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Background: Second primary esophageal cancer often develops in patients with head and neck cancer, and esophagectomy in patients with a history of total pharyngolaryngectomy (TPL) is challenging. However, the clinical outcomes of these patients have yet to be examined in a multicenter setting., Methods: We evaluated the surgical outcomes of a nationwide cohort of 62 patients who underwent esophagectomy for esophageal cancer with a history of TPL., Results: Ivor-Lewis and McKeown esophagectomies were performed in 32 (51.6%) and 30 (48.4%) patients, respectively. Postoperatively, 23 patients (37.1%) developed severe complications, and 7 patients (11.3%) required reoperation within 30 days. Pneumonia and anastomotic leakage occurred in 13 (21.0%) and 16 (25.8%) patients, respectively. Anastomotic leakage occurred more frequently in the McKeown group than in the Ivor-Lewis group (46.7% vs. 6.2%, P < 0.001). The adjusted odds ratio for anastomotic leakage in the McKeown group was 9.64 (95% confidence intervals (CI), 2.11-70.82, P = 0.008). Meanwhile, the 5-year overall survival rates were comparable between the groups (41.8% for Ivor-Lewis and 42.7% for McKeown), and the adjusted hazard ratio of overall survival was 1.44 (95% CI, 0.64-3.29; P = 0.381; Ivor-Lewis as the reference)., Conclusions: In our cohort, anastomotic leakage occurred more frequently after McKeown than Ivor-Lewis esophagectomy, and almost half of patients in the McKeown group experienced leakage. Ivor-Lewis esophagectomy is preferred for decreasing anastomotic leakage when oncologically and technically feasible., (© 2024. The Author(s) under exclusive licence to The Japan Esophageal Society.)

Background: Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP., Methods: Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications., Results: We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks., Conclusion: Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology., Competing Interests: Disclosure The authors have no competing interests or specific funding to disclose, (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

To the best of our knowledge, this is the largest case series describing the use of a melolabial flap for postlaryngectomy pharyngoplasty. It is an excellent alternative for pharyngoplasty, especially in cases post chemoradiotherapy. It accomplishes the goal while removing the restrictions of local and distant flaps. Although donor site morbidity is acceptable, specific consent is required due to the possibility of functional and cosmetic impairment. Additional cases with a larger sample size and a longer follow-up period can assist corroborate our first findings. In addition, because we tend to protect facial vessels for this flap, a follow-up about the compromise of oncological safety at level IB is required. In our case series, however, there was no recurrence until the final follow-up. As a result, it is a better option to pharyngoplasty post laryngectomy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate the risk factors of pharyngocutaneous fistula after total pharyngolaryngectomy (TPL) in order to reduce their incidence and propose a perioperative rehabilitation protocol., Materials and Methods: This was a multicenter retrospective study based on 456 patients operated for squamous cell carcinoma by total laryngectomy or TPL. Sociodemographic, medical, surgical, carcinologic, and biological risk factors were studied. Reactive C protein was evaluated on post-op day 5. Patients were divided into a learning population and a validation population with patients who underwent surgery between 2006 and 2013 and between 2014 and 2016, respectively. A risk score of occurrence of salivary fistula was developed from the learning population data and then applied on the validation population (temporal validation)., Objective: To use a preoperative risk score in order to modify practices and reduce the incidence of pharyngocutaneous fistula., Results: Four hundred fifty-six patients were included, 328 in the learning population and 128 in the validation population. The combination of active smoking over 20 pack-years, a history of cervical radiotherapy, mucosal closure in separate stitches instead of running sutures, and the placement of a pedicle flap instead of a free flap led to a maximum risk of post-op pharyngocutaneous fistula after TPL. The risk score was discriminant with an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI] = 0.59-0.73) and 0.70 (95% CI = 0.60-0.81) for the learning population and the validation population, respectively., Conclusion: A preoperative risk score could be used to reduce the rate of pharyngocutaneous fistula after TPL by removing 1 or more of the 4 identified risk factors.

Rationale: Syncope often occurs in patients with advanced head and neck cancers due to the stimulation of the autonomic nervous system by the tumor. Here, we describe a case of frequent syncopal episodes after laryngopharyngectomy for hypopharyngeal cancer. As all syncopal episodes were observed during the forenoon, we also evaluated the heart rate variability using ambulatory electrocardiography to determine why the syncopal episodes occurred during a specified period of the day., Patient Concerns: A 73-year-old Japanese man who underwent laryngopharyngectomy for recurrent hypopharyngeal cancer started experiencing frequent episodes of loss of consciousness that occurred during the same time period (10:00-12:00). He had never experienced syncopal episodes before the operation. From 23 to 41 days postoperatively, he experienced 9 syncopal episodes that occurred regardless of his posture., Diagnoses: Pharyngo-esophagoscopy revealed an anastomotic stricture between the free jejunum graft and the upper esophagus. Swallowing videofluoroscopy confirmed the dilatation of the jejunal autograft and a foreign body stuck on the oral side of the anastomosis. Contrast-enhanced computed tomography revealed that the carotid artery was slightly compressed by the edematous free jejunum. The patient was diagnosed with carotid sinus syndrome (CSS) as the free jejunum was dilated when consuming breakfast, which may have caused carotid sinus hypersensitivity and induced a medullary reflex., Interventions: Administration of disopyramide was effective in preventing syncope. Heart rate variability analysis using ambulatory electrocardiography showed that parasympathetic dominancy shifted to sympathetic dominancy during 10:00 to 12:00. The significant time regularity of the syncopal episodes may have been affected by modified diurnal variation in autonomic tone activity., Outcomes: After the surgical release and re-anastomosis of the pharyngoesophageal stenosis via an open-neck approach, no recurrent episodes of syncope were reported., Lessons: We reported a case of frequent syncopal episodes limited to the forenoon due to CSS after surgery for hypopharyngeal carcinoma. The patient was treated with anticholinergics followed by the release and re-anastomosis of the pharyngoesophageal stenosis. When syncope occurs after surgery for head and neck lesions, CSS due to postoperative structural changes should be considered as a differential diagnosis of syncope., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature., Methods: Retrospective review., Results: Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09)., Conclusion: Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes., Level of Evidence: 4 Laryngoscope, 131:E875-E881, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP., Methods: We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital., Results: For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively., Conclusions: Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.

