outcomes., (© 2024. The Author(s).)

Purpose: Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of perioperative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy., Patients and Methods: Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n = 72). Postoperatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/d) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid-stimulating hormones were collected, and dosing was adjusted accordingly. The primary endpoints were rates of fistula formation and fistula requiring reoperation, compared with matched historic controls. All patients were monitored for adverse effects., Results: The rate of postoperative hypothyroidism was 21% compared with 49% in a matched historic cohort. The rate of fistula formation was 18.1%, whereas the rate of fistula requiring reoperation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8%, respectively; P = 0.02 and 0.01). Postoperative hypothyroidism and recurrent clinical stage predicted fistula requiring reoperation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation., Conclusions: Postoperative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula formation, and fistula requiring reoperation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population., (©2024 American Association for Cancer Research.)

Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Salvage laryngectomy is more predisposed to complications than primary operations, with pharyngocutaneous fistula (PCF) being among the most challenging to manage. Vascularized flaps are increasingly employed during salvage laryngectomy, with a previous review finding a PCF incidence of 31.2% and 22.2% after primary and flap-assisted closure respectively. We aim to better define the role of vascularized flaps after salvage laryngectomy by performing an updated review comparing the rate of PCF in those undergoing primary or vascularized flap-assisted closure., Data Sources: Pubmed/Medline, CINAHL, and CENTRAL., Review Methods: An updated literature review was conducted of English language literature from 2003 to 2023. A random effects and network meta-analysis of odds ratios (OR) and pooled proportions were conducted., Results: Literature search found 31 studies, including seven from the previous review. Overall random effects pooled PCF rate was 25% (95% CI 0.21; 0.30, I 2  = 72%, p = <0.01), whereas incidence in primary closure was 37% (95% CI 0.32; 0.43, I 2  = 60%, p = <0.01) and 19% (95% CI 0.12; 0.20, I 2  = 47%, p = <0.01) after flap closure. Pooled OR was 0.39 (95% CI 0.28; 0.55, I 2  = 36%, p = 0.04) in favor of vascularized tissues. The number needed to treat was 6.5. The rate of PCF was lower after free and pedicled flaps, and on-lay and patch closure compared to primary closure techniques. Network meta-analysis found all combinations of closure techniques and vascularized tissue were superior to primary closure., Conclusion: The updated analysis has demonstrated a widening in the rates of PCF between primary and vascularized flap-assisted closure. Surgeons should strongly consider the use of free or pedicled flaps in any salvage laryngectomy procedure. Laryngoscope, 134:2991-3002, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: To assess the usage of contralateral infrahyoid muscles as onlay flap in prevention of pharyngo-cutaneous fistula (PCF) in total laryngectomy (TL) patients with high risk factors of PCF development., Methods: This study included 10 patients who suffered from advanced laryngeal carcinoma with presence of risk factors for development of PCF. We added an enforcement muscular layer during neo-pharynx wall repair, the infrahyoid muscle flap of the contralateral side of the tumour origin as an onlay muscular flap to cover the anastomotic site for healing augmentation. Patients were followed up for PCF development where the PCF incidence was calculated., Results: One patient died from congestive heart failure in the 21th post-operative day so, the actual PCF rate in TL patients with high risk factors of PCF development in our study was 11.11% (1 out of 9 cases)., Conclusions: Infrahyoid muscle flap may have a role in preventing PCF after TL in patients with high risk factors of PCF development in this case series study to be further assessed in other studies to justify its role., (© 2024 John Wiley & Sons Ltd.)

We aimed to summarize the surgical treatment for pharyngolaryngeal stenosis and discuss prognosis in patients with Behcet's disease. Six cases of pharyngolaryngeal stenosis caused by Behcet's disease were analyzed retrospectively. All underwent surgical treatment for pharyngolaryngeal stenosis after systematic medical treatment. The follow-up time for the 6 patients was between 1 and 12 years. Four of the 6 patients underwent adhesiolysis as their first procedure. Two of these 4 experienced recurrence of stenosis within 6 months and underwent flap repair as their second procedure. The remaining two patients underwent flap reconstruction as their first procedure and maintained good swallowing function. Three of the 6 patients underwent preoperative tracheotomy because of dyspnea. Tracheal decannulation was successful in all patients. None of the patients experienced recurrence after their final surgical procedure and all recovered to a near-normal condition. Pharyngolaryngeal stenosis caused by Behcet's disease is a rare but severe complication; surgical intervention should be considered in patients with dysphagia after systematic medical treatment., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Pharyngocutaneous fistula (PCF) is a possible complication following total laryngectomy (TL), with a mean incidence of 17%. We intended to investigate the effect of pharyngeal closure type during TL on the prevention of PCF., Methods: We retrospectively reviewed patients that underwent TL with a horizontal pharyngeal closure over a 10-year period. The frequency of PCF clinically, dysphagia, total oral diet, postoperative dilatation of the neopharynx and voice problems were tabulated., Results: Seventy-seven subjects underwent TL due to laryngeal tumor without pharyngeal extension. Of them, 45 underwent a salvage TL. PCF occurred in 1/77 subjects. The rest of the subjects (76/77) did not develop a PCF, neither in the early nor in the late postoperative phase. All subjects (15/77) that underwent implantation of a voice prosthesis were satisfied with their voice. No subject complained about dysphagia. Every subject achieved total oral diet., Conclusion: The horizontal pharyngeal closure is a safe pharyngeal closure technique during TL, reduces PCF rates (< 2%), results in excellent voice rehabilitation and swallowing function, and can also be used during salvage TL instead of a major pectoral flap. This type of closure should be used only in selected patients with laryngeal disease without pharyngeal extension., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Kawasaki Disease (KD) may mimic Parapharyngeal (PPI) and Retropharyngeal Infections (RPI), leading to misdiagnosis as Deep Neck Infections (DNIs). The treatment plans for the two diseases are different, and delayed treatment can lead to serious complications. Therefore, prompt diagnosis and management are necessary. This study was performed to evaluate the clinical features of KD mimicking DNIs and explore the treatment options., Methods: Children with cellulitis or abscess in parapharyngeal or retropharyngeal space in neck CT were included in this study. The medical records of enrolled children were retrospectively reviewed., Results: In total, 56 children were diagnosed with PPI or/and RPI. Twenty-two (39.3%) participants were eventually diagnosed with KD, and 34 (60.7%) were diagnosed with DNIs. Compared with the DNIs group, the KD group had a higher body temperature (p=0.007), and higher levels of AST (p=0.040), ALT (p=0.027), and ESR (p=0.030). Deep cervical cellulitis (p=0.005) were more common in the KD group. However, deep neck abscess often occurred in the DNIs group (p=0.002), with parapharyngeal abscess being the most common type of abscess (p=0.004). The KD mimicking DNIs cases did not respond to antibiotic treatment, but symptoms significantly improved after the use of Immunoglobulin (IVIG) and aspirin., Conclusion: Children with KD may exhibit retropharyngeal or parapharyngeal inflammation in the early stages. KD should be considered a differential diagnosis for children with DNIs, high fever, and no response to antibiotic therapy. Surgery in KD mimicking deep neck abscess requires caution., Level of Evidence: I., (Copyright © 2024 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier España S.L.U. All rights reserved.)

