Reconstruction of a hypopharyngeal defect with a palatal mucoperiosteal free graft

Case Reports

Reconstruction of a Hypopharyngeal Defect With a Palatal Mucoperiosteal Free Graft MARC M. KERNER, MD, PAVEL DULGUEROV, MD, AKIRA ISHIYAMA, BERNARD L. MARKOWITZ, MD, AND GERALD S. BERKE, MD

(Editorial Comment: The authors describe the placement of a free mucoperiosteal graft into the hypopharynx using a transhyoid approach to relieve hypopharyngeal stenosis.)

Stenosis of the pharynx is a complex problem that presents the surgeon with serious challenges. The numerous reconstructive methods described attest to the considerable failure rate that occurs in attempting to entirely eradicate the stenotic lesion. Not infrequently, the dysphagia experienced by the patient after reconstruction is complicated by varying degrees of aspiration, voice alterations, and pharyngocutaneous fistulae. ETIOLOGY OF PHARYNGEAL STENOSIS Cicatricial pharyngeal stenosis should be distinguished from other causes of pharyngeal obstruction, such as tumors or hypertrophy of Waldeyer’s-ring lymphoid tissue. Any anatomic structure that contains a lumen is at risk for stenosis, especially when it is injured circumferentially. Pharyngeal stenosis tends to occur when the mucosa of the pharyngeal wall is denuded along either the entire or a substantial portion of the pharyngeal circumference. The causes of pharyngoesophageal stenosis are best classified according to the

From the Divisions of Head and Neck Surgery and Plastic Surgery, Department of Surgery, UCLA School of Medicine, Los Angeles, CA. Presented at the annual meeting of the Paul H. Ward Society, Manhattan Beach, CA, May 16, 1992. Address reprint requests to Gerald S. Berke, MD, Division of Head and Neck Surgery, UCLA School of Medicine, 10833 LeConte Ave. Los Angeles, CA 90024. Copyright 0 1994 by W.B. Saunders Company 0196-0709/94/l 505-0008$5.00/O 370

American

Journal of Otolaryngology,

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cause of the injury, the most common being caustic ingestion, followed by iatrogenic injury, infections, penetrating trauma to the neck, and various miscellaneous conditions (Table 1). Caustic injuries of the upper digestive tract result from the ingestion of corrosive compounds. The extent of injury depends on the type, concentration, amount, and the time of contact of the corrosive agent.’ The chemical injury causes mucosal ulcerations and frequently involves multiple long segments of mucosa. The healing proceeds through wellcharacterized stages of inflammation, granulation, contraction, and scarification. The contracted circumferential scar typically results in constriction of the lumen. Most often, the ulceration and stricture are located at the midesophagus, but hypopharyngeal stenosis at the level of the esophageal inlet can occur.2 Iatrogenic pharyngeal stenosis can complicate any surgical procedure that involves the pharynx. It most frequently occurs after a wide-field laryngectomy, especially when performed in association with a partial or total pharyngectomy. The incidence of postlaryngectomy stenosis ranges from 20% to 70°&3*4 Other surgical procedures reported to be associated with pharyngeal stenosis include adenotonsillectomy,5*6 uvulopalatopharyngoplasty,7 postlaryngectomy tracheoesophageal fistulas from the placement of voice prostheses,* and horizontal supraglottic laryngectomies.g Infections were the predominant cause of pharyngeal stenosis in the preantibiotic era. Most stenoses of infectious origin resulted from tertiary syphilitic gummas,5*10p11whereas other infectious causes resulting in contrac-

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TABLE 1.

OF HYPOPHARYNGEAL

DEFECT

Causes of Pharyngeal Stenosis

latrogenic Pharyngectomy, partial or total Total laryngectomy Adenoidectomy and tonsillectomy Uvulopalatopharyngoplasty Caustic Injury Infectious Syphilis Rhinoscleroma Diphtheria Tuberculosis Scarlet fever Miscellaneous Behqet’s disease Plummer-Vinson syndrome Lupus

tion and stenosis have included diphthetuberculosis,*2,‘3 ria,5v’2 rhinoscleroma,5*13 and scarlet fever.13 Several rare disorders have been associated with pharyngeal stenosis, including BehCet’s syndrome,” and disease,14 Plummer-Vinson systemic lupus. 5 CASE REPORT A 28-year-old Asian woman sustained a slash injury to the neck. She was initially stabilized at a community hospital and then transferred to UCLA Medical Center for definitive care. A tracheotomy was performed to secure the airway. Neck exploration showed injuries to the left internal jugular

