The Incredible Resection and Reconstruction on Pharyngeal Cancer

## **Chapter 5** Hypopharyngeal Cancer

*Oancea Alina Lavinia Antoaneta, Berteșteanu Șerban Vifor Gabriel, Grigore Raluca and Popescu Bogdan*

#### **Abstract**

Hypopharyngeal cancer is one of the most challenging pathologies regarding location, evolution, prognosis and functional implications. Since the hypopharynx is a crossroad in the digestive and respiratory pathways malignant pathology located at this site can cause dysphagia, odynophagia, respiratory distress and dysphonia. Complex anatomy and physiology of the hypopharynx make for pathology with a poor prognosis in late stages. Diagnosis and therapy are mandatory for ensuring high survival rates and as little functional impairment as possible. Therapy of hypopharyngeal cancer is a difficult test for both physician and patient. It requires a good collaboration between the ENT surgeon, pathologist, radiotherapist, chemotherapist, nutrition therapist and psychologist. Our approach to the subject is due to that data concerning this pathology is limited and the results of the overall oncology therapy are discouraging. Nonetheless, the technical steps of surgery make it difficult for ENT cancer surgeons to approach it, therefore the surgeons' experience plays a very important role in decision making and establishing a good doctor-patient relationship, both during initial therapy and followup. We will also present an original technique developed in our clinic for restoring the continuity of the pharynx after total circular resection using the synthetic prosthesis.

**Keywords:** Hypopharynx, neoplasm, pharynx reconstruction, pharynx cancer, laryngo-pharyngectomy

#### **1. Introduction**

Cancer is still a major problem of modern medicine. Research continues trying to understand the tumor biology mechanisms as well as to find new methods of effective treatment [1]. The hypopharynx is a crossroad in the upper part of the digestive and respiratory pathways and malignant appearance at this level leads to the impairment of two vital functions, breathing and feeding. It also affects speech. Therapy of this pathology creates disability for the patient under economic, social, psychological and medical aspects. Therefore, we can advocate that hypopharyngeal cancer is one of the most challenging cancers pathologies regarding location, evolution, prognosis and functional implications. Therapy of hypopharyngeal cancer is a difficult endeavor for both physician and patient and requires a multidisciplinary approach: ENT surgeon, oncologists, radiologists, vocal rehabilitation specialist, psychologist and nutritionist.

The primary purpose of the oncology management of aero-digestive malignant neoplasms is survival. Nevertheless, preserving respiratory, deglutition and speech functions are mandatory if oncology principles are not broken.

The survival rate for hypopharyngeal cancer is low despite advanced surgical techniques, radiotherapy and chemotherapy. Patients go for medical examination in advanced stages of the disease when the tumor already exceeds the mucous layer and causes cervical lymph node metastases, thus being a challenge for the medical oncology team. Hypopharyngeal cancer management requires the presence of experienced surgeons within trained oncology surgery teams due to the radical surgical therapy aimed to locally control this type of cancer. Oncology radicality overcomes the principle of function preservation which is sometimes impossible to achieve.

#### **2. Surgical anatomy of the hypopharynx**

The pharynx is a muscular-fibrous organ that belongs to the upper aero-digestive tract. It is located anteriorly to the cervical spines and posteriorly to the nasal fossae, oral cavity and larynx with which it communicates at different levels.

From a topographical perspective the pharynx is divided into 3 segments:


a loose cellular tissue that allows surgical and approach and detachment of the two regions. From a surgical perspective, a tumor located in the retro-cricoid region that invades the upper esophageal sphincter raise special problems. Therefore, the anterior wall of the retro-cricoid region is also called "party wall". The retro-cricoid region extends from the portion immediately below the arytenoids to the upper esophageal sphincter and forms the posterior wall of the larynx in the lower region. The anatomical relations explain the extension of the tumors of the post-cricoid region to the recurrent nerve, the paratracheal lymph nodes, the thyroid gland, the common carotid artery with its terminal branches and to the vagus nerves.

From inside out, in a cross-section, the pharyngeal wall is made out of four layers: the lining mucosa represented by a multi-layered squamous cell epithelium, a fibrous stroma developed from the pharyngeal aponeurosis, the muscular layer formed by the pharynx constrictor muscles arranged circularly and the lifting muscles arranged longitudinally and the buccopharyngeal fascia located on the outside. The constrictor muscles are superior, middle and inferior. The middle and inferior constrictor muscles surround the lateral and posterior walls of the hypopharynx that continue inferiorly with the walls of the cervical esophagus. Anteriorly, the posterior cricoarytenoid muscle represents the muscular layer. Below the hyoid bone, where the middle and lower constrictor do not cross, there is a weak point of the pharyngeal lateral wall represented by the thyrohyoid membrane, which is passed through by the vessels, nerves and lymph vessels of the hypopharynx.

The pharyngo-esophageal junction, also known as "Killian's mouth of the esophagus", makes the transition between the hypopharynx and the cervical esophagus. The difficulty of diagnosing pharyngo-esophageal junction cancer is variable depending on the circumstances of appearance and development of the malignant neoplastic lesion at this site.

The branches of the external carotid artery provide the arterial supply. Venous drainage is achieved through the facial vein and pterygoid plexus to the internal jugular vein. Lymphatic circulation drains lymph from the hypopharynx to the jugular lymph nodes. The submucosal layer of the hypopharynx contains a rich lymphatic network that exits superiorly through the thyro-hyoid membrane to reach the superior and middle jugular lymph nodes and the inferior lymphatics drain into the paratracheal and middle jugular lymph nodes.

The hypopharynx is an essential organ in assuring breathing, swallowing and speech. Tumors located at this level can cause swallowing and breathing impairment, both by the mass effect (large tumors) and/or by edema caused by the lymphatic invasion. Tumor invasion of neural structures can cause pharyngeal muscle contraction impairment or intense pain with negative effects on the swallowing process and the quality of life of the patients [2].

Damage to the arytenoid cartilages or recurrent nerves by malignant neoplasia invasion can cause major respiratory impairment with tracheobronchial aspiration phenomena by paresis of the vocal cords. Peritumoral infections can cause impaired swallowing [3, 4].

#### **3. Epidemiology**

The epidemiology of the hypopharyngeal and cervical esophageal cancer deals with the spread of the disease in the human population regarding sex, age, profession, time and space, as well as risk factors that contribute to these phenomena [5, 6].

The main factors involved in the occurrence of this type of cancer are chronic smoking and alcoholism. The risk of cancer occurrence is directly proportional to the ingested dose and alcohol concentration. The average age of onset is between 60 and 65 years, more common in men with a sex ratio of 5:1 men to women. The general tendency of the hypopharyngeal and cervical esophageal cancer is that of increased incidence, due to increased tobacco and alcohol consumption. Increased mortality is also associated with late diagnostic of hypopharyngeal and cervical esophageal cancer. 77.3% of patients are diagnosed with stage 3 or 4 upon admittance to the hospital [7, 8].

Usually, due to the anatomic relation between the site of the hypopharyngeal and cervical esophageal cancer, the two are studied together. Tumor lesions invade both regions at the time of diagnosis, which is usually in the late stages. At the beginning of the 21st century, hypopharyngeal and cervical esophageal cancer is still a major concern worldwide [8].

Piriform sinus location accounts for 85% of cases of hypopharyngeal cancer, 15% affect the posterior wall and the retro-cricoid region. The incidence of hypopharyngeal cancers varies from country to country and sometimes from region to region within the same country. The location of the tumor also differs from country to country and is closely related to the etiology factors involved. Hypopharyngeal and esophageal cancers are more common in countries with low social and economic standards and low education levels [3].

#### **4. Pathology and pathogeny of hypopharyngeal cancer**

The hypopharynx is lined entirely by a malpighian epithelium, so most cancers at this level are differentiated malpighian carcinomas (squamous cell carcinoma). However, hypopharyngeal cancer raises special problems for both pathologists and therapists due to its peculiarities, the way it spreads and the macro-microscopic aspects.

#### **4.1 Morphopathology of hypopharyngeal cancer**

From a macroscopic point of view, the hypopharynx may present two different forms of malignant tumors that are distinguished by their way of extension and prognosis. The ulcero-infiltrative form is most common and is characterized by invasion of the mucosa with more or less deep destruction of adjacent structures. The extension pathways mainly depend on the starting point of the tumor and the greater or lesser resistance of the encountered structures. The diffuse form with extension to the surface has a vegetative aspect being difficult to differentiate from an inflammatory type mucosa. This form develops on the surface without affecting the deep tissues being a carcinoma isolated to the mucosa but with distant spreading, affecting all or only parts of the epithelium of the hypopharynx. It is frequently associated with areas of infiltrative carcinoma and with more or less extensive areas of dysplasia and leucoplakia. There are other forms of cancer at this level with fairly well defined macroscopic and microscopic features: epithelial sarcoma (well-circumscribed tumor, pediculate, with minimal implantation surface, located especially in the membranous part of the piriform sinus and in the retro-cricoid region), wart-like carcinoma or malignant villous keratosis (rare, lymphophilic form, slow evolution, high chemosensitivity), adenoid malpighian carcinoma (muriform appearance, extremely rare, it can be found in the hypopharyngeal adenocarcinomas, non-Hodgkin's malignant lymphomas, melanomas).