Background: Outcomes following surgical intervention for laryngeal and hypopharyngeal tumors are dependent on several factors. In the present study, we sought to determine whether tumor subsite, salvage status, and extent of resection influenced postoperative outcomes., Methods: Retrospective review of 107 patients at a single institution who underwent total laryngectomy or partial/total laryngopharyngectomy., Results: Hypopharyngeal subsite and total laryngopharyngectomy subgroups had inferior speech and swallow outcomes compared to their respective cohorts (P < .05). Salvage patients had inferior 3-year overall survival (P < .05) and swallow outcomes (P < .001). Previously radiated patients had increased fistula rates (29.9% vs 10%, P = .02), and the use of tissue coverage in salvage total laryngectomy had a protective effect on fistula formation (10% vs 37%, P = .04)., Conclusions: By stratifying patients across multiple subgroups, we provide a detailed narrative in surgical outcomes that can be incorporated into treatment planning. Further prospective studies are needed to compare surgical outcomes to those of organ preservation therapy., (© 2019 Wiley Periodicals, Inc.)

Enlargement of tracheoesophageal puncture (TEP) is seen in 1-29% of laryngectomee/laryngopharyngectomee using tracheoesophageal voice. It predisposes patient for recurrent aspiration pneumonia. Surgical closure of TEP is required in 30-67% of patients not responding to conservative measures. Surgical closure of an enlarged TEP using a flap may be time consuming, complex, and logistically challenging to organize. A novel technique of Fascia lata graft closure of an enlarged TEP is presented here. This technique can be useful in carefully selected patients with an enlarged TEP.

Purpose: The aim of the study is to determine the predisposing factors for pharyngocutaneous fistula (PCF) in patients undergoing total laryngectomy (TL) or extended TL and, secondarily, to propose a new severity-based classification system., Methods: This is a retrospective study of 400 patients who underwent TL or extended TL. Major fistula was defined as a fistula (1) persisting for ≥ 4 weeks, (2) requiring surgical treatment, or (3) associated with perioperative mortality., Results: PCF formation occurred in 93 patients (23.3%) and major fistula in 72 (18.0%). Extended surgery with partial or total pharyngectomy, previous treatment with radiotherapy, and postoperative hemoglobin levels < 99 g/L were associated with a significantly higher risk of developing major fistula., Conclusions: We propose a new PCF classification system according to clinical severity. Predictors of major fistula were the type of surgery, previous radiotherapy, and low (< 99 g/L) postoperative hemoglobin levels. We consider the use of onlay flaps in irradiated patients who require partial pharyngectomy.

Background: We devised an advanced pectoral flap (APF) to prevent anastomotic leak after total pharyngolaryngectomy (TPL) and free jejunal reconstruction (FJR) in patients with hypopharyngeal or laryngeal carcinoma. The APF alleviates tension on the skin in the neck, reduces the subcutaneous dead space, and promotes adhesion between the neck skin and the anastomosis., Objective: To investigate whether an APF is effective for prevention of anastomotic leak associated with TPL/FJR., Patients and Methods: Anastomotic leak was compared between APF (n = 65) and non-APF groups (n = 25). Patients who had received preoperative radiotherapy or undergone tracheostomy or skin infiltration requiring neck reconstruction using a pedicle flap were excluded., Results: There were significantly fewer cases of anastomotic leak in the APF group than in the non-APF group (1.5% [1/65] vs. 16.0% [4/25]; p = .02). An APF could be created bilaterally within approximately 15 minutes. Unlike a deltopectoral flap, an APF does not require a skin graft., Conclusions: The postoperative anastomotic leak rate was 1.5% in patients who underwent TPL and FJR for hypopharyngeal or laryngeal carcinoma with an APF., Significance: An APF is easily created and can reduce the incidence of anastomotic leak after TPL and FJR.

Background: Tracheoesophageal puncture (TEP) with voice prosthesis is a widely used technique for voice restoration in laryngectomy and pharyngolaryngectomy patients. Complications include leakage around the prosthesis or a persistent TEP postremoval of the prosthesis., Methods: We describe a method for managing leakage around voice prosthesis or persistent TEP using hyaluronic acid injection. We also present a retrospective audit of our practice., Results: This study had 8 patients who were treated over a 32-month period. All cases had immediate cessation of salivary leak. Duration of efficacy was variable. Five of the 8 cases had permanent resolution of their symptoms after multiple injections. Two cases of persistent TEP were treated surgically after multiple injections. One patient with peripheral leakage continues to have regular injections., Conclusion: Hyaluronic acid injection in the treatment of persistent TEP or peripheral leak around a voice prosthesis is a useful treatment option to provide immediate and occasionally long-lasting relief from symptoms., (© 2018 Wiley Periodicals, Inc.)

Background: Data have been limited on donor-site mechanical bowel obstruction after pharyngolaryngectomy with free jejunum graft reconstruction., Methods: Using a nationwide Japanese inpatient database, we extracted data on patients who underwent pharyngolaryngectomy for hypopharyngeal cancer between July 2007 and March 2014. A Cox proportional hazard model was used to determine the association between background characteristics and the occurrence of mechanical bowel obstruction., Results: Among the 3320 eligible patients from 332 hospitals, 108 patients (3.3%) developed mechanical bowel obstruction after a median 88 (interquartile range 26-217) postoperative days. Multivariable Cox regression analysis revealed that older age (≥60 years old) was independently associated with an increased risk of mechanical bowel obstruction, whereas sex, body mass index [BMI], smoking status, comorbidity at admission, blood transfusion, history of surgery, and hospital type were not., Conclusion: In pharyngolaryngectomy, careful attention should be paid to the risk of abdominal complications and, thus, to the graft choice, especially in elderly patients., (© 2018 Wiley Periodicals, Inc.)

