Temporary reduction of salivation in laryngectomy patients with pharyngocutaneous fistulas by botulinum toxin A injection

The Management of Salivary Fistulas

Postoperative salivary fistula is an especially undesirable complication because it can be difficult to address, may delay postoperative radiation, and always delays enteral nutrition. Patients who are malnourished, have already undergone radiotherapy, or are hypothyroid are at higher risk of developing this problem. Conservative measures work in most patients, but a significant percentage of patients require intervention beyond pressure dressings and tincture of time. Medications, hyperbaric oxygen therapy, and surgical intervention may be required when fistulas do not heal in a timely manner. Decisions about the approach and timing of more aggressive interventions are part of the art of medicine since definitive scientific protocols are lacking.

Role of Exosomes in Pharyngucutaneous Fistula After Total Laryngectomy

Pharyngocutaneous fistula is the most common complication after total laryngectomy and is difficult to heal. Although conservative treatment and surgical repair are effective, they often take longer and additional trips to the operating room, which undoubtedly increases the financial burden on patients. Especially in combination with diseases such as diabetes and hypertension, which affect the efficacy of surgery. Adding growth factors into the repair material can promote fibroblast proliferation, angiogenesis, and accelerate wound healing. A substantial number of studies have shown that a type of nanoscale extracellular vesicle, called exosomes, facilitates organization repair by promoting blood vessel production, protein polysaccharides, and collagen deposition, thereby representing a new type of cellular therapy. At present, there is little research on the application of exosomes in pharyngocutaneous fistula regeneration after total laryngectomy. In this review, we summarize the biological characteristics of exosomes and their application in biomedical science, and highlight their application prospects in pharyngocutaneous fistula regeneration after total laryngectomy.

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.

Treatment Principle Based on the Clinical Staging of Pharyngocutaneous Fistula

Objective

Studies on factors affecting pharyngocutaneous fistulas (PCFs) and PCF repair methods have been widely reported. However, the healing phases of PCF are unclear, and their elucidation could guide clinical treatment.

Methods

Clinical stages of the PCF healing process were identified by a retrospective study of 39 patients with head and neck cancer who developed a PCF.

Results

Different conservative treatments were performed in turn according to three defined stages of the PCF healing process: stage I (drainage and debriding period), stage II (pressure dressing period), and stage III (healing period). A 7-day course of antibiotic therapy was only performed in stage I in 23 patients. The PCF was cured in 30 (76.9%) of 39 patients; the remaining 9 patients underwent subsequent surgical interventions for PCF healing.

Conclusion

The three stages of PCF healing have a certain reference value in guiding clinical treatments. Moreover, antibiotics should be used in stage I when signs of infection are present, but they should not be used in all three phases of conservative treatment.

Effectiveness of Recombinant Human Growth Hormone for Pharyngocutaneous Fistula Closure

Objectives

In laryngeal cancer, which comprises 25% of head and neck cancer, chemotherapy has come into prominence with the increase in organ-protective treatments. With such treatment, salvage surgery has increased following recurrence; the incidence of pharyngocutaneous fistula has also increased in both respiratory and digestive system surgery. We investigated the effects of recombinant human growth hormone on pharyngocutaneous fistula closure in Sprague-Dawley rats, based on an increase in amino acid uptake and protein synthesis for wound healing, an increase in mitogenesis, and enhancement of collagen formation by recombinant human growth hormone.

Methods

This study was experimental animal study. Forty Sprague-Dawley rats were separated into two groups, and pharyngoesophagotomy was performed. The pharyngoesophagotomy was sutured with vicryl in both groups. Rats in group 1 (control group) received no treatment, while those in group 2 were administered a subcutaneous injection of recombinant human growth hormone daily. On day 14, the pharynx, larynx, and upper oesophagus were excised and examined microscopically.

Results

Pharyngocutaneous fistula exhibited better closure macroscopically in the recombinant human growth hormone group. There was a significant difference in collagen formation and epithelisation in the recombinant human growth hormone group compared to the control group.

Conclusion

This study is believed to be the first in which the effect of recombinant human growth hormone on pharyngocutaneous fistula closure was evaluated, and the findings suggest the potential of use of growth hormone for treatment of pharyngocutaneous fistula.

