Abstract
A 64-year-old male with left vocal cord paresis and lung cancer underwent left-sided thyroplasty, followed by chemotherapy. He developed a laryngocutaneous fistula due to silicone block extrusion. The fistula was successfully repaired using a Deltopectoral flap. This is the second reported case of such a fistula and the first repaired with this method.
Keywords: Laryngocutaneous Fistula, Deltopectoral flap, Thyroplasty, Fistula Repair, Vocal cord Paresis
Introduction
A laryngocutaneous fistula (LCF) is an abnormal connection between the larynx and the skin of the neck, allowing air, saliva, or fluids to pass through. It can result from surgeries involving the larynx, severe infections, injuries, or complications from implants. Symptoms include persistent cough, dysphagia, voice changes, neck discharge (saliva, mucus, or pus), and recurrent respiratory infections.
Thyroplasty (medialization laryngoplasty also known as type 1 thyroplasty) is usually done for rehabilitation of voice in patients affected with unilateral vocal cord paresis [1]. Complications after thyroplasty are rare. Few of the complications include revision of implant, inadequate voice outcome, airway problems and implant extrusion. Tucker et al. [2] reported that 30% of complications after thyroplasty occurred after 4 months and were due to implant extrusion. In this case report we discuss the repair of laryngocutaneous fistula by deltopectoral flap formed due to implant extrusion after chemotherapy.
Case Report
A 64-year-old male presented in our OPD with complaint of hoarseness of voice for one month. The patient was investigated and was found to be having left vocal cord palsy. To identify the cause of vocal cord palsy further investigations were done. CT chest revealed a lung mass which was cancerous on biopsy. Patient was referred to a medical oncologist for chemotherapy. As patient desired improvement in his voice, a left sided thyroplasty procedure was performed and silicon block was inserted. Patient then underwent chemotherapy after 4 weeks. The patient tolerated the thyroplasty procedure well for 6 months but after that he started developing a small area of necrosis on the left side of neck at the site of surgery. He was given the option of block removal but he did not agree. The area of necrosis increased and further dehiscence developed. After a year, the silicon block extruded and got lodged into the upper respiratory tract. Bronchoscopy was performed which retrieved the silicon block. Due to extrusion of silicon block a LCF was formed at the level of true vocal cords with subsequent mucous and pus discharge.
A CECT neck was advised and it revealed an 8 mm wide well-defined air containing fistulous tract on left side of neck. The tract was horizontal, coursing through mid-part of the thyroid cartilage, communicating with glottic region (at and just below the level of arytenoid cartilage). No abnormal soft tissue thickening along the tract was noted and both vocal cords appeared adducted. A diagnosis of laryngo-cutaneous fistula on left side of neck at the level of true vocal cords was made. After other relevant investigations the patient was planned for surgery for the closure of LCF. As the diameter of the fistula was considerable, primary closure could not be achieved after fistulectomy and DP flap repair was planned considering the size, location and overall health status of the patient. Direct laryngoscopy and gastrograffin study done post operatively showed no fistula or leak. Figure 1 shows clinical, radiographic, intra-op and post-op pictures.
Fig. 1.
Clinical, radiographic, intra-op and post-op pictures
Discussion & Literature Review
Closure of laryngocutaneous fistulas is challenging, especially when traditional methods fail. The Deltopectoral flap, known for its reliable vascularity and ease of harvest, shows promise in addressing this issue. Despite many reports on pharyngocutaneous fistula closure, literature on LCF closure remains limited, though our case report shows positive results. In a case reported by Maleca and Bryson [3] in 2019, a 73-year-old female who underwent medialization laryngoplasty using a silastic implant for unilateral vocal fold paralysis. More than a year post-surgery, patient presented with anterior neck infection after an animal scratch. CT scan revealed left strap muscle abscess and I & D yielded methicillin-resistant Staphylococcus aureus. Despite antibiotic therapy, persistent neck drainage occurred. Neck exploration revealed LCF necessitating implant and fistulous tract removal. Wound closure involved strap muscle advancement into the laryngoplasty window. After one month, patient showed no recurrent infection, with well-healing wound and improved vocal fold function.
In another case reported by Azuma et al. [4], reported the use of hinge flaps for the closure of LCF. A patient developed 1 × 2 cm LCF due to partial laryngectomy followed by radiotherapy. The patient underwent reconstruction using 2 hinge flaps with triangular extensions at 6 months after development of the fistula. The skin defect was covered by a pedicled latissimus dorsi musculocutaneous flap.
Guo et al. [5] reported repair of LCFs using a thyroid lobe flap. 6 male patients with severe laryngeal fistula post-laryngeal cancer surgery underwent thyroid leaf valve repair after failed conservative treatment for 10 to 45 days. The procedure involved cutting and suturing the thyroid isthmus, freeing the thyroid lobe, and using it as a pedicled flap to cover the fistula opening. At post-op 1 week laryngoscopy confirmed healed fistula.
Ahmadi et al. [6] reported a case of 63-year-old male with a history of chemoradiotherapy for laryngeal cancer 1 year ago. He had now presented with laryngeal actinomycosis. After prolonged penicillin-based treatment, the patient developed LCF due to chondroradionecrosis. They used nasal septum cartilage graft to reconstruct thyroid cartilage defect and cutaneous defect was repaired with pectoralis major myocutaneous flap transposition. Table 1 gives an over view of all the cases. In our case we have used delto-pectoral flap for closure of LCF which has not been reported before. We decided to used DP Flap as the diameter of the fistula was considerable and primary closure after fistulectomy could not be achieved. We also reduced the morbidity of the patient as split thickness skin graft harvesting was avoided to cover the donor site and the de-epithelized skin from DP flap was used to cover the donor site raw area.
Table 1.
Overview of previously reported cases
| Study | Year | LCF cause | Fistula size | Repair by |
|---|---|---|---|---|
| Ahmadi et al. [6] | 2017 | Chondroradionecrosis after laryngeal actinomycosis post chemoradiation for larynx cancer | 8 mm | Nasal septum cartilage graft for thyroid cartilage defect and pectoralis major myocutaneous flap for skin defect. |
| Azuma et al. [4] | 2018 | Partial laryngectomy followed by radiotherapy | 1 x 2 cm | Hinge flaps |
| Meleca and Bryson [3] | 2019 | Medialization laryngoplasty followed by anterior neck infection after animal scratch | Strap muscle advancement | |
| Guo et al. [5] | 2020 | Laryngectomy | Thyroid lobe flap |
LCF formation after thyroplasty is a rare entity. We encourage more discussion on whether thyroplasty should be performed in patients awaiting chemotherapy or those who may require chemotherapy for cancer in future. Even though our patient was under regular follow-up and blood investigation were all under normal limits, the necrosis at thyroplasty site and extrusion of silicon implant could not be explained. The probable causes could be chemotherapy, old age or skin thinning at procedure site.
Conclusion
LCF is a very rare clinical entity and our clinical understanding regarding this is not much. Very few cases have been reported in literature for its occurrence, management and how to approach these cases if encountered clinically should be discussed. In our experience use of deltopectoral flap for the closure of LCF fistula can be a promising approach. More literature and discussion for the management of LCF is needed presently.
Footnotes
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References
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