Background: Incidences of pharyngocutaneous fistulization (PCF) after total laryngectomy (TL) reported in the literature vary widely, ranging from 2.6 to 65.5%. Comparison between different centers might identify risk factors, but also might enable improvements in quality of care. To enable this on a national level, an audit in the 8 principle Dutch Head and Neck Centers (DHNC) was initiated., Methods: A retrospective chart review of all 324 patients undergoing laryngectomy in a 2-year (2012 and 2013) period was performed. Overall PCF%, PCF% per center and factors predictive for PCF were identified. Furthermore, a prognostic model predicting the PCF% per center was developed. To provide additional data, a survey among the head and neck surgeons of the participating centers was carried out., Results: Overall PCF% was 25.9. The multivariable prediction model revealed that previous treatment with (chemo)radiotherapy in combination with a long interval between primary treatment and TL, previous tracheotomy, near total pharyngectomy, neck dissection, and BMI < 18 were the best predictors for PCF. Early oral intake did not influence PCF rate. PCF% varied quite widely between centers, but for a large extend this could be explained with the prediction model. PCF performance rate (difference between the PCF% and the predicted PCF%) per DHNC, though, shows that not all differences are explained by factors established in the prediction model. However, these factors explain enough of the differences that, compensating for these factors, hospital is no longer independently predictive for PCF., Conclusions: This nationwide audit has provided valid comparative PCF data confirming the known risk factors from the literature which are important for counseling on PCF risks. Data show that variations in PCF% in the DHNCs (in part) are explainable by the variations in these predictive factors. Since elective neck dissection is a major risk factor for PCF, it only should be performed on well funded indication.

Background: The treatment modalities for recurrent locally advanced head and neck cancer failure after radiotherapy are limited with poor prognosis. Salvage supra-radical operation seems to be an option. It has not been established which patients will benefit from salvage total pharyngolaryngoesophagectomy., Methods: We retrospectively reviewed 66 patients with previously irradiated recurrent T4 head and neck cancer who underwent salvage total pharyngolaryngoesophagectomy at our institution between January 2001 and June 2014. The clinical outcome and toxicities were analyzed., Results: Flap loss occurred in 2 patients, and the incidence of fistulas and anastomosis strictures was 15.6% (10/66) and 13.6% (9/66), respectively. The median survival time of the entire cohort was 12 months. The interval between radiation and salvage surgery, and microscopic carotid artery invasion were identified as independent prognostic factors for overall survival. The 3-year overall survival rates of patients with (n = 33) and without (n = 33) risk factors were 9.1% and 47.2%, respectively (p = 0.007). A time interval between radiation and salvage surgery ≤6 months and previous concurrent chemotherapy or targeted therapy were risk factors for severe post-operative complications., Conclusions: Salvage total pharyngolaryngoesophagectomy is beneficial to selected patients with recurrent locally advanced head and neck cancer after radiotherapy.

Objective: Concurrent chemoradiotherapy (CCRT) is often performed after total pharyngo-laryngo-esophagectomy (TPLE) or total laryngectomy (TL). Hypothyroidism is one of the side-effects of CCRT. The objective of this study was to ascertain the timing of onset and severity of latent hypothyroidism among patients who underwent radiotherapy (RT) or CCRT after TPLE or TL, using thyroid-stimulating hormone (TSH) as a biomarker, and to explore methods of preventing its development., Methods: Participants comprised 21 patients who underwent these treatments at Tokyo Medical University Hachioji Medical Center between May 2009 and December 2013. TSH, free thyroxine 3, and free thyroxine 4 levels were used as indicators of thyroid function, and thyroid hormone was administered for TSH levels ≥15 µU/mL., Results: Post-radiotherapeutic TSH levels in 17 of the 21 patients (81%) were not within the reference value, and 10 (48%) required thyroid hormone therapy. Pharmacotherapy was initiated within 1 year in 5 of these 10 patients (50%), and between 1 and 3 years in the remaining 5 patients. No patient who did not undergo thyroidectomy required hormone therapy. Early evaluation of thyroid function appears important when postoperative RT, including CCRT, is performed in combination with TPLE or TL., Conclusion: Our study suggested that postoperative CCRT or RT after TPLE or TL, especially hemithyroidectomy, carries a high risk for hypothyroidism.

Salivary bypass tubes (SBT) are increasingly used to prevent pharyngocutaneous fistula (PCF) following laryngectomy and pharyngolaryngectomy. There is minimal evidence as to their efficacy and literature is limited. The aim of the study was to determine if SBT prevent PCF. The study was a multicentre retrospective case control series (level of evidence 3b). Patients who underwent laryngectomy or pharyngolaryngectomy for cancer or following cancer treatment between 2011 and 2014 were included in the study. The primary outcome was development of a PCF. Other variables recorded were age, sex, prior radiotherapy or chemoradiotherapy, prior tracheostomy, type of procedure, concurrent neck dissection, use of flap reconstruction, use of prophylactic antibiotics, the suture material used for the anastomosis, tumour T stage, histological margins, day one post-operative haemoglobin and whether a salivary bypass tube was used. Univariate and multivariate analysis were performed. A total of 199 patients were included and 24 received salivary bypass tubes. Fistula rates were 8.3% in the SBT group (2/24) and 24.6% in the control group (43/175). This was not statistically significant on univariate (p value 0.115) or multivariate analysis (p value 0.076). In addition, no other co-variables were found to be significant. No group has proven a benefit of salivary bypass tubes on multivariate analysis. The study was limited by a small case group, variations in tube duration and subjects given a tube may have been identified as high risk of fistula. Further prospective studies are warranted prior to recommendation of salivary bypass tubes following laryngectomy.

Background: Total pharyngolaryngectomy and cervical esophagectomy (TPLCE) after chemoradiotherapy remains a challenge because of the high rate of complications and few available data on outcomes and safety. The purpose of this study was to evaluate the clinical significance of salvage TPLCE and to compare treatment outcomes between hypopharyngeal cancer and cervical esophageal cancer., Methods: Data from 37 consecutive patients who were diagnosed with potentially resectable hypopharyngeal and cervical esophageal cancer after chemoradiotherapy were retrospectively analyzed. The survival and surgical outcomes were investigated between the hypopharyngeal cancer and cervical esophageal cancer groups., Results: Twenty-six patients were included in hypopharyngeal cancer group and 11 patients were included in cervical esophageal cancer group. The baseline characteristics were balanced between the two groups. Compared to the hypopharyngeal cancer group, the cervical esophageal cancer group had significantly more frequent tracheal-related complications (p < 0.05) and stronger association of distal margin of the cervical esophagus and radiation field with tracheal ischemia after salvage surgery., Conclusions: Salvage TPLCE can offer the exclusive chance of prolonged survival. Association of tracheal ischemia with salvage TPLCE was seen more frequently for cervical esophageal cancer. Therefore, the indication for salvage TPLCE must be carefully considered to maintain the balance between curability and safety.