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vein, glossopharyngeal, and hypoglossal nerves. The vagus nerve was intact; however, the left vocal cord was paretic. Total transection of the upper aerodigestive tract was present at the level of the epiglottis. Initially, the jugular vein was ligated and the tracheal and pharyngeal injuries were repaired primarily in two layers. Postoperatively, the patient had residual speech difficulties secondary to vocal cord paresis and swallowing difficulties most likely secondary to multiple cranial nerve deficits. Throughout the following year, she developed progressive dysphagia for solids and liquids. A complete workup showed a hypopharyngeal stenosis occluding the majority of the pharyngeal lumen at the level of the supraglottis. The lower half of the epiglottis, pharyngoepiglottic folds, and aryepiglottic folds were encased in a dense circumferential scar that extended to the posterior pharyngeal wall (Fig I). Only a &mm central lumen, located to the right of the midline and approximately 1 cm in front of the posterior pharyngeal wall, was present. Throughout the subsequent year, three CO, laser excisions and bougie dilatations were performed in the operating room but were followed by a recurrence of the hypopharyngeal stenosis. A gastrostomy tube was placed percutaneously in the stomach because of inadequate oral intake. One year after the initial injury, and after multiple attempted dilatations failed to resolve the dysphagia, the cicatricial stenosis was resected through an open transhyoid approach. To adequately resect the stenotic scar, a segmental pharyngectomy and subtotal epiglottectomy was required. After this resection, a circumferential mucosal defect of approximately 3 x 3 cm was present across the superior-to-midhypopharynx (Fig 2). To

Fig 1. Preoperative videolaryngoscopic view of the densa rupraglottic scar in the hypopharynx. The epiglottis (arrowheads) is inferior and the posterior pharyngeal wall is superior. A circumferential scar band (white arrow) extends from the epiglottis toward the posterior pheryngeal well, Ieaving a small centml opening approximately 1 cm in diameter to the right of the midline.

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Fig 2. Intraoparativa photograph of mucopariostaal free graft (arrows) sutured into the posterior pharyngaal wall. The posterior pharynx was approached via a transhyoid incision.

reconstruct this mucosal defect, a 3.5 x J-cm palatal mucoperiosteal free graft was harvested and placed in the posterior pharyngeal defect. Primary mucosal closure was performed anteriorly. The patient’s dysphagia resolved considerably during the ensuing 6 months. Numerous indirect laryngoscopies were performed postoperatively to document healing of the graft in the posterior pharyngeal wall. There was no evidence of mucosal slough, and throughout the following 18 months, there was no return of scar formation. On follow-up examination at 18 months, the hypopharynx remained mucosalized without evidence of recurrent necrosis. Six months after sur-

Fig 3. Eighteen-month postoperative vidaolaryngoscopic view of the hypopharyngaal luman showing no racurranca of the scar band and widely patent lumen (arrowheads).

gery, the patient had complete resolution of her symptoms (Fig 3).

Technique of Palatal Mucoperiosteal Graft Harvest The palatal mucosa graft is harvested by sharply incising a central strip of palatal mucosa down to the bony hard palate. The graft shape and size are determined by the defect and size of the palate. Grafts measuring up to 4 x 4 cm are easily procured. Subperiosteal dissection proceeds from anterior to posterior with graft division just before the velum. A cuff of alveolar palatal mucosa, at least 5