Pharyngocutaneous fistulae after total laryngectomy: a systematic review

Nursing care to patients after total laryngectomy should be based on scientific knowledge. Evidence-based practice is a type of approach that stimulates the use of research results in clinical practice. This study presents a systematic review that aimed to identify the main treatments for pharyngocutaneous fistulae after total laryngectomy. Articles were selected from five databases: Pubmed, Cinahl, Biomednet Research Tools, Cochrane Library and Lilacs. The review sample consisted of 37 articles. After analyzing the articles included in the review, results showed that conservative treatment is commonly used for pharyngocutaneous fistulae, recommending intensive hygiene and wound treatment. The use of research results in clinical practice will grant greater consistency to nurses' actions in care for patients with pharyngocutaneous fistulae.

The effect of intranasal injection of botulinum toxin A on the symptoms of vasomotor rhinitis

PURPOSE

Vasomotor rhinitis (VMR) is a common disease that is unrelated to allergy, infection, structural abnormalities, and systemic diseases. Patients with VMR usually complain of nasal obstruction accompanied by profuse watery nasal discharge. The exact pathophysiologic mechanisms of VMR are not known. Some studies suggested that it results from an autonomic nervous system dysfunction. No effective long-term treatment modalities exist for the VMR.

MATERIALS AND METHODS

Thirty patients with VMR were randomly and equally divided into 2 groups. The mean age was 38.46 years (range, 18-59 years; 1 men, 14 women) for group 1 and 41.60 (range, 29-62 years; 4 men, 11 women) for group 2. Five patients with VMR were accepted as a control group. Fifteen patients were injected 10 U of botulinum toxin A (BTX-A) (group 1) and patients in group 2 were injected 20 U to inferior and middle turbinates. Control patients were injected with saline solution into the inferior and middle turbinates.

RESULTS

Total symptom scores generally decreased after the first week and increased after the eighth week. The symptoms of patients (nasal obstruction, sneezing, nasal discharge, and nasal itching) were scored from 1 to 5, with 1 as less severe and 5 as most severe. The statistical significance of the results was analyzed using Kruskal-Wallis and Mann-Whitney U test. When total symptom scores of group 1 (10 U BTX-A) were compared with the control group, there was a statistically significant difference regarding symptoms scores at all control weeks. There was also a statistically significant difference for total symptom scores between group 2 and control group, except for the first control week.

CONCLUSION

Intranasal injection of BTX-A is a highly effective, safe, and simple symptomatic treatment modality with a long-lasting effect for patients with VMR. Botulinum toxin A may be a good alternative especially for the treatment of resistant VMR cases.

Botulinum toxin injections for children with excessive drooling

The objective of this study was to evaluate the feasibility of ultrasonography-guided injections of botulinum toxin A into the parotid glands of children with severe drooling (sialorrhea). Excessive drooling is common in children with chronic neurologic disorders. Preliminary observations in adults suggest that injections of botulinum toxin A into the parotid glands can decrease drooling, but the optimal dose, sites of injection, and concomitant use of imaging during injections and its use for children have not been established. Ultrasonography was used to guide the injection of botulinum toxin (10-25 IU) into both parotid glands of nine children with excessive drooling. Subjective and objective measures of the severity of drooling were collected before and after botulinum toxin A injections. A booster injection was provided if the initial response was inadequate. Injections were well tolerated, and no adverse reactions were observed. Ultrasonography revealed that the parotid gland showed a variable depth, extent, and vascularization. Eight of nine patients needed a booster injection after 1 month. Objective measures of drooling severity were improved in seven of nine patients. However, subjective improvement was reported in only three of nine patients, and this improvement was functionally significant in only one patient. Although intraparotid injection of botulinum toxin A is safe and causes a reduction in saliva production in children, the doses used in this study did not result in functionally significant improvement. Higher doses of botulinum toxin A in the parotid glands or concomitant injections into the submandibular glands can increase the efficacy of these injections. Variability in size, depth, and vascular supply of the parotid gland suggests the importance of ultrasonography guidance for optimizing injections. These results underscore the need for further studies to establish the efficacy of this treatment in children.

Management of Frey's syndrome and hypersialorrhea with botulinum toxin

Botulinum toxin (BTX) is a safe and reliable drug for the treatment of Frey's syndrome and hypersialorrhea. Currently, the intradermal injection of BTX is the standard treatment of Frey's syndrome. A disappearance of Frey's syndrome for 1 to 1.5 year could almost be promised. Recently, BTX was introduced for the treatment of hypersialorrhea. Although some questions exist about the optimal dosage and the type of major salivary glands that should be treated, hypersialorrhea was reduced in almost all affected children and adults for up to 6 months by using ultrasound-guided intraglandular BTX injections.