International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 179-185
http://dx.doi.org/10.4236/ijohns.2013.25038 Published Online September 2013 (http://www.scirp.org/journal/ijohns)
A Simple Combined Antegrade Radiological and
Retrograde Endoscopic Procedure to Recanalise
Fibrotic Hypopharyngo-Oesophageal Occlusions:
Technical Description and Lessons from
Clinical Outcome in Three Cases*
Mohammed S. Miah1, Ian A. Zealley2, Afshin Alijani3, Barry McGuire4,
Rodney E. Mountain1, Suresh Mahendran 1#
1Department of Otorhinolaryngology-Head & Neck Surgery, Ninewells Hospital and
University of Dundee Medical School, Dundee, UK
2Department of Radiology, Ninewells Hospital and University of Dundee Medical School, Dundee, UK
3Department of Upper Gastrointestinal Surgery, Ninewells Hospital and University of
Dundee Medical School, Dundee, UK
4Department of Anaesthesia, Ninewells Hospital and University of Dundee Medical School, Dundee, UK
Received June 2, 2013; revised June 29, 2013; accepted July 9, 2013
Copyright © 2013 Mohammed S. Miah et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Complete hypophar yngo- o esoph ag eal o cclusion is a r ar e co mplication of h ead and n eck r ad ioth er apy an d
a range of other conditions. Absolute dysphagia is acco mpanied by aspiration and depend ence on gastrostomy feeding.
The condition presents a substantial management challenge. Surgical approaches to re-establish pharyngo-oesophageal
continuity are varied, highly invasive and are associated with unpredictable outcomes. Minimally invasive techniques
employing endoscopic and radiological techniques are emerging. This report describes a multidisciplinary approach
which translates two interventional radiology techniques used in the management of central venous occlusions and bil-
iary strictures to the management of three cases of complete hypopharyngo-oesophageal occlusion. Methods: Three
cases with different underlying aetiologies had treatment initiated between 2009 and 2011. Antegrade pharyngoscopic
access to the occlusions was accompanied by retrograde endoscopic access via a small gastrostomy. Luminal continuity
was re-established by the interventional radiology technique of “sharp recanalisation” followed by passage of a wide
bore nasogastric tube which was maintained in situ for 4 - 6 months, a duration of treatment analogous to that applied in
the radiological management of fibrotic biliary strictures. After treatment a radiological contrast swallows examination
was performed to gauge the calibre of the re-established lumen, assess functionality and to ru le out aspiration. Results:
Pharyngo-oesophageal continuity was re-established in all three cases on the first attempt. No complications occurred as
a result of the proced ures. In two cases, the excellent swallowing fun ction was re-established, although on e of these re-
quired prolonged post-treatment adjuvant interventions. In one case no swallowing function resulted, despite apparently
successful re-establishment of luminal continuity. Conclusions: Complete fibrotic o cclusion of the hypopharyngo-oeso-
phageal lumen is rare and presents a substantial management challenge. A minimally invasive treatment combining
antegrade radiological and retrograde endoscopic approaches resulted in successful re-establishment of luminal continu-
ity in three cases of complete fibrotic occlusion of the hypopharyngo-oesophageal lumen. However variable responses
to treatment suggest that both the underlyin g aetiology and the chronicity o f the occlusion may influence the likelihood
of a successful functional outcome. Until definitiv e management guidelines are estab lished, we suggest that such cases
are managed only by motivated multidisciplinary teams keen to develop their exp ertise in th is area.
Keywords: Hypopharynx; Upper Oesophagus; Fibrotic Occlusion; Rendezvous Technique; Pharyngo-Oesophageal
Continuity
*Meetings: The work was presented at the Tri-Society of Head & Neck Oncology Meeting on 2nd Septem ber 20 11 in Sin gapore.
#Corresponding a utho
r
.
C
opyright © 2013 SciRes. IJOHNS

M. S. MIAH ET AL.
180
1. Introduction
Complete fibrotic occlusion of the hypopharyngo-oeso-
phageal lumen is an uncommon but important complica-
tion of successful chemoradiotherapy treatment for head
and neck cancers [1]. Fibrotic occlusion may also occur
after head and neck surgery, corrosive ingestion, chronic
gastro-oesophageal reflux disease, neuromuscular disor-
ders or sepsis [2 ,3]. Affected patients are severely debili-
tated. Their absolute dysphagia necessitates dependence
on gastrostomy feeding but they remain at risk from sa-
liva aspiration.
