Review
Copyright ©The Author(s) 2015.
World J Otorhinolaryngol. Nov 28, 2015; 5(4): 93-104
Published online Nov 28, 2015. doi: 10.5319/wjo.v5.i4.93
Table 1 We suggested the above preoperative considerations to reduce the risk of fistula formation: Level of evidence and references are included where applicable
PreoperativeconsiderationsLevel of evidenceRef.
Extend of surgery
Concurrent neck dissectionIII[29]
Sentinel lymph node biopsyII[75]
Extend of resection--
Choice of flap
Short-term vs long-term complications--
Use of prophylactic flapIII[42,43]
Nutrition
For prophylactic gastrostomyII, III[45-48]
Against prophylactic gastrostomyII, III[49-51]
PEG is preferred over RIGII[52]
Improve preoperative nutritional status--
Optimization of comorbidities
Treat comorbidities (hypothyroidism, diabetes, anemia)--
MRSA decolonizationIII[58,59]
Antibiotics prophylaxisIII[60]
Dental careIV[62]
Table 2 Advantages and disadvantages of dressings used in management of post-operative head and neck fistula
Wound productsAdvantagesDisadvantages
Simple wet-to-dry/wet-to-moist dressingAffordable Readily available No special training/dedicate wound nurseRequire frequent changes, sometimes multiple times a day Cannot be used when wound is high output or exudative Traumatize tissue and disrupt granulation
Hydrocolloid basedProvide microdebridement Maintain moist wound bed Promote granulation and epithelization Readily available Evidence supported use on boneLimited absorbent capacity Malodourous Rigid form factor made it difficult to apply; limited use in wound with deep tracts, undermining May irritate/dessicate perifistular skin May adhere to wound bed and cause pain when removed
Hydrogel basedMay be applied to moderately exudative wound Easy to remove, can be changed daily Maintain moist wound bed Promote granulation and epithelization Mildly analgesicMay not work in highly exudative/high output wound May irritate/macerate perifistular skin Malodorous Require secondary dressing
Silver-coatedProvide autolytic debridment Proven anti-microbial efficacy and decreases bioburden Promote granulation and epithelization May be applied to highly exudative woundCostly Different silver products have different properties; no reliable evidence supporting one product over another May cause discoloration or dermatitis of perifistular skin
Honey-impregnatedCan be changed every other day or longer depends on need Affordable Anti-odor Anti-microbial Mildly analgesic Moisturize and maintain perifistular skinConflicting evidence Only one brand formally approved for Medical use: MedihoneyTM (United States) Different honey from different bees and/or flower species have different efficacy
Negative wound pressure therapyMay be applied to highly exudative wound Little data on safety profile and side effects, especially in diabetic Proven efficacy Promote granulation Promote vascularization Can be used in highly exudative wound Can be combined with other products (Dakin’s solution, octanidine…) to add anti-microbial effectTechnically challenged to achieve airtight seal, especially when fistula is in communication with the aerodigestive tract May require bedside procedure to divert fistula if near tracheostomy Moderate cost Controversy surrounding use directly on vessels Require experience/training and dedicated wound team Dressing change can be painful to patients