What is the management of a postoperative pharyngeal leak after a laryngectomy (surgical removal of the larynx)?

From the Guidelines

Management of a post-operative pharyngeal leak after laryngectomy should prioritize early oral feeding, as supported by the most recent evidence, which suggests that initiation of oral feeding on the first postoperative day is safe 1. This approach is further reinforced by a 2021 systematic review that recommends early oral feeding post primary total laryngectomy to reduce length of stay 1. The initial management should focus on conservative measures including:

• NPO (nothing by mouth) status initially, with a plan to introduce oral feeding as soon as possible
• Nutritional support via a feeding tube, with an energy and protein intake of at least 125 kJ/kg/day and 1.2 g protein/kg/day, respectively 1
• Broad-spectrum antibiotics to prevent infection
• Wound care with regular dressing changes Small leaks (less than 1 cm) may heal spontaneously with these conservative measures within 2-3 weeks. For larger leaks or those that don't respond to conservative management, surgical intervention may be necessary, including local flap repair, pectoralis major myocutaneous flap, or free tissue transfer depending on the size and location of the leak. Salivary diversion using botulinum toxin injections (50-100 units divided among salivary glands) can reduce salivary flow and promote healing. Vacuum-assisted closure devices may be applied to accelerate wound healing in some cases. Throughout management, close monitoring for complications such as carotid artery exposure or rupture, mediastinitis, and sepsis is essential. Optimizing nutrition (maintaining albumin >3.5 g/dL) and controlling local infection are crucial components of successful management, as compromised tissue healing due to factors like prior radiation, malnutrition, tension on the suture line, or technical issues during the initial surgery can contribute to the development of pharyngeal leaks. Dietary counselling and/or nutritional supplements are effective methods of nutrition intervention, and weekly dietitian contact during radiotherapy can help improve patient-centered outcomes 1. Patients who are unable to eat and are reliant on tube feeding should be screened for distress and provided with psychosocial support to assist with quality of life 1.

From the Research

Management of Post-Op Pharyngeal Leak after Laryngectomy

• The management of post-op pharyngeal leak after laryngectomy can be approached through various methods, including conservative management, endoscopic repair, and the use of intraluminal negative pressure wound therapy 2, 3, 4, 5.
• A study published in 2023 found that water soluble swallow (WSS) can be used to rule out salivary postoperative leak after salvage total laryngectomy, with a sensitivity of 72.7% and a negative predictive value of 92.7% 2.
• Another study published in 2014 found that intraluminal negative pressure wound therapy can be used to optimize pharyngeal reconstruction, with a pharyngeal closure rate of 92% and no serious adverse events reported 3.
• A survey of American Head and Neck Society surgeons found that perioperative management of total laryngectomy patients is highly variable, with differences in management based on irradiation status and pharyngeal repair 6.
• Endoscopic repair of pharyngocutaneous fistula after total laryngectomy has been shown to be an effective method, with a mean time to resumption of oral intake of 22 days and no complications reported 4.
• A retrospective study published in 2024 found that videofluoroscopic swallowing study (VFSS) can be used to detect pharyngeal leak after total (pharyngo-) laryngectomy, with a good effectiveness in detecting pharyngeal leak and mitigating evolution into subsequent pharyngocutaneous fistula 5.

Diagnostic Methods

• Water soluble swallow (WSS) can be used to rule out salivary postoperative leak after salvage total laryngectomy 2.
• Videofluoroscopic swallowing study (VFSS) can be used to detect pharyngeal leak after total (pharyngo-) laryngectomy 5.

Treatment Methods

• Conservative management can be used to manage pharyngeal leak after laryngectomy, with a success rate of 46.7% in avoiding pharyngocutaneous fistula 2.
• Endoscopic repair can be used to repair pharyngocutaneous fistula after total laryngectomy, with a mean time to resumption of oral intake of 22 days and no complications reported 4.
• Intraluminal negative pressure wound therapy can be used to optimize pharyngeal reconstruction, with a pharyngeal closure rate of 92% and no serious adverse events reported 3.