Case Reports

Reconstruction of a Hypopharyngeal Defect With a Palatal Mucoperiosteal Free Graft

MARC M. KERNER, MD, PAVEL DULGUEROV, MD, AKIRA ISHIYAMA, MD, BERNARD L. MARKOWITZ, MD, AND GERALD S. BERKE, MD

(Editorial Comment: The authors describe the placement of a free mucoperiosteal graft into the hypopharynx using a transhyoid approach to re- lieve hypopharyngeal stenosis.)

Stenosis of the pharynx is a complex prob- lem that presents the surgeon with serious challenges. The numerous reconstructive methods described attest to the considerable failure rate that occurs in attempting to en- tirely eradicate the stenotic lesion. Not infre- quently, the dysphagia experienced by the pa- tient after reconstruction is complicated by varying degrees of aspiration, voice alter- ations, and pharyngocutaneous fistulae.

ETIOLOGY OF PHARYNGEAL STENOSIS

Cicatricial pharyngeal stenosis should be distinguished from other causes of pharyngeal obstruction, such as tumors or hypertrophy of Waldeyer’s-ring lymphoid tissue. Any ana- tomic structure that contains a lumen is at risk for stenosis, especially when it is injured cir- cumferentially. Pharyngeal stenosis tends to occur when the mucosa of the pharyngeal wall is denuded along either the entire or a substantial portion of the pharyngeal circum- ference. The causes of pharyngoesophageal stenosis are best classified according to the

From the Divisions of Head and Neck Surgery and Plastic Surgery, Department of Surgery, UCLA School of Medicine, Los Angeles, CA.

Presented at the annual meeting of the Paul H. Ward Society, Manhattan Beach, CA, May 16, 1992.

Address reprint requests to Gerald S. Berke, MD, Di- vision of Head and Neck Surgery, UCLA School of Med- icine, 10833 LeConte Ave. Los Angeles, CA 90024.

Copyright 0 1994 by W.B. Saunders Company 0196-0709/94/l 505-0008$5.00/O

cause of the injury, the most common being caustic ingestion, followed by iatrogenic in- jury, infections, penetrating trauma to the neck, and various miscellaneous conditions (Table 1).

Caustic injuries of the upper digestive tract result from the ingestion of corrosive com- pounds. The extent of injury depends on the type, concentration, amount, and the time of contact of the corrosive agent.’ The chemical injury causes mucosal ulcerations and fre- quently involves multiple long segments of mucosa. The healing proceeds through well- characterized stages of inflammation, granula- tion, contraction, and scarification. The con- tracted circumferential scar typically results in constriction of the lumen. Most often, the ulceration and stricture are located at the midesophagus, but hypopharyngeal stenosis at the level of the esophageal inlet can occur.2

Iatrogenic pharyngeal stenosis can compli- cate any surgical procedure that involves the pharynx. It most frequently occurs after a wide-field laryngectomy, especially when performed in association with a partial or total pharyngectomy. The incidence of postlaryn- gectomy stenosis ranges from 20% to 70°&3*4 Other surgical procedures reported to be asso- ciated with pharyngeal stenosis include ade- notonsillectomy,5*6 uvulopalatopharyngo- plasty,7 postlaryngectomy tracheoesophageal fistulas from the placement of voice prosthe- ses,* and horizontal supraglottic laryngecto- mies.g

Infections were the predominant cause of pharyngeal stenosis in the preantibiotic era. Most stenoses of infectious origin resulted from tertiary syphilitic gummas,5*10p11 where- as other infectious causes resulting in contrac-

370 American Journal of Otolaryngology, Vol 15, No 5 (September-October), 1994: pp 370-374

RECONSTRUCTION OF HYPOPHARYNGEAL DEFECT 371

TABLE 1. Causes of Pharyngeal Stenosis

latrogenic Pharyngectomy, partial or total

Total laryngectomy Adenoidectomy and tonsillectomy

Uvulopalatopharyngoplasty

Caustic Injury

Infectious Syphilis Rhinoscleroma

Diphtheria

Tuberculosis

Scarlet fever

Miscellaneous Behqet’s disease

Plummer-Vinson syndrome

Lupus

tion and stenosis have included diphthe- ria,5v’2 rhinoscleroma,5*13 tuberculosis,*2,‘3 and scarlet fever.13

Several rare disorders have been associated with pharyngeal stenosis, including BehCet’s disease,14 Plummer-Vinson syndrome,” and systemic lupus. 5

CASE REPORT

A 28-year-old Asian woman sustained a slash in- jury to the neck. She was initially stabilized at a community hospital and then transferred to UCLA Medical Center for definitive care. A tracheotomy was performed to secure the airway. Neck explora- tion showed injuries to the left internal jugular

vein, glossopharyngeal, and hypoglossal nerves. The vagus nerve was intact; however, the left vocal cord was paretic. Total transection of the upper aerodigestive tract was present at the level of the epiglottis. Initially, the jugular vein was ligated and the tracheal and pharyngeal injuries were repaired primarily in two layers.