To analyse the risk factors and healing factors of pharyngocutaneous fistula (PCF) in patients with laryngeal cancer after total laryngectomy, and to explore the relevant epidemiology. A retrospective analysis was conducted on laryngeal cancer patients who underwent total laryngectomy in our hospital from January 2010 to December 2022. The 349 patients included in the study were divided into a PCF group of 79 and a non-PCF group of 270. Perform one-way analysis of variance and multivariate logistic analysis on various data of patients included in the statistics, and analyse the risk factors and healing factors of PCF. Smoking, history of radiation therapy for laryngeal cancer, history of chemotherapy for laryngeal cancer, tumour location (larynx, pharynx, oesophagus), preoperative albumin, postoperative proteinaemia, <99 haemoglobin, postoperative haemoglobin, postoperative C-reactive protein (CRP) level are the risk factors for PCF. Also, radiation therapy and postoperative proteinaemia were the main reasons for preventing PCF healing. Smoking history, laryngeal cancer, radiation therapy, albumin, haemoglobin and CRP are risk factors for postoperative PCF after total laryngectomy, while radiation therapy and postoperative hypoalbuminaemia are key factors affecting PCF healing., (© 2024 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: We aimed to assess the effectiveness of a single-institution protocol of videofluoroscopic swallowing study (VFSS) for the detection of pharyngeal leak (PL) and its usefulness to mitigate evolution into subsequent pharyngocutaneous fistula (PCF) after total (pharyngo-) laryngectomy (TL)., Methods: This retrospective single-center study was conducted between February 2014 and December 2022. We included all patients who underwent TL and performed a VFSS between Day 7 and Day 14 postoperatively to detect a subclinical PL., Results: Two-hundred and forty-eight patients met the inclusion criteria. Among the 186 patients (75%) with a negative VFSS, 11 patients (5.9%) developed a secondary PCF after oral intake resumption (false negative of VFSS). Among the 62 patients (25%) with a positive VFSS, the occurrence of a PCF was avoided in 59.7% of cases., Conclusion: This study showed a good effectiveness of VFSS in the detection of PL after TL, alongside a usefulness to mitigate evolution into subsequent PCF., (© 2024 Wiley Periodicals LLC.)

Objective: The objective of this study was to compare the outcomes vertical and T-shaped pharyngoplasty closure techniques after total laryngectomy (TL) and to evaluate the factors associated with the development of pharyngocutaneous fistula., Materials and Methods: We performed a retrospective study that included patients with a histopathological diagnosis of laryngeal cancer that underwent TL between 2009 and 2021., Results: Fifty-seven patients were included in the study. A total of 14 patients underwent a vertical closure of the neopharynx (24.6%), while 43 patients underwent a T-shaped closure (74.4%). Pharyngocutaneous fistula was the most common complication, observed in 40.4% of cases (n = 23). No difference in the rate of complications was observed between groups, with the exception of tracheal dehiscence which was reduced in patients with T-shaped closure (n = 2, 4.7% vs. n = 5, 35.7%, p = 0.002). Diabetes mellitus was more frequently observed in patients withthe development of pharyngocutaneous fistula (n = 7, 30.4% vs. n = 3, 8.8%, p = 0.03)., Conclusions: Although complicationswere lower in the T-shaped closure group, we could not establish the superiority of either technique.

Background: Pharyngocutaneous fistula is one of the most common complications following total laryngectomy. It increases hospital stay and the financial burden on patients, and prolongs nasogastric feeding. This paper presents novel techniques for prevention of pharyngocutaneous fistula., Method: A retrospective study was conducted at a tertiary referral centre to assess the effectiveness of continuous extramucosal pharyngeal suturing and the hydrogen peroxide leak test in prevention of pharyngocutaneous fistula in 59 patients who had undergone total laryngectomy with or without partial pharyngectomy for locally advanced cancers of the larynx and hypopharynx., Results: The incidence of pharyngocutaneous fistula in our study was 6.8 per cent, which is considerably lower than the incidence reported in various previous studies., Conclusion: The continuous extramucosal suturing technique provides watertight closure of the neopharynx and can be recommended as a reliable method for neopharyngeal closure post total laryngectomy to reduce the occurrence of pharyngocutaneous fistula.

Pharyngocutaneous fistula (PCF) is a major complication after total laryngectomy, with significant morbidity and mortality. Whether mechanical stapler closure of the pharynx reduces fistula rates compared to hand-sewn techniques remains unclear. We conducted an updated systematic review and meta-analysis to clarify this question. Five databases were systematically searched from inception through November 2023 for studies comparing stapler versus suture closure for fistula outcomes after laryngectomy. Odds ratios (OR) were pooled using random-effects models and fixed-effects models. Subgroup and sensitivity analyses were performed. Risk of bias was appraised using NHLBI tools. Nine studies with 803 patients were included. Mechanical closure significantly reduced fistula incidence versus suture closure (OR = 0.57, 95% CI 0.34-0.95, p = 0.03). Subgroup analysis found that stapling's protective effect varied by patient age, country/region, linear stapler size and female percentage. Stapling reduced fistula odds by 80% in the Turkey subgroup (OR = 0.20, 95% CI 0.09-0.50) but showed no benefit in other regions. Patients <60 years showed an 84% fistula reduction with stapling (OR = 0.17, 95% CI 0.06-0.45), whereas older subgroups did not. Linear stapler size of 60 mm significantly reduced fistula occurrence while 75 mm did not. There was no evidence that low female percentage mitigated stapling benefits. Mechanical stapler closure after total laryngectomy meaningfully reduces the likelihood of postoperative PCF formation compared to hand-sewn closure, especially for patients younger than 60 years old. The absolute risk reduction supports its utility to prevent this complication., (© 2024 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Laryngeal and hypopharyngeal cancers often require surgical treatment, which can lead to the development of pharyngocutaneous fistula (PCF). Our research aimed to assess the predictive value of skeletal muscle mass (SMM) and systemic inflammation indices for PCF and construct a clinically effective nomogram., Methods: A nested case-control study of 244 patients matched from 1171 patients with laryngeal or hypopharyngeal cancer was conducted. SMM was measured at the third cervical level based on CT scans. A PCF nomogram was developed based on the univariate and multivariate analyses., Results: Glucose, white blood cell count, platelet-to-lymphocyte ratio, and skeletal muscle index were independent risk factors for PCF. The area under the curve for the PCF nomogram was 0.841 (95% CI 0.786-0.897). The calibration and decision curves indicated that the nomogram was well-calibrated with good clinical utility., Conclusions: The nomogram we constructed may help clinicians predict PCF risk early in the postoperative period, pending external validation., (© 2023 Wiley Periodicals LLC.)