Purpose: To highlight cervical spondylodiscitis as an infrequent complication following an invasive procedure on the neopharynx in patients previously treated with circumferential pharyngolaryngectomy with pectoralis major myocutaneous flap reconstruction., Methods: Patients diagnosed with cervical spondylodiscitis after circumferential pharyngolaryngectomy between 2001 and 2013 were retrospectively studied using a questionnaire sent to the French head and neck tumour study group. Medical history; tumour management; clinical symptoms; biological, microbiological and imaging results; and management of the infection were collected for each patient., Results: Six men aged 51-66 years were diagnosed with spondylodiscitis on average 5.6 years after circumferential pharyngolaryngectomy, and a mean 2 months following an invasive procedure on the neopharynx (oesophageal dilatation, phonatory prosthesis insertion). The patients presented with cervical pain and increased CRP level. MRI showed epidural abscess and communication between the pharynx and vertebral bodies in most cases. Microbiological samples yielded bacteria from the pharynx flora. Infection was managed using antibiotics adjusted according to the culture results and spinal immobilisation for duration of 6-12 weeks. No surgical treatment was required. During follow-up, no patient experienced recurrence or residual disability., Conclusions: Cervical spondylodiscitis is a rare but potentially severe complication following an invasive procedure on the neopharynx after circumferential pharyngolaryngectomy. Therefore, the onset of nonspecific symptoms should not be overlooked, and MRI must be performed if infection is suspected. Microbiological confirmation is critical in optimising treatment, which should be aggressive, even if overall prognosis seems to be good.

Background: Primary total laryngopharyngectomy is the treatment of choice in many cases of locally advanced hypopharyngeal and laryngeal cancer. Development of pharyngocutaneous fistulae is the most common postoperative complication. A recent Danish study showed significantly increased rates of anastomosal leakage after colorectal resection in patients receiving diclofenac treatment., Methods: We retrospectively analyzed 67 patients after primary total laryngopharyngectomy to determine whether diclofenac increases the risk for development of pharyngocutaneous fistula analogously to leakage in the colorectal area., Results: The fistula rate in the total study population (n = 67) was 19.4%. In the group receiving diclofenac postoperatively (n = 31), the fistula rate was 25.8%. In the patient group not receiving diclofenac (n = 36), the fistula rate was 13.9% (p = .219)., Conclusion: Our results suggest that cyclooxygenase-2 (COX-2) selective nonsteroidal anti-inflammatory drugs (NSAIDs) should be administered with caution after laryngopharyngectomy. Additional studies on larger cohorts are required to further evaluate our findings. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1515-E1520, 2016., (© 2015 Wiley Periodicals, Inc.)

Background: Risk factors for pharyngocutaneous fistula and associated delay in free oral feeding after pharyngolaryngectomy for patients with hypopharyngeal cancer remain uncertain., Methods: We used a Japanese national inpatient database to perform a retrospective cohort study between 2007 and 2013. We performed multivariable logistic regression analysis to identify patient characteristics associated with pharyngocutaneous fistula formation, and Cox regression analysis to evaluate factors affecting the interval from pharyngolaryngectomy to free oral feeding., Results: Among 549 eligible patients, 33 had developed pharyngocutaneous fistula, 19 of whom required surgical closure. Preoperative radiotherapy significantly increased risk of pharyngocutaneous fistula (odds ratio [OR] = 3.17; 95% confidence interval [CI] = 1.10-9.12; p = .033). Pharyngocutaneous fistula significantly prolonged the interval to oral feeding (median days, 67 vs 20 in those with and without pharyngocutaneous fistula, respectively; hazard ratio [HR], = 0.26; 95% CI = 0.15-0.44; p < .001)., Conclusion: Preoperative radiotherapy was associated with increased occurrence of pharyngocutaneous fistula and subsequent delay in free oral feeding. © 2015 Wiley Periodicals, Inc. Head Neck 38: E-E, 2016., (© 2015 Wiley Periodicals, Inc.)

Background: Voice restoration after laryngopharyngectomy can be achieved with an autologous ileocolic flap. We have observed that the length of the flap influences vocal outcome. This investigation aimed to evaluate the association between ileocolic flap length and vocal quality after laryngopharyngectomy., Methods: The charts of patients who underwent voice rehabilitation with an ileocolic flap after laryngopharyngectomy between 1 January 2011 and 30 December 2012 were abstracted. The length of ileum segment in the ileocolic flap was stratified, and voice outcome was evaluated three months post-operatively, while adjusting for confounding variables., Results: There was a significant association between flap length and loudness, maximum phonation time and sound pressure level (p < 0.05). All three parameters were best in the 10 cm length group., Conclusion: Voice rehabilitation after laryngopharyngectomy is possible with an ileocolic flap. The optimal ileocolic flap contains a 10 cm ileum segment. Complications are frequent but amenable to revision surgery.

Background: Gastric conduit ischemia is sometimes correlated with anastomosis-related morbidities after esophagectomy and pharyngolaryngectomy.1 (-) 5 A lack of connection between the right and left gastroepiploic vessels and intraoperative injury to these vessels could cause conduit ischemia. In addition, tensioned anastomosis due to a short gastric tube also could contribute to anastomotic leaks. This report introduces a reconstruction technique using a pedunculated gastric tube with duodenal transection for these cases., Methods: Creation of a gastric tube in the greater curvature of the stomach is performed with linear staplers. Only the right gastroepiploic vessels are preserved. The gastric tube is finally fashioned with a width of approximately 4 cm. The peripheral right gastroepiploic vessels to the pylorus are sacrificed. After the bulbs are transected, a pedunculated gastric tube is moved, with confirmation whether it has sufficient length for anastomosis in the neck. After the anal side of the gastric tube is transected, Roux-en-Y gastrointestinal anastomosis is performed. Finally, esophagogastric or pharyngogastric anastomosis is performed., Results: Between November 2011 and September 2014, 18 patients underwent the reported reconstruction technique due to short gastric tubes in 10 patients and a lack of connection between the right and left gastroepiploic vessels in 8 patients. Anastomotic leaks occurred in three patients (16.7 %), conduit necrosis in no patients, and strictures in no patients, respectively. Two patients had an anastomotic grade 2 leak, and one patient had an anastomotic grade 3 leak., Conclusion: The current reconstruction technique is a good alternative for patients at risk of conduit ischemia and patients with a short gastric tube after esophagectomy and pharyngolaryngectomy.

