Classification and Management of Tracheoesophageal and Tracheopharyngeal Fistulas After Laryngectomy

Persistent tracheopharyngeal (TPF) and tracheo-oesophageal (TEF) fistulas after laryngectomy create a therapeutic challenge. The current classification of TPFs and TEFs is based on clinical experience without detailed anatomical information. In this study, casts of TPFs/TEFs were obtained from 16 patients; these were the first steps in manufacturing customised prostheses. Fistulas were classified according to the shape and dimension of the tracheopharyngeal and tracheo-oesophageal silicone casts and prostheses as well as on epithetic requirements. Four different types of fistulas were classified: Type A, a fistula with a straight axis between the neopharynx and oesophagus; Type B, a fistula with a stenosis of the neopharynx but a straight axis; Type C, the axis between the neopharynx and oesophagus is flexed anteriorly; and Type D, neighbouring structures are absent creating a large defect. This classification system might improve the manufacturing processes of customised prostheses in individual cases with challenging tracheopharyngeal and tracheo-oesophageal fistulas.

Section: Discussionmentioning

confidence: 99%

Treatment of tracheopharyngeal and tracheo-oesophageal fistulas following laryngectomy and fistula classification based on individual silicone casts

Herzog

Lorenz²,

Glien

et al. 2014

“…In some cases these TEF or TPF go hand in hand with stenoses of the neopharynx. According to the location, size and associated stenoses, TEF/TPF can be classified as type I: high TEF; type II: enlarged high TEF; type III: deep TEF; type IV: TPF; and type V: TPF associated with pharynx stenosis) [9]. Several published surgical approaches revealed that TEF/TPF can be closed by radial forearm flap [1,2,6,12], sternocleidomastoid muscle flap [23], pectoralis major flap [5], deltopectoral flap [16], multiple layer closure [14] or tracheal ascension [3].…”

Section: Introductionmentioning

confidence: 99%

Treatment of large pharyngotracheal fistulas after laryngectomy by a novel customized pharyngeal stent

Herzog

Greiner

2011

Persisting tracheoesophageal (TEF) and/or tracheopharyngeal (TPF) fistulas after laryngectomy are incessant problems that can lead to a tremendous loss of quality of life among patients. As soon as surgical options for closing fistulas become impractical, then alternative approaches to stent the fistulas gain significant value. Conventional stents seldom seal the entire fistula, might dislocate and tend to induce tissue proliferation and cause discomfort to the patient. On the basis of these side effects a novel customized pharyngeal stent has been developed to completely seal the fistula without dislocation and discomfort. The anatomic dimensions of the neopharynx in two patients were obtained by a silicone cast of the respective neopharynx and the stent was manufactured according to this anatomical model. The soft silicone edges of the stent match the pharyngeal anatomic structures and follow the changes of the base of the tongue during the process of swallowing. Nevertheless, the stents are rigid enough to remain in place. The reported two patients were able to subsist by themselves orally most of the time without any signs of leakage at all. One stent had to be explanted after 7 months due to an enlargement of the fistula. The second stent is still in place for 10 months up to now without any side effects.

“…The insertion of a voice prosthesis is a simple and rapid surgical procedure and an easy method of voice rehabilitation that is associated with only a low rate of complications. The literature describes only a few cases of severe life-threatening complications such as oesophageal perforation with mediastinitis, soft-tissue abscesses, or spinal injuries [1,13,25]. In contrast, minor local problems occur more often and include the formation of biofilms on the prosthesis with subsequent prosthesis failure, spasms, or stenoses in the cricopharyngeal segment with limited swallowing and voicing as well as granulation tissue formation in the region of the tracheo-oesophageal fistula, periprosthetic leakage as a result of fistula enlargement with subsequent aspiration symptoms [13,14,29,30].…”

Section: Introductionmentioning

confidence: 99%

The management of periprosthetic leakage in the presence of supra-oesophageal reflux after prosthetic voice rehabilitation

Lorenz¹,

Grieser²,

Ehrhart³

et al. 2010

The objective of the study was to investigate the influence of anti-reflux medications on the management of periprosthetic leakage in laryngectomised patients with prosthetic voice rehabilitation. Sixty patients underwent laryngectomy and prosthetic voice rehabilitation. In a prospective non-randomised study, we examined the patients clinically and assessed the presence of reflux disease using 24-h dual-probe pH monitoring before and 6 months after oral anti-reflux treatment with proton pump inhibitors (PPIs). The severity of reflux, the effectiveness of anti-reflux therapy, and the clinical success of treatment were evaluated. Reflux parameters before and after anti-reflux therapy as well as the severity and incidence of periprosthetic leakage before and after PPI therapy were the main outcome measures. The absolute number of reflux events was 162.2 (±144.3) before treatment and 63.1 (±87.9) after treatment with PPIs (p = 0.031). The reflex area index score decreased from 327.1 (±419.3) without PPIs to 123.8 (±249.7) with PPIs (p = 0.0228). The mean DeMeester score was 108.3 (±85.4) before treatment and 47.4 (±61.7) after 6 months of treatment (p = 0.0557). The relative risk of periprosthetic leakage decreased to 0.5 after anti-reflux treatment. In 19 patients, leakage problems were successfully managed by rigorous treatment with PPIs. No further surgical procedures were required in these cases. Rigorous anti-reflux treatment leads to an improvement in parameters that can be assessed objectively by 24-h dual-probe pH monitoring. In the majority of patients, the symptoms associated with periprosthetic leakage can be improved or cured.