A variety of techniques to re-establish the pharyngo-
oesophageal lumen have been described, including major
surgical procedures involving excision of the occluded
segment followed by reconstruction: this approach is as-
sociated with substantial surgical risk and outcomes are
unpredictable [2-5]. The surgical approach may require
multiple procedures followed by repeated dilatation pro-
cedures to maintain the established lumen.
We describe the successful translation of two interven-
tional radiology tech niques which h ave been successfu lly
applied successfully to re-establish anatomic pharyngo-
oesophageal continuity in patients without recourse to
major surgery. We present our experience managing
three patients with differing aetiologies and report out-
comes.
2. Materials and Methods
Between March 2009 and August 2011 three patients
with complete fibrotic occlusion s of the hypo pharynx /up-
per-oesophagus were referred to the otolaryngology de-
partment. All patients had complete dysphagia and were
dependent on gastrostomy tub e feeding.
2.1. Case 1
A 62-year-old male smoker developed absolute dys-
phagia soon after treatment of a T3N0M0 laryngeal car-
cinoma by chemoradiotherapy. Mucositis led to intoler-
ance of oral feeding and he became totally dependant on
his gastrostomy feeding tube. Once the mucositis had re-
solved it became apparent that he had developed absolute
dysphagia. Total occlusion of the hypopharynx/upper-
oesophageal segment was observed at rigid pharyngo-
scopy and at barium swallow (Figure 1(A)).
2.2. Case 2
A 76-year-old female presented with a 10-year histor y of
progressive dysphagia to solids and semi-solids associ-
ated with weight loss and recurrent ch est infections. This
was accompanied by episodes of absolute dysphagia. A
previous barium swallow had demonstrated delay in ini-
tiating swallowing with marked prominence of crico-
pharyngeus with proximal hold up in the hypopharynx.
There was a prior history of chronic gastroesophageal re-
flux disease and Sjogren’s syndrome. Previous flexible
oesophagoscopy had identified a tight cricopharyngeal
sphincter which led to rigid oesophagoscopy and dilata-
tion, this procedure being repeated a further five times,
followed by two external approach cricopharyngeal myo-
tomy procedures and three botulinum toxin injections.
These various procedures led to transient symptomatic
improvement but eventually the absolute dysphagia could
not be resolved and she became dependent on gastros-
tomy feeding. At this stage rigid pharyngoscopy and ba-
rium swallow demonstrated total fibrotic occlusion of the
pharyngo-oesop hageal lumen (Figure 1(B)).
2.3. Case 3
A 46-year-old male non-smoker presented with absolute
dysphagia two years after treatment of a T3N2M0 lateral
pharyngeal wall carcinoma with ablative and reconstruc-
tive surgery (split-lip mandibu lotomy, excision of tumour,
radial forearm free flap reconstruction and neck dissec-
tion). Post-operatively he had struggled with oral intake
and this deteriorated further during chemoradiotherapy:
as he developed significant mucositis he became totally
dependant on his gastrostomy feeding tube. Rigid pha-
ryngoscopy and barium swallow demonstrated total fi-
brotic occlusion of the pharyngo-oesophageal lumen (Fig-
ure 1(C)).
2.4. Technical Note
The principal aim of the re-canalisation procedure we de-
scribe is to re-establish anatomic pharyngo-oesophageal
continuity without recourse to major surgery. The tech-
nique we have employed to re-establish and maintain th e
pharyngo-oesophageal lumen involves adaptation of two
interventional radiology techniques; the first developed
to re-establish luminal co ntinuity in occluded great veins
in the mediastinum (the so-called “sharp recanalisation”
procedure) and the second developed to manage chal-
lenging bile duct strictures non-op eratively (Figure 2) [6 ,
7].
The procedure is performed under general anaesthetic.
The initial step is to establish that the occlusion is short.
If an occlusion had been greater than 3 - 4 cm in length
we would not have proceeded to the “sharp recanalisa-
tion” technique as the risk of injury to non-target struc-
tures in the neck would have been considered too high. A
rigid pharyngoscope is clamped into position such that
that the upper limit of the occlusion is both visualised
and accessible. Through an upper midline mini-laparo-
tomy (3 cm in length) the gastric body is delivered and a
12 mm conventional laparoscopic port is inserted into the
stomach and secured with a purse string suture. The

M. S. MIAH ET AL. 181
A B
C
Figure 1. Pre-treatment radiological contrast swallow im-
ages for Cases 1-3, labeled A-C respectively. In each case
complete occlusion of the hy popharyngo-oe sophageal lumen
is evident: no contrast passes into the cervical oesophagus.
