Total laryngectomy involves dissection of strap muscles and thyroid, stoma formation, excision of the larynx, epiglottis, and hyoid bone, and closure of the remaining pharyngeal mucosa to create the neopharynx. “T shaped closure” and “vertical closure” techniques for neopharynx closure are practiced locally based on preference of the surgeon.
T shaped closure involves creating a T shaped suture line with a midline trifurcation. Vertical closure involves a single midline longitudinal suture line only.
Fig. 1: "T-shaped" closure
Lack of mucosal support after hyoidectomy may lead to prolapse of the mucosa inferiorly, forming a pseudoepiglottis. A mucosal pouch results anterior to the pseudoepiglottis, known as a pseudodiverticulum. This is more common after the vertical closure technique. Accumulation of food in the diverticulum can cause dysphagia in a subgroup of patients. [2]
Fig. 2: Pseudodiverticulum without anastomotic leak.
Contrast lying in a pouch anterior to the pseudoepiglottis.
A pseudodiverticulum can be further complicated by anastomotic leak and pharyngocutaneous fistula.
Fig. 3: Pseudodiverticulum with anastomotic leak.
Contrast is passing into the subcutaneous tissues inferior to a pseudodiverticulum.
Anastomotic leak is the most common complication following pharyngeal closure, and characteristically occurs along the anterior closure line of the neopharynx, particularly at the trifurcation point of a T-shaped closure.[3]
Fig. 4: Leak along the anterior closure line.
Fig. 5: AP view of leak along anterior closure line with pooling of contrast.
When the leak communicates with the skin, a pharyngocutaneous fistula is formed. This must be promptly recognised as it causes increased morbidity, delays starting adjuvant therapy, prolongs hospitalisation, increases treatment costs and reduces the quality of life.[4]
Fig. 6: Pharyngocutaneous fistula. Contrast leaks from the anterior neopharynx, passes through the subcutaneous tissues and leaks through the skin wound. Contrast can be seen running down the anterior chest wall.
Fig. 7: Pharyngocutaneous fistula lateral view.