#### **4.2 Dissemination pathways**

Tumor dissemination is achieved through direct local extension, lymphatic or hematogenous pathways. Finding the primary site and the pathway of dissemination is essential for the management of these tumors. Hypopharyngeal cancer is very rarely detected in the initial stage due to lack of symptoms.

Regarding local dissemination, tumors of the piriform sinus are located in its anterior angle from where the extension is made to the external and internal walls towards: 1. the internal wall of the sinus, from where it extends through the larynx (it is difficult to establish the pharyngeal or laryngeal origin of the tumor); 2. the lateral wall of the hypopharynx, from where it extends anteriorly to the anterior angle of the piriform sinus and the pharyngo-epiglottic fold, then to the thyroid cartilage and soft tissues of the anterior and superior cervical region to the lateral wall of the oropharynx.

The most important dissemination route is lymphatic. Lymph node invasion is present in 75% of patients at the time of diagnosis, detectable by palpation or imaging studies. For 10% of patients, lymph node involvement is bilateral from the time of presentation. Malignant tumors of the piriform sinus, lateral wall and posterior wall of hypopharynx usually spread towards the middle internal jugular lymph nodes. Tumors of the retro-cricoid region spread to the paraoesophageal, paratracheal and supraclavicular fossa [3].

#### **4.3 Distant site metastasis**

Distant site metastases are common. Patients with advanced cervical lesions and lymph node invasion are prone to develop distant site metastases to the lungs, liver, bones and brain.

#### **5. Stages and grades**

According to the American Joint Committee on Cancer (AJCC), the TNM staging of carcinomas originating in the hypopharynx is as follows (**Table 1**) [9].

#### **6. Clinical and paraclinical evaluation of patients with hypopharyngeal cancer**

Hypopharyngeal cancer is asymptomatic in the early stages, which is why most patients refer to a doctor in the advanced stages of the disease. The clinical examination corroborated with the paraclinical investigations contribute to positive and differential diagnosis. Histopathological examination is mandatory.

#### **6.1 Symptoms**

In early-stage tumors, symptoms are non-specific and may mimic laryngopharyngeal reflux or globus sensation. The first manifestation of the disease usually consists of unilateral dysphagia, especially during swallowing saliva. Very often patients go see a specialist due to the appearance of a cervical tumor or due to difficulty in breathing [10]. Dysphagia is progressive, initially for solid food and later for liquids. Severe dysphagia


*Hypopharyngeal Cancer DOI: http://dx.doi.org/10.5772/intechopen.102579*


#### **Table 1.**

*Table 1.Hypopharyngeal cancer TNM staging according to the American Joint Committee on Cancer (AJCC).*

and odynophagia are symptoms that occur in advanced cancers when the entire hypopharynx or cervical esophagus are invaded. Any unilateral dysphagia that persists for more than 2–3 weeks requires an ENT consultation. Weight loss is significant, sometimes leading to cachexia, so the assessment of nutritional status is an important element in establishing therapeutic management. Pharyngeal paresthesia, reflex otalgia, hemoptysis may be present. Dysphonia and dyspnea occur in late stages by the invasion of the pharyngo-laryngeal wall, recurrent paralysis or peritumoral inflammation [7].

#### **6.2 Clinical examination**

Inspection may suggest the condition by the presence of a cachectic patient, with the presence of a latero-cervical tumor or with anterior prominence of the larynx, hypersialorrhea and putrid breath. Performing bucco-pharyngoscopy we can detect synchronous buccopharyngeal cancers or tumor extension to this level.

The most reliable method of diagnosis in hypopharyngeal cancer is a direct examination of the pharynx and larynx so all structures can be assessed. Examination of the mucosa is mandatory and it can be done by using direct pharyngo-laryngocopy or fiber optic examination with or without digital image subtraction filters. Indirect pharyngo-laryngoscopy permits an overview of the tumor, its location and size, as well as the mobility of the vocal cords. Retro-cricoid tumors, as well as those located at the apex of the piriform sinus which is very difficult to highlight. Indirect signs like oedema, mucosal erythema, stagnant secretions or salivary stasis require further investigation (**Figures 1** and **2**).

**Figure 1.** *Extensive tumor comprising all walls of the hypopharynx – circular tumor of the hypopharynx.*

**Figure 2.** *Infiltrative tumor of the left pyriform sinus with the invasion of the left hemilarynx.*

Palpation of the neck leads to the detection of metastatic lymph nodes. Spread towards cervical tissues through the mobility of the laryngeal skeleton can also be appreciated [11].

#### **6.3 Paraclinical evaluation**

To establish the correct and complete diagnosis, as well as to achieve the biological balance of the patient, the clinical examination must be completed with a paraclinical evaluation. Pharyngo-esophageal barium examination might reveal the location of the lower limit of the tumor and degree of extension. The main method of pre-therapeutic evaluation is computerized tomography scan (CT) with contrast which, compared to magnetic resonance imaging (MRI), provides us with important data related to cartilage invasion. Positron emission tomography scan and computed tomography (PET-CT) is to be considered mainly for stages III and IV, for the detection of the primary tumor, regional and distant recurrences, as well as for evaluation of oncology therapy response [3]. MRI helps to assess tumor extension to the submucosa, to the hyo-thyro-epiglottic fossa, paraglottic space, subglottic space and invasion of muscle tissue [12]. Rigid endoscopy performed under general anesthesia provides a clear view of the mucosa, determines the lower extension of the tumor and the relationship with the piriform sinus, upper esophageal sphincter and cervical esophagus and allows sampling biopsies in optimal conditions. Breathing and speech cannot be examined.

Since it is a cost-effective, non-invasive method of evaluating lymph nodes ultrasound examination is yet another imaging modality that has been recommended, but not preferred, for assessing the primary tumor site [13]. Chest CT scans or PET-CT are mandatory for the evaluation of distant site metastases. The therapy management plan is established by a multidisciplinary team. In addition, dental and nutritional evaluation should not be forgotten.

The only method that gives a certainty diagnosis is sampling biopsy during the endoscopic examination, followed by the histopathological examination and/or immunohistochemistry. Oncology therapy management, prognosis and follow-up must be determined by the tumor board [14].

#### **7. Treatment of hypopharyngeal cancer**

The treatment of hypopharyngeal cancer is complex, comprising a series of therapeutic methods consisting of surgery, radiotherapy and chemotherapy. These are applied successively or simultaneously, depending on the stage of the malignant neoplasm, but also on the general biology status of the patient [15]. For stage I and II cancers treatment consist of surgery or radiation therapy. Unfortunately, these patients are difficult to diagnose in stages T1N0 and T2N0 because of their lack of symptoms. Standard regimens of therapy for stages III and IV meaning resectable tumor include radical surgery followed by adjuvant radiotherapy and chemotherapy. Stage IV disease with the unresectable tumor benefits from elective treatment of radiotherapy combined with neoadjuvant chemotherapy [16, 17]. Unresectable tumors benefit from palliative surgical techniques (tracheotomy to maintain respiratory flow, gastrostomy for optimal nutrition). Neoadjuvant chemotherapy is used to reduce the volume of tumors and to convert them into operable or radiation-treatable tumors. It is used to treat patients with advanced local lesions to improve loco-regional control or survival [17, 18]. If the tumor has been converted by chemotherapy to a lower stage surgery will be performed according to the initial T! Psychological counseling of patients with hypopharyngeal cancer is mandatory both in the pre-therapeutic stage, during therapy and post-therapy.

#### **7.1 Surgical therapy**

The aim of the surgical treatment is to achieve a complete tumor resection with the preservation of functions as much as possible, minimizing a possible local or systemic recurrence. In some cases, the surgery is not performed either due to the invasion of the common carotid artery, prevertebral fascia or due to the lack of reconstruction possibilities or given by the functional status of the patient.

