Vacuum assisted closure in the management of wound healing disorders in the head and neck: a retrospective analysis of 23 cases

Novel approach of combined endoluminal and external vacuum therapy for wound healing disorders after salvage pharyngeal reconstruction

OBJECTIVE

Patients with recurrent head and neck carcinoma are considered for salvage surgery if resectability with clear margins is achievable. However, postoperative complications such as wound healing disorders and pharyngocutaneous fistulas remain significant challenges. While various reconstructive surgical techniques exist, supportive vacuum therapy-both external and endoluminal-has been explored as an alternative treatment modality.

TYPE OF STUDY

We present a case report of a 60-year-old male patient with recurrent laryngeal cancer who underwent salvage laryngopharyngectomy following multiple previous surgical procedures and definitive radiochemotherapy. Due to persistent pharyngocutaneous fistula formation despite multiple reconstructions using pectoralis major flaps, an anterolateral thigh flap, and a fasciocutaneous deltopectoral flap, a novel approach combining endopharyngeal and external vacuum therapy was implemented.

RESULTS

Over six weeks, with vacuum system changes performed twice weekly, the pharyngocutaneous fistula successfully closed, leading to complete wound healing.

CONCLUSION

This case demonstrates the potential effectiveness of a combined endopharyngeal and external vacuum therapy approach for treating persistent pharyngocutaneous fistulas when conventional surgical options are exhausted. Notably, the patient was able to resume oral food consumption following therapy, highlighting the functional benefits of this novel treatment strategy.

[Therapy of tumor recurrences or secondary carcinomas in pretreated area is not compatible with the primary therapy in non-previously treated tissue - an overview]

There are different initial situations in the treatment of local or locoregional recurrences, secondary carcinomas or residual squamous cell carcinomas of the head and neck region after primary therapy. The majority of patients with locoregional recurrences have had prior treatment consisting of surgery and/or postoperative radiotherapy or radiochemotherapy or primary radiotherapy or radiochemotherapy. In any case, it is a matter of new tumor growth in a previously treated area, which must be taken into account for the therapy decision. The biological backgrounds are diverse and are described in more detail and clinically classified in the present work.

Negative Pressure Wound Therapy in the Head and Neck: A Summary of Uses and Application Techniques

Negative pressure wound therapy (NPWT) has had an expanded role in the management of complex wounds including its increasing use for complex wounds in the head and neck region. Challenges for use in the head and neck region include variations in surface topography and the proximity of sensitive mouth, nose, ear, eye, and tracheal openings. Despite these challenges, NPWT has been used in the head and neck immediately following free flap surgery, to prepare wounds for skin grafting or local flaps, to treat orocutaneous and pharyngocutaneous fistulas, to treat necrotizing and deep neck space infections, to temporize and palliate, and to treat chronic wounds with exposed bone and hardware among others. This review demonstrates the proven track record of successful uses of NPWT in the aforementioned scenarios, provides suggestions to improve efficacy, as well as an algorithm for use in certain clinical situations.

Non-Surgical Strategies for Assisting Closure of Pharyngocutaneous Fistula after Total Laryngectomy: A Systematic Review of the Literature

Background: Pharyngocutaneous fistula (PCF) is a frequent complication after total laryngectomy, with an incidence of up to 65%. Many conservative or invasive approaches are available and the choice among them is usually made on a case-by-case basis. The aim of the present review is to critically summarize the available evidence of the effectiveness of the non-surgical management of PCF. Methods: A systematic review and a meta-analysis of the literature were conducted, according to the PRISMA guidelines. Studies investigating botulinum toxin therapy, scopolamine transdermal patch, hyperbaric oxygen therapy (HBOT), and negative pressure wound therapy (NPWT) were assessed. Complete fistula closure after the initiation of non-surgical treatment was the main outcome. Results: After the application of selection criteria, a total of seven articles and 27 patients were included in the present review. All the eligible studies were descriptive case series, while only one article used a standard group as a comparison. The mean age was 63.3 and 14 patients (51.9%) had previously received RT. The reported comorbidities were diabetes, ischemic heart disease, hypertension, dyslipidemia, COPD, and atrial fibrillation. With a mean healing time of 25.0 days, the overall success rate was 92.6%. Conclusions: Non-surgical treatment of PCF is only based on the experience of small series. Although success rates seem promising, the absence of properly designed comparative studies does not allow us, at present, to identify ideal candidates for these non-invasive management strategies for PCF.

Impact of Previous Irradiation on Wound Healing after Negative Pressure Wound Therapy in Head and Neck Cancer Patients-A Systematic Review

(1) Background: Negative pressure wound therapy (NPWT) has been effectively used for wound management in comparison to traditional dressings. The purpose of this study was to provide an evidence-based review of NPWT in head and neck cancer patients, as well as the impact of previous irradiation and other risk factors on wound healing. (2) Material and Methods: We conducted a comprehensive search in PubMed, Medline, Embase, Web of Science, and Cochrane Library databases for relevant literature. (3) Results: 15 studies fulfilled the inclusion criteria. The most common etiologies requiring NPWT were defects post tumor resection and flap reconstruction and oro/pharyngo-cutaneous fistulas. The neck was found to be the most common site of involvement (47.3%). The overall wound healing response rate was 87.5%. The median negative pressure recorded was 125 mm of Hg, with a median dressing change time of three days. Previous irradiation (p = 0.01; OR = 4.07) and diabetes mellitus (DM) (p = 0.001; OR = 5.62) were found to be significantly associated with delayed wound healing after NPWT. (4) Conclusion: NPWT treats complex wounds in head and neck cancer patients and should represent a significant armamentarium in head and neck cancers. Previous irradiation and DM have detrimental effects on wound healing after NPWT.