Total laryngo-pharyngo-esophagectomy (TLPE) with gastric pull-up reconstruction is still considered to be associated with major complications and a significant risk of in-hospital death. Minimally invasive esophagectomy, avoiding thoracotomy and laparotomy, has been increasingly performed for esophageal malignancies with the hope of reducing mortality and morbidity, such as pulmonary complications. The aim in this study was to assess early and long-term morbidity as well as treatment outcomes in patients treated with TLPE with gastric pull-up reconstruction via thoracoscopy, laparoscopy and cervical incision. From 2004 to 2013, 10 patients with a median age of 64 years (range 47-71 years) underwent minimally invasive TPLE with gastric pull-up reconstruction. Seven of the 10 patients had previously received radiotherapy. As for early postoperative complications, no patient died during the early postoperative period, and pneumonia was observed in 1, skin necrosis in 1, pseudomembranous enterocolitis in 1, arrhythmia in 2, hemorrhage in the neck in 2, anastomotic leakage in the neck in 3, and tracheal necrosis in 6 patients. Three patients developed tracheostomal stenosis as a long-term postoperative complication, and an anastomotic stricture was observed in one patient. All patients were able to achieve oral intake, but 3 patients required feeding tube support. In conclusion, postoperative systemic complications during the early postoperative period were considered to be acceptable, although wound complications such as tracheal necrosis and anastomotic leakage were commonly observed. Therefore, this minimally invasive procedure might help reduce mortality and morbidity in patients requiring TLPE with gastric pull-up reconstruction.

Reconstruction for patients with advanced squamous cell carcinoma of the hypopharynx (SCCHP) after radical surgery is a challenge for head and neck surgeons, especially when one flap alone cannot entirely cover the defects. In this report, we describe the successful use of gastric pull-up combined with pectoralis major flaps for single-stage reconstruction after total laryngopharyngoesophagectomy in patients with SCCHP. We retrospectively reviewed the records of 23 patients with stage IV SCCHP who underwent this reconstructive procedure. Surgical details and perioperative morbidity were described, and functional and oncologic outcomes were evaluated. We used the gastric pull-up and pectoralis major flap procedure to reconstruct the defects for all 23 patients. In 13 patients the combined flaps were used to restore intestinal continuity, and in 10 patients the defects were repaired using gastric pull-up alone and covered by the pectoralis major flap. All the combined flaps worked well, and patients recovered normal swallowing function a mean 19.6 days after surgery. After an overall mean follow-up time of 25.3 months, six patients were still alive at the time of this analysis with no evidence of disease. Our results indicate that for patients with advanced SCCHP after total laryngopharyngoesophagectomy, using a pectoralis major flap combined with gastric pull-up enables one-stage reconstruction even when gastric pull-up alone cannot restore intestinal continuity. Furthermore, the functional and oncologic outcomes from this study suggest that this reconstructive procedure is safe and reliable, and more patients with advanced disease could be considered.

Background: Total pharyngolaryngectomy (TPL) is a conventional and standard surgical method for locoregional control of advanced hypopharyngeal cancer (HPC). This study aimed to define the clinicopathological prognostic factors of TPL by evaluating our surgical experience of TPL in the treatment of HPCs., Methods: We retrospectively reviewed the clinical charts of patients with HPC who were treated between 1995 and 2011 at the University of Tokyo Hospital and enrolled 119 patients who underwent TPL as an initial curative treatment., Results: The mean follow-up period was 46 months (range, 2-164 months). The 5-year overall survival (OS), disease-specific survival (DSS), locoregional control rates, and relapse-free survival for all patients were 44, 53, 76, and 50 %, respectively. In multivariate analysis, the number of ≥4 metastatic lymph nodes (LNs) was a significant poor prognostic factor for both OS and DSS (p = 0.03 and p = 0.01). Patients with moderate to severe comorbidities had poor prognoses for OS (p = 0.002). In addition, patients with the number of ≥4 metastatic LNs had a higher incidence of distant metastases (p < 0.0001)., Conclusions: The locoregional control rate following TPL was acceptable and the number of metastatic LNs was associated with the incidence of distant metastases.

Due to the significant morbidity and mortality associated with pharyngocutaneous fistula in pharyngoesophageal reconstruction following cancer resection, the purpose of this retrospective study is to examine the selection of tubed skin flaps that impact anastomotic integrity. The flaps evaluated included radial forearm flap versus anterolateral thigh flap, and fasciocutaneous anterolateral thigh flap versus chimeric anterolateral thigh flap. The outcome of interest is the incidence of pharyngocutaneous fistula. The radial forearm group had a significantly higher rate of fistula than the anterolateral thigh group (56.6% vs. 30.2%, p = 0.03). No significant difference in the incidence of fistula was demonstrated between fasciocutaneous and chimeric anterolateral thigh flap (36.8% vs. 25%, p = 0.51). The anastomotic integrity in pharyngoesopharyngeal reconstruction is affected by choice of skin flaps. Anterolateral thigh flap appears to be a viable option for pharyngoesophageal reconstruction. The more technical demand of the anterolateral thigh flap must be weighed against an easily harvested radial forearm flap.

Tracheal necrosis is a rare life-threatening phenomenon that most often occurs after thyroid operations or prolonged intubation. Conservative treatment can be one choice in extensive tracheal necrosis. We report the case of a 59-year-old man, with tracheal necrosis that developed after pharyngolaryngectomy, that we treated conservatively using hyperbaric oxygen therapy and antibiotic therapy. The follow-up was assured by tracheobronchoscopy. A year after his discharge, the trachea was totally healed., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study compared the incidence of salivary fistula between groups with an early or late reintroduction of oral feeding, and identified the predictive factors for salivary fistula., Methods: A randomised trial was performed using 89 patients with larynx or hypopharynx cancer, assigned to 2 groups (early or late). In the early group, oral feeding was started 24 hours after total laryngectomy or total pharyngolaryngectomy, and in the late group, it was started from post-operative day 7 onwards. The occurrence of salivary fistula was evaluated in relation to the following variables: early or late oral feeding, nutritional status, cancer stage, surgery performed, and type of neck dissection., Results: The incidence of salivary fistula was 27.3 per cent ( n  = 12) in the early group and 13.3 per cent ( n  = 6) in the late group ( p  = 0.10). The following variables were not statistically significant: nutritional status ( p  = 0.45); tumour location ( p  = 0.37); type of surgery ( p  = 0.91) and type of neck dissection ( p  = 0.62). A significant difference ( p  = 0.02) between the free margins and invasive carcinoma was observed., Conclusion: The early reintroduction of oral feeding in total laryngectomised patients did not increase the incidence of salivary fistula.

