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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 42-45

Closure of irradiated tracheocutaneous fistula with pectoralis major muscle flap and split skin graft


Department of Plastic Surgery, M S Ramaiah Medical College Hospital, Bengaluru, Karnataka, India

Date of Submission17-Apr-2021
Date of Acceptance27-May-2021
Date of Web Publication03-Jul-2021

Correspondence Address:
Dr. George Taliat
Department of Plastic Surgery, M S Ramaiah Medical College Hospital, New BEL Road, M S Ramaiah Nagar, MSRIT Post, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_8_21

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  Abstract 


Tracheocutaneous fistula in an irradiated neck is often difficult to manage. Simple closure often leads to dehiscence and recurrence. We present a patient with supraglottic carcinoma, postradiotherapy, who presented with a persistent trachea-cutaneous fistula. We excised the fistula along with surrounding indurated tissue and covered the defect adequately with skin graft for tracheal lining and pectoralis muscle flap as a muscle cover. Fistula was closed and wound healed well. There was no recurrence of fistula as evidenced with indirect laryngoscopy. Pectoralis major flap is a well-vascularized flap that can be used to cover defects in anterior lower neck. Simple skin graft with a cover of muscle flap was enough to give adequate tracheal lining.

Keywords: Pectoralis major muscle flap, pedicled flap, postradiation, split skin graft, tracheo-cutaneous fistula


How to cite this article:
Taliat G, Gogi A, Mohan K. Closure of irradiated tracheocutaneous fistula with pectoralis major muscle flap and split skin graft. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2021;5:42-5

How to cite this URL:
Taliat G, Gogi A, Mohan K. Closure of irradiated tracheocutaneous fistula with pectoralis major muscle flap and split skin graft. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Dec 4];5:42-5. Available from: https://www.aiaohns.in/text.asp?2021/5/1/42/320578




  Introduction Top


Prolonged dependency on tracheostomy tube may increase the risk of developing a tracheocutaneous fistula (TCF) as the stoma may get epithelized. Radiation causes delay in wound healing, contractures, endarteritis, fibrosis, and exposure of vital structures.[1] Various methods of closure of TCF have been described in previous literature.[2] In our case report, we present a patient with supraglottic carcinoma postradiation and a TCF following failure of closure of decannulated tracheostomy which was closed with a pectoralis major muscle flap and lined with split skin graft.


  Case Report Top


A 53-year-old male patient who is a known case of supraglottic carcinoma presented with an open wound over the anterior neck for 2 months with discharge from the wound on coughing. He had undergone a tracheostomy and direct laryngoscopy and biopsy 6 months ago. Biopsy confirmed squamous cell carcinoma. The patient was retained on tracheostomy while being subjected to primary radiotherapy and chemotherapy. The Patient was decannulated from tracheostomy after 3 months. However, the patient reported persistent wound over the anterior neck. Primary closure was attempted with simple skin sutures which failed. The patient was examined and found to have a fistula over anterior neck measuring 1 cm × 2 cm located 2 cm superior to suprasternal notch. There was a significant induration and fibrosis of the surrounding tissues extending around 7 cm × 6 cm. Serous discharge was seen with coughing. There was no stridor, difficulty in breathing or talking [Figure 1].
Figure 1: Tracheocutaneous fistula at presentation

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Contrast computed tomography neck revealed a TCF with surrounding inflammation and scarring. Upper gastrointestinal endoscopy revealed no extension of fistula to esophagus.

The patient was intubated intraorally with assistance of video laryngoscopy.

The surrounding area of fibrosis around was excised, resulting in a defect of 8 cm × 7 cm. The fistulous tract was debrided and epithelized tissue removed. The debrided tissue was sent for biopsy which later revealed “nonspecific inflammatory changes and scarring” [Figure 2].
Figure 2: Defect after debridement of surrounding indurated, scarred margins

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Pectoralis major muscle flap marked and raised as described in literature. The initial incision was extended proximally to reach the defect [Figure 3].
Figure 3: Pectoralis major muscle flap harvested

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A split skin graft was harvested from the thigh of size 10 cm × 12 cm. A small piece measuring 1.5 cm × 2.5 cm was cut from the graft, sutured to the fistula opening with the epithelial surface facing the fistulous opening [Figure 4].
Figure 4: Split skin graft placed over the fistulous opening as lining

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The muscle flap was resurfaced over the graft like a flap on-lay over the skin graft [Figure 5].
Figure 5: Muscle flap draped over the skin graft

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Flap inset was complete, and the donor site was closed primarily. The external surface of flap was then covered with the rest of the skin graft [Figure 6].
Figure 6: Immediate postoperative

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Patient extubated without any complications after 24 h of surgery once edema settled. Regular dressings were done and wound healed well by 14 days [Figure 7].
Figure 7: Fourteen days postoperative

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Indirect laryngoscopy on 14th postoperative day showed well-healed wound at the fistula site. There were no signs of stenosis on video laryngoscopy and correlated clinically as the patient did not have stridor or blood tinged sputum [[Figure 8] and Video 1 [Additional file 1]]. At 2-month follow-up, bulk of the flap was reduced, and the flap was well settled [Figure 9].
Figure 8: Video laryngoscopy picture

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Figure 9: Two-month follow-up

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  Discussion Top


Persistent cannulations of tracheostomy often lead to persistent TCF. Extended duration of cannulation allows the formation of an epithelized scar.[3] There are many surgical procedures to close the TCF.[2] It is imperative to approach each case individually and decide the best approach. More commonly done procedures are simple closure and hinged turn over flap. Auricular/rib cartilage can be harvested or a vascularized free tissue transfer has also been documented to effectively close a fistula.