Figure 2. Images A-D demonstrate the key elements of the
recanalisation procedure. A: Rigid pharyngoscopic view of
the upper limit of the occlusion; B: Retrograde flexible oe-
sophagoscopy via mini-laparotomy and gastrostomy; C:
Flexible oesophagoscopic view of the lower limit of the oc-
clusion; D: Endoscopic view of puncture through the oc clu-
sion using the radiological needle.
laparoscopic port thus creates a convenient air-tight ret-
rograde access into the stomach for the insertion of the
flexible oesophagoscope. The port also facilitates gastric
insufflation with carbon dioxide, in addition to the endo-
scopic gas insufflation, for better visualization and nego-
tiation of the gastro-oesophageal junction. The flexible
oesophagoscope is advanced up the oesophagus until the
lower aspect of the occlusion is encountered. Once the
antegrade pharyngoscope and the retrograde flexible oe-
sophagoscope are in place an image intensifier is posi-
tioned for lateral fluoroscopy of the cervical region.
Fluoroscopy is employed to gauge the length of the oc-
cluded segment. An interventional radiologist then uses a
long needle and co-axial catheter assembly (Rosch-Uchi-
da Transjugular Liver Access Set, Cook Medical, Amer-
sham, UK) to puncture across the occlusion from the
upper end, using a combination of direct visualization
and fluoroscopy for needle guid ance. Entry into th e distal
oesophageal lumen is confirmed by watching the flex ible
oesophagoscope images from below the occlusion. After
the co-axial needle and catheter assembly has been ad-
vanced into the oesophageal lumen below the occlusion
the needle component is withdrawn and a 260 cm stiff
radiological guidewire (Amplatz, Boston Scientific, Na-
tick, MA, USA) passed down the catheter into the distal
oesophageal lumen where it is grasped via the flexible
oesophagoscope, thus achieving “rendezvous” between
the patent lumen above and below the occlusion. The
guidewire is then withdrawn down through the distal oe-
sophagus and out through the mini-laparotomy, thereby
creating through-and-through guidewire access across the
occlusion.
Gentle dilatation of the occlusion is performed using
an 8 mm balloon catheter in order to create a channel
wide enough to accommodate passage of an 18 Fg Ryle’s
tube. In order to convert the per-oral guidewire access
across the occlusion into per-nasal access a radiological
catheter is inserted through the nose and its tip pulled out
of the mouth. The upper end of the guidewire is then fed
retrogradely into the tip of the per-nasal catheter and,
once a sufficient length of guidewire has been thus de-
ployed, the per-nasal catheter containing the upper end of
the guidewire is withdrawn back through the mouth and
nose until the guidewire is exiting per nares.
At this stage a modified 18 Fg Ryle’s tube is passed
over the guidewire and through the occlusion, under fluo-
roscopic guidance. The Ryle’s tube is modified by cut-
ting a cruciate incision in its tip in order that it may be
advanced over the guidewire with the smallest possible
profile: this manoeuvre avoids the larger, eccentric pro-
file which would result if the Ryle’s tube were advanced
over the guidewire via the side-hole at the tip of the tube.
Finally the Ryle’s tube is secured using a nasal septal
bridle and the gastrostomy and mini-laparotomy are
closed.
Postoperatively, the patients receive a seven day co urs e

M. S. MIAH ET AL.
182
of proton pump inhibitor to minimize the risk of bleed
from the gastrostomy site. A post-operative chest radio-
graph was performed to rule out a pneumomediastinum,
and the patients were observed closely in order to iden-
tify mediastinitis early should it develop. In all three
cases the Ryle’s tubes were left in-situ for a minimum of
4 - 6 months. This duration of dwell time was based on
long-term patency reported in analogous studies on the
percutaneous catheter management of fibrotic bile duct
strictures [7].
The patients were encouraged to swallow fluids as and
when they feel able, and were followed-up as outpatients
initially at two weeks and thereafter at two monthly in-
tervals to gauge tolerance of the treatment regime and
assess progress on swallowing. After 4 - 6 months rigid
pharyngoscopy under general anaesthetic was performed
to inspect and record the condition of the re-established
lumen, and the Ryle’s tubes were removed. Subsequently
a radiological water-soluble contrast swallow examina-
tion was performed to assess the patency and function of
the previously occluded segment.
