Endoscopic Management of Pharyngocutaneous Fistula: A Case Report

Abstract

Pharyngocutaneous fistula is a comparatively rare complication following neck surgery, presenting challenges in management and potential morbidity. These patients are difficult to treat by any conventional techniques and often a multidisciplinary approach is required for treating such patients. Here, we present a case of a 43/M patient who developed a pharyngocutaneous fistula following anterior discectomy for cervical compression. Since endoscopy provides a minimal invasive approach for managing such complex cases, we decided to use endoscopic fistula plug insertion in this patient. This case underscores the importance of early recognition and tailored intervention in the management of pharyngocutaneous fistulae.

Keywords

pharyngocutaneous fistula (PCF) - endoscopic management - fistula plug

Introduction

Pharyngocutaneous fistula (PCF) is a complex and resource-intensive complication that may arise subsequent to a variety of neck surgeries, such as thyroidectomy, neck dissection, and laryngectomy.[1] This condition is characterized by an abnormal communication between the pharynx and the skin of the neck, resulting in an incessant discharge of fluid and an elevated risk of infection.[1]

Given the potential morbidity associated with this complication, it is imperative to promptly identify and manage PCF using appropriate interventions to facilitate expedited wound healing. Surgical treatment using distant flaps or local flaps is commonly performed for PCF, but recurrence can still occur despite exhausting all therapeutic options.[2]

Endoscopic management may offer potential benefits in the management of PCF. It allows for a less invasive approach, potentially reducing the morbidity associated with surgical interventions.[3] Endoscopic techniques, such as endoscopic suturing or fibrin glue application, have been used to close the fistula and promote healing.[3] Endoscopic management allows for better visualization and assessment of the fistula site, facilitating targeted treatment and reducing the risk of complications.[4] Overall, endoscopic management holds promise as a less invasive and potentially more effective approach to the management of PCF, offering improved outcomes and reduced morbidity compared to traditional surgical interventions.

Fistula plugs are biosynthetic devices made up of porcine small intestinal submucosa. They promote healing and prevent recurrence of anal fistulas. Use of anal fistula plug is a standard mode of treatment for treating high anal fistulae.[5]

We have used the similar principal for managing PCF using endoscopic approach.

Case Presentation

A 43-year-old male patient presented with complaints of persistent purulent discharge from the surgical site post-anterior cervical discectomy. A cutaneous opening was seen just lateral to the sternomastoid muscle in the supraclavicular region on the right side ([Fig. 1]). A contrast computed tomography (CT) showed a fistulous communication between the pharynx and the cutaneous opening ([Fig. 2]).

Fig. 1 Methylene Blue study showing external fistulous opening in the neck.

Fig. 2 CT scan showing fistulous track. CT, computed tomography.

A conservative management with broad-spectrum antibiotics and strict PEG tube feeding did not help in closure of the fistula. Hence the patient was referred to our hospital for further management.

To ensure the comprehensive management of the patient's condition, a collaborative approach was adopted by involving the surgical, otolaryngology, and gastroenterology teams. Given the chronic nature of the PCF and risk of injury to surrounding vital structures, it was decided that endoscopic closure would be pursued as the primary treatment modality.

Procedure

The procedure was done under general anesthesia with endo tracheal tube.

Patient was in supine position. A gastroscope was inserted in the pharynx. The internal opening of the fistula could not be delineated endoscopically. So, a catheter was inserted through the external opening and Methylene Blue dye was injected in the fistulous tract. The dye was seen coming in the pharynx and thereby the internal opening was confirmed. A flexible tip guide-wire was then inserted through the opening and was brought out from the external opening ([Fig. 3]). A balloon dilator was passed over the guide-wire and the tract was dilated ([Fig. 4]). After dilation the fistula plug was passed over the guide and then plug inserted over the guide-wire into the fistulous tract covering its entire extent ([Fig. 5]).

Fig. 3 Guide-wire and a canula brought out from the internal opening to the external opening.

Fig. 4 Dilation of the track using a pneumatic balloon.

Fig. 5 Loading of fistula plug over the guide-wire.

