Otolaryngologist-assisted fluoroscopic-guided nasogastric tube placement in the postoperative laryngectomy patient.

INTRODUCTION Enteral tube feeding is the preferred method of nutrition for patients unable to take nutrition by mouth, but who maintain adequate gastrointestinal function, especially in the hospital setting. Following total laryngectomy, enteral feeding through a nasogastric tube (NGT) is maintained for a period of days to weeks to allow for adequate nutritional support and postoperative healing. The anastomosis and proper healing of the neopharynx is critical for postoperative swallow function, speech, and prevention of wound complications, such as fistulae formation. An NGT may be used postoperatively and is typically removed after the patient passes a barium swallow leak test. In the perioperative setting, the NGT allows for noninvasive and nonpermanent enteral access that is readily reversible and well tolerated. Traditionally, an NGT is placed in the operating room (OR) at the time of laryngectomy. Despite best efforts at securing the NGT, reinsertion may be necessary due to clogging, misplacement, or accidental removal. Several techniques are available for replacement, including blind insertion, placement with the assistance of a fiberoptic nasolaryngoscope or pediatric gastroscope, or direct visualization in the OR. Any technique used in the acute postoperative setting should minimize trauma to the neopharyngeal suture line in an effort to prevent dehiscence and leak. We have found fluoroscopic guidance for NGT replacement in the laryngectomy patient to be safe, effective, and reliable. The otolaryngology and radiology literature have ample studies comparing techniques of NGT placement. However, few studies specifically address the challenge of gaining enteral access in the postoperative laryngectomy patient. Furthermore, there is a lack of discussion of fluoroscopic guidance of NGT placement that specifically addresses the passage of the NGT over the neopharynx. Fluoroscopic-guided NGT replacement provides an alternative minimally invasive technique for gaining enteral access when bedside flexible endoscopy or direct visualization in the OR is not feasible. The reasons for failure at bedside endoscopy NGT placement may range from difficulty visualizing the anatomy with the endoscope to intolerance of simultaneous NGT placement and nasal endoscopy. As fluoroscopic guidance may be more time intensive and costly, we advocate for a trial of fluoroscopic-guided NGT placement only after an unsuccessful attempt at bedside placement with nasopharyngoscopy guidance. The technique may also be appropriate in any patient with complicated anatomy following head and neck reconstructive surgery. In this article, we describe relevant anatomy seen in lateral neck films of the postlaryngectomy patient, case examples, and the specific setup for and technique of otolaryngologist-assisted fluoroscopic-guided NGT placement. Our technique employs a team approach, including an otolaryngologist, radiologist, radiology technologist, and the patient. An otolaryngologist familiar with patientspecific procedure and anatomy is ideally equipped to perform the NTG placement.