Cost-effective management of pharyngocutaneous fistulas following laryngectomy

A pharyngocutaneous fistula following a total laryngectomy is not an uncommon occurrence. The incidence of this serious complication ranges worldwide from 7.6 percent to 50 percent. It usually exacerbates post-operative morbidity and increases expense with prolonged hospitalization. This complication often requires additional operative procedures or if untreated may lead to a fatal complication such as carotid artery rupture. There are multiple predisposing factors leading to poor wound healing in this patient population. These factors include prior radiation therapy, chemotherapy, compromised nutrition, and associated surgical procedures including radical neck dissection. A treatment strategy for difficult fistulas with undermining is presented here. The cornerstones of this approach include opening the area large enough for packing and cleansing, diverting the copious pharyngeal secretions and providing an optimal wound environment through the use of an amorphous hydrogel dressing (Intrasite* Gel, Smith & Nephew United, Inc., Largo, FL). This treatment strategy led to complete and sustained healing when utilized by the authors in the following patients. It was successful even in heavily irradiated tissue with its severe changes of compromised vascularity, increased dermal fibrosis and epidermal thinning. The authors have found this technique a cost-effective alternative to secondary surgery, applicable in both the acute and home care settings.