Parapharyngeal abscesses leading to complications, although rare after the advent of antibiotics, can lead to serious complications. One such complication is carotid erosion that can lead to a potentially fatal carotid artery blowout. We report a case of a previously healthy infant who presented with fever, ear bleed and progressively increasing swelling in the right side of his neck that led to airway compromise. The child required immediate securing of the airway at presentation. Imaging revealed lobulated abscess with multiple bleeding points eroding the carotid vessels, along with internal jugular venous thrombus. Surgical exploration was done and abscess debulked. Histopathology revealed aspergillus, which was treated with antifungals. He was discharged on oral warfarin after 40 days of hospital stay and remains well on follow-up. Sentinel ear bleed warrants close observation for possibility of carotid artery blowout in children with parapharyngeal abscesses., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Pharyngocutaneous fistula (PCF) formation following open surgical treatment of hypopharyngeal cancer (HPC) is a common and troublesome complication. To date, the postoperative protocol of restarting oral intake is not clear, and vast discrepancies exist in the literature and among institutions. This study aimed to explore the impact of a postoperative protocol of restarting oral intake on PCF formation after open surgical treatment of primary HPC, and its impact on overall survival (OS) and swallowing function based on the functional outcome swallowing scale (FOSS)., Materials and Methods: This was a prospective observational study of 42 patients who received open surgical treatment for primary HPC at Beijing Friendship Hospital between April 2019 and August 2021. This cohort included two groups: patients who restarted oral intake on the 10th postoperative day (Group 1), and those who started on the 20th (Group 2). The Chi-square test and Fisher's exact chi-squared test were used for comparing qualitative data among the groups., Results: Group 1 (n = 27) and Group 2 (n = 15) were comparable in clinical characteristics. PCF occurred in 7 (25.9%) patients in Group 1, while none occurred in Group 2 ( P = 0.038). The 2-year OS of all 42 patients was 75.6%; 65.8% and 93.3% for Groups 1 and 2, respectively ( P = 0.07). The swallowing function was satisfactory (FOSS Grades 0-III) for 19 (70.4%) patients in Group 1 and 15 (100%) patients in Group 2 ( P = 0.035). Laryngeal preservation was achieved in 25 (59.5%) patients, while decannulation was successful in 22 (88.0%) patients., Conclusions: Delayed oral feeding significantly reduces PCF after open surgical treatment of primary HPC, and improves the swallowing function outcome without jeopardizing the OS., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Total laryngectomy (TL) is a surgical procedure commonly performed on patients with advanced laryngeal or hypopharyngeal carcinoma. One of the most common postoperative complications following TL is the development of a pharyngocutaneous fistula (PCF), characterized by a communication between the neopharynx and the skin. PCF can lead to extended hospital stays, delayed oral feeding, and compromised quality of life. The use of a myofascial pectoralis major flap (PMMF) as an onlay technique during pharyngeal closure has shown potential in reducing PCF rates in high risk patients for development of PCF such as patients undergoing TL after chemoradiation and low skeletal muscle mass (SMM). Its impact on various functional outcomes, such as shoulder and neck function, swallowing function, and voice quality, remains less explored. This study aims to investigate the effectiveness of PMMF in reducing PCF rates in patients with low SMM and its potential consequences on patient well-being., Methods: This multicenter study adopts a randomized clinical trial (RCT) design and is funded by the Dutch Cancer Society. Eligible patients for TL, aged ≥ 18 years, mentally competent, and proficient in Dutch, will be enrolled. One hundred and twenty eight patients with low SMM will be centrally randomized to receive TL with or without PMMF, while those without low SMM will undergo standard TL. Primary outcome measurement involves assessing PCF rates within 30 days post-TL. Secondary objectives include evaluating quality of life, shoulder and neck function, swallowing function, and voice quality using standardized questionnaires and functional tests. Data will be collected through electronic patient records., Discussion: This study's significance lies in its exploration of the potential benefits of using PMMF as an onlay technique during pharyngeal closure to reduce PCF rates in TL patients with low SMM. By assessing various functional outcomes, the study aims to provide a comprehensive understanding of the impact of PMMF deployment. The anticipated results will contribute valuable insights into optimizing surgical techniques to enhance patient outcomes and inform future treatment strategies for TL patients., Trial Registration: NL8605, registered on 11-05-2020; International Clinical Trials Registry Platform (ICTRP)., (© 2024. The Author(s).)

