Abstract
Background/Aim: A pharyngeal fistula is the most common complication of total laryngectomy; thus, accurate diagnosis and treatment are important. Diagnosis is usually made by the finding of leakage of the contrast agent outside the pharynx during swallowing contrast examination. Herein, we encountered a case in which fine leaks not detected on contrast examination during swallowing were visualized and diagnosed by computed tomography (CT) imaging with oral contrast media with the patient in a prone position. Case Report: During imaging in a prone position, the contrast agent entered the sutures on the cephalocaudal and ventral sides of the surgical site, which were particularly prone to leaks due to gravity, and it was possible to diagnose minute leaks. When there is a high risk of postoperative pharyngeal fistula, such as in reconstructive cases with a pedunculated flap or with overlapping risk factors such as preoperative irradiation, CT imaging with contrast medium in a prone position is considered useful when swallowing contrast examination does not provide a clear diagnosis. However, suture failure is possible, and this should be evaluated. Conclusion: This case suggests that routine prone CT may lead to the early detection of postoperative pharyngeal fistula in high-risk cases. Further accumulation of cases is required to confirm our findings.
A problematic complication after total laryngectomy for malignant tumors of the pharynx, total pharyngolaryngectomy, or total laryngectomy to prevent aspiration is pharyngofistula caused by suture failure or wound dehiscence. Pharyngeal fistulas interfere with the initiation of oral intake and often lead to the deterioration of the patient’s general condition and other complications due to infection; thus, accurate diagnosis and treatment are important. Usually, the diagnosis is based on the finding of leakage of contrast medium outside the pharynx during contrast-enhanced swallowing; however, it is difficult to delineate minute leaks. Herein, we report a case in which a patient who had undergone total pharyngolaryngectomy was diagnosed with a microscopic leak that was not possible to visualize by swallow contrast imaging but was visualized by CT imaging with an oral contrast medium with the patient in a prone position.
Case Report
An 80-year-old man presented with cough and sore throat in January 2020 and dysphagia and hoarseness in June 2020. He visited our hospital on June 2020. He had a left, pear-shaped depression and a tumor extending over the laryngolaryngeal folds to the upper glottis and posterior wall of the hypopharynx in front of the valley of the glottis. The tumor was found centered on the left pear-shaped depression, extending beyond the laryngolaryngeal folds to the upper glottis, in front of the valley of the epiglottis, and partially to the posterior wall of the hypopharynx. Left vocal cord paralysis was also observed. After close examination, the patient was diagnosed with hypopharyngeal cancer cT4aN3bM0 stage IVb according to the Union for International Cancer Control version 8 criteria (1). Smoking history included the consumption of 40 cigarettes per day for 40 years. Considering his history of atrial fibrillation, chronic heart failure, and hypertension, as well as his age, reconstruction using a free skin valve was considered difficult, and he underwent total pharyngolaryngectomy and reconstruction using a penile skin valve with the pectoralis major muscle. On postoperative day 10, a swallowing contrast examination was performed, but no leakage was found. On postoperative day 14, the patient developed a fever, and blood tests showed an elevated inflammatory response. On postoperative day 15, a CT scan with an oral contrast medium was performed with the patient in a supine position. Although there was no obvious leak of contrast medium, an air leak was observed around the left side of the pharynx (Figure 1). On postoperative day 18, CT with an oral contrast medium was performed in a prone position to investigate the leak further. The leak was observed in the reconstructed area of the cephalic pharynx (Figure 2). The patient was treated conservatively by abstaining from eating and drinking because the extent of the leak and inflammatory response improved. After CT imaging under the same conditions showed an improvement in the leakage, the patient was allowed to start drinking water on postoperative day 43 and resume oral intake on postoperative day 46.
A computed tomography scan was performed with oral contrast medium with the patient in a supine position, and although there was no obvious leak of contrast medium, an air leak was observed around the left side of the pharynx. A: Axial view. B: Sagittal view.
Although it could not be seen in a supine position when computed tomography was performed, with the patient in a prone position under the combined use of an oral contrast agent, a leak was observed in the pharyngeal preparation on the cranial side. A: Axial view. B: Sagittal view.
Ethics statement. Written informed consent was obtained from the patient regarding the use of their personal information, privacy protection, and publishing.