There are several types of surgery that can be performed:


#### *Hypopharyngeal Cancer DOI: http://dx.doi.org/10.5772/intechopen.102579*

• Total circular pharyngo-laryngectomy, indicated in cancer of the pharyngoesophageal junction comprising the retro-cricoid region, the hypopharyngeal posterior wall and the cervical esophagus, T3-T4 stage tumors. Hypopharynx and larynx are completely resected circularly between the plane of the hyoid bone and that of the first tracheal ring, sometimes requiring inferior extension or extension to the thyroid gland [3, 4]. Reconstruction of the remaining defect is the difficult part of this intervention and requires the collaboration of the ENT specialist with the general surgeon and sometimes with the thoracic surgeon if the lower resection limit decreases in the upper mediastinum. Reconstruction is performed with musculo-cutaneous flap from the pectoralis major muscle, delto-pectoral tubular flap, free radial flap or jejunum-free flap, colonic transposition, revascularized fascio-cutaneous flaps, synthetic pharyngeal-esophageal prostheses.

As a first intraoperative stage after total circular pharyngo-laryngectomy a Montgomery tube can be placed between the pharyngostomy and the esophagostomy. In the ENT Clinic of Colțea Clinical Hospital in Bucharest, Romania, Professor Dr. Cristian Radu Popescu restored the pharyngo-esophageal continuity using a Montgomery esophageal prosthesis (**Figure 3**) [20].

This procedure has been used in patients without metastasis to the seventh lymph node station. The insertion of this synthetic prosthesis is done on the inside. The prosthesis is funnel-shaped at the upper pole and after adjusting the trusses of the esophageal and pharyngeal section to fit the ends of the prosthesis it is sutured at the base of the tongue and oro or hypopharynx with non-resorbable threads. The lower end of the prosthesis is inserted into the remaining esophagus over 5 cm. No suture is required at this level. The prelaryngeal muscles are fixed over the prosthesis. Postoperative feeding of the patient is performed by gastrostomy or by the nazogastric feeding tube inserted through the prosthesis at the moment of insertion. Because this method shortens and simplifies reconstructive intervention, without the esthetic defect left after flap reconstruction it has tolerance to radiotherapy comparable to other reconstructive methods, the material is biocompatible and allows the

#### **Figure 3.**

*Montgomery prosthesis is used for primary reconstruction of the upper digestive tract. The upper funnel-shaped portion of the prosthesis is sutured at the base of the tongue and the lower end is inserted in the esophagus.*

resumption of oral nutrition. This method is now used as an alternative to reconstruction with flaps and not as a temporary solution [3].

Reconstruction of the defect can be performed with transposition of the small or large intestine in a mixed surgical team – ENT surgeon – general surgeon – vascular surgeon. This type of reconstruction favors a more natural feeding and deglutition process. However, it has more possible and life-threatening complications than primary reconstruction with Montgomery prosthesis (**Figures 4**–**7**).

#### **Figure 4.**

*Dissection and identification of a portion of the small intestine and vessel pedicle which will be resected and transposed to the neck area to reconstruct the upper digestive tract defect.*

**Figure 5.** *Small intestine sample prepared for transposition.*

#### **Figure 6.**

*Measuring the graft before suturing it in the neck region for reconstruction.*

#### **Figure 7.**

*Attaching vascular pedicle to the external carotid artery and internal jugular vein.*

Oncological excision of the tumor must be accompanied by lymph node dissection, even if macroscopically metastatic lymph nodes. Micrometastases can occur in fatty tissue after complete resection. Neck dissection is done depending on the degree of lymph node invasion, but regardless of the N staging, station IV must be dissected if the pharyngo-esophageal junction is invaded [4].

There are four major types of neck dissection published by the Academy's Committee for Head and Neck Surgery and Oncology:


#### **7.2 Radiotherapy**

Radiotherapy as a single therapy is useful in T1 tumors, in rare T2 stage cases, in elderly patients, in patients who refuse surgery or as palliative treatment.

Radiotherapy in combined treatment regimens can be used before and after surgery. In our experience, the best treatment regimen is surgery followed by radiotherapy. Before radiotherapy, the patient needs a dental check-up to treat any conditions in this area, the treatment of comorbidities and the improvement of the general nutrition and biological status.

#### **7.3 Chemotherapy**

Chemotherapy is the treatment of hypopharyngeal cancer is used only in association with other methods of oncology therapy, not as a single way of treatment. Cytostatic drugs decrease tumor volume, improve clinical status and can prolong life. Adjuvant chemotherapy is instituted after surgical excision of the tumor and is used after or along with radiotherapy to eradicate a possible residual disease or micrometastases. Neoadjuvant chemotherapy is administered preoperatively to reduce tumor volume and primary tumor vascularization. It plays a role in lowering the chance of intraoperative tumor dissemination.

#### **7.4 Nutrition**

An important component in the therapeutic management of hypopharyngeal cancer is clinical nutrition. In hypopharyngeal cancer, we find a severe dysphagic syndrome that can lead to altered nutritional status, both by the cachexia-anorexia syndrome specific to the neoplastic disease, and by local causes that lead to weight loss and malnutrition. Tumor resection can cause severe disturbances to the complete cessation of food intake, and radiation therapy alters the taste and affects the surrounding normal tissues, compromising nutritional status.

Clinical nutrition can be achieved by the enteral or parenteral route. Enteral feeding is preferable in the case of a functional gastrointestinal tract and is made through the nasalintestinal tubes (nasogastric, nasoduodenal or nasojejunal), stents mounted in the upper digestive tract, through the esophagostoma, gastrostoma or jejunostoma. The patient must learn to administer his own enteral nutrition, which can last for several months. If enteral feeding is not possible, the parenteral route of nutritional support is used, so that malnutrition does not compromise the surgery and the patient's life. Postoperatively, patients have a strict contraindication to oral feeding, and even swallowing saliva can adversely affect the prognosis by the appearance of fistulas. The nutritional intake is ensured on the nasogastric tube, gastrostoma, jejunostoma, nasojejunal tube. The nasogastric tube is kept for at least 10 days, depending on the reconstructive procedure used.

The nutrition of these patients includes a complete plan tailored to the condition of the patients and their nutritional status to reduce morbidity and mortality, being considered a method of adjuvant treatment with chemo- and radiotherapy in patients with hypopharyngeal cancer [3].

#### **8. Prognosis**

Hypopharyngeal cancer is asymptomatic in early-stage and patients go to a physician in advanced disease stages when metastases are already present and the prognosis is reserved. At the presentation, to the physician 50% of patients show cervical lymph node metastases. The survival rate in hypopharyngeal cancer depends on the tumor stage. Patients in T1-T2 stages have a survival rate at five years of approximately 60%. For patients in stages T3-T4 the survival rate decreases to 17–25%. Cancers in stages I and II, located on the posterior wall of the hypopharynx, have a much better prognosis compared to pyriform sinus cancers, even if it is small, but cause early metastases. Cancers of the retro-cricoid region are diagnosed in advanced stages with extended metastases at paratraheal and mediastinal sites with a severe prognosis. Patients with hypopharyngeal cervical esophagus cancer who have suffered reconstructions, have a two-year survival rate between 9 and 39%. The five-year survival rate in hypopharyngeal cancers is the lowest of cancers with other head and neck localizations [3].

#### **9. Conclusions**

Hypopharyngeal cancer mainly affects men around the age of 60. It is mostly located in the pyriform sinus, being a squamous cell carcinoma. Being asymptomatic in the early stages patients at the time of diagnosis are classified in stages III and IV of the disease, presenting cervical lymph node metastases and extensive tumors. Most patients require extensive surgical interventions and only a few can benefit from partial interventions. The type of neck dissection depends on the level of lymph node invasion. More than 50% of patients present local recurrences in the first five years after the surgical intervention, the risk of local recurrences being significantly higher in retro-cricoid and posterior wall tumors than in pyriform sinus tumors. The survival rate of hypopharyngeal cancer patients is influenced by tumor location and tumor stage. Therapy must be individualized, multimodal, with correct evaluation for each case and by involving several specialists like surgeons, radiotherapists, chemotherapists, nutritionists, psychologists. Surgical treatment remains the indication with the best results both as first intent and after radiotherapy failure, although it involves the sacrifice of the larynx. Montgomery pharyngoplasty after circular pharyngo-laryngectomy through the C. R. Popescu technique is a viable reconstructive alternative for oral feeding with small complications, low mortality rates and low hospitalization period. Surgery must be followed by radiotherapy and chemotherapy.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Oancea Alina Lavinia Antoaneta1,2\*, Berteșteanu Șerban Vifor Gabriel1,2, Grigore Raluca1,2 and Popescu Bogdan1,2

1 General Medicine Faculty, ENT Head and Neck Surgery Department, University of Medicine and Pharmacy "Dr. Carol Davila" Bucharest, Bucharest, Romania