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formation, presence of hair-bearing tissue in the pharyngeal lumen, and a high incidence of stricture when the entire lumen needs to be and replaced.17p18 The need for multiple highly specialized surgical procedures are further disadvantages of free flaps and visceral transpositions. Local rotation flaps have been described for the repair of small defects of the hypopharThese flaps ynx 1g-23 and nasopharynx.*3,24 provide excellent tissue coverage with a wellvascularized donor tissue; however, the incidence of restenosis is high, and patients are frequently left with speech and swallowing deficits. Split-thickness skin grafts have been used extensively to line small defects in the oral cavity after tumor excisions. These grafts do have some inherent disadvantages, including unpredictable contracture, malodorous discharge, occasional hair growth from the graft site, and pain and potential wound complications at the donor site.1”‘25 Restenosis does occur with skin grafts; however, they remain the workhorse material for lining defects in the oral and hypopharyngeal region.26 We have found palatal mucosa to be an excellent source of donor material for repairing small-to-moderate size (4 x 4 cm) defects of the oral cavity and pharynx. Historically, its use has been limited to vestibuloplasty,25 and alveolar ridge reconstruction. However, palatal mucoperiosteal grafts have properties that make it a desirable graft material in the oral cavity. These include its similarity to the surrounding tissue, its inherent strength, and the fact that it shows little primary contracture when harvested and placed in the recipient site. In one study,25 free mucosal palatal grafts were found to contract approximately 20% in

mm, is left in place to allow for mucosal regeneration. The greater palatine neurovascular bundle is spared. The graft is thinned by hand, meshed, and sutured into the defect with resorbable sutures. No stenting or bolstering is used. The patient is fed through a nasogastric or gastrostomy tube to maintain adequate nutrition. The bony palate develops a thin mucosal layer within 2 weeks.

DISCUSSION Surgical treatment of pharyngeal stenosis typically requires the resection of the stenotic scar and reconstruction of the resulting defect. The mucosal defect can vary in size but is usually small (~3 cm), and more importantly, tends to involve the entire circumference of the pharynx. As in other visceras, circumferential defects lead to a restenosis and provide difficult reconstructive situations. Reconstruction methods of pharyngeal, esophageal, and hypopharyngeal defects can be divided into vascularized and nonvascularized transferred tissue [Table 2). Vascularized flaps include local mucosal flaps, regional pedicled flaps, visceral transpositions, and free flaps.16 Nonvascularized autotransplants consist of skin grafts of various thickness. Each of these methods have inherent risks, benefits, and distinct indications. Free flaps and visceral transposition techniques are used when large segments of the pharynx and the esophagus are removed, mostly after cancer resections. For defects of moderate size (4 to 6 cm), regional pedicled flaps, such as the deltopectoral skin flap or pectoralis major myocutaneous flap, provide adequate tissue coverage with excellent blood supply. The disadvantages of these flaps include donor site cutaneous scars and morbidity, their inherent bulk, potential for fistula TABLE2. Reconstructive

Free Tissue Transfers Radial forearm free flap Rectus abdominus myocutaneous free flap Jejunal free flap

Methods

for Pharyngeal

Regional Pedical Flaps Deltopectoral

Stenosis Visceral Transposition Techniques

flap

Pectoralis major myocutaneous flap

Gastric

pull-up

Colonic interposition

Local Flaps Base of tongue Local mucosal flaps

Skin Grafts flap

Split-thickness grafts Full-thickness grafts

skin skin

Palatal mucoperiosteal grafts

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the first 6 months, and after that time period, contracture was virtually negligible. Although our clinical impression of the patient presented in this report is that there was complete graft survival and minimal primary and secondary contraction, we have not substantiated this histologically because we did not perform another biopsy in this area during the patient’s recovery. However, we do believe that palatal mucosa grafts have similar properties to full-thickness skin grafts in regard to revascularization and maintenance of cytoarchitecture, as other investigators have suggested.z6 Furthermore, our observation of this graft in this patient, and in subsequent patients in which it has been used, leads us to believe that palatal mucoperiosteal grafts tend to undergo less primary contracture when compared with full- or split-thickness skin grafts, particularly when lining the alveolar ridges or buccal sulci. One advantage of palatal mucosa free grafts over split-thickness skin grafts is minimal donor site morbidity. The bony palatal defect is left uncovered and heals within 3 to 4 weeks, The regenerated mucosa has a normal pink color but is slightly thinner than the normal palatal mucosa. Pain is minimal, and there are no external scars. However, despite these advantages, we do not recommend its use in radiated fields or in large defects. In summary, a palatal mucosal graft was successfully used to address a recalcitrant hypopharyngeal cicatricial stenosis. We are encouraged by this result and have begun to use this free palatal mucosa for repair of small-tomoderate-size oropharyngeal defects that require a graft. Further clinical and basic histochemical studies are now underway, and will hopefully clearly define the indications and biochemical characteristics of this donor tissue. REFERENCES 1. Krey H: On the treatment of corrosive lesions in the esophagus: An experimental studv. Acta Otolarvnnol _ _ supp1 (&o&h) lO:iOZ-107,1952 2. Alford BR. Harris HH: Chemical burns of the mouth. pharynx, and esophagus. Ann Otol Rhino1 Laryngol 68: 122-128, 1959