Discussion
Pharyngeal fistulas can occur with any flap after head and neck reconstruction. This is because, after head and neck reconstruction, the site is exposed to pressure from swallowing, saliva, and other contaminants. In addition to surgery, other treatment options for head and neck cancer include drug and radiation therapies. A history of preoperative treatment may delay postoperative wound healing and be one of the causes of pharyngeal fistula formation (2).
Although postoperative pharyngeal fistulas are generally examined by fluoroscopy with swallow contrast, it has been reported that CT imaging with oral contrast is useful for accurate identification of the fistula site and early diagnosis of microscopic suture defects (3). In the previous report, the patient was placed in a supine position; however, in our case, CT was performed in a prone position. Both supine and prone positions provide more detailed information as the contrast medium enters the micropharyngeal fistula due to gravity. The advantage of the prone position is that the contrast medium remains anterior to the pharyngeal sutures, especially the cephalocaudal sutures and ventral side of the operative site, where the lumen for leakage is located (the dorsal side is anterior to the vertebral body), and may be useful in the early detection and diagnosis of leakage.
In general, the materials used for reconstruction include the anterolateral femur, forearm, pectoralis major, and free jejunum valves. The incidence of fistulas was reported by Tripathi et al. to be 12% for reconstruction using the pectoralis major valve (4). However, Chao et al. reported the incidence of fistula was higher for the pectoralis major valve than for the free flap (24.7 vs. 8.9%), and the revision surgery rate was higher (5). In contrast, the fistula rate in free jejunocutaneous valve reconstruction is as low as 3% (6-8). In the present case, the fistula may have developed because of the use of a sternocutaneous valve. Risk factors for the development of postoperative fistula include the use of an open drain, history of cardiovascular disease, longer operative time (9), smaller skin valve size (10), preoperative chemoradiotherapy, neck dissection, anemia, systemic disease (11, 12), smoking, advanced age, previous partial laryngectomy, previous tracheostomy, complicated thyroidectomy, complicated tongue root resection, low nutrition (13), subspecies (supraglottic >glottic), T-stage (T2<T3), preoperative irradiation history, postoperative hemoglobin <12.5 g/dl, and positive margins (14). Many studies have reported that preoperative irradiation is significantly associated with the development of postoperative pharyngeal fistulas (3, 11, 12, 14-16). Therefore, it is important to check for risk factors preoperatively, as patients with many risk factors are considered to be at a high risk of developing postoperative fistulas.
Our patient had a history of cardiovascular disease, smoking, advanced age, low nutritional status, and stage 3 disease. In addition, because the patient had a history of suspected microscopic suture insufficiency and reconstruction with a sternal skin valve, CT was performed in a prone position. As a result, a microscopic leak was found. This suggests that CT imaging with an oral contrast medium in a prone position may be useful in cases of reconstructive surgery with a sternal valve, when many risk factors are present or when suture insufficiency is suspected, and detailed confirmation is needed.
One drawback of prone CT with oral contrast is the difficulty in maintaining posture. In many head and neck cancer surgeries, neck dissection and vascular suturing are performed, and the neck has little mobility, making it difficult to raise the patients’ arms. The use of a pillow and cushion can reduce the physical burden, and the pillow can be elevated to prevent pharyngeal reflux of contrast media.
In our case, the pectoralis major muscle flap was used after pharyngolaryngectomy, but prone CT with oral contrast is also applicable for leak checks after reconstructive surgery using flaps and after suturing the pharyngeal mucosa after simple laryngectomy. In addition, it may be used for the early detection of minute leaks by screening after considering the type of flap and risk factors for leakage. Accumulation of further cases is necessary in the future.
Conclusion
We encountered a case in which CT with oral contrast of the patient in a prone position was useful for the diagnosis of postoperative pharyngeal fistula. CT with oral contrast medium in this position helped in the early diagnosis of microscopic pharyngeal fistula that it was not possible to detect by conventional examination.
Therefore, CT imaging with oral contrast in a prone position is useful in patients with a high risk of postoperative pharyngeal fistula or suspected suture insufficiency.
Acknowledgements
The Authors would like to thank Editage (www.editage.com) for English language editing.
Footnotes
Authors’ Contributions
Risa Tagaya drafted the article. Ryota Tomioka revised the article. Kunihiko Tokashiki treated the patient. Isaku Okamoto devised the method. Kiyoaki Tsukahara supervised the article.
Conflicts of Interest
The Authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
- Received June 20, 2023.
- Revision received July 22, 2023.
- Accepted July 24, 2023.
- Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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