Endoscopic Dilation of Refractory Postlaryngectomy Strictures: A Case Series and Literature Review

Abstract

Background. Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported. Materials and Methods. Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores. Conclusions. Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.

Neopharyngeal Stricture following Laryngectomy

“…68 These refractory strictures have been defined as an anatomic restriction because of cicatricial luminal compromise or fibrosis causing dysphagia in absence of inflammation. 61,89 These are diagnosed clinically when luminal patency of at least 14 mm is not attained after five or more dilations at intervals of 2 to 4 weeks. 89 One identified risk factor for development of refractory strictures was found to be use of fluoroscopy during dilation.…”

“…90 Proposed treatments for these refractory strictures have included topical or intralesional mitomycin C, esophageal stents, home self-dilations using Maloney bouginage, and even through regional or free flap tissue reconstruction. 60,61,81,90,91 Self-expanding metal stents (SEMSs) are normally reserved for palliative treatment in the case of advanced esophageal cancers causing malignant stricture. However, SEMS have also been employed for the treatment of benign refractory strictures.…”

“…60 Some researchers have observed that it is not uncommon for patients with a history of PCF to develop treatment-refractory strictures well after fistula has resolved. 61 It is likely that the inflammation for the PCF leads to increased scar contracture in the neopharynx and, thus, stricture formation. It is then reasonable to conclude that prevention of PCF could also be protective against stricture formation.…”

“…90 Proposed treatments for these refractory strictures have included topical or intralesional mitomycin C, esophageal stents, home self-dilations using Maloney bouginage, and even through regional or free flap tissue reconstruction. 60 61 81 90 91…”

“…However, SEMS have also been employed for the treatment of benign refractory strictures. 61 72 Conventional endoscopic stricture dilation with bougie or balloon is performed, followed by passing of the SEMS over the same guidewire. Under endoscopic guidance, the SEMS is passed to the site of the stricture and deployed, and left for 4 to 8 weeks before removal.…”