Aim: This study aims to explore the impact of endotracheal tube cuff deflation methods on extubation stress responses and postoperative pharyngeal complications in patients treated with gynecological laparoscopic surgery., Methods: In this study, retrospective clinical data of 94 patients treated with gynecological laparoscopic surgery under general anesthesia in Northwest Women's and Children's Hospital from June 2023 to June 2024 were collected and analyzed. Patients were assigned into two groups based on the cuff deflation methods used after anesthesia: Group A (45 patients) adopted a one-time deflation method, while Group B (49 patients) employed a gradual deflation method. Surgery-associated indicators were recorded, with heart rate (HR), mean arterial pressure (MAP), rate pressure product (RPP), epinephrine (E), norepinephrine (NE), and cortisol (Cor) levels monitored at selected time points: before cuff (T0), immediately after extubation (T1), 1 minute post-extubation (T2), 5 minutes post-extubation (T3), and 10 minutes post-extubation (T4). The incidence of pharyngeal complications was also compared between the two groups., Results: Compared with Group A, Group B displayed smaller variations in HR, MAP, and RPP at T1, T2, and T3 (p < 0.05). Group B also showed smaller variations in E, NE, and Cor levels at T2, T3, and T4 in contrast with Group A (p < 0.05). The incidence of complications such as coughing, sore throat, and hoarseness was conspicuously attenuated in Group B compared to Group A (6.12% vs 22.22%, p < 0.05)., Conclusions: Gradual deflation of the endotracheal tube cuff dramatically ameliorates extubation stress responses, stabilizes hemodynamics, and alleviates pharyngeal discomfort in patients treated with gynecological laparoscopic surgery.

Background: Nutritional factors in developing some malignancies have been investigated recently., Objective: In this study, we evaluated the role of vitamin D in advanced laryngeal cancer and its association with the development of pharyngocutaneous fistula (PCF) following total laryngectomy., Study Design: A cross-sectional, case-control study was conducted., Methods: Fifty-five patients with advanced laryngeal cancer referred for total laryngectomy were included. We also considered 55 healthy individuals after matching age and sex as a control group. Serum levels of 25(OH)D 3 were measured using a commercially available enzyme-linked immunosorbent assay (ELISA) kit. The association of serum 25(OH)D 3 with PCF following total laryngectomy was also determined., Results: Vitamin D was significantly lower in patients with advanced laryngeal cancer than in the control group ( p < 0.001). Moreover, our results showed that a mean serum concentration of 25(OH)D 3 in patients with PCF was significantly lower than in patients without PCF ( p < 0.001)., Conclusion: Vitamin D deficiency is highly prevalent in advanced laryngeal cancer, most pronounced in those who develop a PFC following total laryngectomy., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: The determination of cytokines in the postoperative drainage (POD) fluid could be a method for early detection of the development of a pharyngocutaneous fistula (PCF)., Materials and Methods: We conducted a prospective two-center study involving 28 patients. PODs were collected on Day 1 (D1) and Day 2 (D2) postoperatively for determination of a cytokine panel and cytobacteriological examination., Results: Eleven (39%) patients presented with PCF on average 13 ± 5.5 days after surgery. Patients with PCF had higher IL-10 (121 vs. 40.3, p = 0.04, effect size (ES) = 0.98 [0.16, 1.79]) and TNFα level (21.2 vs. 2.2, p = 0.02, ES = 0.83 [0.03, 1.63]) on D2. An IL-10 threshold of 72 pg/mL on D2 was diagnostic of the occurrence of PCF with a sensibility of 70%, specificity of 88%., Conclusion: The determination of cytokines in POD fluid on D2 is a reliable tool for predicting the development of a PCF after total laryngectomy., (© 2023 Wiley Periodicals LLC.)

Background/aim: A pharyngeal fistula is the most common complication of total laryngectomy; thus, accurate diagnosis and treatment are important. Diagnosis is usually made by the finding of leakage of the contrast agent outside the pharynx during swallowing contrast examination. Herein, we encountered a case in which fine leaks not detected on contrast examination during swallowing were visualized and diagnosed by computed tomography (CT) imaging with oral contrast media with the patient in a prone position., Case Report: During imaging in a prone position, the contrast agent entered the sutures on the cephalocaudal and ventral sides of the surgical site, which were particularly prone to leaks due to gravity, and it was possible to diagnose minute leaks. When there is a high risk of postoperative pharyngeal fistula, such as in reconstructive cases with a pedunculated flap or with overlapping risk factors such as preoperative irradiation, CT imaging with contrast medium in a prone position is considered useful when swallowing contrast examination does not provide a clear diagnosis. However, suture failure is possible, and this should be evaluated., Conclusion: This case suggests that routine prone CT may lead to the early detection of postoperative pharyngeal fistula in high-risk cases. Further accumulation of cases is required to confirm our findings., (Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Significance Statement: Pharyngeal fistulas to the cervical spine resulting in vertebral osteomyelitis are a rare, yet clinically important, complication of total laryngectomy performed in conjunction with chemoradiotherapy or radiation therapy. This complication is likely underdiagnosed and can have a high mortality rate. It is very important that clinicians are aware of this complication as early diagnosis and management may improve patient outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Transoral robotic surgery (TORS) has become increasingly recognised as a safe and effective treatment for early oropharyngeal squamous cell carcinoma, often performed in conjunction with neck dissection (ND) and vessel ligation. It has been proposed that performing the neck dissection in a staged fashion prior to TORS results in low rates of transoral haemorrhage and pharyngocutaneous fistula, and may aid in TORS patient selection by eliminating patients who would require multi-modality treatment based on nodal pathology. This study aims to assess the effect of staged neck dissection with TORS in mitigating pharyngocutaneous fistulae and post-operative haemorrhage as well as the impact of staged ND on TORS patient selection., Methods: A retrospective cohort analysis was performed of patients undergoing staged ND with intent to proceed to TORS at two Australian hospitals between 2014 and 2022. Incidence of post-operative haemorrhage and pharyngocutaneous fistula and length of inpatient stay was identified. The number of patients who did not proceed to TORS was recorded., Results: One hundred and four patients were identified who underwent staged neck dissection with an intention to proceed to TORS. Six patients did not proceed to TORS following pathological assessment of the neck dissection specimen and ninety-eight patients (91 primary, 7 salvage) underwent TORS. There were six cases of secondary haemorrhage (one major, two intermediate and three minor). There were no cases of pharyngocutaneous fistula., Conclusion: Staged neck dissection prior to TORS results in low rates of haemorrhage and pharyngocutaneous fistula and can improve TORS patient selection., (© 2023. Crown.)

