Background: Because of the difficulty of airtight sealing and risk of salivary contamination, negative-pressure wound therapy (NPWT) has rarely been applied for postoperative fistula following head and neck surgery; thus, its utility remains unclear. Methods: We applied NPWT in 34 patients who developed orocutaneous and pharyngocutaneous fistula after head and neck surgery. Here we retrospectively analyzed the utility of NPWT for managing those fistulas. Results: Thirty-two patients (94.1%) underwent NPWT as scheduled without adverse events. In 28 patients (82.4%), fistula closure was completed only by NPWT, and the mean period to fistula closure was 30.4 days. The mean period to closure did not differ significantly between fistulas with (21.7 days) and without (39.1 days) previous irradiation. Conclusions: Airtight sealing can be maintained and postoperative fistula can be closed by NPWT with a high success rate, even after previous irradiation. NPWT is an effective and minimally invasive treatment for postoperative fistula. K E Y W O R D Sfistula closure, head and neck cancer, negative-pressure wound therapy, orocutaneous fistula, pharyngocutaneous fistula

Background Lymphatic diseases due to lymph vessel injuries in the pelvis and groin require immediate clinical attention when conventional treatments fail. We aimed to clarify the effectiveness of and indications for lymphaticovenular anastomosis (LVA) to treat these lymphatic diseases. Methods We retrospectively evaluated six patients who underwent LVA for lymphatic diseases due to lymph vessel injuries in the pelvis and groin. Specific pathologies included groin lymphorrhea (N = 3), chylous ascites (N = 2), and retroperitoneal lymphocele (N = 1). The maximum lymphatic fluid leakage volume was 150–2600 mL daily. Conventional treatments (compression, drainage, fasting, somatostatin administration, negative pressure wound therapy, or lymph vessel ligation) had failed to control leakage in all cases. We performed lower extremity LVAs after confirming the site of lymph vessel injury using lymphoscintigraphy. We preferentially placed LVAs in thigh sites that showed a linear pattern by indocyanine green lymphography. Postoperative lymphatic fluid leakage volume reduction was evaluated, and leakage cessation was recorded when the drainage volume approached 0 mL. Results LVA was performed at an average of 4.3 sites (range, 3–6 sites) in the thigh and 2.7 sites (range, 0–6 sites) in the lower leg. Lymphatic fluid leakage ceased in all cases after a mean of 6 days (range, 1–11 days) postoperatively. No recurrence of symptoms was observed during an average follow‐up of 2.9 (range, 0.5–5.5) years. Conclusions LVA demonstrates excellent and rapid effects. We recommend lower extremity LVA for the treatment of lymphatic diseases due to lymph vessel injuries in the pelvis and groin.

Toxic shock syndrome is a rare but life-threatening complication after breast implant surgery. We describe a 77-year-old woman who developed toxic shock syndrome caused by methicillin-resistant Staphylococcus aureus after breast implant reconstruction. Despite a high fever and markedly increased white blood cell count, suggesting severe infection, she initially had no symptoms of local findings, such as wound swelling and redness of the breast. Soon after diagnosis of toxic shock syndrome and removal of her breast implant, she was recovered from the shock state. To date, 16 cases of toxic shock syndrome have been reported, including this case, and they were related to breast implants or tissue expander surgery. The common and noteworthy characteristic of these cases was the lack of local findings, such as swelling or redness, which suggests infection. Therefore, early diagnosis is generally difficult, and the initiation of proper treatment can be delayed without knowledge of this characteristic. Toxic shock syndrome requires early diagnosis and treatment. If the patient has a deteriorated vital sign after breast implant surgery or tissue expander breast reconstruction, toxic shock syndrome should be suspected, even if there are no local signs of infection, and removal of the artifact should be considered as soon as possible.

Although negative pressure wound therapy (NPWT) is widely used, its application to the head and neck region remains challenging due to anatomical complexities. This report presents the case of a female patient presenting with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes, uncontrolled diabetes and severe bilateral sensorineural hearing loss. The patient had undergone cochlear implant surgery and five months later the wound was infected with methicillin-resistant Staphylococcus aureus (MRSA). NPWT was started shortly after removing the internal receiver and was stopped 11 days later. NPWT helped in controlling infection and led to a successful wound closure. In this case, NPWT was effective in treating infectious wounds around the auricle after cochlear implant surgery. Declaration of interest: The authors have no financial support for this article and no conflict of interest directly relevant to the content of this article.

Background: We report a novel reconstruction technique that maintained effective swallowing after total glossolaryngectomy (TGL) by restoring pharyngeal constriction using a vascularized vastus lateralis muscle transfer. Methods: A 65-year-old male with recurrent tongue cancer underwent TGL and anterolateral thigh flap reconstruction with the vastus lateralis muscle. The bilateral cut ends of the remaining posterior pharyngeal wall constrictor muscle were sutured to the transferred vastus lateralis muscle so that the two muscles encircled the reconstructed pharynx. The femoral nerve of the vastus lateralis muscle was coapted to the hypoglossal nerve. Results: Videofluorographic examination showed the contrast bolus flowing smoothly with little assistance from gravity. Laryngoscopic examination showed circumferential constriction of the reconstructed pharynx. The patient could swallow soft food without placing the bolus in his posterior oral cavity or drinking simultaneously. Conclusion: The restoration of pharyngeal constriction introduces the possibility of functional swallowing in patients after TGL. K E Y W O R D S anterolateral thigh flap, functional swallowing, pharyngeal constrictor muscle, total glossolaryngectomy, vastus lateralis muscle transfer

Summary: Surgeons have traditionally believed that swallowing is mainly dependent on gravity after total glossolaryngectomy. However, swallowing function after total glossolaryngectomy varies widely among patients, and a thorough analysis is lacking. The authors aimed to clarify the swallowing function after total glossolaryngectomy and determine whether it is primarily dependent on gravity. The authors retrospectively analyzed videofluorographic examinations of patients who underwent total glossolaryngectomy and free or pedicle flap reconstruction. The authors enrolled 20 patients (12 male; mean age, 61 years; age range, 43 to 89 years). All patients demonstrated constriction of the reconstructed pharynx to some degree, and no patient’s ability to swallow was dependent on gravity alone. Videofluorography showed excellent barium clearance in eight patients and poor clearance in 12. All patients with excellent clearance showed strong constriction of the posterior pharyngeal wall, whereas only 8.3 percent of the patients with poor clearance showed adequate constriction, which was significantly different (p = 0.0007). Velopharyngeal closure and lip closure also contributed significantly to excellent clearance (p = 0.041). The shape of the reconstructed pharynx (depressed, flat, protuberant) showed no statistically significant association with excellent clearance. Contrary to previous understanding, constriction of the remnant posterior pharyngeal wall played an important role in swallowing after total glossolaryngectomy, and gravity played a secondary role. Dynamic posterior pharyngeal wall movement might result from the increased power of the pharyngeal constrictor muscle and compensate for the immobility of the transferred flap. A well-functioning pharyngeal constrictor muscle and complete velopharyngeal and lip closures can contribute to excellent barium clearance in patients after total glossolaryngectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.