Management of post-operative fistula in head and neck surgery: Sweeping it under the carpet?

Table 2 Advantages and disadvantages of dressings used in management of post-operative head and neck fistula

Wound products	Advantages	Disadvantages
Simple wet-to-dry/wet-to-moist dressing	Affordable Readily available No special training/dedicate wound nurse	Require frequent changes, sometimes multiple times a day Cannot be used when wound is high output or exudative Traumatize tissue and disrupt granulation
Hydrocolloid based	Provide microdebridement Maintain moist wound bed Promote granulation and epithelization Readily available Evidence supported use on bone	Limited absorbent capacity Malodourous Rigid form factor made it difficult to apply; limited use in wound with deep tracts, undermining May irritate/dessicate perifistular skin May adhere to wound bed and cause pain when removed
Hydrogel based	May be applied to moderately exudative wound Easy to remove, can be changed daily Maintain moist wound bed Promote granulation and epithelization Mildly analgesic	May not work in highly exudative/high output wound May irritate/macerate perifistular skin Malodorous Require secondary dressing
Silver-coated	Provide autolytic debridment Proven anti-microbial efficacy and decreases bioburden Promote granulation and epithelization May be applied to highly exudative wound	Costly Different silver products have different properties; no reliable evidence supporting one product over another May cause discoloration or dermatitis of perifistular skin
Honey-impregnated	Can be changed every other day or longer depends on need Affordable Anti-odor Anti-microbial Mildly analgesic Moisturize and maintain perifistular skin	Conflicting evidence Only one brand formally approved for Medical use: MedihoneyTM (United States) Different honey from different bees and/or flower species have different efficacy
Negative wound pressure therapy	May be applied to highly exudative wound Little data on safety profile and side effects, especially in diabetic Proven efficacy Promote granulation Promote vascularization Can be used in highly exudative wound Can be combined with other products (Dakin’s solution, octanidine…) to add anti-microbial effect	Technically challenged to achieve airtight seal, especially when fistula is in communication with the aerodigestive tract May require bedside procedure to divert fistula if near tracheostomy Moderate cost Controversy surrounding use directly on vessels Require experience/training and dedicated wound team Dressing change can be painful to patients