Background: The aim of this study is to investigate the impact of preoperative gastrostomy in patients undergoing pharyngolaryngectomy (PL) on gastrostomy tube dependence at 6 months postoperatively., Methods: A retrospective review of patients undergoing PL for laryngeal squamous cell carcinoma between 2005 and 2019 was performed. Parameters were collected and analyzed within the multivariate models., Results: Ninety-three patients (82% male, mean age 63.4 [SD 9.4]) were included. Preoperative tube placement and pharyngocutaneous fistula (PCF) were associated with an increased likelihood of gastrostomy tube dependence at 6 months (odds ratio 6.43, CI 1.1-38.3, p = 0.041) after adjusting for multiple confounding factors. There was no difference in the incidence of delayed oral feeding, PCF, or hospital stay between the groups., Conclusions: Preoperative tube and PCF are associated with an increased likelihood of tube dependence at 6 months. Patients for preoperative tube insertion should be carefully selected and early oral feeding reintroduction should be encouraged., (© 2023 Wiley Periodicals LLC.)

Objective: (1) Compare proportions of collapse, obstruction, or mixed instances on drug-induced sleep endoscopy findings of obese and nonobese children with obstructive sleep disordered breathing. (2) Determine the frequency of collapse in general between both groups., Study Design: Retrospective case-control study., Setting: Tertiary pediatric center., Methods: Obese (body mass index >95 percentile) children presenting with obstructive sleep disordered breathing (>33 on the pediatric sleep questionnaire) were identified from a prospectively kept surgical database. Only those who had undergone drug-induced sleep endoscopy were eligible. Age and sex pair-matched nonobese children were identified. Only nonsyndromic, neurologically normal, surgically naïve patients were included. The frequency of obstructive, collapse, and mixed pharyngeal patterns was documented in both groups. A comparison of proportions was then undertaken (χ 2 test)., Results: Over a 5-year period, 73 consecutive children with obesity were identified (40 males; mean of 8.5 ± 3.0 years, 2.8-13.1). They were matched with 73 nonobese children (8.4 ± 3.0 years, 2.6-14.1). The obese group exhibited significantly more pharyngeal collapses (62:47) (p = .0021 odds ratio [OR] 3.358, 95% confidence interval [CI] 1.52-7.42). The proportion of pharyngeal findings on drug-induced sleep endoscopy was significantly different (p = .000129) between the 2 groups; obese (61 mixed: 3 obstruction: 9 collapse) and nonobese (48 mixed: 22 obstruction: 4 collapse)., Conclusion: The predominance of hypopharyngeal collapse in children with obesity may explain the likelihood of failure of surgery directed at obstructive findings. This may also strengthen the case for drug-induced sleep endoscopy in this group at the initial surgery to guide it rather than after the failure of adenotonsillectomy., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

A meta-analysis study to assess the effect of possible risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy of laryngeal carcinoma. A comprehensive literature examination till January 2023 was implemented and 1794 linked studies were appraised. The picked studies contained 3140 subjects with total laryngectomy of laryngeal carcinomas in the picked studies' baseline, 760 of them were PCF, and 2380 were no PCF. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of possible risk factors for PCF after total laryngectomy of laryngeal carcinomas and surgical wound infection after total laryngectomy of laryngeal carcinoma by the dichotomous and continuous styles and a fixed or random model. The PCF had a significantly higher surgical wound infection (OR, 6.34; 95% CI, 1.89-21.27, P = .003) compared with the no PCF in total laryngectomy of laryngeal carcinomas. The smoking (OR, 1.73; 95% CI, 1.15-2.61, P = .008), and preoperative radiation (OR, 1.90; 95% CI, 1.37-2.65, P < .001) had significantly higher PCF as a risk factor in total laryngectomy of laryngeal carcinomas. The preoperative radiation had a significantly lower spontaneous PCF closure (OR, 0.33; 95% CI, 0.14-0.79, P = .01) compared with the no preoperative radiation in total laryngectomy of laryngeal carcinomas. However, the neck dissection (OR, 1.34; 95% CI, 0.75-2.38, P = .32), and alcohol intake (OR, 1.95; 95% CI, 0.76-5.05, P = .17), had no significant effect on PCF in total laryngectomy of the PCF had a significantly higher surgical wound infection, and preoperative radiation had a significantly lower spontaneous PCF closure in total laryngectomy of laryngeal carcinomas. Smoking and preoperative radiation were shown to be risk factors for PCF, however, neck dissection and alcohol intake were not shown to be risk factors for PCF in total laryngectomy of laryngeal carcinomas. Although precautions should be taken when commerce with the consequences because some of the picked studies for this meta-analysis was with low sample sizes., (© 2023 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Aim: Pharyngeal leak (PL) and pharyngocutaneous fistula (PCF) are serious complications following total laryngectomy and their incidence is higher in the salvage setting. The aim of this study is to describe the accuracy of water soluble swallow (WSS) to rule out salivary postoperative leak after salvage total laryngectomy (STL) to expedite start of oral intake., Material and Methods: Retrospective study including patients undergoing STL between 2008 and 2021 at Guy's Hospital. WSS was routinely performed within 15 days post operation., Results: Sixty-six patients underwent STL. Nine developed clinically diagnosed PCF; one died before having WSS. Fifty-six patients underwent WSS post STL. WSS was performed within 15 days after STL when no postoperative complications occurred (76.8%). Among patients undergoing WSS with no clinical suspicion for fistula (56), PL was identified in 15 cases (26.8%). They were managed conservatively; PCF was avoided in 7(46.7%) cases. Three patients (7.3%) developed PCF after having started oral intake with a negative WSS. These three cases were further analysed, 2 cases where recorded at the beginning of the studied period when less experience was available possibly leading to incorrect results. Sensitivity and negative predictive value (NPV) for fistula prediction were 72.7% and 92.7%, respectively., Conclusion: Taking into account the high NPV of WSS, it is safe to start oral intake after negative WSS. Further studies to evaluate its accuracy earlier on after SLT are justified taking into account the results and the impact that delayed feeding has on patient's quality of life., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Pharyngocutaneous fistula is a serious complication after head and neck reconstruction and concurrent chemoradiotherapy, yet no consensus or practical protocols regarding the surgical timing and specific procedures could be found in the current literature. The authors aimed to review their clinical experience in surgical management and develop an algorithmic approach accordingly. A retrospective review of all hypopharyngeal cancer patients who developed pharyngocutaneous fistula during 2017 to 2021 at E-Da Hospital was conducted. Seventeen patients developed pharyngocutaneous fistula in all 321 pharyngeal cancer admissions during this period. Three patients received interventions at acute stage (≤2 weeks), with two direct repairs Three patients received interventions at acute stage (≤2 weeks), with two direct repairs and one regional flap coverage then negative pressure wound therapy. Nine received interventions at subacute stages (2 weeks to 3 months), with 4 resolved after debridement and direct repair yet another 4 underwent regional flap reconstruction and 1 free flap reconstruction. Five chronic fistula (>3 months) received secondary reconstructions utilizing a double-layered repair of local turn-over flaps for the internal mucosal opening and another flap harvest (four regional flaps and one free flap) to cover the outer skin defect. All patients after the palliative surgery achieved complete remission of fistula at follow follow-up. Different conservative and surgical approaches should be adopted according to the acute, subacute, and chronic stages of pharyngocutaneous fistula after palliative head and neck reconstructions.