3. Results
Re-establishment of pharyngo-oesophageal luminal pa-
tency was achieved using this technique was successful
on the first attempt in all three cases. A functional swal-
low was re-established in two of the three cases. No com-
plications were observed.
3.1. Case 1
During the recanalisation procedure the occluded seg-
ment was found to be 1.5 cm long. The patient reported
some discomfort from the presence of the Ryle’s tube but
tolerated its presence for the recommended duration.
During the later weeks of the treatment period the patient
reported symptoms consistent with bile reflux. At rigid
pharyngoscopy at the end of treatment a patent lumen
substantially wider than the Ryle’s tube itself was evi-
dent around the tube: there was also evidence of bile re-
flux (Figure 3). The patient tolerated oral fluids and soft
diet soon after removal of the Ryle’s tube. The subse-
quent radiological water-soluble contrast swallow study
demonstrated re-establishment of the hypopharynx/up-
per-oesophagus lumen with no hold up of contrast (Fig-
ure 4(A)). The previously occluded segment was found
to be distensible and no aspiration was observed. The
gastrostomy tube was removed two weeks after removal
of the Ryle’s tube. At 42 month follow-up the patient
was managing an oral diet, including most solids and all
fluids, and had gained 13 kilograms in weight. His emo-
tional affect, previously withdrawn and depressed, was
enormously improved. No further intervention has been
required.
3.2. Case 2
During the recanalisation procedure the occluded seg-
ment was found to be 2 cm long. The patient tolerated
the presence of the Ryle’s tube very well. However, de-
spite the fact that hypopharyngeal-oesophageal luminal
continuity was achieved using the technique described
the patient was unable to swallow fluids during the whole
of the treatment period, and also after removal of the
Ryle’s tube at 6 months. A radiological water-soluble
contrast study demonstrated a rat’s tail appearance of the
cervical oesophagus at the level of the previously re-
canalised occlusion, accompanied by dilatation of the oe-
sophagus above this level and hold up of contrast (Fig-
ure 4(B)). No active peristalsis was observed. To date,
this patient has not been able to produce a functional
swallow.
3.3. Case 3
During the recanalisation procedure the occluded seg-
ment was found to be 2 cm long. At rigid pharyngo scopy
the fibrotic occlusion appeared to be substantially more
dystrophic and distorted than the other two cases. This
patient did not tolerate the presence of the Ryle’s tube
well. An early re-inspection of the occlusion site was
performed at three months at the patient’s request. The
re-established lumen was found to be patent and expan-
sile clinically: the lumen accommodated the 18 Fg Ryle’s
tube alongside two fully inflated 8 mm balloon catheters
(Figure 5). Biopsies were taken and these demonstrated
the presence of active granulation tissue. In view of this
finding the patient agreed to persist with the Ryle’s tube
in situ for a further month. During this period intensive
swallow therapy support was also instituted. After a total
of four months of treatment the patient was still unable to
swallow fluids but reported reflux of gastrostomy feed
solution. The Ryle’s tube was removed and the patient
Figure 3. Rigid pharyngoscopic images of the mature re-
canalised hypopharyngo-oesophageal lumen in case 1 be-
fore (image A) and after (image B) removal of the Ryle’s
tube which had been in situ for six months. The diameter of
the lumen was substantially greater than the Ryles’ tube
itself. Bile reflux was evident after removal of the Ryle’s
tube (image B): this patient had reported symptoms of bile
reflux during the latter weeks of treatment.

M. S. MIAH ET AL. 183
continued with swallowing therapy exercises. Over the
next two months further balloon dilatation procedures
were performed under rigid pharyngoscope endoscopic
guidance in order to maintain the calibre of the recanal-
ised lumen during this extended period of swallowing
therapy exercises. Six months after the recanalisation
procedure the patient was swallowing fluids with ease,
and has subsequently been building up consistencies. A
radiological water-soluble contrast study at nine months
post re-canalisation demonstrated a patent and functional
pharyngo-oesophageal lumen (Figure 4(C)). At 18 months
follow-up, this patient is now managing soft diet and
semi-solids.
4. Discussion
Management of fibrotic hypopharyngo-oesophageal oc-
clusions presents a major challenge. Surgical resection of
the occluded segment and reconstruction carries substan-
tial procedural risks and outcomes are unpredictable [2,
3,8].
