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Laryngopharyngeal Repair in Salvage Laryngectomy

  • Head and Neck Reconstruction (E. Rosenthal, Section Editor)
  • Published:
Current Otorhinolaryngology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Although associated with significant morbidity including fistula, stricture, poor voice rehabilitation, and even death, salvage laryngectomy and laryngopharyngectomy will remain as important surgical procedures as long as transoral surgery and chemoradiation therapy continue to be employed primarily in the treatment of laryngeal malignancy.

Recent Findings

Multi-institutional retrospective analyses indicate that onlay pectoralis myofascial flaps may reduce the incidence of post-operative fistula to 10–15 % compared to 30 % associated with primary closure alone. Regional and distant fasciocutaneous flaps have limited morbidity and their use may minimize the rates of stricture. Employment of salivary bypass tubes appears to reduce the incidence of fistula to less than 10 %. Voice rehabilitation outcomes with tracheoesophageal puncture are equivalent between fasciocutaneous flaps and primary closure, and better than the voice quality attained with enteric flaps or pectoralis flaps.

Summary

Pectoralis onlay flaps are a viable option in select patients undergoing primary closure who are aware of the associated morbidity and voice outcomes. Free tissue transfer, in particular the anterolateral thigh flap, used in conjunction with salivary bypass tubes offers an ideal balance of donor site morbidity, post-operative fistula, and voice rehabilitation, and should be considered for appropriate patients.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003;349(22):2091–8.

    Article  CAS  PubMed  Google Scholar 

  2. Lefebvre JL, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx preservation in pyriform sinus cancer: preliminary results of a European organization for research and treatment of cancer phase III trial. EORTC head and neck cancer cooperative group. J Natl Cancer Inst. 1996;88(13):890–9.

    Article  CAS  PubMed  Google Scholar 

  3. Rigby MH, Hayden RE. Total glossectomy without laryngectomy—a review of functional outcomes and reconstructive principles. Curr Opin Otolaryngol Head Neck Surg. 2014;22(5):414–8.

    Article  PubMed  Google Scholar 

  4. Chazen JL, Glastonbury CM. Total laryngectomy for squamous cell carcinoma: recognizing disease patterns to aid detection of tumor recurrence. Clin Imaging. 2014;38(5):659–65.

    Article  PubMed  Google Scholar 

  5. Chen MM, Holsinger FC, Laccourreye O. Salvage conservation laryngeal surgery after radiation therapy failure. Otolaryngol Clin North Am. 2015;48(4):667–75.

    Article  PubMed  Google Scholar 

  6. Lin DT, Yarlagadda BB, Sethi RK, et al. Long-term functional outcomes of total glossectomy with or without total laryngectomy. JAMA Otolaryngol Head Neck Surg. 2015;141(9):797–803.

    Article  PubMed  Google Scholar 

  7. Sinclair CF, Carroll WR, Desmond RA, Rosenthal EL. Functional and survival outcomes in patients undergoing total glossectomy compared with total laryngoglossectomy. Otolaryngol Head Neck Surg. 2011;145(5):755–8.

    Article  PubMed  Google Scholar 

  8. Patel UA, Moore BA, Wax M, et al. Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg. 2013;139(11):1156–62.

    Article  PubMed  Google Scholar 

  9. Varvares MA, Cheney ML, Gliklich RE, et al. Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction. Head Neck. 2000;22(5):463–8.

    Article  CAS  PubMed  Google Scholar 

  10. Blackwell K, Urken M. Laryngopharygeal and pharyngoesophageal reconstruction. In: Urken ML, editor. Multidisciplinary head & neck reconstruction: a defect-oriented approach. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 693.

    Google Scholar 

  11. Deschler DG, Doherty ET, Reed CG, Singer MI. Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx. Otolaryngol Head Neck Surg. 1998;118(6):771–6.

    Article  CAS  PubMed  Google Scholar 

  12. Sweeny L, Golden JB, White HN, Magnuson JS, Carroll WR, Rosenthal EL. Incidence and outcomes of stricture formation postlaryngectomy. Otolaryngol Head Neck Surg. 2012;146(3):395–402.

