Microvascular flap reconstruction of major pharyngeal resections with the intent of laryngeal preservation

Objective: To determine the functional outcome in patients undergoing pharyngeal reconstruction with free tissue transfer with the intent of functional laryngeal preservation. Design: Retrospective medical record review. Setting: Academic tertiary care hospital. Patients: The study population comprised 45 patients who underwent a major pharyngeal resection with or without a partial laryngeal resection (2 patients died peri-operatively, leaving 43 to evaluate). The majority (n=35 [81%]) had advanced (T3 or T4) primary tumors at presentation and underwent subsequent reconstruction using free tissue transfer at a tertiary care hospital. Main Outcome Measures: The rate of functional larynx preservation, best swallow score based on the Functional Outcome Swallowing Scale, and need for tracheostomy. Thirteen independent variables relevant to function and 6 postoperative outcome variables were studied following treatment, and their correlation with laryngeal function was determined. Results: Of the 43 patients, 35 (81%) had T3 (n=9) or T4 (n=26) squamous cell carcinoma at presentation. There was 100% flap survival. Thirty-one patients (72%) tolerated an oral diet, with 24 (56%) achieving an exclusively oral diet. Only a history of gastroesophageal reflux disease had a statistically significant correlation with poor swallowing; having had a cranial nerve removed did not achieve statistical significance (P=.06). The majority of patients had their best swallow by 10 months. Of the 43 patients, 42 (97%) achieved native laryngeal speech and 36 (84%) were decannulated. The need for a tracheostomy did not correlate with any of the preoperative independent variables. Conclusions: Free tissue transfer allows for successful reconstruction of complex pharyngeal defects that functionally threaten the remaining larynx. In properly selected patients, functional laryngeal preservation, decannulation, and use of laryngeal speech can be reliably achieved. Excellent swallowing function can less reliably be predicted.