Importance: Method of direct clinical monitoring of tissue perfusion in free tissue reconstruction of pharyngeal defects., Objective: To describe a novel and effective method of incorporating a cutaneous skin paddle into laryngopharyngectomy reconstruction for direct clinical monitoring of anterolateral thigh free flaps., Design: Retrospective review of pharyngoesophageal reconstruction for laryngopharyngectomy defects performed between August 1, 2008, and March 1, 2011, using the anterolateral thigh flap., Setting: Tertiary care academic medical center., Participants: Consecutive patients undergoing laryngopharyngectomy where free tissue transfer is indicated., Interventions: Anterolateral thigh free flap reconstruction with suprastomal cutaneous monitoring paddle., Main Outcome Measures: Postoperative complications, including flap failure, fistula, and stricture. Postoperative functional outcomes of swallowing and vocal capability were also measured., Results: Twenty-one patients (mean age, 62.2 years; range, 39-81 years) underwent total laryngectomy with near-total or total pharyngectomy and immediate reconstruction with an anterolateral thigh free flap. The reconstructions included a cutaneous monitor paddle distal to the pharyngoesophageal anastomosis. Twenty patients were treated for squamous cell carcinoma and received either adjuvant or neoadjuvant radiation therapy. There were no partial or total flap losses. A late pharyngocutaneous fistula occurred at 6 weeks in 1 patient (5%), requiring exploration, and anastomotic stricture occurred in 4 patients (19%). All patients except 1 were able to swallow solid foods at a mean follow-up of 11.1 months. Nineteen patients (90%) underwent tracheoesophageal puncture and attained an intelligible voice. One patient (5%) had stomal stenosis requiring surgical management., Conclusions and Relevance: The suprastomal cutaneous monitoring paddle enables direct monitoring of an otherwise buried reconstructive flap. This method allows direct clinical observation for microvascular compromise without a need for further procedures and without any increase in morbidity or compromise of speech and swallow functions., Level of Evidence: 4.

Objective: To evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma., Materials/methods: A retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated., Results: 33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 14 patients (42.4%) developed fistulas and 9 patients (27.3%) developed strictures. Except for 4 patients (12.1%), all achieved varying degree of oral intake with 29 patients (60.6%) being completely independent from tube feeding. The mean interval to start oral intake was 15.1 days. The 5-year overall survival and disease-free survival rates were 51.8% and 53.7%, respectively. The pN status is an independent predictor of overall survival and disease-free survival (P = 0.027 and 0.038, respectively)., Conclusion: Pharyngoesophageal reconstruction after salvage laryngopharyngectomy remains challenging even in the experienced hands. Reconstructive microsurgeons who are prepared to take on these cases should be equally well prepared to manage the potential postoperative complications.

Objective: To determine the early risk factors for enlargement of the tracheoesophageal puncture (TEP) after total laryngectomy., Design: Retrospective cohort study., Setting: The University of Texas MD Anderson Cancer Center, Houston., Patients: The study included 194 patients who underwent total laryngectomy (with or without pharyngectomy) and TEP (2003-2008)., Main Outcome Measures: Multiple logistic regression methods were used to evaluate early risk factors for an enlarged TEP., Results: The incidence of an enlarged TEP was 18.6% (36 of 194 patients). After adjustment for follow-up time and radiotherapy history, patients with nodal metastases had a significantly higher risk of TEP enlargement (adjusted odds ratio, 6.6; 95% CI, 1.6-26.6) than those with node-negative disease. Total laryngopharyngectomy significantly increased the risk of an enlarged TEP (adjusted odds ratio, 4.5; 95% CI, 1.4-14.7) compared with simple total laryngectomy. Before multivariable adjustment, the preoperative body mass index was also significantly associated with enlargement (P for trend, .04)., Conclusions: These data suggest that 2 clinical factors-nodal staging and extent of resection-may help identify those at highest risk for TEP enlargement early after surgery. These simple indicators may ultimately aid in patient selection and prevention of an enlarged TEP after total laryngectomy.

Conclusions: We successfully reduced the incidence of pharyngocutaneous fistulas (PCFs) in high-risk patients undergoing surgery by using pectoralis major myocutaneous flaps (PMMCFs) and deltopectoral flaps (DPFs) to cover suture lines., Objectives: We used coverage of suture lines with PMMCFs and DPFs in patients with high risk of PCFs undergoing total laryngectomy (TL) or total pharyngolaryngectomy (TPL) to determine whether coverage of suture lines during salvage surgery can reduce the incidence of PCFs., Methods: This retrospective study was based on a review of 52 patients who underwent salvage TL or TPL between 2001 and 2011; we have been using PMMCFs or DPFs during salvage surgery since 2008. Details of postoperative complications including PCFs were analyzed., Results: The incidence rate of PCF was lower in the flap group (7.7%) than that in the non-flap group (30.1%). No carotid ruptures were observed in the flap group (0%) as contrasted with patients in the non-flap group (7.7%).

