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Interim Prosthetic Management of Pharyngostoma and Esophagostoma
Interim Prosthetic Management of Pharyngostoma and Esophagostoma GEORGE P. ARGERAKIS, D.D.S.* JAMES B. LEPLEY, D.D.S.**
The surgical treatment of bulky tumors of the head and neck may result in the creation of elective pharyngeal and esophageal fistulas. Primary closure of surgical defects may be complicated by lack of approximating tissues, poor blood supply, and previous irradiation. Any of these events may lead the surgeon to create a fistula at a suitable location where future complications would be kept at a minimum. While the need for an elective tube feeding esophagostomy to aid difficult feeding problems is recognized, the stomas usually close spontaneously with no difficulty once the tube is removed. Large esophagostomas are usually the sequelae of radical surgical excision of exceedingly bulky tumors. Prosthetic closure of a pharyngostoma or esophagostoma provides great assistance to the patient. The patient with a pharyngostoma cannot talk, swallow saliva, or take nourishment by mouth. The patient with an esophagostoma also cannot swallow or take nourishment by mouth. Such a patient may have had a laryngectomy and will not recover the ability to speak. If these defects are closed with a prosthesis, the surgeon has greater control over the patient's diet, can evaluate the problem of aspiration, and can proceed with reconstructive surgical procedures in an orderly, planned manner. During this prolonged wait, the patient may lead a more normal life with nearly restored physiologic function of speech and deglutition. This is a great boost to his morale. Case I. A 77-year-old woman was admitted in December 1967 with a diagnosis of recurrent epidermoid carcinoma of the left buccal mucosa. She From the Dental Service, Department of Surgery ''Clinical Assistant Attending Dental Surgeon ''"'Attending Dental Surgeon and Chief of Dental Service
Surgical Clinics of North America- Vol. 49, No.2, April, 1969
285
286
GEORGE
P. ARGERAKIS, jAMES B. LEPLEY
Figure 1 (Case 1). The defect resulting from surgical excision of the left buccal mucosa.
Figure 2 (Case 1). Silicone rubber prosthesis in position.
PROSTHETIC MANAGEMENT OF PHARYNGOSTOMA AND ESOPHAGOSTOMA
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Figure 3 (Case 2). Pharyngostoma resulting from radical surgery for epidermoid carcinoma of the base of the tongue.
had had chemotherapy, irradiation, and surgical treatment for the disease, which had resulted in a hemimandibulectomy and the tongue had been sutured to the buccal mucosa. At this admission, wide excision of the left buccal mucosa resulted in a large defect lateral and posterior to the tongue (Fig. 1 ). An alginate impression was made of the defect and adjacent external tissues, and a room temperature vulcanizing silicone rubber prosthesis
Figure 4 (Case 2). thesis in place.
The pros-
288
GEORGE
P.
ARGERAKIS, ]AMES
B.
LEPLEY
Figure 5 (Case 2). A modified Barton bandage used to retain the prosthesis.
was constructed (Fig. 2). The prosthesis functioned well, and the patient was able to talk, eat, and swallow. Unfortunately, she developed unmanageable recurrence of disease and was placed in a rest home in terminal condition.
Case 2. A 53-year-old man was admitted in August 1967 with a diagnosis of epidermoid carcinoma of the base of the tongue. Right radical neck dissection, right subtotal mandibulectomy, resection of three fourths of the tongue, and pharyngectomy with construction of a pharyngostoma were done (Fig. 3). An alginate impression was made of the defect and surrounding tissue. A silicone rubber prosthesis was constructed to close the pharyngostoma (Fig. 4). With the prosthesis retained in place by use of a modified Barton bandage, the patient was able to talk and swallow saliva and a soft diet without aspirating (Fig. 5). Pressure of swallowing and constant moisture precluded the use of adhesive, a situation that existed in all three cases described. Evaluation eliminated the need for laryngectomy, and the patient retained his larynx. He was able to return to work while awaiting reconstructive surgical efforts. Case 3. A 60-year-old woman was admitted in September 1967 with the diagnosis of epidermoid carcinoma of the larynx and cervical esophagus.
PROSTHETIC MANAGEMENT OF PHARYNGOSTOMA AND ESOPHAGOSTOMA
289
Figure 6 (Case 3). An esophagostoma.
Her history included radiation therapy for thyroid cancer 20 years before. She underwent total laryngectomy and cervical esophagectomy. A subsequent surgical effort to close the defect by means of a pectoral tube graft failed (Fig. 6). An alginate impression of the defect and adjacent areas was made.
Figure 7 (Case 3). thesis in position.
The pros-
290
GEORGE
P.
ARGERAKIS, JAMES
B.
LEPLEY
A prosthesis was formed from silicone rubber, which successfully closed the defect and enabled the patient to eat a soft diet by mouth for the first time in 9 months (Fig. 7). The prosthesis was held in place by means of an elastic bandage. Summary Elective formation of esophagostomas and pharyngostomas is often an essential part of staged surgery for removal of bulky tumors of the head and neck. Three cases of interim prosthetic management of these defects have been described.