Postoperatively, the patient had residual speech difficulties secondary to vocal cord paresis and swallowing difficulties most likely secondary to multiple cranial nerve deficits. Throughout the fol- lowing year, she developed progressive dysphagia for solids and liquids. A complete workup showed a hypopharyngeal stenosis occluding the majority of the pharyngeal lumen at the level of the supra- glottis. The lower half of the epiglottis, pharyn- goepiglottic folds, and aryepiglottic folds were en- cased in a dense circumferential scar that extended to the posterior pharyngeal wall (Fig I). Only a &mm central lumen, located to the right of the midline and approximately 1 cm in front of the posterior pharyngeal wall, was present.

Throughout the subsequent year, three CO, laser excisions and bougie dilatations were performed in the operating room but were followed by a recur- rence of the hypopharyngeal stenosis. A gas- trostomy tube was placed percutaneously in the stomach because of inadequate oral intake.

One year after the initial injury, and after multi- ple attempted dilatations failed to resolve the dys- phagia, the cicatricial stenosis was resected through an open transhyoid approach. To ade- quately resect the stenotic scar, a segmental phar- yngectomy and subtotal epiglottectomy was re- quired. After this resection, a circumferential mu- cosal defect of approximately 3 x 3 cm was present across the superior-to-midhypopharynx (Fig 2). To

Fig 1. Preoperative video- laryngoscopic view of the densa rupraglottic scar in the hy- popharynx. The epiglottis (ar- rowheads) is inferior and the

posterior pharyngeal wall is su- perior. A circumferential scar band (white arrow) extends

from the epiglottis toward the

posterior pheryngeal well, Ieav- ing a small centml opening ap-

proximately 1 cm in diameter to the right of the midline.

372 KERNERETAL

Fig 2. Intraoparativa photo- graph of mucopariostaal free

graft (arrows) sutured into the posterior pharyngaal wall. The

posterior pharynx was ap- proached via a transhyoid inci- sion.

reconstruct this mucosal defect, a 3.5 x J-cm pal- atal mucoperiosteal free graft was harvested and placed in the posterior pharyngeal defect. Primary mucosal closure was performed anteriorly. The pa- tient’s dysphagia resolved considerably during the ensuing 6 months. Numerous indirect laryngos- copies were performed postoperatively to docu- ment healing of the graft in the posterior pharyn- geal wall. There was no evidence of mucosal slough, and throughout the following 18 months, there was no return of scar formation.

On follow-up examination at 18 months, the hy- popharynx remained mucosalized without evi- dence of recurrent necrosis. Six months after sur-

gery, the patient had complete resolution of her symptoms (Fig 3).

Technique of Palatal Mucoperiosteal Graft Harvest

The palatal mucosa graft is harvested by sharply incising a central strip of palatal mucosa down to the bony hard palate. The graft shape and size are determined by the defect and size of the palate. Grafts measuring up to 4 x 4 cm are easily pro- cured. Subperiosteal dissection proceeds from an- terior to posterior with graft division just before the velum. A cuff of alveolar palatal mucosa, at least 5

Fig 3. Eighteen-month post- operative vidaolaryngoscopic

view of the hypopharyngaal lu- man showing no racurranca of the scar band and widely patent lumen (arrowheads).

RECONSTRUCTION OF HYPOPHARYNGEAL DEFECT 373

mm, is left in place to allow for mucosal regenera- tion. The greater palatine neurovascular bundle is spared. The graft is thinned by hand, meshed, and sutured into the defect with resorbable sutures. No stenting or bolstering is used. The patient is fed through a nasogastric or gastrostomy tube to main- tain adequate nutrition. The bony palate develops a thin mucosal layer within 2 weeks.

DISCUSSION

Surgical treatment of pharyngeal stenosis typically requires the resection of the stenotic scar and reconstruction of the resulting defect. The mucosal defect can vary in size but is usu- ally small (~3 cm), and more importantly, tends to involve the entire circumference of the pharynx. As in other visceras, circumfer- ential defects lead to a restenosis and provide difficult reconstructive situations.

