Salivary fistula: Blue dye testing as part of an algorithm for early diagnosis

Abstract

ObjectiveOrocutaneous and pharyngocutaneous fistula (OPCF) is a debilitating complication of head and neck surgery for squamous cell carcinoma (SCC), resulting in delayed adjuvant treatment and prolonged hospitalization. As yet, there is no established test that can help in prompt and accurate diagnosis of OPCF. This study aims to determine the accuracy of bedside blue dye testing and its role as part of an algorithm for early diagnosis. We also analyze the risk factors predisposing to OPCF.Study DesignRetrospective cohort study from 2012 to 2014.MethodsPatients with head and neck SCC who underwent major resection and reconstruction, at risk of OPCF, were included. Results of blue‐dye and video‐fluoroscopic swallow‐studies (VFSS) testing for OPCF were recorded. For the patients that were noted to develop OPCF, the length of time to diagnosis of fistula and subsequent mode of management were examined.ResultsOf the 93 patients in this study, 25 (26.9%) developed OPCF. Advanced T‐classification (T3/T4) was the only significant predisposing risk factor (p = 0.013). The sensitivity and specificity of the bedside blue dye testing was found to be 36.4% and 100%, respectively. The test positive patients were diagnosed with OPCF at a median of postoperative day (POD) 9.5 as compared to POD 13 for the test negative patients (p = 0.001). Early diagnosis was associated with faster fistula resolution with treatment.ConclusionBlue dye testing is a simple bedside test that can assist in the early diagnosis of OPCF in patients, allowing treatment to be instituted earlier with improved outcomes.Level of Evidence3

Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center

“…Though there could be much overlap and interplay between these factors, it is important to identify them in order to minimize the occurrence of OCF. Given the fact that they significantly contribute to the morbidity and also subsequently delay the initiation of adjuvant treatment thereby affects the survival as well …”

“…Factors such as preexisting comorbidities, previous treatment received (surgery/radiotherapy/chemotherapy), subsite, stage of disease, preoperative Hb, albumin, positive margins, neck dissection, SSI, and prior tracheostomy have been implicated as predisposing factors for the development of PCFs . However, there is no literature that exclusively looks at the above‐mentioned predisposing factors in relation to OCF . Most of the evidence is extrapolated from what literature is available in relation to PCF.…”

“…Orocutaneous fistula (OCF) is a common and dreaded complication following surgery for OSCC as it predisposes the patients to infection and leads to exposure of vessels, making them vulnerable for vascular complications such as carotid blow out. It also delays wound healing and subsequently the initiation of adjuvant treatment, thus having an impact on the oncological outcomes . Initiation of oral feeds is often delayed in these patients with OCF to aid healing; hence, they are dependent on nasogastric tube feeding, which in turn may have an impact on the quality of life for these patients.…”

Ultrasonographic swallowing examination for early detection of neopharyngeal fistula after salvage total laryngectomy: A preliminary study

“…However, its sensitivity has been variably reported as 26%‐63% and it cannot provide detailed anatomical information about the neopharynx and specific fistula site, even in cases where fistula is detected . Wound amylase measurement is the simplest noninvasive method used to demonstrate salivary leakage, but reported results pertaining to its usefulness are inconsistent, and as an increase in wound amylase is merely a result associated with neopharyngeal fistulas it cannot depict the presence of a fistula per se . Compared with these aforementioned methods, USSE is easily applicable at the bedside, entails no radiation exposure, and can provide more detailed anatomical information about the neopharynx as well as the presence of neopharyngeal fistula, and facilitates subsequent therapeutic intervention.…”

“…7,8 Several methods for detecting neopharyngeal fistula and determining the viability of resuming oral feeding have been proposed, including the barium swallow test and measurement of wound amylase concentration. 4,7,9,11,12 The barium swallow test is the most commonly used method for detecting neopharyngeal fistula after laryngectomy, but it cannot be performed at the bedside, requires the ingestion of a contrast agent, entails radiation exposure, and is reportedly associated with sensitivity of as low as 26%. 1,6 Wound amylase concentration can be measured at the bedside very easily, but it is not a diagnostic method that demonstrates the presence of fistula per se.…”