Outcomes following pharyngeal reconstruction in total laryngectomy – Institutional experience and review of literature

ABSTRACT Background: Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction. Materials and Methods: Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction. Results: Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003). Conclusion: Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

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The techniques of nonmuscular closure of hypopharyngeal defect following total laryngectomy: the assessment of complication and pharyngoesophageal segment

The Journal of Laryngology & Otology ◽

10.1017/s0022215100139337 ◽

1997 ◽

Vol 111 (11) ◽

pp. 1060-1063 ◽

Cited By ~ 10

Author(s):

Ching-Ping Wang ◽

Tzu-Chan Tseng ◽

Rheun-Chuan Lee ◽

Shyue-Yih Chang

Keyword(s):

Total Laryngectomy ◽

Fistula Formation ◽

Voice Rehabilitation ◽

Pharyngocutaneous Fistula ◽

Swallowing Function ◽

Pharyngeal Muscle ◽

Constrictor Muscle ◽

Pharyngoesophageal Segment ◽

Pharyngeal Muscles ◽

Closure Group

AbstractThe usual method of reconstructing a hypopharyngeal defect during total laryngectomy includes pharyngeal muscle layer closure, which may result in high pharyngoesophageal pressure. We hypothesize that nonclosure of the pharyngeal muscle can reduce the pressure of the pharyngoesophageal segment which can reduce the chances of the formation of pharyngocutaneous fistulae. A technique of nonmuscular closure of a hypopharyngeal defect is presented. The differences in the rate of fistula formation and swallowing function between patients with usual and nonmuscular closure were also studied. Sixty consecutive laryngectomees were enrolled in this study. Thirty patients received usual closure after total laryngectomy, whereas the other 30 patients underwent non closure of their pharyngeal muscles. One patient (3.3 per cent) in the nonmuscular closure group and three patients (10 per cent) in the usual closure group developed a pharyngocutaneous fistula. The pharyngoesophageal pressures of the nonmuscular closure group were significantly lower than those of the usual closure group. We conclude that the technique of nonclosure of the pharyngeal constrictor muscle after total laryngectomy is relatively more simple and is not associated with a higher rate of fistula formation. Furthermore, nonclosure of the pharyngeal constrictor muscle is preferable to muscular closure because it reduces the spasm of the pharyngoesophageal segment which limits voice rehabilitation.

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Longitudinal Changes of Tongue Thickness and Tongue Pressure in Neuromuscular Disorders

BMC Neurology ◽

10.1186/s12883-021-02225-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

George Umemoto ◽

Shinsuke Fujioka ◽

Hajime Arahata ◽

Nobutaka Sakae ◽

Naokazu Sasagasako ◽

...

Keyword(s):

Neuromuscular Disorders ◽

The Other ◽

Tongue Pressure ◽

Swallowing Function ◽

Longitudinal Changes ◽

Swallowing Dysfunction ◽

The Relationship ◽

Lateral Sclerosis

Abstract Background Swallowing dysfunction is related to major cause of adverse events and an indicator of shorter survival among patients with neuromuscular disorders (NMD). It is critical to assess the swallowing function during disease progression, however, there are limited tools that can easily evaluate swallowing function without using videofluoroscopic or videoendoscopic examination. Here, we evaluated the longitudinal changes in tongue thickness (TT) and maximum tongue pressure (MTP) among patients with amyotrophic lateral sclerosis (ALS), myotonic dystrophy type 1 (DM1), and Duchenne muscular dystrophy (DMD). Methods Between 2010 and 2020, TT and MTP were measured from 21 ALS, 30 DM1, and 14 DMD patients (mean ages of 66.9, 44.5, and 21.4 years, respectively) at intervals of more than half a year. TT was measured, by ultrasonography, as the distance from the mylohyoid muscle raphe to the tongue dorsum, and MTP was determined by measuring the maximum compression on a small balloon when pressing the tongue against the palate. Then we examined the relationship between these evaluations and patient background and swallowing function. Results Mean follow-up periods were 24.0 months in the ALS group, 47.2 months in the DM1group, and 61.1 months in the DMD group. The DMD group demonstrated larger first TT than the other groups, while the DM1 group had lower first MTP than the ALS group. The ALS group showed a greater average monthly reduction in mean TT than the DM1 group and greater monthly reductions in mean body weight (BW) and MTP than the other groups. Significant differences between the first and last BW, TT, and MTP measures were found only in the ALS group. Conclusions This study suggests that ALS is associated with more rapid degeneration of tongue function over several years compared to DMD and DM1.