Post-placement of the fistula plug, the patient was kept on broad-spectrum antibiotics and on-tube feeding. Slowly the wound discharge was reduced and after about 2 to 3 weeks there was a complete closure of the fistula ([Fig. 6]).

Fig. 6 Completely healed fistula.

A follow-up CT scan with oral contrast was done to confirm complete closure ([Fig. 7]).

Fig. 7 CT scan showing no leak. CT, computed tomography.

Follow-up endoscopic evaluations confirmed the integrity of the closure site, and the patient remained asymptomatic during subsequent visits. Furthermore, nutritional support and wound care were optimized, which contributed to favorable long-term outcomes.

Discussion

PCF is undoubtedly a challenging complication that can arise following major neck surgeries. Formation of PCF can be attributed to multiple factors, such as patient-related factors, disease-related factors, and surgery-related factors.[6]

As the fistula forms, it creates a continuous conduit to the external environment and further increases wound infection, which would cause further damage to the surrounding tissue and lead to further inflammation that can spread to the nearby structures like carotid artery and jugular vein, which may cause these vessels to rupture. It can also influence the overall treatment and recovery of patients. This would further delay resumption of oral feeding in patients who are already malnourished and cause other accompanying complications such as extensive scar formation for longstanding fistula leading to stricture, making fistulae a major cause for increased mortality and morbidity[2]

As this is a difficult area to approach, it necessitates a multidisciplinary approach for optimal management. Traditional surgical repair, while effective in some cases, carries a significant risk of recurrence, particularly in patients with complex or recurrent fistulas. Re-surgery in these cases is often fraught with difficulties, including scar tissue, altered anatomy, and increased risk of injury to surrounding vital structures.[2]

Endoscopic closure has emerged as a valuable alternative, offering a minimally invasive option with high success rates and reduced morbidity compared to traditional surgical approaches. Various endoscopic techniques are available, including clip placement, fibrin sealant application and fistula plug insertion. The treatment can be tailored to the specific characteristics of the fistula tract, further enhancing the likelihood of successful closure. Importantly, endoscopic interventions do not preclude subsequent surgical management if necessary, providing a flexible treatment pathway for complex cases.[3] [4]

Our case demonstrates the successful application of endoscopic fistula plug insertion for PCF management. This technique, adapted from the well-established use of fistula plugs in anal fistulae, offers a promising option for patients with recurrent or persistent PCFs. The use of biosynthetic materials promotes tissue regeneration and provides a robust seal, reducing the risk of recurrence.

Conclusion

PCF is a well-recognized complication that may occur following major neck surgery, requiring early recognition and tailored intervention for optimal management. The utilization of endoscopic techniques provides a highly effective and minimally invasive approach for the management of PCF. However, it is important to note that further research is necessary to evaluate the long-term efficacy and safety of endoscopic techniques in this specific patient population.

Conflict of Interest

None declared.

• References

• 1 Sapundzhiev N, Nikiforova L, Spasova B, Ivanova D, Balev B. Endoscopic repair of pharyngocutaneous fistula following laryngectomy. Cureus 2019; 11 (10) e5871
• 2 Gebhardt B, Pudszuhn A, Veit Hofmann M. Treatment options for pharyngocutaneous fistula – a retrospective analysis at the Charité over the past 20 years. Laryngorhinootologie 2023; 102 (S 02): S237-S238
• 3 Mirkin KA, Pauli EM. Endoscopic management of enterocutaneous fistulae. Digestive Disease Interventions 2021; 5 (02) 177-185
• 4 Patel S, DeLong CG, De Jesus Sanchez L, Goyal N, Pauli EM. The novel use of flexible endoscopic techniques in the management of pharyngocutaneous fistulas. Digestive Disease Interventions 2021; 5 (04) 319-323
• 5 Ky AJ, Sylla P, Steinhagen R, Steinhagen E, Khaitov S, Ly EK. Collagen fistula plug for the treatment of anal fistulas. Dis Colon Rectum 2008; 51 (06) 838-843
• 6 Do SB, Chung CH, Chang YJ, Kim BJ, Rho YS. Risk factors of and treatments for pharyngocutaneous fistula occurring after oropharynx and hypopharynx reconstruction. Arch Plast Surg 2017; 44 (06) 530-538

Publication History

Article published online:
08 April 2025