Reconstruction methods of pharyngeal, esophageal, and hypopharyngeal defects can be divided into vascularized and nonvascular- ized transferred tissue [Table 2). Vascularized flaps include local mucosal flaps, regional pedicled flaps, visceral transpositions, and free flaps.16 Nonvascularized autotransplants consist of skin grafts of various thickness. Each of these methods have inherent risks, benefits, and distinct indications.

Free flaps and visceral transposition tech- niques are used when large segments of the pharynx and the esophagus are removed, mostly after cancer resections. For defects of moderate size (4 to 6 cm), regional pedicled flaps, such as the deltopectoral skin flap or pectoralis major myocutaneous flap, provide adequate tissue coverage with excellent blood supply. The disadvantages of these flaps in- clude donor site cutaneous scars and morbid- ity, their inherent bulk, potential for fistula

formation, presence of hair-bearing tissue in the pharyngeal lumen, and a high incidence of stricture when the entire lumen needs to be replaced.17p18 The need for multiple and highly specialized surgical procedures are fur- ther disadvantages of free flaps and visceral transpositions.

Local rotation flaps have been described for the repair of small defects of the hypophar-

ynx 1g-23 and nasopharynx.*3,24 These flaps provide excellent tissue coverage with a well- vascularized donor tissue; however, the inci- dence of restenosis is high, and patients are frequently left with speech and swallowing deficits.

Split-thickness skin grafts have been used extensively to line small defects in the oral cavity after tumor excisions. These grafts do have some inherent disadvantages, including unpredictable contracture, malodorous dis- charge, occasional hair growth from the graft site, and pain and potential wound complica- tions at the donor site.1”‘25 Restenosis does oc- cur with skin grafts; however, they remain the workhorse material for lining defects in the oral and hypopharyngeal region.26

We have found palatal mucosa to be an ex- cellent source of donor material for repairing small-to-moderate size (4 x 4 cm) defects of the oral cavity and pharynx. Historically, its use has been limited to vestibuloplasty,25 and alveolar ridge reconstruction. However, pala- tal mucoperiosteal grafts have properties that make it a desirable graft material in the oral cavity. These include its similarity to the sur- rounding tissue, its inherent strength, and the fact that it shows little primary contracture when harvested and placed in the recipient site. In one study,25 free mucosal palatal grafts were found to contract approximately 20% in

TABLE 2. Reconstructive Methods for Pharyngeal Stenosis

Regional Visceral Free Tissue Pedical Transposition Transfers Flaps Techniques

Radial forearm free Deltopectoral flap Gastric pull-up

flap

Rectus abdominus Pectoralis major Colonic

myocutaneous myocutaneous interposition free flap flap

Jejunal free flap

Local Flaps Skin Grafts

Base of tongue flap Split-thickness skin grafts

Local mucosal Full-thickness skin flaps grafts

Palatal

mucoperiosteal grafts

374 KERNER ET AL

the first 6 months, and after that time period, contracture was virtually negligible.

Although our clinical impression of the pa- tient presented in this report is that there was complete graft survival and minimal primary and secondary contraction, we have not sub- stantiated this histologically because we did not perform another biopsy in this area during the patient’s recovery. However, we do be- lieve that palatal mucosa grafts have similar properties to full-thickness skin grafts in re- gard to revascularization and maintenance of cytoarchitecture, as other investigators have suggested.z6 Furthermore, our observation of this graft in this patient, and in subsequent patients in which it has been used, leads us to believe that palatal mucoperiosteal grafts tend to undergo less primary contracture when compared with full- or split-thickness skin grafts, particularly when lining the alveolar ridges or buccal sulci.

One advantage of palatal mucosa free grafts over split-thickness skin grafts is minimal do- nor site morbidity. The bony palatal defect is left uncovered and heals within 3 to 4 weeks, The regenerated mucosa has a normal pink color but is slightly thinner than the normal palatal mucosa. Pain is minimal, and there are no external scars. However, despite these ad- vantages, we do not recommend its use in ra- diated fields or in large defects.

In summary, a palatal mucosal graft was successfully used to address a recalcitrant hy- popharyngeal cicatricial stenosis. We are en- couraged by this result and have begun to use this free palatal mucosa for repair of small-to- moderate-size oropharyngeal defects that re- quire a graft. Further clinical and basic histo- chemical studies are now underway, and will hopefully clearly define the indications and biochemical characteristics of this donor tis- sue.

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