    Article  PubMed  Google Scholar 

  13. Mura F, Bertino G, Occhini A, Mevio N, Scelsi D, Benazzo M. Advanced carcinoma of the hypopharynx: functional results after circumferential pharyngolaryngectomy with flap reconstruction. Acta Otorhinolaryngol Ital. 2012;32(3):154–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  14. Burke MS, Kaplan SE, Kaplowitz LJ, et al. Pectoralis major myocutaneous flap for reconstruction of circumferential pharyngeal defects. Ann Plast Surg. 2013;71(6):649–51.

    Article  CAS  PubMed  Google Scholar 

  15. Piazza C, Taglietti V, Nicolai P. Reconstructive options after total laryngectomy with subtotal or circumferential hypopharyngectomy and cervical esophagectomy. Curr Opin Otolaryngol Head Neck Surg. 2012;20(2):77–88.

    Article  PubMed  Google Scholar 

  16. Yin D, Tang Q, Wang S, et al. Xenogeneic acellular dermal matrix in combination with pectoralis major myocutaneous flap reconstructs hypopharynx and cervical esophagus. Eur Arch Otorhinolaryngol. 2015;272(11):3457–61.

    Article  PubMed  Google Scholar 

  17. Gilbert MR, Sturm JJ, Gooding WE, Johnson JT, Kim S. Pectoralis major myofascial onlay and myocutaneous flaps and pharyngocutaneous fistula in salvage laryngectomy. Laryngoscope. 2014;124(12):2680–6.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Hanasono MM, Lin D, Wax MK, Rosenthal EL. Closure of laryngectomy defects in the age of chemoradiation therapy. Head Neck. 2012;34(4):580–8.

    Article  PubMed  Google Scholar 

  19. Miyamoto S, Sakuraba M, Nagamatsu S, Kamizono K, Fujiki M, Hayashi R. Combined use of free jejunum and pectoralis major muscle flap with skin graft for reconstruction after salvage total pharyngolaryngectomy. Microsurgery. 2013;33(2):119–24.

    Article  PubMed  Google Scholar 

  20. Emerick KS, Herr MA, Deschler DG. Supraclavicular flap reconstruction following total laryngectomy. Laryngoscope. 2014;124(8):1777–82.

    Article  PubMed  Google Scholar 

  21. Shenoy A, Patil VS, Prithvi BS, Chavan P, Halkud R. Supraclavicular artery flap for head and neck oncologic reconstruction: an emerging alternative. Int J Surg Oncol. 2013;2013:658989.

    PubMed  PubMed Central  Google Scholar 

  22. Collar RM, Zopf D, Brown D, Fung K, Kim J. The versatility of the temporoparietal fascia flap in head and neck reconstruction. J Plast Reconstr Aesthet Surg. 2012;65(2):141–8.

    Article  PubMed  Google Scholar 

  23. Kadota H, Fukushima J, Kamizono K, et al. A minimally invasive method to prevent postlaryngectomy major pharyngocutaneous fistula using infrahyoid myofascial flap. J Plast Reconstr Aesthet Surg. 2013;66(7):906–11.

    Article  PubMed  Google Scholar 

  24. Lee JC, Chu YH, Lin YS, Kao CH. Reconstruction of hypopharyngeal defects with submental flap after laryngopharyngectomy. Eur Arch Otorhinolaryngol. 2013;270(1):319–23.

    Article  PubMed  Google Scholar 

  25. Mirghani H, Leymarie N, Amen F, Qassemyar Q, Leclere FM, Kolb F. Pharyngotracheal fistula closure using the internal mammary artery perforator island flap. Laryngoscope. 2014;124(5):1106–11.

    Article  PubMed  Google Scholar 

  26. Ahmed A, Visavadia BG, Farrell R, Gilhooly M. Use of double skin paddle for pharyngoesophageal reconstruction using tubed radial forearm free flap. Br J Oral Maxillofac Surg. 2014;52(7):661–3.

    Article  PubMed  Google Scholar 

  27. • Knott PD, Seth R, Waters HH, et al. Short-term donor site morbidity: a comparison of the anterolateral thigh and radial forearm fasciocutaneous free flaps. Head Neck. 2016;38(Suppl 1):E945-8. Nice retrospective study comparing the morbidities of an ALT free flap vs a radial forearm free flap for head and neck reconstruction.