Objective: To compare the key functional results (regarding swallowing and voice rehabilitation) in patients treated by pharyngo-laryngectomy with flap reconstruction, versus standard, wide-field, total laryngectomy., Method: We studied 97 patients who had undergone total laryngectomy and pharyngo-laryngectomy with flap reconstruction. The main outcome measures were swallowing (i.e. solid food, soft diet, fluid or enteral feeding) and fluent voice development., Results: There were 79 men and 18 women, with follow up of one to 19 years. Voice (p = 0.037) and swallowing (p = 0.041) results were significantly worse after circumferential pharyngo-laryngectomy than after non-circumferential pharyngo-laryngectomy. There was no significant difference in voice (p = 0.23) or swallowing (p = 0.655) results, comparing total laryngectomy and non-circumferential pharyngo-laryngectomy. The presence of a post-operative fistula significantly influenced voice (p = 0.001) and swallowing (p = 0.009) outcomes., Conclusion: The additional measures involved in pharyngo-laryngectomy do not confer any functional disadvantage, compared with total laryngectomy, but only if the procedure is non-circumferential. Functional results of circumferential pharyngo-laryngectomy are worse than those of both non-circumferential pharyngo-laryngectomy and total laryngectomy. If oncologically possible and safe, it is better to keep a pharyngo-laryngectomy non-circumferential.

Background: The purpose of this prospective study was to investigate shunt-related and device-related complications and microbial colonization of voice prostheses in patients after pharyngolaryngectomy with jejunal autograft reconstruction in comparison to patients after standard laryngectomy., Methods: Nine patients after pharyngolaryngectomy with jejunal autograft reconstruction (group 1) and 14 patients after standard laryngectomy (group 2) equipped with the Provox(®) 2 voice prostheses were followed up over 2 years. Anamnestic data, documentation of shunt-related or device-related complications, the Provox(®) 2 indwelling time, and standard microbiological procedures of voice prostheses were used for analyses., Results: A total of 157 prostheses were replaced. No significant difference in mean prosthesis indwelling time (p = .45) was observed between group 1 (116 ± 114 days) and group 2 (129 ± 99 days). Patients with jejunal autograft reconstruction needed prosthesis replacements more frequently within the first 60 days after prosthesis insertion in comparison to patients after standard laryngectomy (p = .007). The main indication for replacement in both groups was the device leakage (group 1: 93.1%, group 2: 92.1%). Prostheses of group 1 were more often colonized with Staphylococcus aureus (p = .027) and Enterobacteriaceae (p = .015)., Conclusion: This study demonstrated that, in comparison with patients after standard laryngectomy, patients after jejunal autograft reconstruction have similar shunt-related and device-related complications and prosthesis indwelling times. Therefore, tracheoesophageal voice rehabilitation could be strongly recommended in these patients., (Copyright © 2010 Wiley Periodicals, Inc.)

Objectives: To determine whether postoperative complication rates and speech outcomes differ between patients undergoing primary versus secondary tracheoesophageal puncture following total laryngectomy with free flap reconstruction., Study Design: Retrospective clinical study in a tertiary academic center., Methods: Between November 2004 and June 2010, 137 patients underwent total laryngectomy or laryngopharyngectomy with pharyngeal free flap reconstruction for malignant disease. Data was collected on patient and operative demographics, early postoperative complications, speech outcomes, and predictive factors for tracheoesophageal puncture failure., Results: Thirty patients (22%) had a primary tracheoesophageal puncture performed at the time of laryngectomy, 27 patients (20%) received secondary punctures (>3 months postlaryngectomy), and 80 patients (58%) never received a puncture. Patient and operative demographics were similar between groups (P < .05), apart from proportionately more hypopharyngeal tumors in the "no puncture" group (P < .002). Similar numbers of patients in primary and secondary puncture groups achieved intelligible speech (67% vs. 71%, P = .82) and both groups reported good patient-perceived voice-related quality of life. Salvage surgery and nonpatch radial forearm free flap reconstruction both trended toward increased early postoperative complication rates (P = .09)., Conclusions: There is no difference in the early postoperative complication rate for primary versus secondary tracheoesophageal puncture following total laryngectomy with concurrent free flap reconstruction. Radial forearm patch free flap reconstruction achieves good speech outcomes., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

The case of a 68-year-old woman with postoperative speech and swallowing problems following a circumferential pharyngolaryngectomy and neopharyngeal reconstruction with a jejunal free flap is presented. The primary tumor was an extended papillary thyroid carcinoma (pT4N0M0). For vocal restoration, an indwelling Provox(®) 1 voice prosthesis was inserted secondarily. The patient received speech and swallowing therapy, including digital maneuvers at the level of the proximal (cervical) part of the jejunal graft to improve speech and swallowing function. Pre- and/ or post-treatment data on speech and swallowing function were gathered using the following assessment methods: esophageal insufflation test, Voice Handicap Index (VHI), videofluoroscopy of phonation (VFSph), digital high-speed endoscopy of jejunal vibration during voice production, fiber-optic endoscopic evaluation of swallowing (FEES), and videofluoroscopy of swallowing (VFSs). This case clearly demonstrates that even after extensive laryngopharyngectomy with jejunal free flap reconstruction, a tailored rehabilitation program can improve both voice and swallowing function, and that these results clearly can be objectified/visualized, underlining the validity of this approach., (© The Author(s) 2010. This article is published with open access at Springerlink.com)

Objective: To survey the risk factors of pharyngeal stenosis after laryngopharyngectomy in patients with advanced hypopharyngeal cancers., Study Design: Case series with chart review., Setting: Tertiary medical center., Subjects and Methods: Pharyngeal stenosis rates and risk factors were compared between two groups of laryngopharyngectomy patients: a group that underwent concurrent chemoradiation therapy followed by surgical salvage, and a surgery initiated group with adjuvant chemoradiation., Results: Of 160 patients, 25 developed pharyngeal stenosis, which was diagnosed by barium esophagography with a pooling of barium contrast above the neopharyngeal inlet. These patients required nasogastric tube feeding or gastrostomy feeding because an oral liquid diet could not meet their nutritional needs. Primary closure and old age were risk factors for pharyngeal stenosis. Pharyngeal stenosis did not affect survival in patients with advanced hypopharyngeal cancer who underwent laryngopharyngectomy., Conclusion: Primary closure reconstruction is discouraged in patients over the age of 65 years., (Copyright © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Objective: To investigate the use of anterolateral thigh flaps versus radial forearm free flaps for the reconstruction of laryngopharyngectomy defects in a prospective, randomized study., Methods: Nineteen patients who were to undergo laryngopharyngectomy were randomized into either anterolateral thigh or radial forearm groups. The primary outcome measure was complication rate (eg, flap failure, fistula formation, pharyngeal stenosis). Secondary outcome measures included donor-site morbidity (limb function, cosmesis, pain)., Results: There was a significant (p = .04) increase in reconstructive complications in the anterolateral thigh group, including esophageal stenosis and pharyngeal fistulae. There was no significant difference in donor-site complications., Conclusion: There is an increased free flap complication rate without decreased flap donor-site morbidity when using the anterolateral thigh flap to reconstruct laryngopharyngectomy defects. As such, we recommend the radial forearm free flap as the preferred flap for reconstruction of laryngopharyngectomy defects.

