A Comparative Study of Pharyngeal Repair in Two Layers Versus Three Layers, Following Total Laryngectomy in Carcinoma of Larynx

Abstract

Larynx is the second most common site for cancer in the upper aerodigestive tract. One of the dreaded complications following total laryngectomy has been pharyngo cutaneous fistula (PCF). PCF merits special attention due to its significant negative impact on the recovery process. Total laryngectomy profoundly alters speech. Effective voice restoration is essential for the rehabilitation of these patients. Inadequate consensus exists as to the best technique of pharyngeal repair to decrease incidence of PCF and ensure good quality voice following total laryngectomy. 21 patients were included in the study for total laryngectomy with trachea oesophageal voice prosthesis placement. Patients were randomised into 2 groups. Group A had their pharynx repaired in two layers and Group B had it done in three layers. Post operatively the patients were followed up for a period of 12 months to look for incidence of PCF. Subjective and objective evaluation of voice was done. 9.52% of patients developed PCF. All of the cases of PCF were in the group repaired in three layers. In cases with repair by two layers the mean Voice Handicap Index 10 (VHI 10) score was 19.27 and those with three layers pharyngeal repair was 23.20. Average maximum phonation time amongst the study population was 13.09. In three layers and two layers pharyngeal repair the average maximum phonation time was 12.56 and 13.58 respectively. Surgical repair of pharynx in two layers excluding the third layer of pharyngeal musculature reduces the chance of PCF. Two layers pharyngeal repair supplemented by cricopharyngeal myotomy led to significantly better voice outcome.

Pharyngeal Reconstruction Methods to Reduce the Risk of Pharyngocutaneous Fistula After Primary Total Laryngectomy: A Scoping Review

“…Shukla et al [ 44 ] compared a single vs. a double-layer suture using the T-shape technique and found a statistically significant difference favoring two-layer suture (PCF rate 12.5% vs. 33.3%). Wang et al [ 45 ] and Saha et al [ 46 ] compared the two-layer suture with a modified technique using the remnant of constrictor muscles as suture reinforcement and found a statistically significant difference favoring the two-layer technique without muscle reinforcement (PCF rate 3% vs. 10% and 0% vs. 27%, respectively).…”

Total Laryngectomy: A Review of Surgical Techniques

“…Thus, the combination of neurectomy and myotomy may be superior to either technique alone in cricopharyngeal spasm prevention [75]. A study comparing combined myotomy-neurectomy to pharyngeal myotomy alone found a lower incidence of cricopharyngeal spasm in the combined myotomy-neurectomy group, but that study did not show a significant difference in speech outcomes between these two groups [75,80].…”

“…Non-closure, half-muscle closure, horizontal closure, and crossover zigzag neopharyngoplasty were superior to the traditional three-layer closure. One study also suggests that these modified methods may be performed in combination with pharyngoesophageal myotomy to minimize the intra-luminal pressure of the neopharynx which may lead to an improved voice outcome [80]. Currently, these additional or modified techniques have shown more success in voice restoration than the traditional three-layer closure, and are associated with lower rates of voice restoration failure (between 0% and 10%) [77,[79][80][81][82][83][84].…”

“…One study also suggests that these modified methods may be performed in combination with pharyngoesophageal myotomy to minimize the intra-luminal pressure of the neopharynx which may lead to an improved voice outcome [80]. Currently, these additional or modified techniques have shown more success in voice restoration than the traditional three-layer closure, and are associated with lower rates of voice restoration failure (between 0% and 10%) [77,[79][80][81][82][83][84]. Based on the literature, pharyngoesophageal myotomy is the most commonly used technique [74][75][76][77]79,80,83,84].…”

“…Currently, these additional or modified techniques have shown more success in voice restoration than the traditional three-layer closure, and are associated with lower rates of voice restoration failure (between 0% and 10%) [77,[79][80][81][82][83][84]. Based on the literature, pharyngoesophageal myotomy is the most commonly used technique [74][75][76][77]79,80,83,84]. However, there is still no consensus on the superiority of any of these additional or modified techniques because of the lack of standard assessments of voice quality and wellcontrolled studies.…”