2 ENT Head and Neck Surgery Clinic, "Colțea" Clinical Hospital Bucharest, Bucharest, Romania

\*Address all correspondence to: dr.alina.oancea@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**Chapter 6**

## Pharynx Reconstruction and Quality of Life

*Paula Luiza Bejenaru, Raluca Grigore, Bogdan Popescu, Alexandru Nicolaescu, Mihnea Cojocărița-Condeescu, Catrinel Simion-Antonie, Gloria Berteșteanu, Anca Cirstea, Teodora Diaconu, Bianca Taher, Simona Rujan, Dan Popescu and Șerban V.G. Berteșteanu*

#### **Abstract**

Patients who are diagnosed with squamous cell carcinoma of the pharynx have a first delayed presentation, with advanced stages of the disease. Therefore, they frequently require a multimodal approach—by surgery, radio, and chemotherapy. Due to anatomic spatial limits and particularities, therapy can imply large organ resection with difficulties in reconstruction. Nowadays, there is a paradigm shift in the management of this pathology, with significant first referral to oncology departments and initiation as the first line of treatment of radio/radio-chemotherapy. As a consequence, salvage surgery may be mandatory in some selected cases. The proposed chapter will address the oncological particularities of the pharynx, with a focus on the oro- and hypopharynx, ways of reconstruction after oncological ablative surgery of these segments, and impact on quality of life (QoL) index. Speech, respiratory, and deglutition rehabilitation of these patients is essential and will be a distinct topic. This paper will have the structure of a literature review with clinical examples of reconstruction from ENT and Head and Neck Surgery Department of Coltea Clinical Hospital, Bucharest. Reconstruction methods used in our clinic are regional flaps and biocompatible prostheses in advanced stages. QoL index in our clinic is assessed with questionnaires developed by the European Organization for Research and Treatment of Cancer – EORTC QLQ C30.

**Keywords:** pharynx carcinoma, oncology, deglutition, reconstruction methods, QoL

#### **1. Introduction**

The pharynx is the main structure, in addition to the oral cavity, shared by two organ systems. It is funnel-shaped, the upper end being wider and located just below the lower surface of the skull, and the lower end being narrower and located at the level of the sixth cervical vertebra. Its muscular-membranous integrity allows it to mediate several vital functions such as swallowing, air conduction, and voice production [1].

Performing surgical operations in the pharynx require delicate technique in order to preserve the physiology of the organ. Reconstruction of the pharynx is probably the most demanding task of the surgeon. Treatment for advanced *laryngeal and hypopharyngeal cancer* can cause anatomical and functional sequelae. Surgery aims at curing, but also keeping the organ's function. In tumors in which there is the need to remove the entire larynx or in cases of *hypopharyngeal tumors* with the need to remove the larynx, closing the remaining pharynx, in most of the cases done primarily, can be performed in two ways, cross-sectional or T closure. In *pyriform recess* tumors, a part of the pharyngeal wall is resected together with the primary tumor meaning that the pharyngeal remain is smaller, thus one should use the "T closure" technique or the flap [1, 2].

#### **1.1 Oncological disease of the oropharynx - diagnosis**

The pharynx, with its anatomical and physiological particularities, is an increasingly common site for head and neck malignancies, as apart from individual genetic characteristics, it is an often offended part of the human body—both infectious diseases and environmental exposure to risk factors (alcohol, tobacco intake) have a well-established cause—effect relation. On the other hand, as we have a better understanding of viral oncogenesis, human papillomavirus (HPV)—associated squamous cell carcinoma (SCC) of the oropharynx (OPSCC)—is nowadays a distinct entity from the traditional tobacco and smoking-related OPSCC [3].

SCC is the most common malignancy of the oropharynx, with a rate of 90% from all malignancies. It is an invasive epithelial neoplasm with degrees of squamous differentiation and with a high lymphophilia, as it may present with early and extensive lymph nodes metastases. Epithelial precursor lesions, especially erythroplakia, severe dysplasia, and carcinoma in situ (CIS) are involved in the development in patients with a history of tobacco and alcohol consumption. These tumors are aggressive, with a high disruption of cellular histology, invasion of lymphovascular space, neurotropism, and infiltration of other tissues such as muscle and cartilage. SCC can be keratinizing to nonkeratinizing and well-differentiated to poorly differentiated. HPV-associated OPSCC has a different histopathology with a lack of keratinization and mature squamous differentiation [3].

Other types of malignant carcinomas, with lower rates of appearance, of the oropharynx may include lymphoepithelial, salivary gland tumors, soft tissue tumors, hematolymphoid tumors, and mucosal malignant melanoma [3].

#### *1.1.1 Clinical*

Presentation is often in advanced stages, as the symptoms of early tumors are nonspecific. Mainly, dysphagia, foreign body sensation or pain in the throat, oral bleeding, referred otalgia, or neck mass may be patients' complaints. The presentation may also be as an unknown primary with an isolated nodal mass and no upper aerodigestive tract lesions or radiologic imaging [3].

After a thorough anamnesis, with emphasis on risk factors and social aspects, physical examination should have a great focus on the tongue (appearance and movement), tonsillar, fossae, retromolar trigone, soft palate (appearance and mobility), base of the tongue, vallecular, and pharyngeal walls. Inspection and especially palpation of the tongue base, tonsillar fossa, sensate testing, and an office endoscopy complete the examination. A complete head and neck investigation is mandatory for excluding synchronous cancers and bimanual palpation of the neck to assess lymph nodes [3].

*Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

#### *1.1.2 Imaging*

Precise evaluation and treatment plans require detailed imaging with a focus on soft tissues, vascular, and bony structures. Consequently, computed tomography (CT) and magnetic resonance imaging (MRI) are both used, either as one or complementary [3].

Positron emission tomography (PET) with CT can be useful for unknown primary, synchronous primary tumors and distant metastases. Limitations of these techniques are influenced by previous surgery or radiotherapy (RT), and it is not usually used for tumor staging [3].

Gray-scale and Doppler ultrasonography (USG) studies of the neck are useful tools for the evaluation of the lymph nodes. Fine-needle aspiration (FNA) can be done simultaneously for the purpose of establishing a histologic diagnosis [3].

Distant metastatic spread may appear in organs such as the lung, liver, skeletal system and brain, and CT of the lung and/or MRI of the abdomen are recommended [3].

#### *1.1.3 Endoscopy*

As an in-office procedure, oropharyngeal lesions biopsy can be performed if the site of the tumor is the tonsil or soft palate. FNA with USG of the lymph nodes may assist the diagnosis in selected facilities. On the other hand, when the site involves base of the tongue, inferior tonsillar, or posterior oropharyngeal wall endoscopy, with or without microscopic assistance may be the next step in the diagnosis. Pan endoscopy under general anesthesia is an important tumor evaluation and biopsy tool, and also can be used to rule out secondary malignancy [3].

#### *1.1.4 Biopsy*

Although frozen sections are close in accuracy to the final diagnosis up to 90%, the final treatment decision is based on standard histopathologic evaluation [3].

#### *1.1.5 Testing for HPV or p16 and staging*

Testing for HPV or its surrogate marker, p16 overexpression delineates tumor diagnosis and prognosis, and nowadays, the new system of staging developed by the American Joint Committee presents some differences between non-HPV-associated (p16 negative) and HPV-associated OSCC. The main ones are regional lymph nodes (N), with differences in pathologic N category, as metastasis in more than 4 lymph nodes stages in N2 disease [3].

#### **1.2 Oncological disease of the hypopharynx - diagnosis**

SCC of the hypopharynx and esophagus are head and neck rare afflictions (3–5% of head and neck HN SCC) with the worst prognosis, as they tend to present in late stages, with significant submucosal extension and a hard clinically and radiologically estimation of the disease. Organ-preserving protocols involve a slow rehabilitation, with high rates of complications, like stricture or impossibility of decannulation due to aspiration events. On the other hand, advanced tumors often require reconstructive surgery, with a multidisciplinary approach. Rarely, in 5% of the cases, other types of carcinoma, such as adenocarcinoma, sarcomata, and lymphoma can affect the hypopharynx [3].

In the etiology of the SCC of the pharynx, the most cited carcinogen is alcohol intake. Although HPV can be detected in hypopharyngeal cancers, there is no strong correlation between the diseases, until up to date [3].

Plummer-Vinson or Patterson-Brown-Kelly syndrome, which affects primarily women (85% of the cases) is a syndrome that is associated with postcricoid and upper esophageal carcinoma. It involves dysphagia, iron deficiency anemia, and the presence of hypopharyngeal and esophageal webs. Chronic irritation may result in hypopharyngeal webs with progression to carcinoma. Improved nutrition and prenatal care may decline the incidence [3].