A
B
C
Figure 4. Post-treatment radiological contrast swallow im-
ages for Cases 1-3, labeled A-C respectively. Images A and
C demonstrate the functional recanalised hypopharyngo-
oesophageal lumen which was the final result for cases 1
and 3 respectively. Image B demonstrates the non-func-
tional outcome which was the final outcome for case 2.
There is a rat’s tail appearance in the cervical oesophagus
with no evidence of peristaltic activity, and hold up of con-
trast in the dilated hypophary nx above.
A
B
Figure 5. Rigid pharyngoscope images in Case 3 before
balloon dilatation (A) and during dilation of twin radio-
logical balloon catheters (B). The images demonstrate that
the recanalised lumen exhibits elasticity and that it can ac-
commodate the 18 Fg Ryle’s tube and two inflated 8 mm
balloon catheters simultaneously. Despite this apparently
excellent outcome this patient required extensive post-treat-
ment swallowing therapy and several further one-off dilata-
tion procedures before a satisfactory functional swallow
was re-established.
Interventional radiology “sharp recanalisation” tech-
niques applied from the upper end of the occlusion, with-
out simultaneous access at the lower aspect of the occlu-
sion, may be unsafe because of the potential for inadver-
tent puncture of non-target structures and creation of fis-
tulae to the pleura, lung, mediastinum, or airway [4,5].
The technique described is an adaptation of percuta-
neous, radiologically-guided approaches to the manage-
ment of occlusions of the great veins of the mediastinum
and bile duct strictures (Figure 2) [6,7]. Success rates for
recanalization of mediastinal great veins ranging between
80% - 100% [6] have been reported. The long term suc-
cess employing the technique with bile duct strictures is
dependent on the duration the stent is in situ with mini-
mum recommended duration of 6 months [7]. Further
support for this has been gained from our own experience
managing patients with severe hypopharynx/upper-oe-
sophagus strictures with radiological balloon dilatation

M. S. MIAH ET AL.
184
followed by long-term Ryle’s tube placement (several
months). We have previously reported durable functional
outcomes achieved with 1 - 4 years follow-up in three
patients [9].
Concurrent antegr ade-retrograde r endezvous technique
has been described previously, with different technical
approaches and variable outcomes [4,5,8,10,11]. Most
commonly the rendezvous technique relies on retrograde
flexible oesophagoscopy or fluoroscopy through the gas-
trostomy tube site. During an early attempt in our ex-
perience using this approach we attempted this manoeu-
vre but were unable to cannulate the oesophagus. This
may have been due to our inexperience and/or the invo-
lutional changes in the oesophagus and at the gastro-
oesophageal junction which occur after the prolonged
oesophageal redundancy which inevitably results from
the upstream occlusion. We had also learned of an at-
tempted retrograde oesophagoscopy via the gastrostomy
site at another centre which resulted in loss of continuity
at the gastrostomy site, requiring immediate laparotomy
for repair and creatio n of a second remote gastrostomy. It
was these experiences which led us to opt for securing
robust, controllable retrograde access by means of a
mini-laparotomy. This limited open surgical approach
was selected in preference to a laparoscopic approach in
view of the presence of local adhesions related to the
pre-existing gastrostomy feeding tube insertion. A further
difference between the technique described and previ-
ously reported rendezvous procedures is the long dura-
tion (4 - 6 months) of nasogastric tube placement which
follows the initial recanalisation procedure.
Oxford et al. and Maple et al. described the short term
use of nasogastric tubes as stents to maintain patency of
the re-established hypopharyngo-oesophageal lumen [8,
10] after serial balloon dilatations. In their series’ gas-
trostomy tube feeding was discontinued in 67% and 57%
respectively. Five of the six patients treated by Oxford et
al maintained hypopharyngo-oesophageal luminal pa-
tency with a minimum follow-up of 12 months. Two of
the seven cases described by Maple et al developed evi-
dence of oesophageal microperforation after their ren-
dezvous procedures, and a further case developed early
re-stenosis requiring repeated subsequent dilatation pro-
cedures. A paediatric case described by Zur et al. re-
quired seventeen dilatation procedures during an 18-
month period, accompanied by kenalog injections and
topical mitomycin-C application on two occasions [11].