    Article  PubMed  Google Scholar 

  28. Nojima K, Brown SA, Acikel C, et al. Defining vascular supply and territory of thinned perforator flaps: Part I. Anterolateral thigh perforator flap. Plast Reconstr Surg. 2005;116(1):182–93.

    Article  CAS  PubMed  Google Scholar 

  29. Ghazali N, Hanna TC, Dyalram D, Lubek JE. The value of the “papillon” anterolateral thigh flap for total pharyngolaryngectomy reconstruction: a retrospective case series. J Oral Maxillofac Surg. 2016;74(2):406–14.

    Article  PubMed  Google Scholar 

  30. Hayden R, Patel A, Mullin D. The ‘papillon’ flap for pharyngolaryngectomy reconstruction: a new technique. Presented at the Eight International Conference on Head and Neck Cancer, Toronto. 2012.

  31. Revenaugh PC, Waters HH, Scharpf J, Knott PD, Fritz MA. Suprastomal cutaneous monitoring paddle for free flap reconstruction of laryngopharyngectomy defects. JAMA Facial Plast Surg. 2013;15(4):287–91.

    Article  PubMed  Google Scholar 

  32. Kram YA, Russell MS, Russell MD, Knott PD. Single-stage, double-conduit microvascular pharyngotracheal reconstruction. J Reconstr Microsurg. 2015;31(3):233–5.

    Article  PubMed  Google Scholar 

  33. Perez-Smith D, Wagels M, Theile DR. Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 consecutive cases. J Plast Reconstr Aesthet Surg. 2013;66(1):9–15.

    Article  PubMed  Google Scholar 

  34. Timmermans AJ, Lansaat L, Theunissen EA, Hamming-Vrieze O, Hilgers FJ, van den Brekel MW. Predictive factors for pharyngocutaneous fistulization after total laryngectomy. Ann Otol Rhinol Laryngol. 2014;123(3):153–61.

    Article  PubMed  Google Scholar 

  35. Teknos TN, Myers LL, Bradford CR, Chepeha DB. Free tissue reconstruction of the hypopharynx after organ preservation therapy: analysis of wound complications. Laryngoscope. 2001;111(7):1192–6.

    Article  CAS  PubMed  Google Scholar 

  36. Basheeth N, O’Leary G, Sheahan P. Pharyngocutaneous fistula after salvage laryngectomy: impact of interval between radiotherapy and surgery, and performance of bilateral neck dissection. Head Neck. 2014;36(4):580–4.

    Article  PubMed  Google Scholar 

  37. Genden EM. Use of vascularized muscle flaps in the healing of compromised wounds. JAMA Otolaryngol Head Neck Surg. 2013;139(11):1162.

    Article  PubMed  Google Scholar 

  38. Powell J, Ullal UR, Ahmed O, Ragbir M, Paleri V. Tissue transfer to post-chemoradiation salvage laryngectomy defects to prevent pharyngocutaneous fistula: single-centre experience. J Laryngol Otol. 2014;1:1–3.

    Google Scholar 

  39. •• Sayles M, Grant DG. Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. Laryngoscope 2014;124(5):1150–63. Systematic review analyzing fistula rates among primary and salvage laryngectomies.

  40. •• Guimaraes AV, Aires FT, Dedivitis RA, et al. Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: a systematic review. Head Neck. 2016;38(Suppl 1):E2317-21. Systematic review of impact of pectoralis major flap on fistulas for salvage laryngectomy.

  41. •• Paleri V, Drinnan M, van den Brekel MW, et al. Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review. Laryngoscope 2014;124(8):1848–53. Systematic review of impact of flap reconstruction/reinforcement on fistulas for salvage laryngectomy.

  42. •• Patel UA, Moore BA, Wax M, et al. Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg 2013;139(11):1156–62. Multi-institutional retrospective review of various closure types for salvage laryngectomy.

  43. Khan NA, Medina JE, Sanclement JA, Krempl GA. Fistula rates after salvage laryngectomy: comparing pectoralis myofascial and myocutaneous flaps. Laryngoscope. 2014;124(7):1615–7.

    Article  PubMed  Google Scholar 

  44. Withrow KP, Rosenthal EL, Gourin CG, et al. Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure. Laryngoscope. 2007;117(5):781–4.