The surgical treatment of bulky tumors of the head and neck may result in the creation of elective pharyngeal and esophageal fistulas. Primary closure of surgical defects may be complicated by lack of approximating tissues, poor blood supply, and previous irradiation. Any of these events may lead the surgeon to create a fistula at a suitable location where future complications would be kept at a minimum. While the need for an elective tube feeding esophagostomy to aid difficult feeding problems is recognized, the stomas usually close spontaneously with no difficulty once the tube is removed. Large esophagostomas are usually the sequelae of radical surgical excision of exceedingly bulky tumors. Prosthetic closure of a pharyngostoma or esophagostoma provides great assistance to the patient. The patient with a pharyngostoma cannot talk, swallow saliva, or take nourishment by mouth. The patient with an esophagostoma also cannot swallow or take nourishment by mouth. Such a patient may have had a laryngectomy and will not recover the ability to speak. If these defects are closed with a prosthesis, the surgeon has greater control over the patient's diet, can evaluate the problem of aspiration, and can proceed with reconstructive surgical procedures in an orderly, planned manner. During this prolonged wait, the patient may lead a more normal life with nearly restored physiologic function of speech and deglutition. This is a great boost to his morale. Case I. A 77-year-old woman was admitted in December 1967 with a diagnosis of recurrent epidermoid carcinoma of the left buccal mucosa. She From the Dental Service, Department of Surgery ''Clinical Assistant Attending Dental Surgeon ''"'Attending Dental Surgeon and Chief of Dental Service
Surgical Clinics of North America- Vol. 49, No.2, April, 1969
285
286
GEORGE
P. ARGERAKIS, jAMES B. LEPLEY
Figure 1 (Case 1). The defect resulting from surgical excision of the left buccal mucosa.
Figure 2 (Case 1). Silicone rubber prosthesis in position.
PROSTHETIC MANAGEMENT OF PHARYNGOSTOMA AND ESOPHAGOSTOMA
287
Figure 3 (Case 2). Pharyngostoma resulting from radical surgery for epidermoid carcinoma of the base of the tongue.
had had chemotherapy, irradiation, and surgical treatment for the disease, which had resulted in a hemimandibulectomy and the tongue had been sutured to the buccal mucosa. At this admission, wide excision of the left buccal mucosa resulted in a large defect lateral and posterior to the tongue (Fig. 1 ). An alginate impression was made of the defect and adjacent external tissues, and a room temperature vulcanizing silicone rubber prosthesis
Figure 4 (Case 2). thesis in place.
The pros-
288
GEORGE
P.
ARGERAKIS, ]AMES
B.
LEPLEY
Figure 5 (Case 2). A modified Barton bandage used to retain the prosthesis.
was constructed (Fig. 2). The prosthesis functioned well, and the patient was able to talk, eat, and swallow. Unfortunately, she developed unmanageable recurrence of disease and was placed in a rest home in terminal condition.
Case 2. A 53-year-old man was admitted in August 1967 with a diagnosis of epidermoid carcinoma of the base of the tongue. Right radical neck dissection, right subtotal mandibulectomy, resection of three fourths of the tongue, and pharyngectomy with construction of a pharyngostoma were done (Fig. 3). An alginate impression was made of the defect and surrounding tissue. A silicone rubber prosthesis was constructed to close the pharyngostoma (Fig. 4). With the prosthesis retained in place by use of a modified Barton bandage, the patient was able to talk and swallow saliva and a soft diet without aspirating (Fig. 5). Pressure of swallowing and constant moisture precluded the use of adhesive, a situation that existed in all three cases described. Evaluation eliminated the need for laryngectomy, and the patient retained his larynx. He was able to return to work while awaiting reconstructive surgical efforts. Case 3. A 60-year-old woman was admitted in September 1967 with the diagnosis of epidermoid carcinoma of the larynx and cervical esophagus.
PROSTHETIC MANAGEMENT OF PHARYNGOSTOMA AND ESOPHAGOSTOMA
289
Figure 6 (Case 3). An esophagostoma.
Her history included radiation therapy for thyroid cancer 20 years before. She underwent total laryngectomy and cervical esophagectomy. A subsequent surgical effort to close the defect by means of a pectoral tube graft failed (Fig. 6). An alginate impression of the defect and adjacent areas was made.
Figure 7 (Case 3). thesis in position.
The pros-
290
GEORGE
P.
ARGERAKIS, JAMES
B.
LEPLEY
A prosthesis was formed from silicone rubber, which successfully closed the defect and enabled the patient to eat a soft diet by mouth for the first time in 9 months (Fig. 7). The prosthesis was held in place by means of an elastic bandage. Summary Elective formation of esophagostomas and pharyngostomas is often an essential part of staged surgery for removal of bulky tumors of the head and neck. Three cases of interim prosthetic management of these defects have been described.