An encouraging observation made at rigid pharyngo-
scopy at the end of the six month treatment period in the
first case described here was the large calibre of the re-
established hypopharyngo-oesophageal lumen in com-
parison to the diameter o f the Ryle’s tub e (Figure 3). We
hypothesise that this phenomenon may have been due to
continuous relative movement of the tube and the muco-
sal surface during the treatment period.
4.1. Anatomic versus Functional Outcome
The procedure described successfully re-established pha-
ryngo-oesophageal luminal continuity in all three cases
on the first attempt. However the varied outcomes indi-
cate that re-establishment of luminal continuity does not
necessarily confer the immediate return of a functional
swallow.
Two of the cases had fibrotic occlusion after oncologi-
cal treatment for pharyngeal cancers: Case 1 had chemo-
radiotherapy only whereas Case 3 had major ablative and
reconstructive surgery followed by radiotherapy. At the
time of recanalisation it was noted that Case 3 appeared
to have a greater extent of mature fibrosis than the other
cases. We speculate that this is due to two factors 1) the
presence of a free flap and 2) the prolonged interval to
the recanalisation attempt.
Of all 3 cases, Case 1 has clearly enjoyed the best out-
come developing a durable functional swallow imme-
diately after treatment. Case 3 required intensive swallow
therapy and repeated dilatations before also developing a
durable functional swallow: his own motivation and per-
severance have undoubtedly been an important contrib-
uting factor in this outcome.
Case 2 never established a functional swallow. While
the precise aetiology of the occlusion in this case was
unclear the history supported a diagnosis of chronic gas-
troesophageal reflux disease leading to stricture forma-
tion and even tually complete fibro tic occlusio n. The mul-
tiple prior interventions (five dilatations, two myotomies
and three botulinum toxin injections) may have exacer-
bated the neurological component of the chronic inflam-
matory process at the site of occlusion. Following appar-
ently successful treatment a radiological contrast swal-
low demonstrated complete absence of any muscular
contractility around the site of the recanalised occlusion.
It appeared that there was no effective propulsive force to
propel ingested fluid through the abundant, redundant
hypopharyngeal mucosa above the recanalised segment.
An attempt to place a stent across the recanalised seg-
ment was unsuccessful; a failure attributed to the pres-
ence of the excess mucosal tissue. No further interven-
tion is planned. This patient remains dependent on gas-
trostomy tube feeding.
The outcome in case 2 suggests that re-establishment
of functional swallow is more likely to be successful in
patients with no prior history of oesophageal dysfunction
before developing fibrotic occlusion. The outcome in
case 3 suggests that a combination of ablative and recon-
structive surgery with adjuvant treatments, followed by a
prolonged period of absolute dysphagia prior to the in-
tervention described, may have all contributed towards a
more protracted course to a functional outcome. The ex-

M. S. MIAH ET AL.
185
perience of the three cases suggests that some degree of
patient selection coupled with careful patient counseling
may be important if recanalisation procedures such as
that described are to be successful in re-establishing a
functional swallow. The scarcity of cases of complete
occlusion is reflected in the limited literature on mini-
mally invasive recanalisation techniques such as that de-
scribed. In view of this, and the varied outcomes de-
scribed in this manuscript, it is suggested that until de-
finitive advice on patient selection and recanalisation
techniques has been developed these cases are managed
only in centres where efforts are being made to develop
an experience base. It is also suggested that a multidisci-
plinary team approach, with detailed prospective plan-
ning and patient education, is necessary for minimally
invasive recanalisation therapy techniques such as this to
be effective.
4.2. Ethical Considerations
Thankfully despite the increasing use of chemoradio-
therapy as primary treatment modality in locally ad-
vanced malignancies of the upper aerodigestive system
especially those with Human Papilloma Virus associated
aetiology, cases of complete fibrotic occlusion are rare.
Although the technique described is novel it is, in effect,
merely an adaptation of existing surgical and, interven-
tional radiology procedures for which complications and
outcomes are established. This background of a transla-
tional approach to therapy formed the basis of our dis-
cussion with all three patients. However they were also
informed that the combination of techniques was novel
and that consequently the outcomes pertaining to swal-
low could not be predicted with any degree of certainty.
All three patients benefited from a multidisciplinary team
approach and w ere fully co gnisant of the fact that the ex-
perience base for minimally invasive recanalisation pro-
cedures such as that described is small and in evolution.