Introduction: The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario., Methods: A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included., Results: A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce., Conclusion: We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique., (© 2023. The Author(s).)

Background: Pharyngocutaneous fistula formation represents a major postoperative complication following total laryngectomy. We aimed to investigate the risk factors for pharyngocutaneous fistula development after total laryngectomy and to identify factors that lead to severe cases of pharyngocutaneous fistula., Methods: Patients who underwent total laryngectomy between January 2013 and February 2021 were included in the study and were divided into 2 groups: Those with and without pharyngocutaneous fistula. The severity of pharyngocutaneous fistula was graded using the Clavien-Dindo classification., Results: Patients with pharyngocutaneous fistula experienced longer operative time, greater intraoperative blood loss, greater decrease in perioperative hemoglobin level, and longer postoperative hospitalization. Unlike in lower-severity cases, patients with grade IIIb pharyngocutaneous fistula underwent preoperative radiotherapy or chemoradiotherapy; preoperative treatment was thus a risk factor for higher severity of pharyngocutaneous fistula (odds ratio, 35; P = 0.004)., Conclusion: Salvage laryngectomy was found to be a predictor of severe pharyngocutaneous fistula development. Prolonged operative time, increased intraoperative blood loss, and decreased postoperative hemoglobin level were found to be predictors of postlaryngectomy pharyngocutaneous fistula formation., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: A literature review and meta-analysis was performed to assess for difference in rate of complications and need for revision surgery between endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy. The hypothesis was that endoscopic stapler-assisted diverticulotomy has a lower complication rate but endoscopic carbon dioxide laser diverticulotomy has a lower need for revision surgery., Method: This was a systematic review of English-language studies comparing endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy for the treatment of Zenker's diverticulum. Meta-analysis of results with regard to rate of pharyngeal perforation, major post-operative complication and need for re-operation was performed., Results: Nine retrospective studies were included with pooled analysis of 417 endoscopic stapler-assisted diverticulotomy and 413 endoscopic carbon dioxide laser diverticulotomy cases. Meta-analysis found no significant difference in rate of pharyngeal perforation, major complication or need for re-operation between the two groups., Conclusion: This study demonstrated both endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy to be a safe alternative to open surgery for Zenker's diverticulum. Both appear to be similar in terms of adverse events and efficacy. The authors recommend either approach, guided by surgeon's preference and experience, where patients are unsuitable for an open surgery approach.

Objectives: To assess the predictive value of various risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy., Methods: The characteristics of each study were collected from six databases up to January of 2022. Risk for bias was assessed using the QUADAS-2 tool., Results: A total of 58 studies in 9845 patients were included in the analysis. The incidence of PCF was 21.69%, 95% confidence intervals (CI) [0.20; 0.24] in the included studies. Age (OR = 1.33, 95% CI [1.12; 1.58]), postoperative anemia (OR = 2.29, 95% CI [1.47; 3.57]), diabetes mellitus (OR = 1.81, 95% CI [1.20; 2.71]), tumor site (above or below the glottis) (OR = 1.47, 95% CI [1.15; 1.88]), previous radiation therapy (OR = 2.06, 95% CI [1.56; 2.72]), previous tracheostomy (OR = 1.26, 95% CI [1.04; 1.53]), surgery timing (salvage vs. primary) (OR = 2.08, 95% CI [1.46; 2.97]), extended total laryngectomy (including pharyngectomy) (OR = 1.96, 95% CI [1.28; 3.00]), primary tracheoesophageal puncture (OR = 0.61, 95% CI [0.40; 0.93]), and postoperative hypoproteinemia (OR = 9.98, 95% CI [3.68; 27.03]) were significantly associated with the occurrence of PCF. In view of predictive ability, postoperative hypoproteinemia showed the highest accuracy (sensitivity = 51%, specificity = 90%, area under the curve = 0.84)., Conclusion: Multiple patient-, disease-, and surgery-related factors are risk factors for PCF. In particular, postoperative hypoproteinemia could be a good predictive factor for PCF in patients undergoing total laryngectomy. Laryngoscope, 133:742-754, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

The management of pharyngocutaneous fistulas (PCFs) is challenging. A multidisciplinary treatment approach according to the clinical needs of a patient is essential for PCF management. Here, we describe the use of a double-layer closure technique involving a radial forearm free flap (RFFF) and a Freka-Trelumina nasojejunal tube in the reconstruction of a refractory PCF.

Background: No consensus exists regarding the most effective reconstruction after total laryngectomy with partial pharyngectomy (TLwPP). This study aims to compare different reconstructive techniques (pectoralis major myo-cutaneous flap, PMMCF; anterolateral thigh flap, ALTF; radial forearm free flap, RFFF) after TLwPP in terms of pharyngocutaneous fistula (PCF), stenosis and feeding tube dependence (FTD) incidence., Methods: The Scopus, PubMed/MEDLINE, Cochrane Library, and Google Scholar databases were searched. A single-arm meta-analysis was performed for PCF incidence, stenosis incidence, and FTD incidence on the entire cohort. An arm-based network analysis was conducted to compare three different surgical interventions (PMMCF, ALTF, RFFF)., Results: A total of 13 studies and 232 patients were included in the network meta-analysis. The lowest PCF absolute risk was measured for the RFFF (11.7%, 95% CI: 2.8%-33.4%), compared to the ALTF (13.4%, 95% CI: 4.5%-32.1%) and the PMMC (49.0%, 95% CI: 19.2%-79.3%). The RFFF showed a stenosis absolute risk of 0.0% (95% CI: 0.0%-1.1%), while a higher stenosis incidence was measured for the ALTF (5.7%, 95% CI: 0.8%-25.2%) and the PMMCF (11.6%, 95% CI: 0.8%-55.1%). The RFFF showed the lowest absolute risk of FTD incidence (6.8%, 95% CI: 0.5%-28.1%) compared to the other reconstructive techniques (PMMCF: 12.4%, 95% CI: 2.4%-42.1%; ALTF: 17.5%, 95% CI: 6.4%-38.9%)., Conclusions: The RFFF seems the best choice for reconstruction of partial pharyngeal defects after TLwPP due to the lower incidence of PCF, stenosis and FTD compared to the ALTF and the PMMCF., (© 2022 Wiley Periodicals LLC.)