#### *1.2.1 Clinical*

As it is stated before, patients with hypopharyngeal and esophagus usually present in advanced stages of the disease. Clinical examination may reveal dysphagia, neck mass, sore throat, hoarseness, referred otalgia, shortness of breath, hemoptysis, gastroesophageal reflux (GERD), or even asymptomatic. Also, these patients may present with weight loss and malnourishment [3].

The examination should focus on the mucosa of the aerodigestive tract for primary and synchronous cancers evaluation. Flexible endoscopy (**Figures 1** and **2**), as well as neck palpation, is mandatory [3].

#### **Figure 1.**

*Fiberoptic flexible view of the pharynx with hypopharyngeal carcinoma—note edema and saliva pooling.*

#### **Figure 2.** *Fiberoptic flexible view of the pharynx with hypopharyngeal carcinomas—note the laryngeal involvement.*

#### *Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

Operative endoscopy, with complementary laryngoscopy and esophagoscopy are next steps in work-up. If it is possible, an assessment of second primary of the esophagus should be performed. Biopsy of the tumor is essential for diagnosis and further management. The pathology is usually SCC, but other rare lesions can occur: lymphomas, adenocarcinoma and neuroendocrine tumors, and thyroid malignancies with direct invasion; extremely rare: sarcomas, liposarcomas, angiosarcomas, and synovial sarcomas [3].

#### *1.2.2 Imaging*

Hypopharyngeal cancer has a particularity of submucosal spread that may be undetectable on clinical or radiographic examination. It is essential for the examination to focus on submucosal extension, involvement of the thyroid gland and metastasis to paratracheal and upper mediastinal lymph nodes, invasion of the prevertebral fascia, and carotid artery involvement as well. Cross-sectional CT or MRI is used for primary evaluation. CT is preferred as it assesses cartilage invasion. PET-CT is used for the detection of loco-regional recurrence and persistent disease [3].

#### *1.2.3 Staging*

Hypopharyngeal carcinoma and cervical esophagus carcinoma have different staging with appropriate treatment management (**Figure 3**). For hypopharyngeal tumors, involvement of the larynx, with fixation, is a sign of local significant spreading. For esophageal primary tumors, the assessment is based on the spreading of the layers of the esophageal wall [3].

**Figure 3.** *Fiberoptic flexible view of the pharynx after base of the tongue carcinoma surgery and epiglottoplasty.*

#### **1.3 Treatment of pharyngeal carcinoma**

Squamous cell carcinoma of the pharynx is defined by a late presentation, with the advanced stage that often implies submucosal spreading and early lymphatic metastasis. These characteristics predict a poor prognosis [4].

**Figure 4.** *Edema and mucositis after radiotherapy for oropharyngeal carcinoma.*

In addition, along with scientific discoveries, new staging and ways of treatment appear and oropharyngeal carcinoma now requires tumor human papillomavirus (HPV) testing by p16 immunohistochemistry (IHC). Based on the result, there are clinical stages and consequently therapeutically differences. However, even in advanced stages, there is an indication of concurrent systemic therapy/RT (preferred in p15 HPV + T0–3, N3 or T4, N0–3), surgery (resection of primary with neck dissection), or induction chemotherapy followed by RT or clinical trials (**Figure 4**) [5].

Nowadays, stage-related ways of treatment begin to have a different angle, with organ preservation protocol with chemoradiation therapy and encouragement of conservation surgery that will maintain laryngeal functioning. Regardless, survival and oncological disease-free are mandatory and most patients diagnosed with hypopharyngeal carcinoma still need radical surgery—with total laryngectomy, partial of total pharyngectomy, and even esophagectomy. As a result, these kinds of surgeries are real challenges of reconstruction, especially when treating a circumferential defect [4].

Generally, it is well established that a residual mucosa bigger than 3 cm in width may grant a good primary closure. In other cases, a pedicled or free tissue transfer patch may be inserted. Reconstructive methods may include local flaps, myocutaneous flaps, free fasciocutaneous flaps, free jejunal interposition, gastric pull-up, and use of biocompatible materials—each with advantages and limitations. These are in straight relation with surgical team experience and resources [4].

There is a paradigm shift regarding pharynx carcinoma treatment and patients are discharged to trials of systemic therapy even in advanced stages. At present, advanced cancer requiring/amendable to pharyngectomy with total laryngecotmy (T1–3, N0–3; T1, N+) may have as a choice of treatment: induction chemotherapy, or partial/ total laryngopharyngectomy with neck dissection, thyroidectomy, and pretracheal and ipsilateral paratracheal lymph node dissection, or concurrent systemic therapy/RT, or clinical trials. After induction chemotherapy, complete response with stable or improved disease in the neck, NCCN guidelines recommend to go along with definitive RT or systemic therapy/RT. On the other hand, a partial response, depending on the nodal disease, means that the case may be treated with surgery or systemic therapy/RT. Advanced stages, with clinical T4a, N0–3 has as treatment of choice surgery, induction chemotherapy, concurrent systemic therapy, or admission to

#### **Figure 5.**

*Recurrent oropharyngeal carcinoma with bleeding—After surgical and RT therapy; note the presence of nasogastric feeding tube and the edema.*

clinical trials. At follow-up, clinical changes will demand an adapted treatment [5] (**Figure 5**).

With treatment development, a variety of surgical skills and reconstruction techniques can deliver an adequate QoL for the patients, without certain differences between them. Even if different ways of treatment may seem even in oncological response, it is certain that salvage surgery is associated with additional complications (**Figures 6** and **7**) [6]. Finally, patient selection and empowerment are critical in treatment and follow-up.

At the beginning, surgery of the upper aerodigestive tract malignancies presented a high rate of mortality (80%—Billroth's laryngectomies). As follows, surgical techniques advancement was necessary, taking into consideration that this kind of carcinoma affects two main vegetative functions, respiration and alimentation. Some authors elaborated an algorithm with treatment choices of defects of the laryngopharynx, hypopharynx, and cervical esophagus, with emphasis on complications of laryngopharyngectomy and back-up management [7].

#### **Figure 6.** *Fiberoptic flexible view NBI assisted after hypopharyngeal carcinoma surgery with primary reconstruction.*

#### **Figure 7.**

*Fiberoptic flexible view NBI assisted after hypopharyngeal carcinoma surgery with primary reconstruction. Closeup on the right reconstructed pharyngeal wall.*

#### **2. Reconstruction of the pharynx**

Oropharyngeal reconstruction is a complex and difficult process that should perform a combined evaluation of the size, location of the defect, patient's age and comorbid status, and the use of the simplest reconstruction with the highest level of function. For small defects healing by secondary intention is the simplest way of approach; but with extensive lesions, the next steps in the reconstruction ladder should be primary closure, skin grafts, local and regional flaps, or free flaps (**Figure 8**) [3].

Hypopharyngeal defects often require a multidisciplinary approach and are associated with a high risk of mortality and morbidity—fistula development and vascular offense are the main concerns in this kind of surgery. Thus, the goals of reconstruction are the protection of the great vessels, restoration of the pharyngeal conduit, protection of the airway, and rehabilitation of the voice. Options for reconstruction are local and regional cervical skin flaps and deltopectoral, pectoralis, and latissimus flaps; gastric and colonic interpositions; and revascularized fascial and gastroomental autogenous transplants. Literature reviews conclude that vascularized tissue use has a reduced fistula rate, even when patient history includes RT. The decision must also be made in a ladder fashion and consider if the defect is partial or circumferential [3].

Certain milestones should be reached for an ideal hypopharyngeal reconstruction: single-stage procedure, high success rate for tissue transfer, low donor-site morbidity, low fistula and stenosis rates, restoration of the ability to speak and swallow, able to achieve a successful reconstruction in heavily radiated areas, and tolerance of postoperative radiotherapy [8].

In general practice, it is well established that a residual mucosa bigger than 3 cm in width grants primary closure. On contrary, a pedicled or free tissue transfer patch may be inserted [3].

In straight correlation with surgeon's experience, reconstructive methods may include local flaps, myocutaneous flaps, free fasciocutaneous flaps, free jejunal interposition, gastric pull-up, colon interposition, or even use of biocompatible materials each with advantages and throwbacks, with a brief review in **Table 1**.

*Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

#### **Figure 8.**

*Advanced oropharyngeal carcinoma—Trans mandibular approach.*



#### **Table 1.**

*Means of reconstruction after oncological surgery of the pharynx.*

#### **2.1 Local flaps**

Healing by secondary intention can be used for defects less than 5 to 6 cm and it is not advisable when the pharynx communicates with the neck and after open procedures. When it is possible, this procedure is preferred from primary closure, as it can give oncological surveillance over profound margins and gives less tension and contracture. Primary closure has the benefits of decreased pain after surgery, less chance of secondary bleeding, and superior results in speech and swallowing rehabilitation [3].