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Dysphagia in Perry Syndrome: Pharyngeal Pressure in Two Cases

Case Reports in Neurology ◽

10.1159/000457900 ◽

2017 ◽

Vol 9 (2) ◽

pp. 161-167 ◽

Cited By ~ 1

Author(s):

George Umemoto ◽

Yoshio Tsuboi ◽

Hirokazu Furuya ◽

Takayasu Mishima ◽

Shinsuke Fujioka ◽

...

Keyword(s):

Tube Feeding ◽

Oral Intake ◽

Normal Diet ◽

Oral Feeding ◽

Tongue Pressure ◽

Normal Range ◽

Swallowing Function ◽

Pharyngeal Pressure ◽

Swallowing Dysfunction ◽

The Impact

Background: To investigate the impact of dysphagia in Perry syndrome (PS), an autosomal dominant parkinsonism caused by mutation of DCTN1, which is associated with hypoventilation, depression, and weight loss. Case Presentation: We used tongue pressure measurements and manofluorography to investigate swallowing function in 2 patients with PS. Case 1, a 60-year-old male showing parkinsonism, and case 2, a 49-year-old male admitted with pneumonia, were diagnosed as having PS based on the DCTN1 gene analysis. Case 1 showed a pharyngeal retention of the bolus on videofluorography (VF) and a few swallows were required for its passage into the esophagus. However, tongue pressure and manometry were within the normal range. This patient could eat a normal diet under supervision. Case 2 required artificial ventilation and tube feeding on admission. The VF image showed a slow transfer of the bolus, delayed swallow reflex, and pharyngeal retention of the bolus that required several swallows for its passage into the esophagus. The tongue pressure was within the normal range, but manometry showed a significant decrease in pressure at the hypopharynx and upper esophageal sphincter. The oral intake of the patients was limited to 2 cups of jelly per day. Conclusions: The investigation of swallowing dysfunction of 2 cases of PS showed that maintaining pharyngeal pressure within the normal range was very important for oral feeding success and prognosis.

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Peri-operative factors predisposing to pharyngocutaneous fistula after total laryngectomy: analysis of a large multi-institutional patient cohort

Journal of Otolaryngology - Head and Neck Surgery ◽

10.1186/s40463-017-0233-z ◽

2017 ◽

Vol 46 (1) ◽

Cited By ~ 6

Author(s):

Nicole L. Lebo ◽

Lisa Caulley ◽

Hussain Alsaffar ◽

Martin J. Corsten ◽

Stephanie Johnson-Obaseki

Keyword(s):

Total Laryngectomy ◽

Pharyngocutaneous Fistula ◽

Patient Cohort

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Postlaryngectomy Pharyngocutaneous Fistula: Incidence, Predisposing Factors, and Therapy

Otolaryngology ◽

10.1016/j.otohns.2005.07.025 ◽

2005 ◽

Vol 133 (5) ◽

pp. 689-694 ◽

Cited By ~ 76

Author(s):

Jacopo Galli ◽

Eugenio De Corso ◽

Mariangela Volante ◽

Giovanni Almadori ◽

Gaetano Paludetti

Keyword(s):

