Total hypopharyngeal reconstruction.

In advanced hypopharyngeal carcinoma, the tumor may involve the entire hypopharyngeal mucosa and the larynx. After total laryngohypopharyngectomy is done, reconstruction of the circumferential defect of the hypopharynx is a challenge. We described our results of using a myomucosal tongue flap with dermal or skin graft (MTF) in 8 patients and using a tubed pectoralis major myocutaneous flap (TPMF) in 10 patients to reconstruct the total hypopharynx. There was no operative mortality. Fistula formation occurred in 3 patients of the MTF group and 4 in the TPMF group but all had spontaneous healing after conservative treatment. One in the MTF group and 4 in the TPMF group had stenosis of the anastomotic sites. Almost all responded well with periodic dilatation. Only one patient in the TPMF group who had been previously irradiated required gastrostomy for feeding. The 5-year actuarial survival rate of our patients was 32 per cent. These results show that total hypopharynx can be reconstructed with the above noted procedures. The survival rate is good, the morbidity rate is acceptable, and the perioperative mortality rate is zero.

The Amatsu tracheoesophageal shunt operation for voice restoration after total laryngectomy.

Vocal rehabilitation after total laryngectomy using tracheoesophageal shunt with sphincter mechanism or Amatsu's operation was performed in 12 patients at the department of Otolaryngology, Chiang Mai University from January 1993 to December 1998. Serviceable voice was attained within 10-14 days postoperatively. The success rate of voice restoration was 75 per cent with a good maximum phonatory time of 8 seconds. Tracheal aspiration which was found in 4 patients was managed conservatively without complication. The Amatsu tracheoesophageal shunt is a single stage operation which provides the patients with a good success rate of voice restoration, few complications, easy learning, and prosthesis free.

Esophageal foreign bodies.

A retrospective study of 310 patients with foreign bodies in the esophagus was analyzed. The most common age of the esophageal foreign body patients was between 0 to 9 years old (32.6%), and a coin was the most common foreign object in children. Bone, fish bone and bolus of meat were found commonly in adults, while dentures were encountered in the old age group. History of foreign body ingestion, dysphagia and odynophagia were usually presented by the patients. Roentgenographic study was useful in diagnosis and plan of management. Rigid esophagoscopy under general anesthesia is recommended in all patients with suspected history of foreign body, even though plain films of the chest and neck failed to demonstrate any significant findings. Complications can be reduced if the treatment is conducted within 24 hours of foreign body impaction.

Acute external laryngeal injury.

A retrospective study of 35 patients with acute external laryngeal injury who were treated at Maharaj Nakorn Chiang Mai Hospital from January 1989 to 1998 was done. Eighty-six per cent of the patients with blunt trauma had been injured from a motor vehicle accident and the rest had a penetrating injury from a stab wound. The frequent signs and symptoms were hoarseness, skin contusion, pain and subcutaneous emphysema. The severity of the injury was classified into minor and major groups. There were 2 patients in the minor group and 33 in the major group. Both patients in the minor injury group had good result from conservative treatment. All patients in the major injury group, except one with left vocal cord paralysis, required surgical management. No airway problem was found in any patient and only one patient had unintelligible voice after treatment. Twenty-three per cent had minor complications and responded well to conventional treatment. Early diagnosis and proper management gave the best outcome of the patient's airway and voice.

Mandibular reconstruction: free flap vs AO plate.

The purpose of this study was to compare the use of the AO reconstruction plate with immediate free vascularized bone graft mandibular reconstruction. From April 1989 to December 1993 we performed 13 cases of mandibular reconstruction. Reconstruction plates were used in 4 and immediate free bone grafts were used in 9 patients. The overall success rate for use of the plate was 2 of 4 (50%). In one of the plate failure patients, the plate was removed eight months postoperatively. She was able to wear a dental prosthesis. Cancer destruction and microvascular anastomosis of the first seven free flaps were performed by one surgical team. Only 4 free flaps were successful (success rate was 44%). We found that the use of AO plate with flap for lateral defect was relatively safe, simple, functional, time-saving, cosmetically acceptable and could be used successfully in post-operative irradiated patients. Success rate of the free flap was better with two surgical teams. The long-term result of the free flap was more reliable than the AO plate.

Esophageal conduit in nearly hopeless corrosive esophageal stricture patient.

The case report of a 28 year old woman with strictured esophagus from corrosive esophagitis for 4 months is presented. Barium swallowing showed a strictured esophagus extending from T2 to the aortic knob and needed frequent dilatations. The patient had a perforated thoracic esophagus and mediastinitis on last dilatation. Cervical esophagostomy, transabdominal esophageal bandaging and jejunostomy feeding were done along with intravenous broad spectrum antibiotics. On esophagoscopy, there was complete stenosis of the cervical esophagus 2 cm from the postcricoid area. The large intestine from the caecum, transverse colon and descending colon was chosen as the esophageal conduit because of adequate length to pass subcutaneously. The caecum was anastomosed to the cervical esophagus and descending colon to the stomach. Seven days postoperatively, the patient could take liquids and soft porridge orally. There was a small leakage from the cervical anastomosed, spontaneous closure was achieved 3 weeks postoperatively. We chose the right side colon as the esophageal conduit because of adequate length to pass subcutaneously. Mediastinal and transhiatal routes could not be passed because of previous mediastinitis from thoracic esophageal perforation. This may be an alternative choice of operation for high cervical esophageal stenosis with previous mediastinitis.