For oropharyngeal reconstruction, local flaps may be used after open procedures. The palatal island, uvulopalatal, inferior and superior pharyngeal, the superiorconstrictor advancement-rotation (SCARF), facial artery myomucosal (FAMM), and the buccinators myomucosal flaps can be considered as the main local flaps for oropharyngeal defects. These flaps can be used for limited defects [3].

#### **2.2 Regional flaps**

#### *2.2.1 The pectoralis major flap reconstruction technique*

The pectoralis major miocutaneous (PMMC) flap is an often used flap, with an excellent blood supply—from the pectoral branch of the thoracoacromial artery [4]. Its main advantages are single-stage reconstruction with muscle bulk, which is important in filling large defects; it can be rapidly raised from the anterior chest wall and it does not require multidisciplinary teams, with additional expertise in microvascular or abdominal surgery, the morbidity of the donor site is low, and with high importance, it comes from a nonirradiated area in salvage surgery. However, this flap seems to be too bulky, and after reconstruction some authors report high fistula and stricture rates. Still, it is a helpful choice for salvage surgery, for elderly patients and for patients with severe comorbidities—when time management needs to be optimal [4].

The pectoralis major muscle is a thick, fan-shaped muscle, that lies underneath the breast tissue. It has three parts of origin, a clavicular one, at the anterior surface of the medial half of the clavicle, a sternocostal one on the anterior surface of the sternum and the first seventh costal cartilages, and one abdominal at the level of the right abdominal muscle sheath. The insertion is made through a common tendon formed by the three parts of origin at the intertubercular sulcus of the humerus [9].

#### *Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

**Figure 9.** *Arterial supply of the pectoralis major muscle.*

**Figure 10.** *Skin island and vascular pedicle of the PMMC.*

#### **Figure 11.** *Skin island and vascular pedicle of the PMMC.*

It is a superficial muscle, being covered by skin, subcutaneous connective tissue, the medial and intermediate supraclavicular nerves, and the mammary gland. It covers the small pectoralis, anterior serratus, subclavius muscles, ribs, and intercostal spaces. The close relationship with the pleura must be taken into account when harvesting the flap.

The arterial supply of the pectoralis major is provided by the pectoral branches of the thoracoacromial artery, the perforating branches of the internal thoracic artery, and the perforating branches of the lateral thoracic artery (**Figure 9**). Its venous drainage is through the pectoral vein, which drains into the subclavian vein [10, 11].

The first step when using a chest flap for reconstruction is to determine the length of the flap required. A dry gauze is used to perform the measurement. This is placed on the middle of the collarbone, this being the place where the pectoral flap will be rotated. The upper limit of the flap is measured, and then the gauze is pivoted lower to establish the lower edge of the flap. The boundaries of the skin tissue island are achieved by drawing a line from the acromion to the xiphoid process. A second line is drawn perpendicular to the clavicle at the intersection of the lateral third with 2/3 medial of the clavicle. The intersection of the two lines represents the upper limit of the skin islet. The lower limit of the skin island is represented by the 7th rib, the lateral one is the extremity of the pectoralis major muscle, and the medial one is the middle sternum (**Figure 10**). Preferably, the island should have an elliptical shape to facilitate closure [12].

*Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

#### **Figure 12.**

*Transposition of the flap and compression dressing with 2 catgut.*

The next step is to expose the large pectoralis muscle. The dissection is performed from medial to lateral. After exposing the pectoralis major muscle, its edge is sutured to the subcutaneous connective tissue of the skin island. An incision is then made from the medioclavicular level to the myocutaneous island. Lifting of the flap is done by digital dissection, deep to the pectoralis major muscle.

Dissection of the vascular pedicle must be done carefully so as not to damage it and compromise the flap. It is recommended to leave an equal thickness of tissue around the flap (**Figure 11**).

A subcutaneous tunnel is made at the level of the clavicle through which the flap is transposed at the level of the defect (**Figure 12**). A drain is placed at the level of the pectoral defect, at a distance from the vascular pedicle. The suture is made in 2 planes. A compression dressing is held in place for 2 days (**Figure 13**).

Most often, reconstruction of the hypopharynx with the PMMC is performed after total laryngectomy. Because the posterior wall of the larynx is attached to the anterior wall of the pharynx, a significant part of the pharyngeal wall may be excised during total laryngectomy. If it is necessary to reconstruct the entire circumference of the pharynx, it is recommended to use a free flap (tubularized anterolateral tight, radial

**Figure 13.** *Transposition of the flap and compression dressing with 2 catgut.*

**Figure 14.** *Gigant oropharyngeal and cervical defect which needed PMMC reconstruction.*

#### *Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

forearm fasciocutaneous free flap or jejunum). Defects of the pharynx extending below the clavicle are most commonly reconstructed with a gastric pull-up or colon interposition flap.

After harvesting and lifting the flap at the neck level using the technique described above, the flap is rotated 180 degrees to bring the skin side in. The closure of the defect begins at the caudal extremity of the pharynx. The right edge of the remaining pharynx is sutured to the left edge of the flap with 2–0 catgut sutures. Reconstruction of the pharyngoesophageal defect is done in the form of a racquet. A nasogastric feeding tube is inserted and passed into the distal esophagus before complete closure of the pharyngeal defect [13].

When an anterior cervical soft tissue defect is also present, a prelaminated pectoralis major pedicled flap can be used for reconstruction. This flap can provide two epithelial surfaces. This is a two-step procedure that involves first implanting a skin graft under the pectoralis major muscle. After maturation of the added tissue, the myocutaneous flap is transferred onto the neck, where the grafted surface is used for pharyngeal lining [14].

PMMC is also used for the reconstruction of defects of the oropharynx (**Figures 14** and **15**), but with a rather high complication rate. Complications include partial necrosis and less often total necrosis and fistula development. Due to the gravitational force, as it is a heavy flap, has a tendency to pull away, causing separation of the suture line, especially at the superior edge.

**Figure 15.** *Appearance of the patient 2 days after PMMC reconstruction for extensive pharyngeal resection and cervical region defect.*

#### *2.2.2 The sternocleidomastoid (SCM) flap*

The sternocleidomastoid (SCM) is used as a pedicled flap in head and neck reconstruction since 1908, and although it has been previously associated with high complication rates, recent reviews state that preservation of the vascular pedicles and techniques improvements make it an adequate choice, especially when free flap surgery is inappropriate [15].

The muscle originates from the upper edge of the sternal manubrium, from the medial quarter of the upper face of the clavicle; the two muscle heads merge into a single muscle belly that is directed upwards and laterally. Insertions arrive at the mastoid process of the temporal bone and at the anterior portion of the superior nuchal line. SCM has fibers arranged in parallel; it is not a pennate muscle. The sternomastoid portion is the muscle area that develops a greater percentage of contractile strength than the other portions [16].

The arterial supply is given by branches of the external carotid artery (occipital artery and superior thyroid artery), which can be palpated, feeling the heartbeat in the medial-anterior portion of the muscle. The external jugular vein passes inferiorly and posteriorly the SCM, from which it drains venous blood (external posterior jugular vein and anterior jugular vein) [16]. Superior and middle pedicles are the most important to be preserved, as they give the major blood supply to the muscle. The inferior pedicle is the most controversial, with variations of origin—suprascapular artery, thyroid artery, or transverse cervical artery, and it cannot be relied on to perfuse the entire muscle. Some studies conclude that preserving the superior thyroid arteriovenous system is critical for the survival of the flap. Also, care to be taken to external jugular vein, as venous limitations may also affect flap viability [15].

Anatomic studies suggest that only one pedicle may not be not enough, as ischemic complications may appear due to a low vascularization in the distal end of

#### *Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

the muscle and some authors advocate the use of superior and middle pedicle, with dissection at the highest length to allow flap rotation. Single-headed SCM flaps can repair soft tissue defects up to 8 cm 6 cm, and if a bone is needed an SCM flap with a clavicular bone graft can fix mandibular defects up to 6 cm long. The skin incision should be parallel to the muscle from the angle of the mandible, and with a clear view of the occipital and superior thyroid arteries. Skin platysma flaps are raised anterior to posterior to the SCM and muscle should be raid with its investing fascia. Separation from its superior or inferior bony attachments is done with a combination of blunt and sharp dissection. After flap harvesting, selective functional neck dissection can be performed. Suturing the skin on the muscle may be favorable for skin perfusion as it decreases tension and avoids tearing of the delicate perforators to the skin [17].