Risk Factor ◽

Total Laryngectomy ◽

Radical Neck Dissection ◽

Predisposing Factors ◽

Spontaneous Closure ◽

Pharyngocutaneous Fistula ◽

Systemic Diseases ◽

Surgical Closure ◽

Number Of Factors ◽

Wait And See

OBJECTIVE: The pharyngocutaneous fistula (PCF) is a serious complication after total laryngectomy, and its etiology is not well understood yet. The aim of our study was to evaluate predisposing factors, incidence, and management of this complication. STUDY DESIGN AND SETTING: This was a retrospective study of 268 patients who underwent total laryngectomy in our clinic (January 1990-December 2001). A number of factors potentially predisposing to PCF formation were evaluated. RESULTS: A PCF was observed in 16% of patients. Systemic diseases, previous radiotherapy, supraglottic origin of tumor, and concurrent radical neck dissection were significantly associated with PCF. Spontaneous closure was noted in 28 patients, whereas a surgical closure was necessary in 15 patients. CONCLUSIONS: In presence of a specific risk factor, PCF can be expected; nevertheless, its prevention remains very difficult. Moreover, given the high percentage of spontaneous closure, we suggest the “wait and see” approach for 28 days before proceeding with a surgical approach.

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Pharyngocutaneous Fistula after Total Laryngectomy: Incidence, Cause, and Treatment

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348949410301010 ◽

1994 ◽

Vol 103 (10) ◽

pp. 801-805 ◽

Cited By ~ 64

Author(s):

George Papazoglou ◽

George Terzakis ◽

George Doundoulakis ◽

George Dokianakis

Keyword(s):

Total Laryngectomy ◽

Major Complication ◽

Predisposing Factors ◽

Morbidity And Mortality ◽

Red Cross ◽

Pharyngocutaneous Fistula ◽

Common Complication ◽

Methods Of Treatment

Postoperative pharyngocutaneous fistula is a major complication of total laryngectomy that prolongs the short hospitalization of 2 to 3 weeks to many weeks or even months. It is a common complication that increases the morbidity and mortality of the procedure. In the Department of Otolaryngology of the Red Cross Hospital of Athens, 310 patients underwent total laryngectomy from January 1980 through December 1989. Twenty-eight patients developed a fistula (incidence 9%). The incidence, predisposing factors, and methods of treatment of this complication are analyzed and discussed.

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Ventricular size determination and management of ventriculomegaly and hydrocephalus in patients with diffuse intrinsic pontine glioma: an institutional experience

Journal of Neurosurgery ◽

10.3171/2020.10.jns203257 ◽

2021 ◽

pp. 1-7

Author(s):

Adriana Fonseca ◽

Palma Solano ◽

Vijay Ramaswamy ◽

Uri Tabori ◽

Annie Huang ◽

...

Keyword(s):