Pharyngocutaneous fistula (PCF) caused by a previous anterior cervical spine fixation plate more than a decade ago has not been reported yet. A 70-year-old man with dysphagia was diagnosed as supraglottic cancer. After partial laryngectomy and concurrent chemoradiation, due to increasing arytenoid lesion, total laryngectomy was followed. Pharyngocutaneous fistula occurred but resolved spontaneously. However, retropharyngeal granulation tissue emerging from the anterior cervical spine fixation plate caused delayed PCF. Dysphagia and PCF resolved after fixation plate removal., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Pharyngeal pouches are generally treated with surgery, via either an endoscopic or an external approach. Large pouches extending to the mediastinum carry an increased risk of post-operative mediastinitis in the event of a leak following external approach surgery, and may not always be amenable to endoscopic stapling., Methods: Transcervical stapling is a newly described technique that uses the endoluminal stapling approach but in which the diverticuloscope is inserted into the pharynx via a neck incision., Conclusions: This technique has been used successfully on three patients with large pharyngeal pouches, where endoscopic stapling was not possible due to access limitations., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Pharyngocutaneous fistula is one of the most common and serious complications associated with total laryngectomy. Numerous studies tried to evaluate causative and predisposing factors associated with this complication, but data are considerably variable and there is still no international consensus. Incidence rate varies considerably between studies, with reported rates from 3% to 65%. This 4K video presents our T-shaped four-step technique (FST) for closing the pharyngeal mucosa after total laryngectomy in a step-by-step manner. All sutures were performed by braided absorbable 3/0 26 mm 1/2c (Vicryl plus 3.0; Ethicon, Somerville, NJ, USA). Recordings were performed using a Karl Storz 4K 3D VITOM® exoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany). We have been described this technique through a high-definition video, showing each step, and tips from the authors. Our T-shaped pharyngoplasty closure technique can be divided into four steps: 1. "Key Stitches"; 2. "Area Refinement Stitches"; 3. "Modified Connell Suture"; 4. "Modified Purse String Suture." Our T-shaped FST closure technique proved to be an effective and reproducible method, which we feel could be the preferred choice for primary pharyngoplasty closure., (© 2022 Wiley Periodicals LLC.)

Purpose: To compare the efficacy of different reconstructive techniques in preventing pharyngocutaneous fistula (PCF) after salvage total laryngectomy (STL)., Methods: An arm-based network analysis was conducted using a Bayesian hierarchical model according to the PRISMA-NMA guidelines., Results: A total of 1694 patients with a median age of 64 years (n = 1569, 95% CI: 62-66 years) were included. If compared to primary pharyngeal closure alone, only a pedicled flap onlay (PFO) showed a statistically significant reduction in PCF rate (OR: 0.35, CI: 0.20-0.61). PFO seemed to perform better than other treatments according to the rank probabilities test (39.9% chance of ranking first)., Conclusions: A pedicled flap placed with an overlay technique might be preferred over a patch reconstruction to prevent PCF after STL., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Radiotherapy is considered a risk factor for pharyngocutaneous fistula after a total laryngectomy. This study aimed to analyse the impact of exclusive radiotherapy versus chemoradiotherapy and the time interval between radiotherapy and surgery on the risk of pharyngocutaneous fistula., Method: This study was a retrospective revision of 171 patients treated with a total laryngectomy after radiotherapy or chemoradiotherapy., Results: Pharyngocutaneous fistula occurred in 33 patients (19.3 per cent). Patients previously treated with chemoradiotherapy showed a non-significant higher pharyngocutaneous fistula rate compared with patients treated with radiotherapy (25.0 per cent vs 18.0 per cent; p = 0.455). Patients with a pharyngocutaneous fistula after chemoradiotherapy treatment required a surgical repair more frequently than patients treated with radiotherapy ( p = 0.005). There were no significant differences in the pharyngocutaneous fistula rate depending on the time interval between radiotherapy and surgery ( p = 0.580)., Conclusion: There were no differences in the pharyngocutaneous fistula rate after total laryngectomy depending on the previous treatment with radiotherapy or chemoradiotherapy, or depending on the interval between radiotherapy treatment and surgery.

Objectives: Pharyngocutaneous fistula (PCF) is a major morbidity of salvage total laryngectomy (TL). Understanding the factors predicting PCF is fundamental to managing laryngeal cancer. We aim to assess factors associated with PCF following salvage TL in a multicenter, international retrospective cohort study of academic centers in the US and Canada., Results: In total, 550 patients post-salvage TL were identified (mean [SD; range] age, 64 [10.4; 32-90] years; 465 [85 %] male and 84 [15 %] female) between 2000 and 2014. Rate of PCF was 23 % (n = 127) with median time to PCF of 2.9 weeks. Surgical management of PCF was required in 43 % (n = 54) while 57 % (n = 73) required wound care alone. Rates of PCF differed by primary treatment modality [radiation, 20 % (n = 76); chemoradiation, 27 % (n = 40); not available (n = 6)] and use of vascularized tissue in pharyngeal closure [free/regional flap, 18 % (n = 25); no vascularized tissue/primary closure, 24 % (n = 98); not available (n = 4)]. There was no statistically significant association between PCF and treatment with chemoradiation (HR, 1.32; 95 % CI, 0.91-1.93, p = 0.14) or lack of vascularized tissue reconstruction (HR, 1.41, 95 % CI 0.91-2.18, p = 0.12). Significant association between PCF and advanced stage (T3 or T4), positive margin, close margin (&lt;5mm), lymphovascular invasion and pre-operative tracheostomy were identified on univariable analysis. Positive surgical margin (HR, 1.91; 95 % CI, 1.11 to 3.29) was the only significant association on multivariable analysis., Conclusion: We highlight positive surgical margin as the only variable significantly associated with increased risk of PCF following salvage TL on multivariable analysis in a large cohort across several major head and neck oncology centers., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier Ltd.)