With a high versatility in head and neck reconstruction, this regional pedicled flap can be used as a myocutaneous, myofascial, myoperiosteal, or osteaomuscular flap. This flap is best used for defects below the level of the zygomatic arch. It is not advisable to use this flap if the tumor directly invades the muscle or if the neck dissection cannot be done adequately in order to preserve the pedicles, as oncological safety is the priority. The history of radiation is not an absolute contraindication [18] (**Figure 16**).

#### *2.2.3 The supraclavicular (SC) flap*

The supraclavicular flap is a versatile fasciocutaneous flap designed along the axis from the supraclavicular fossa extending over the shoulder. It is useful in the reconstruction of a variety of head and neck defects and can be ideal for pharyngeal and esophageal reconstruction [19].

Key anatomic landmarks are the SC triangle with identification of the cutaneous perforator of the supraclavicular artery. The supraclavicular flap is an elongated ellipse over the supraclavicular region with an inferior extension to the deltoid tip. It

**Figure 17.** *Supraclavicular flap for oral cavity reconstruction.*

can cover up to 8 cm of the defect. Flap elevation is done from distal to proximal, in a subfascial plane, and care should be taken to avoid injury of the cephalic vein on the ventral surface. Donor site can be closed primarily and drain placement is recommended (**Figure 17**) [18].

#### **2.3 Multidisciplinary approach: Free flaps and other types of reconstruction**

This kind of approach requires a multidisciplinary team, and the head and neck team must determine the approximate size of each tissue needed for reconstruction, thus communication is vital. Time management, especially when using tourniquets and gentle dissection of an intact vascular pedicle, is also of great importance. In addition, topical measures can assure viability: copious micro-irrigation with saline or heparinized lidocaine (2% lidocaine, 100 U/ml heparin) and papaverine irrigation (30 mg/mL). The free flap paddle should be manipulated while having a native supply. A delicate microsurgical technique and good pedicle geometry are the most important factors in microvascular anastomosis. The end-to-end anastomotic technique is the most commonly used. Postoperative monitoring is essential and visible flap inspection with pinprick can be supplemented by digital palpation and Doppler monitoring [3].

#### *2.3.1 Radial forearm free flap*

Radial forearm-free flap is considered the best choice for near-total laryngopharyngectomy defects, with high advantages, especially in tailoring options. Likewise, it has low donor site morbidity and can be harvested in one-stage surgery. It tolerates well postoperative radio-therapy and has seemed to have superior speech rehabilitation. As disadvantages, some authors report high complications rate, with stricture or fistula but which are manageable with conservative measures [20].

#### *2.3.2 The free jejunal flap*

In esophageal involvement, the free jejunal flap is a reliable way of reconstruction, with certain anatomical advantages. It is stated that up to 20 cm of jejunum can be harvested and as it comes along with the vascular mesentery, that allows obliteration of possible defects and protect the vascular structures of the neck. Deglutition rehabilitation seems to be earlier, but it may present with dysphagia because of uncoordinated peristalsis. Flaws of this flap are the quality of voice rehabilitation with excessive mucus production, the need for a microvascular reconstructive team, and in addition, abdominal surgical complications [21].

#### *2.3.3 Gastric pull-up reconstruction*

Gastric pull-up reconstruction is a surgical technique in which the stomach is brought, through the mediastinum to the neck along with the entire esophagus. The main indication for this procedure is esophageal carcinoma, with thoracic segment involvement. The main advantages are a great vascularization, with pedicle on the right gastric and gastroepiploic vessels, only one anastomosis is needed, one-step procedure, and the lowest stricture rate of all flaps. On the other hand, it presents high morbidity and mortality, with an overall incidence of complications of between 26% and 55%. Mediastinitis, difficulties in swallowing and voice rehabilitation, dumping syndrome are the main concerns postoperatively [4].

#### **2.4 Transoral surgery techniques**

As transoral surgery evolved, with even robotic-assisted (TORS), reconstructive ways for oropharyngeal defects should take into consideration structural features, such as creating an anatomic barrier between the neck and the pharynx and to ensure adequate coverage of the carotid artery. Functional considerations are restoring swallowing function, preserving speech and articulation, preventing aspiration, and maintaining velopharyngeal competence. Some authors created an algorithm that submits the factors determining more advanced reconstructions: number of subsides involved, exposure of the great vessels, communication with the neck, size of the defect (palate, tongue base), and radiation history. In defects with >50% of palatal defect, pharyngocervical communication and exposed carotid artery, after transoral robotic surgery, the authors recommend considering regional or free flaps [22].

Other authors found ingenious ways in TORS reconstruction, direct transposition of the ipsilateral naso-septal flap into the oropharynx via a trans palatal tunnel at the hard-soft palate junction [23].

As most centers and surgeons use more than one technique in reconstruction for hypopharyngeal carcinoma, multiple factors play in flap choice. Risk and benefit analysis is extremely important, especially for patients with circumferential loss of the pharyngoesophagus. Skin flaps have less donor morbidity than visceral flaps but are limited in obese patients. Free flaps need longer operative time but provide larger and more adaptable paddles for reconstruction [19] (**Figure 18**).

**Figure 18.** *Transoral surgery setup for base of the tongue carcinoma.*

#### **2.5 Biocompatible materials**

A possible alternative in reconstruction for esophageal defects can be Montgomery salivary bypass tube. Precisely, this tube has two spherical zones which enable better stability and optimal saliva leaking along of tube, regardless of the head and neck position. Silicon rubbers used in prosthesis construction are the most appropriate solution in terms of morbidity, biocompatibility, functionality, and bacterial and fungal biofilm formation. A study conducted in "Coltea" Clinical Hospital, ENT

department, Bucharest, concluded that insertion of a bacteriostatic agent, such as silver nanoparticles, decreases the fatigue strength, increases flexibility, and offers an optimal local protection solution against fungi development [6] (**Figures 19** and **20**).

#### **Figure 19.**

*Total circular pharyngolaryngectomy with radical neck dissection (note the carotid artery) and reconstruction with Montgomery salivary tube.*

#### **Figure 20.**

*Total circular pharyngolaryngectomy with radical neck dissection (note the carotid artery) and reconstruction with Montgomery salivary tube.*

#### **3. Improving QoL and rehabilitation**

#### **3.1 QoL after reconstructive surgery**

The European Organization of Research and Treatment of Cancer (EORTC) QoL questionnaire (QLQ) is an integrated system for assessing the health-related QoL (HRQoL) of cancer patients participating in international clinical trials. The core questionnaire, QLQ-C30, is composed of both multi-item scales and single-item measures. These include five functional scales, three symptom scales, a global health status/QoL scale, and six single items. Each of the multi-item scales includes a different set of items—no item occurs in more than one scale. All of the scales and single-item measures range in score from 0 to 100. A high scale score represents a higher response level. The scaling technique described above is based upon the widely applied Likert method of summated scales, in which the constituent items within each scale are simply summed. This makes several assumptions about the nature of the items, the most important of which are (a) that it is appropriate to give equal weight to each item, and (b) that each item is graded on a linear or equal-interval scale. The raw QLQ-C30 scores can be transformed into scores ranging from 0 to 100 [24].

Swallowing, mastication, and speaking are major factors that affect the HRQoL of patients one year after operation for pharyngeal cancer. Some authors advocate that flap reconstruction after oropharyngeal cancer surgery can improve patients' QoL postoperatively [25]. Furthermore, there are studies that conclude that still surgery should be considered as a first-line therapy for oropharyngeal cancer because the surgery-based group achieved equivalent treatment outcomes and slightly better QOL scores than the RT-based group [26].

If the cancer is diagnosed in the late stages, disfigurement, chewing, speech, and shoulder function can be significantly below the preoperative level throughout the follow-up. Sociodemographic factors, heavy drinking, and unemployment may be predictive factors of QoL. Still, there is data that claims that surgical treatment, even with free flaps reconstruction, can improve QoL, with direct influence on pain and improvement of diet [27].

In terms of HRQoL, more prospective and multicenter clinical trials should be performed.

#### **3.2 Deglutition rehabilitation**

After surgery, the visualization of pharynx is an essential part of a complete examination. Indirect view of the pharynx can be performed with either a mirror or a flexible fiberoptic endoscope. The procedure can be performed when patients are awake, and it is usually well-tolerated. The remaining pharynx can be seen with the mirror and inspected for asymmetry and any potential mucosal abnormalities [28].

Flexible fiberoptic endoscopy can be used for the simple evaluation of the pharynx and also for the assessment of the degree of dysphagia. Dysphagia is a common problem after neck surgery, with an incidence up to 70%, and contributes to compromised nutrition, weight loss which can both lead to diminished quality of life and decreased psychological well-being. Swallowing is a very complex physiological action that is rapid from the beginning to the end [28].

