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Pharyngeal fistulae after laryngectomy

SINCE Patrick H. Watson performed the first total laryngectomy on a patient with a luetic granuloma at Edinburgh in 1868, morbidity and mortality as a result of this operation have steadily decreased. This has mainly been brought about by a continuing improvement in operation technique, modern anaesthesia and the use of chemotherapeutics and antibiotics. However, one still cannot say that a disturbed postoperative course is a rarity; the occurrence of a pharyngeal fistula, for instance, is a regularly recurring complication. As recently as 1965 Shaw, writing about glottic cancer, speaks about 'the usual crop of temporary pharyngeal fistulae'. Thestay in hospital is usually considerably lengthened by this complication which means an extra psychical burden for the patient, who often already has a tendency towards depression. Moreover, the training in oesophageal speech is delayed, as is eventual post-operative radiation treatment. In some cases a second operation is necessary to close the pharyngeal defect. The fact that the pharynx and the cervical oesophagus do not have a serous layer accounts for the slow healing of the pharyngeal suture line compared with an intestinal anastomosis. Furthermore, it is well known that pre-operative radiation therapy has a detrimental effect on the healing process (Mill 1956, Riccabona 1962, Baker 1963). The combination of laryngectomy with a radical neck dissection is also believed to have a harmful influence (Schweitzer 1962), in the same way as an infection in the operation field (Andre et al. 1964). Reports on the frequency of pharyngeal fistulae after laryngectomy are variable (see Table I).