    Article  PubMed  Google Scholar 

  45. Tan NC, Lin PY, Kuo PJ, et al. An objective comparison regarding rate of fistula and stricture among anterolateral thigh, radial forearm, and jejunal free tissue transfers in circumferential pharyngo-esophageal reconstruction. Microsurgery. 2015;35(5):345–9.

    Article  PubMed  Google Scholar 

  46. Morrissey AT, O’Connell DA, Garg S, Seikaly H, Harris JR. Radial forearm versus anterolateral thigh free flaps for laryngopharyngectomy defects: prospective, randomized trial. J Otolaryngol Head Neck Surg. 2010;39(4):448–53.

    PubMed  Google Scholar 

  47. Lopez F, Obeso S, Camporro D, Fueyo A, Suarez C, Llorente JL. Outcomes following pharyngolaryngectomy with fasciocutaneous free flap reconstruction and salivary bypass tube. Laryngoscope. 2013;123(3):591–6.

    Article  PubMed  Google Scholar 

  48. Kao HK, Abdelrahman M, Chang KP, Wu CM, Hung SY, Shyu VB. Choice of flap affects fistula rate after salvage laryngopharyngectomy. Sci Rep. 2015;5:9180.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Fink DS, Pena S, Hanby D, Kunduk M, McWhorter AJ. Repair of pharyngocutaneous fistula after total laryngectomy: a novel endoscopic approach. Head Neck. 2015;37(7):E81–4.

    Article  PubMed  Google Scholar 

  50. Asher SA, White HN, Illing EA, Carroll WR, Magnuson JS, Rosenthal EL. Intraluminal negative pressure wound therapy for optimizing pharyngeal reconstruction. JAMA Otolaryngol Head Neck Surg. 2014;140(2):143–9.

    Article  PubMed  Google Scholar 

  51. Neubauer P, Canadas K, Sasaki CT. Delayed platysma myocutaneous turnover flap for repair of pharyngocutaneous fistula. Am J Otolaryngol. 2015;36(1):93–6.

    Article  PubMed  Google Scholar 

  52. Kucuk N, Sari M, Midi A, Yumusakhuylu AC, Findik O, Binnetoglu A. Effectiveness of recombinant human growth hormone for pharyngocutaneous fistula closure. Clin Exp Otorhinolaryngol. 2015;8(4):390–5.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Weiss BG, Ihler F, Matthias C, Canis M. Coated collagen patches for closure of pharyngo-cutaneous fistulas. Am J Otolaryngol. 2014;35(2):246–50.

    Article  CAS  PubMed  Google Scholar 

  54. • Stephenson KA, Fagan JJ. Effect of perioperative proton pump inhibitors on the incidence of pharyngocutaneous fistula after total laryngectomy: a prospective randomized controlled trial. Head Neck 2015;37(2):255–9. Randomized Control Trial demonstrating benefit of PPI in reducing fistulas.

  55. Montgomery WW. Salivary bypass tube. Ann Otol Rhinol Laryngol. 1978;87(2 Pt 1):159–62.

    Article  CAS  PubMed  Google Scholar 

  56. Rodrigo Tapia JP, Llorente Pendas JL, Suarez Nieto C. Insertion of montgomery salivary bypass tube under local anesthesia in patients with pharyngocutaneous fistula following total laryngectomy. Acta Otorrinolaringol Esp. 2004;55(5):244–6.

    Article  CAS  PubMed  Google Scholar 

  57. Kejner AE, Rosenthal EL. Method for removing hypopharyngeal salivary bypass tubes. Laryngoscope. 2011;121(7):1478–9.

    Article  PubMed  Google Scholar 

  58. Murray DJ, Gilbert RW, Vesely MJ, et al. Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube. Head Neck. 2007;29(2):147–54.

    Article  PubMed  Google Scholar 

  59. •• Punthakee X, Zaghi S, Nabili V, Knott PD, Blackwell KE. Effects of salivary bypass tubes on fistula and stricture formation. JAMA Facial Plast Surg 2013;15(3):219–25. Retrospective review demonstrating reduction in fistula rates with use of salivary bypass tubes.