Radiation has several adverse effects on wound healing. Matrix metalloproteinases-1 is decreased, and fibroblasts generate a disorganized deposition of collagen fibers.[4] Clinical sequelae to radiotherapy are skin atrophy, soft-tissue fibrosis, desquamation, ulceration, fistula formation, and vessel rupture.[5]

In our case, simple closure with suturing was attempted however was unsuccessful. The surrounding irradiated indurated tissue, with inflamed and infected tissue, ruled out a hinged turn over flap. We chose not to include a free cartilage graft as a free cartilage graft and skin graft both being avascular would not take up when overlapped on each other. Furthermore, the defect being only 1 cm vertically, cartilage would not be required. Due to the presence of irradiated, infected, and indurated tissues, a distant well-vascularized muscle flap was chosen. Since the fistula defect was 1 cm × 2 cm, muscle flap was chosen rather than a musculocutaneous one. A musculocutaneous flap would need some de-epithelialization as well as would add to the bulk at the neck.

Pectoralis major based flaps have been workhorse flaps for head-and-neck reconstruction.[6] A reliable vascularity from the pectoral branch of thoracoacromial artery ensures the flap survival. Muscle flaps have demonstrated rapid, early augmentation of blood flow, bacterial elimination, and rapid collagen deposition.[7]

The present flap though bulky, is denervated, hence with time will reduce in size gradually. The successful take of the skin graft for the lining for the inner surface of the trachea prevented the in growth of granulation tissue, which would otherwise lead to decrease in the lumen of the trachea.

In a similar study by Murono et al., a deltopectoral flap was prefabricated with a skin graft on the inner lining of the flap. The flap was delayed and later used to close a trachea-esophageal fistula in second stage.[8] In our study, the skin graft was placed simultaneously with flap in a single staged procedure. The presence of well-vascularized bed helped in good take of the skin graft.

In another study by Royer et al., the authors used a radial forearm-free flap with conchal cartilage and buccal mucosa to close a TCF done in three stages.[9] Although this gave a superior quality of reconstruction aesthetically, it was done in three stages over 3 and half months. In our study, we reconstructed in single stage, and the patient was back to normal life by 1 week.


  Conclusion Top


TCF closure with a skin graft lining and a pectoralis muscle flap is a good and simple option for single-staged reconstruction in an irradiated and infected region.

Acknowledgment

Dr. Mysore Venkatesh – Head of Department of Plastic Surgery, M S Ramaiah Medical College hospital, Bangalore.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hurwitz DJ. Complicated neck contracture treated with a pectoralis major myocutaneous flap. Plast Reconstr Surg 1979;63:843-7.  Back to cited text no. 1
    
2.
Kao CN, Liu YW, Chang PC, Chou SH, Lee SS, Kuo YR, et al. Decision Algorithm and Surgical strategies for managing tracheocutaneous fistula. J Thorac Dis 2020;12:457-65.  Back to cited text no. 2
    
3.
Eaton DA, Brown OE, Parry D. Simple technique for tracheocutaneous fistula closure in the pediatric population. Ann Otol Rhinol Laryngol 2003;112:17-9.  Back to cited text no. 3
    
4.
Gu Q, Wang D, Gao Y, Zhou J, Peng R, Cui Y, et al. Expression of MMP1 in surgical and radiation-impaired wound healing and its effects on the healing process. J Environ Pathol Toxicol Oncol 2002;21:71-8.  Back to cited text no. 4
    
5.
Marks JE, Freeman RB, Lee F, Ogura JH. Pharyngeal wall cancer: An analysis of treatment results complications and patterns of failure. Int J Radiat Oncol Biol Phys 1978;4:587-93.  Back to cited text no. 5
    
6.
Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73-81.  Back to cited text no. 6
    
7.
Gosain A, Chang N, Mathes S, Hunt TK, Vasconez L. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1990;86:1152-62.  Back to cited text no. 7
    
8.
Murono S, Ishikawa E, Nakanishi Y, Endo K, Kondo S, Wakisaka N, et al. Closure of tracheoesophageal fistula with prefabricated deltopectoral flap. Asian J Surg 2016;39:243-6.  Back to cited text no. 8
    
9.
Royer AK, Royer MC, Ting JY, Weisberger EC, Moore MG. The use of a prefabricated radial forearm free flap for closure of a large tracheocutaneous fistula: A case report and review of the literature. J Med Case Rep 2015;9:251.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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