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3. Kaplan JN, Dobie RA, Cummings CW: The incidence of hypopharyngeal stenosis after surgery for laryngeal cancer. Otolaryngol Head Neck Surg 89:956-959, 1981 4. McConnel FMS, Duck SW, Hester TR: Hypopharyngeal stenosis. Laryngoscope 94:1162-1165, 1984 5. Fiji FA: Cicatricial stenosis of the nasopharynx: Correction by means of a skin graft. Plast Reconstr Surg 2:97104,1947 6. Cotton RT: Nasopharyngeal stenosis. Arch Otolaryngo1 Head Neck Surg 111:146-148, 1985 7. Ghorayeb BY: Cicatricial velopharyngeal stenosis. Arch Otolarvngol Head Neck Sum 114:192-194. 1988 8. Andre& iC, Mickel RA, He&on DG: Complications following tracheoesophageal puncture for voice rehabilitation. Laryngoscope 97:562-567, 1987 9. Ward PH: Personal communication, June 1991 10. Lehmann WB, Pope TH, Hudson WR: Nasopharyngeal stenosis. Laryngoscope 78:371-385, 1968 11. Stevenson EW: Cicatricial stenosis of the nasopharynx. A comprehensive review. Laryngoscope 69:20352067,1969 12. Wright J, Smith H: Diseases of the Nose and Throat. Philadelphia, PA, Lea & Febiger, 1914 13. Kazanjian VH, Holmes EM: Stenosis of the nasopharynx and its correction. Arch Otolaryngol Head Neck Surg 44:261-273, 1946 14. Brookes G: Pharyngeal stenosis in Behcet’s syndrome. Arch Otolaryngol Head Neck Surg 169:759-752, 1983 15. Kruisinga RJH, Huizinga E: The too small mouth in patients with “Plummer-Vinson” syndrome. Ann Otol Rhino1 Laryngol 68:115-121, 1959 16. Fabian RL: Reconstruction of the laryngopharynx and cervical esophagus. Laryngoscope 94:1334-1359, 1984 17. Schuller DE: Reconstructive options for pharyngeal and/or cervical esophageal defects. Arch Otolarvngol _ Head Neck Surg 111_19%197,1985 18. Schechter GL, Baker JW, Gilbert DA: Functional evaluation of pharyngoesophageal reconstructive techniques. Arch Otolaryngol Head Neck Surg ll3:46-44, 1987 19. Asherson N: Pharyngectomy for post-cricoid carcinoma: One stage operation with reconstruction of the pharynx using the larynx as an autograft. J Laryngol Otol 68:550-559, 1954 29. Som ML: Laryngoesophagectomy: Primary closure with laryngotracheal autograft. Arch Otolaryngol Head Neck Surg 63:474-480, 1956 21. Sisson GA: Reconstruction of the hypopharynx and cervical esophagus after radical excisional surgery. Laryngoscope 66:1268-1290, 1956 22. Haranandani LH: Tongue as pedicle flap for reconstruction of pharnyx in one stage laryngopharyngectomy. Rev Laryngol Otol Rhino1 88:111-113, 1967 23. Pierce MK: Cervical esophageal strictures--A surgical approach. Laryngoscope 90:95-97, 1980 24. Mackenty JE: Three new plastic operations on the nose and throat. Med Ret 80:1071-1075, 1911 25. Hall HD, O’Steen AN: Free grafts of palatal mucosa in mandibular vestibuloolastv. _, I Oral Sure 28:565-574, 1970

26. Schramm VL, Johnson JT, Myers EN: Skin grafts and flaps in oral cavity reconstruction. Arch Otolaryngol Head Neck Surg 109:175-177, 1983