  60. Bitter T, Pantel M, Dittmar Y, Guntinas-Lichius O, Wittekindt C. Stent migration to the ileum: a potentially lethal complication after montgomery salivary bypass tube placement for hypopharyngeal stenosis after laryngectomy. Head Neck. 2012;34(1):135–7.

    Article  PubMed  Google Scholar 

  61. Clements KS, Rassekh CH, Seikaly H, Hokanson JA, Calhoun KH. Communication after laryngectomy: an assessment of patient satisfaction. Arch Otolaryngol Head Neck Surg. 1997;123(5):493–6.

    Article  CAS  PubMed  Google Scholar 

  62. Divi V, Lin DT, Emerick K, Rocco J, Deschler DG. Primary TEP placement in patients with laryngopharyngeal free tissue reconstruction and salivary bypass tube placement. Otolaryngol Head Neck Surg. 2011;144(3):474–6.

    Article  PubMed  Google Scholar 

  63. Johnson A, Grammer T, Medina J. Primary tracheoesophageal puncture in salvage laryngectomy patients. Laryngoscope. 2013;123(5):1227–30.

    Article  PubMed  Google Scholar 

  64. Sethi RK, Kozin ED, Lam AC, Emerick KS, Deschler DG. Primary tracheoesophageal puncture with supraclavicular artery island flap after total laryngectomy or laryngopharyngectomy. Otolaryngol Head Neck Surg. 2014;151(3):421–3.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Emerick KS, Tomycz L, Bradford CR, et al. Primary versus secondary tracheoesophageal puncture in salvage total laryngectomy following chemoradiation. Otolaryngol Head Neck Surg. 2009;140(3):386–90.

    Article  PubMed  Google Scholar 

  66. Alam DS, Vivek PP, Kmiecik J. Comparison of voice outcomes after radial forearm free flap reconstruction versus primary closure after laryngectomy. Otolaryngol Head Neck Surg. 2008;139(2):240–4.

    Article  PubMed  Google Scholar 

  67. Mendelsohn M, Morris M, Gallagher R. A comparative study of speech after total laryngectomy and total laryngopharyngectomy. Arch Otolaryngol Head Neck Surg. 1993;119(5):508–10.

    Article  CAS  PubMed  Google Scholar 

  68. • Revenaugh PC, Knott PD, Alam DS, Kmiecik J, Fritz MA. Voice outcomes following reconstruction of laryngopharyngectomy defects using the radial forearm free flap and the anterolateral thigh free flap. Laryngoscope. 2014;124(2):397–400. Retrospective review demonstrating no difference in TEP voice quality between ALT and RFFF free flap reconstructions.

  69. Fujiwara T, Shih HS, Chen CC, Tay SK, Jeng SF, Kuo YR. Interdigitation of the distal anastomosis between tubed fasciocutaneous flap and cervical esophagus for stricture prevention. Laryngoscope. 2011;121(2):289–93.

    Article  PubMed  Google Scholar 

  70. Yu P, Lewin JS, Reece GP, Robb GL. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap. Plast Reconstr Surg. 2006;117(3):968–74.

    Article  CAS  PubMed  Google Scholar 

  71. Patel RS, Goldstein DP, Brown D, Irish J, Gullane PJ, Gilbert RW. Circumferential pharyngeal reconstruction: history, critical analysis of techniques, and current therapeutic recommendations. Head Neck. 2010;32(1):109–20.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, 2233 Post Street, 3rd Floor, San Francisco, CA, 94115, USA

    Shethal Bearelly, Chase M. Heaton, Rahul Seth & P. Daniel Knott

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  1. Shethal Bearelly
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  2. Chase M. Heaton
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  3. Rahul Seth
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  4. P. Daniel Knott
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Correspondence to P. Daniel Knott.

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Dr. Shethal Bearelly, Dr. Chase M. Heaton, Dr. Rahul Seth, and Dr. P. Daniel Knott declare that they have no conflicts of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Head and Neck Reconstruction.

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Bearelly, S., Heaton, C.M., Seth, R. et al. Laryngopharyngeal Repair in Salvage Laryngectomy. Curr Otorhinolaryngol Rep 4, 211–218 (2016). https://doi.org/10.1007/s40136-016-0125-1

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