The aim of this study is to determine whether the preventive positioning of a salivary bypass tube (SBT) after total laryngectomy (TL) reduces the incidence of postoperative pharyngocutaneous fistula (PCF) and pharyngeal stenosis (PS). This study was conducted in conformity with the PRISMA statement. 1960 patients with a median age of 62.0 years were included. A SBT was placed in 980 (50%) patients (SBT group). The cumulative PCF incidence in the SBT group was 15.8% (95% CI: 9.3-23.6). The measured pooled OR comparing PCF incidence in patients with SBT compared to those without was 0.40 (95% CI: 0.24-0.65). The pooled PS incidence in the SBT group was 12.3% (95% CI: 5.4-21.6). The measured pooled OR comparing PS incidence in patients with SBT compared to those without was 0.43 (95% CI: 0.24-0.65). PCF and PS could be prevented by the intra-operative placement of a SBT., (© 2022 Wiley Periodicals LLC.)

Background: The use of staplers in surgical repair of the pharynx after laryngectomy has gained traction in recent years, with differing results., Objective: In this study, we compare the use of stapler suturing (SS) after laryngectomy in comparison with the manual suturing (MS) technique in laryngeal cancer patients regarding pharyngocutaneous fistula (PCF) formation, operative time, blood loss, margin status, and length of hospital stay., Methods: We conducted a retrospective cohort study of laryngeal cancer patients undergoing pharyngeal repair after total laryngectomy by either a stapler or manual suturing. Demographic data, stage of disease, postoperative complications, duration of hospital stay, and operative time were collected., Results: A total of 59 laryngeal cancer patients were included, of which 22 underwent SS and 37 had MS. Our cohort was predominantly males (98%), and similar mean ages were observed across both suturing groups (60.5 vs 59.9, P = 0.83). Negative margins were more frequent with SS (100% vs 86.5%, P = 0.13) yet this difference was not statistically significant, whereas preoperative tracheostomy procedure was present more in MS patients (43.2% vs 0, P = 0.003). Lymph node involvement was higher in the manual suturing cohort, yet this difference was statistically insignificant (41.2% vs 25%, P = 0.49). The muscle flap procedure was significantly higher in the MS cohort (70.3% vs 20%, P = 0.001). In both groups, comparable PCF rates were noted (13.3% vs 10.8%) and there was no association between salvage laryngectomy and PCF occurrence in the entire cohort. For surgery details, there was no statistical difference between both groups in blood loss, hospitalization length, or oral feeding start. Only surgical time was significantly lower in the stapler cohort (277 vs 372.6 minutes, P = 0.000)., Conclusion: Both suturing techniques did not show any statistically significant difference in PCF rates. However, was markedly reduced with stapler use in comparison to manual suturing. Further randomized studies with larger sample size are needed to validate the role of stapler suturing for pharyngeal repair., Competing Interests: The authors declare no conflict of interest, (© 2022 Wisam Algargaz, Issa Mohamad, Suhaib Eid, Asim Khanfa, Hassan Abushukair.)

Objective : To analyze the effect of intraparotid injection of botulinum neurotoxin A (BoNT-A) on salivary production and the course of pharyngocutaneous fistula (PCF) in post-radiation therapy salvage surgery. Methods : A total of 13 patients who had undergone total laryngectomy or pharyngolaryngectomy were treated with BoNT-A to both parotid glands, within three days from PCF onset. The salivary flow was evaluated using a subjective rating scale as the percentage of normal function from 0% (no saliva) to 100% (normal saliva flow), before injection, every day for 2 weeks, and once a week for three months. PCFs were monitored daily. Results : Spontaneous closure of PCF occurred in 7/13 (53.84%) cases 13.6 days (range: 7-18) after treatment; 6/13 (46.16%) patients needed revision surgery. Salivary flow significantly decreased in all patients seven days after injection (from 67.2% to 36.4%; p < 0.05). Patients who had undergone either conservative or surgical treatment did not differ in salivary flow before injection, whereas the mean percentages of salivary flow calculated at each time point after injection were different ( p < 0.05). Conclusions : BoNT-A contributed to the closure of the fistula in most of our cases. The subjective perception of salivary flow predicted the closure of PCF. The mean time to closure may contribute to establishing the timing of PCF surgical treatment.

Pharyngocutaneous fistula is the most common complication after total laryngectomy and is difficult to heal. Although conservative treatment and surgical repair are effective, they often take longer and additional trips to the operating room, which undoubtedly increases the financial burden on patients. Especially in combination with diseases such as diabetes and hypertension, which affect the efficacy of surgery. Adding growth factors into the repair material can promote fibroblast proliferation, angiogenesis, and accelerate wound healing. A substantial number of studies have shown that a type of nanoscale extracellular vesicle, called exosomes, facilitates organization repair by promoting blood vessel production, protein polysaccharides, and collagen deposition, thereby representing a new type of cellular therapy. At present, there is little research on the application of exosomes in pharyngocutaneous fistula regeneration after total laryngectomy. In this review, we summarize the biological characteristics of exosomes and their application in biomedical science, and highlight their application prospects in pharyngocutaneous fistula regeneration after total laryngectomy., Competing Interests: The authors declare that they have no conflict of interest., (© 2022 Chen et al.)

Introduction: One of the most common complications in the immediate and late postoperative period following total laryngectomy or pharyngolaryngectomy is pharyngocutaneous fistulae (PCF) formation and pharyngoesophageal stenosis (PES), causing significant mortality and morbidity. Since 1978, Montgomery salivary bypass tube (MSBT) has been used to reduce the incidence of PCF and PES. The aim of this retrospective study was to analyze the outcomes of using MSBT both as a tool to prevent PCF and PES and to treat these complications in the postoperative period., Methods: Between January 2013 and December 2019, we inserted 109 MSBT in 87 patients with laryngeal/hypopharyngeal cancer treated in the Unit of Otolaryngology of our University Hospital., Results: Sixty (86.9%) patients healed from complications with primary and secondary placement of MSBT. Seven patients presented a persistence of PCF and 2 presented a recurrence of PES. Secondary placement of MSBT allowed treating successfully 15 (83%) of 18 patients. Only 3 of them presented a PCF at the end of the follow-up period., Conclusion: According to our experience, the MSBT is an affordable, easy to apply and well-tolerated tool. Although it is generally used for PCF treatment, it can also be used intraoperatively for PCF and PES prevention.