Systematic review of negative pressure wound therapy for head and neck wounds with fistulas: Outcomes and complications

Fistula formation in head and neck wounds is considered one of the most challenging complications that a head and neck reconstructive surgeon may encounter. The current mainstay of treatment is aggressive surgical debridement followed by vascularised soft tissue coverage. Negative pressure wound therapy (NPWT) has been successfully used for the closure of complicated wounds for decades. This study analysed the outcomes and complications of NPWT in the management of head and neck wounds with fistulas. A systematic search of studies published between January 1966 and September 2019 was conducted using the PubMed, MEDLINE, EMBASE, and SCOPUS databases and using the following key words: "negative pressure wound therapy," "head and neck," and "fistula." We included human studies with abstract and full text available. Analysed endpoints were rate of fistula closure, follow-up duration, and complications if present. Nine retrospective case series (Level IV evidence) that collectively included 122 head and neck wounds with orocutaneous fistulas, pharyngocutaneous fistulas, and salivary contamination were examined. The number of patients included in each study ranged from 5 to 64. The mode of NPWT varied among the included studies, with most adopting a continuous pressure of -125 mm Hg. Mean durations of NPWT ranged from 3.7 to 23 days, and the reported fistula closure rate ranged from 78% to 100%. To achieve complete wound healing, six studies used additional procedures after stopping NPWT, including conventional wound dressings and vascularised tissue transfer. Information regarding follow up was provided in only three of the nine studies, where patients were followed for 5, 10, and 18 months. No serious adverse events were reported. NPWT for head and neck wounds with fistulas may be considered a safe treatment method that yields beneficial outcomes with a low risk of complications. The current data originated mainly from studies with low levels of evidence characterised by heterogeneity. Therefore, definitive recommendations based on these data cannot be offered. Additional high-quality trials are warranted to corroborate the findings of this systematic review.

[Endoscopic negative pressure therapy of a post-laryngectomy pharyngocutaneous fistula-first report of a new therapeutic method. German version]

In the current first report, it is shown how a post-laryngectomy pharyngocutaneous fistula was successfully closed by endoscopic negative pressure therapy (ENPT; also termed endoscopic vacuum therapy, EVT). The duration of negative pressure treatment was 14 days. Up until now, ENPT has been used for treatment of transmural defects in the rectum and esophagus. The new endoscopic method can also be used in the ENT field for closure of pharyngocutaneous fistulas.

Necrotizing Fasciitis Following Herpes Zoster Ophthalmicus in an Immunocompromised Patient

Necrotizing fasciitis (NF) is a rare infection that spreads rapidly along the subcutaneous soft tissue planes. NF rarely involves the periorbital region due to the excellent blood supply of this region. We report a case of periorbital necrotising fasciitis following herpes zoster (HZ) in an immunocompromised 70-year-old patient with a dramatically rapid evolution into septic shock. In our patient, the surprisingly rapid spread of the bacterial superinfection led the periorbital cellulitis to turn into frank NF within 2 hours, with an overwhelming evolution. Despite the prompt start of a systemic antibiotic therapy and the immediate surgical intervention, the patient had a septic shock; she was treated in ITU for 31 days and then discharged to a medical ward and eventually died for a mix of complications of the medical treatment and comorbidities. This case is unique because any documented cases of periorbital NF triggered by HZ had never led to a septic shock and death. Ophthalmologists should be aware that even common skin lesions caused by shingles can determine a dramatic clinical picture, in presence of predisposing factors.

Esophagocoloplasty fistula successfully treated with vacuum-assisted closure

Esophageal fistulas in the cervical region are usually difficult to manage and carry a high morbidity. We report a case of an esophago-colonic fistula after colonic interposition, successfully managed with vacuum-assisted closure 'V.A.C. system', (Kinetic Concepts Inc., San Antonio, TX, USA). The patient initially presented with purulent fluid from the cervical wound 13 days after surgery. Esophagogram confirmed a leak. Since the patient had a history of anastomotic leaks, a surgical intervention was not the treatment of choice. In light of this, conservative treatment with V.A.C. system was initiated. She underwent full recovery.

Vacuum-assisted closure therapy after resection of giant basal cell carcinoma of the scalp

Management of complicated wounds is a challenge in head and neck reconstruction. Although the negative pressure wound therapy or wound vacuum-assisted closure has been widely used in complicated wounds and shows promising results, its application in the head and neck region after reconstruction for the head and neck cancer is rarely presented. A 77-year-old woman underwent a radical resection of an extensive basal cell carcinoma of the scalp and forehead involving the periosteum, where classic reconstruction was difficult, but successfully treated with negative pressure wound therapy. Negative pressure wound therapy is an efficacious tool in cases of complex and extensive defects, when we expect immediate reconstruction with poor results, as would be probable with this scalp lesion.

Facial nerve function preservation with vacuum-assisted closure

IMPORTANCE

Laboratory and clinical studies have shown that vacuum-assisted closure (VAC) therapy increases wound blood flow and granulation tissue formation and decreases accumulation of fluid and bacteria. Many publications outline the use of VAC dressings in the treatment of sternal, sacral, upper and lower extremity, perineal, and abdominal wounds, but few describe its use in the head and neck region. No report to date has addressed the use of VAC therapy in helping to preserve facial nerve integrity.

OBSERVATIONS

We present a case of a 64-year-old woman who underwent tissue debridement for necrotizing fasciitis of the left face, neck, and upper chest. She subsequently had exposed facial nerve that was covered with a VAC dressing and demonstrated complete granulation by postoperative day 7 with preservation of function.

CONCLUSIONS AND RELEVANCE

This case highlights the effectiveness of VAC in eliminating infectious material and promoting granulation tissue formation. This is the first time that VAC therapy has been shown to maintain neural function when placed directly on functioning cranial nerves.