Proportional Hazards ◽

Univariate Analysis ◽

Diffuse Intrinsic Pontine Glioma ◽

Survival Advantage ◽

Ventricular Size ◽

Pontine Glioma ◽

Asymptomatic Patients ◽

Institutional Experience ◽

Csf Diversion ◽

The Impact

OBJECTIVE There is no consensus on the optimal clinical management of ventriculomegaly and hydrocephalus in patients with diffuse intrinsic pontine glioma (DIPG). To date, the impact on survival in patients with ventriculomegaly and CSF diversion for hydrocephalus in this population remains to be elucidated. Herein, the authors describe their institutional experience. METHODS Patients diagnosed with DIPG and treated with up-front radiation therapy (RT) at The Hospital for Sick Children between 2000 and 2019 were identified. Images at diagnosis and progression were used to determine the frontal/occipital horn ratio (FOR) as a method to measure ventricular size. Patients with ventriculomegaly (FOR ≥ 0.36) were stratified according to the presence of symptoms and categorized as follows: 1) asymptomatic ventriculomegaly and 2) symptomatic hydrocephalus. For patients with ventriculomegaly who did not require CSF diversion, post-RT imaging was also evaluated to assess changes in the FOR after RT. Proportional hazards analyses were used to identify clinical and treatment factors correlated with survival. The Kaplan-Meier method was used to perform survival estimates, and the log-rank method was used to identify survival differences between groups. RESULTS Eighty-two patients met the inclusion criteria. At diagnosis, 28% (n = 23) of patients presented with ventriculomegaly, including 8 patients who had symptomatic hydrocephalus and underwent CSF diversion. A ventriculoperitoneal shunt was placed in the majority of patients (6/8). Fifteen asymptomatic patients were managed without CSF diversion. Six patients had resolution of ventriculomegaly after RT. Of 66 patients with imaging at the time of progression, 36 (55%) had ventriculomegaly, and 9 of them required CSF diversion. The presence of ventriculomegaly at diagnosis did not correlate with survival on univariate analysis. However, patients with symptomatic hydrocephalus at the time of progression who underwent CSF diversion had a survival advantage (p = 0.0340) when compared to patients with ventriculomegaly managed with conservative approaches. CONCLUSIONS Although ventriculomegaly can be present in up to 55% of patients with DIPG, the majority of patients present with asymptomatic ventriculomegaly and do not require surgical interventions. In some cases ventriculomegaly improved after medical management with steroids and RT. CSF diversion for hydrocephalus at the time of diagnosis does not impact survival. In contrast, our results suggest a survival advantage in patients who undergo CSF diversion for hydrocephalus at the time of progression, albeit that advantage is likely to be confounded by biological and individual patient factors. Further research in this area is needed to understand the best timing and type of interventions in this population.

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Swallowing Disorders as a Predictor of Unsuccessful Extubation: A Clinical Evaluation

American Journal of Critical Care ◽

10.4037/ajcc2008.17.6.504 ◽

2008 ◽

Vol 17 (6) ◽

pp. 504-510 ◽

Cited By ~ 9

Author(s):

Philippe Colonel ◽

Marie Hélène Houzé ◽

Hélène Vert ◽

Joachim Mateo ◽

Bruno Mégarbane ◽

...

Keyword(s):

Area Under Curve ◽

Characteristic Curve ◽

Upper Airway ◽

Central Nervous System Disease ◽

Multivariate Logistic Regression Model ◽

Swallowing Function ◽

System Disease ◽

Swallowing Dysfunction ◽

Gag Reflex ◽

Bedside Tests

Background Unsuccessful extubation may be due to swallowing dysfunction that causes airway obstruction and impairs patients’ ability to cough and expectorate. Objective To determine whether swallowing assessment before extubation is helpful in predicting unsuccessful extubation due to airway secretions. Methods This prospective study included all patients intubated orotracheally for more than 6 days. Before extubation, 3 tests designed to assess (1) cervical, oral, labial, and lingual motility; (2) gag reflex; and (3) swallowing were used at the bedside. Causes of reintubation were identified, and their relationship to patients’ swallowing function before extubation was evaluated. Results Sixty-two patients were enrolled. Data on 55 patients reintubated for swallowing dysfunction were analyzed. Nine patients were reintubated because of obstruction related to upper airway secretions. Evaluation before extubation enabled prediction of 7 of those 9 unsuccessful extubations. Among the 23 patients with central nervous system disease, 3 of 4 unsuccessful extubations were predicted. According to a multivariate logistic regression model, motility and swallowing were independent predictors of unsuccessful extubation (area under receiver-operating-characteristic curve, 80%). The gag reflex was the only significant predictor of the ability to cough (area under curve, 73%) and excessive pulmonary secretion (area under curve, 67%). Swallowing was an independent predictor of the need for suctioning (area under curve, 78%). Conclusions Using simple bedside tests to evaluate swallowing before extubation is helpful when deciding whether to extubate patients who have been intubated for more than 6 days. Involvement of nurses in these decisions would improve patients’ management.

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