5. Conclusion
Total fibrotic occlusion of the hypopharynx/upper-oe-
sophagus tract is rare but poses a substantial man ag ement
challenge. The minimally invasive recanalisation de-
scribed combines elements of existing surgical and inter-
ventional radiology techniques, none of which require
extraordinary or unusual experience or expertise. Al-
though luminal continuity was re-established in all three
cases, the variable outcomes suggest that the underlying
aetiology and the chronicity of the occlusion may be im-
portant variables influencing the likelihood of re-estab-
lishing a functional swallow. We suggest that until de-
finitive management algorithms can be developed, this
type of procedure only be performed for patients who
ave been appropriately counseled and only by motivated
multidisciplinary teams who are keen to develop their
expertise in this area.
h
REFERENCES
[1] H. B. Caglar, R. B. Tishler, M. Othus, et al., “Dose to
Larynx Predicts for Swallowing Complications after In-
tensity-Modulated Radiotherapy,” International Journal
of Radiation Oncology Biology Physics, Vol. 72, No. 4,
2008, pp. 1110-1118. doi:10.1016/j.ijrobp.2008.02.048
[2] M. Chirica, C. de Chaisemartin, N. Munoz-Bongrand, et
al., “Colonic Interposition for Esophageal Replacement
after Caustic Ingestion,” Journal De Chirurgie (Paris),
Vol. 146, No. 3, 2009, pp. 240-249.
[3] J. W. Hong, H. S. Jeong, D. H. Lew, et al., “Hypopharyn-
geal Reconstruction Using Remnant Narrow Pharyngeal
Wall as Omega-Shaped Radial Forearm Free Flap,” Jour-
nal of Craniofacial Surgery, Vol. 20, No. 5, 2009, pp.
1334-1340.
[4] S. J. Tang, S. Singh and J. M. Truelson, “Endotherapy for
Severe and Complete Pharyngo-Esophageal Post-Radia-
tion Stenosis Using Wires, Balloons and Pharyngo-Eso-
phageal Puncture (PEP) (with Videos),” Surgical Endo-
scopy, Vol. 24, No. 1, 2010, pp. 210-214.
[5] B. Pogorzelski, R. Kiesslich and W. Mann, ”Rendezvous
Technique for Complete Hypopharyngeal Stenosis. Indi-
cations and Variations of Combined Endoscopy,” HNO,
Vol. 57, No. 8, 2009, pp. 781-788.
[6] S. Athreya, P. Scott, G. Annamalai, et al., “Sharp Re-
canalization of Central Venous Occlusions: A Useful
Technique for Haemodialysis Line Insertion,” British
Journal of Radiology, Vol. 82, No. 974, 2009, pp. 105-
108. doi:10.1259/bjr/19820366
[7] S. Misra, G. B. Melton, J. F. Geschwind, et al., “Percuta-
neous Management of Bile Duct Strictures and Injuries
Associated with Laparoscopic Cholecystectomy: A Dec-
ade of Experience,” Journal of the American College of
Surgeons, Vol. 198, No. 2, 2004.
doi:10.1016/j.jamcollsurg.2003.09.020
[8] J. T. Maple, B. T. Petersen, T. H. Barron, et al., “Endo-
scopic Management of Radiation-Induced Complete Up-
per Esophageal Obstruction with an Antegrade-Retro-
grade Rendezvous Technique,” Gastrointestinal Endo-
scopy, Vol. 64, No. 5, 2006, pp. 822-828.
doi:10.1016/j.gie.2006.06.026
[9] M. S. Miah, I. A. Zealley, R. E. Mountain and S. Mahen-
dran, “Severe Benign Hypopharynx/Upper-Oesophageal
Strictures: Successful Treatment with a Novel Interven-
tional Radiology Technique in Three Patients,” Clinical
Otolaryngology, Vol. 37, No. 4, 2012, pp. 313-317.
[10] L. E. Oxford and Y. Ducic, “Retrograde Balloon Dilation
of Complete Cervical Esophageal and Hypopharyngeal
Strictures,” The Journal of Ototaryngotography, Vol. 55,
No. 5, 2006, pp. 327-331. doi:10.2310/7070.2005.0127
[11] K. B. Zur, P. E. Putnam and M. J. Rutter, “Combined
Retrograde and Anterograde Hypopharyngeal Puncture
and Dilatation in a Child with Complete Hypopharyngeal
Stenosis,” International Journal of Pediatric Otorhino-
laryngology, Vol. 71, No. 1, 2007, pp. 153-157.
doi:10.1016/j.ijporl.2006.07.023