Background: Permanent dysphagia occurring after laryngectomy or laryngopharyngectomy can usually be treated by periodic dilation. Occasionally, however, conservative treatment is insufficient, and patients require long-term tube feeding. We describe 4 cases with stricture after laryngopharyngectomy who underwent insertion of self-expandable plastic stents (SEPSs) across the stricture for treatment of dysphagia., Objective: The aim of this study was to evaluate the role of SEPSs in postlaryngopharyngectomy strictures., Design: An interventional study of management of 4 patients of dysphagia after laryngopharyngectomy with SEPSs., Setting: Medical gastroenterology unit in a tertiary care hospital., Patients: Four patients with dysphagia after laryngopharyngectomy., Interventions: SEPS placement and removal after 3 months., Main Outcome Measurements: Improvement in dysphagia., Methods: Four patients with dysphagia after laryngopharyngectomy underwent dilation of stricture followed by SEPS placement for 3 months., Results: Three patients had grade IV, and 1 grade III dysphagia. Endoscopy showed stricture at 10 to 14 cm from the incisors. Stricture was dilated up to 15 mm on 3 occasions, 2 weeks apart. A silicone Polyflex stent was placed across the stricture and removed after 3 months. No dysphagia recurred after 2 months. No significant complications were noted., Limitations: Small sample size., Conclusions: SEPSs dilate postlaryngopharyngectomy strictures and prevent restenosis even after removal., (Copyright 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Objective: To assess the efficacy of radiologically guided balloon dilatation for the treatment of dysphagia secondary to neopharyngeal strictures in patients who have undergone laryngectomy., Study Design: Retrospective case series., Subjects and Methods: Twenty consecutive patients with pharyngeal stricture and dysphagia following total laryngectomy or pharyngolaryngectomy. Patients underwent balloon dilatation of the stricture under radiological guidance. The main outcome measure was maintenance of swallowing., Results: Five patients gained relief of their dysphagia with one balloon dilatation only. Nine patients required more than one dilatation to maintain swallowing. Two patients had balloon dilatation procedures and stent insertion for palliative relief of dysphagia from known recurrent malignant disease. Three patients failed to maintain swallowing with repeat dilatations. No patients suffered any significant complications such as perforation., Conclusions: Radiologically guided balloon dilatation is minimally invasive and safe. It is well tolerated. It may be repeated frequently, and can successfully relieve pharyngeal strictures in patients who have undergone total laryngectomy or pharyngolaryngectomy.

Unlabelled: Dysphagia can be a consequence of total laryngectomy even in the absence of symptoms and it could indeed directly or indirectly compromise quality of life., Aim: To evaluate the characteristics of swallowing after total laryngectomy and pharyngolaryngectomy with pharyngeal T closure, correlating them with the Quality of Life in Swallowing Disorders questionnaire., Methods: A prospective evaluation was performed in 28 patients; fifteen undergoing total laryngectomy and thirteen undergoing total pharyngolaryngectomy. Swallowing was evaluated through videofluoroscopy regarding the preparatory, oral and pharyngeal phases of swallowing, and the quality of life related to swallowing questionnaire was employed to measure quality of life., Results: Anatomical and functional changes were observed under videofluoroscopic evaluation. Dysphagia was diagnosed in 18 patients (64.3%), being mild in 66.6% and moderate/severe in 33.3%. The questionnaire indicated good quality of life in almost all scales. Complaints of dysphagia were associated to the burden (p=0.036) and mental health scale (p=0.031). The questionnaire indicated impact on the mental health scale for patients with severe dysphagia (p=0.012)., Conclusions: High incidence of dysphagia was observed in some quality of life assessments, especially of mild degree.

Background: Despite progress made with reconstruction, morbidity is still elevated after (pharyngo)laryngectomy. The present study was designed to determine the incidence and predisposing factors of the complications following (pharyngo)laryngectomy., Methods: Primary surgical treatment was delivered in 60 patients. Seventy-five patients underwent surgical salvage following radiotherapy. Different factors were evaluated as potentially predisposing to fistula formation., Results: Stenosis is rare: 5.1% in the present series. A pharyngocutaneous fistula developed in 48.8% of patients. After a multivariate analysis, the site of the tumour was defined as a significant risk factor for pharyngocutaneous fistula formation., Conclusions: Despite progress made with reconstruction, morbidity is still elevated after major resection of the phary golarynx. Stenosis, a frequent complication when partial pharyngectomy is needed, is rare: 5.1% in the present series. Fistulas are relatively frequent but the majority resolved either with local irrigation or with subsequent flaps. The site of the tumour was a significant risk factor for pharyngocutaneous fistula formation, as defined by a multivariate analysis.

Objective: To assess the predictive value of wound amylase as an indicator for pharyngocutaneous fistula development following laryngectomy for cancer., Design and Setting: We conducted a prospective observational study at a tertiary referral center of 102 consecutive laryngeal or hypopharyngeal cancer patients undergoing laryngectomy with or without pharyngectomy., Intervention: Data were collated on potential predictors of fistula formation compared with rate of development of clinical fistulas, all confirmed radiologically., Main Outcome Measures: Rate of fistula formation was determined for the following potential predictors: extent of resection (extended laryngectomy), postoperative wound (drain) amylase, previous radiotherapy, neck dissection, preoperative and postoperative hemoglobin and albumin levels, and postoperative transfusion. Sensitivity, specificity, and positive and negative predictive values of significant predictors were ascertained., Results: The only significant predictors of fistula formation were extent of resection (extended laryngectomy) and drain amylase >4000 IU/L. If both factors are combined, the sensitivity, specificity, and positive and negative predictive values for fistula development are 83, 94, 63, and 98 percent, respectively., Conclusion: We advocate that patients be managed postoperatively according to the presence or absence of these given predictors to reduce occurrence of fistula formation in the high-risk group.