Fiberoptic endoscopic assessment of swallowing (FEES) is a portable procedure that may be completed in outpatient clinic space or at the bedside. FEES involves passing a

flexible endoscope through the nose and toward the pharynx to observe swallowing in real-time. FEES is a reliable and sensitive tool for assessing dysphagia [29].

American Speech-Language-Hearing Association (ASHA) states that a clinicalinstrumental evaluation of swallowing should reveal: organic and functional alterations in the structures involved, the degree of efficacy of swallowing in its various stages, adequate protection of the lower airways, and coordination between breathing and swallowing. Moreover, it should detect and possibly quantify any penetration of the bolus in the tracheal-bronchial tree. The diagnostic tools used for studying swallowing disorders should be able to assess the various movements that take place during all stages of swallowing in relationship to the type of bolus administered, as well as evaluate the efficacy of the rehabilitation procedures [30, 31].

In spite of the fact that FEES supplies limited information compared to videofluoroscopy because it only investigates the pharyngeal stage followed by a moment of "white-out" in the swallow, it is now employed as a routine procedure. Videoendoscopy permits a static and dynamic evaluation of the structures in the upper airways and upper digestive tract [30, 31].

After the static evaluation of the morphology and function of the upper airways and upper digestive tract, we can also perform a dynamic evaluation of swallowing. For that we administer a bolus to the patient. During the examination, compensatory positions may be kept to improve swallowing efficacy, and also therapeutic maneuvers can be applied in order to establish the appropriate rehabilitation approach for managing, feeding, and swallowing techniques. So, FEES offers the possibility to study the physiology of swallowing, the evaluation of the presence, degree, and type of dysphagia, and is also a good method for establishing the best means of feeding, for advising diets, and for planning any other diagnostic investigation [32].

During FEES we can also use narrow-band imaging (NBI). The optical NBI filter allows a narrow band light with two wavelengths (415 nm blue light and 540 nm green light) to penetrate the tissue to different depths, corresponding to the peaks of absorption of hemoglobin. NBI light is absorbed by vessels but reflected by mucosa, and thus, maximum contrast of vessels and the surrounding mucosa is achieved. Using filtered narrow banded light, pathological epithelial changes are better observed which improves the early detection of dysplasia and carcinoma and allows a better demarcation of benign lesions. Moreover, NBI also helps the assessment of swallowing. It allows better visualization of the bolus and generally leads to much sharper optical contrasts, especially under difficult examination conditions. Consequently, detection of smaller bolus quantities is enhanced and distinction of the bolus from surrounding structures is facilitated [33].

After the assessment of the dysphagia, the rehabilitation plan is determined firstly using postures. The chin-down posture pushes the anterior pharyngeal wall posteriorly, and the tongue base closer to the posterior pharyngeal wall, thus narrowing the airway entrance and reducing aspiration. The head-back posture uses gravity to clear the bolus from the oral cavity and is useful in patients who have difficulty with oral transit of the bolus. Head rotation toward the damaged side of the pharynx closes the damaged side so that the bolus flows down the more-nearly normal side. The lateral head tilt posture may be used for patients who have both unilateral oral and pharyngeal impairment on the same side [34].

In addition to the use of postures, swallow maneuvers may be added. Swallow maneuvers are designed to place specific aspects of the oropharyngeal swallow under voluntary control in order to improve the process. Moreover, some patients may benefit from the modification of bolus size and consistency which may also be

#### *Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

effective in eliminating aspiration in patients treated for head and neck cancer. For some patients, a larger volume bolus may be effective at eliciting a more rapid pharyngeal swallow by increasing the sensory input for the patient and so increasing

#### **Figure 21.**

*Free flap reconstruction after fistula complication with vocal prosthesis slightly migrated but with good functional outcome.*

awareness of the bolus in the oral cavity. However, patients who require multiple swallows to clear a single bolus will probably benefit from smaller bolus sizes in order to reduce residue and the risk of aspiration [34].

#### **3.3 Voice rehabilitation**

Voice rehabilitation is the result of some techniques in which a patient can reach a good functional outcome, with optimal social reinsertion. Voice handicap index, swallowing problems, stoma-related issues, and pain are the most important aspects that can influence QoL index after extensive pharyngeal and laryngeal surgery. Speech therapy, additional nursing care, and patient empowerment may influence the final result after surgery.

After oropharyngeal surgery with primary closure, voice and swallowing may be affected, and the use of radial forearm graft seems to allow a good function. On the other hand, regardless of the way of reconstruction, if the larynx is preserved, the persistence of aspiration/ penetration and consequently the need for a tracheostomy are factors that influence the voice.

After total laryngectomy, with a total separation of the aero-digestive system, air cannot reach higher structures involved in speech, but even though, the neopharynx that is sutured with different techniques can become a neoglottis with soundproducing capacity. Voice rehabilitation after total laryngectomy can be achieved by

esophageal speech (EP), use of an electrolarynx, or tracheoesophageal fistula with a vocal prosthesis (VP).

Tracheoesophageal speech (TES) with VP is the gold standard of voice rehabilitation after total laryngectomy. The main principle of the VP, as a unilateral valve, is that it redirects the exhaled air when the stoma is occluded. As a result, speech is possible as the air reaches the neopharynx, with secondary vibrations, and also the oral cavity. It is a relatively easy to learn technique, with primary placement possibility and low morbidity rates. On the other hand, ES is a difficult-to-learn technique, in which the air is injected with the tongue toward the pharynx and esophagus to make them vibrate. The electrolarynx is a device that produces vibrations and after placing it near the oral cavity, a robotic speech may be achieved.

Hypopharyngeal cancer surgical treatment, even in circular defects and with the need for total reconstruction can now benefit from voice rehabilitation with the use of vocal prosthesis. TES seems to be with good outcome after myofasciocutaneous free flaps and with a lower quality ("wet" or "gurgle" character) after free intestinal flaps. Although some authors claim that after PMMC flap reconstruction a successful TES can be hardly achieved, it has remained a critical reconstructive tool [4, 8] (**Figures 21**–**23**).

#### **4. Conclusion**

The pharynx, as a rendez-vous place of basic physiological and social needs—food intake, breathing, and social interactions, requires a stepped fashion cancer treatment, with a high focus on QoL. Reconstruction is probably one of the most demanding tasks for a head and neck surgeon and often implies a multidisciplinary approach for better outcomes. Keystones after surgery are speech, swallowing, and pulmonary rehabilitation.

#### **Conflict of interest**

The authors declare no conflict of interest.

All authors have contributed equally and would like to thank their colleagues for their considerable work and support.

### **Author details**

Paula Luiza Bejenaru1,2\*, Raluca Grigore1,3, Bogdan Popescu1,3, Alexandru Nicolaescu1,4, Mihnea Cojocărița-Condeescu1,3, Catrinel Simion-Antonie1,3, Gloria Berteșteanu1,5, Anca Cirstea1,3, Teodora Diaconu1,3, Bianca Taher1,3, Simona Rujan1,3, Dan Popescu1,6 and Șerban V.G. Berteșteanu1,3

1 "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania

2 Dr. Nicolae Kretzulescu" Medical Center for Diagnosis and Ambulatory Treatment, Bucharest, Romania

3 ENT Head and Neck Surgery Clinic, "Colțea" Clinical Hospital, Romania

4 ENT Head and Neck Surgery Compartment, "Prof. Dimitrie Gerota" Emergency Hospital of the Ministry of Internal Affairs, Romania

5 ENT Head and Neck Surgery Clinic, "Dr. Carol Davila" Central Military Hospital, Romania

6 ENT Department, Emergency County Hospital, Targoviste, Romania

\*Address all correspondence to: drpaulabejenaru@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

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*Pharynx Reconstruction and Quality of Life DOI: http://dx.doi.org/10.5772/intechopen.104411*

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## *Edited by Tang-Chuan Wang*

The pharynx is an incredible structure in the human body. The pharynx moves food or water from the mouth to the esophagus and moves air from the nasal and oral cavities to the larynx or voice box. There are some conditions that can cause the pharynx to not function properly, affecting digestion, respiration, phonation, or sleep. One of the most challenging conditions is pharyngeal cancer. This book provides a comprehensive overview of the pharynx and addresses advances in the treatment of pharyngeal disorders, including surgery and reconstruction techniques.

Published in London, UK © 2022 IntechOpen © Rost-9D / iStock

Pharynx - The Incredible Rendezvous Sites of Gas, Liquid and Solid

Pharynx

The Incredible Rendezvous Sites of Gas,

Liquid and Solid

*Edited by Tang-Chuan Wang*