Pharyngocutaneous Fistula after Total Laryngectomy: IFOS Consensus on Prevention, Diagnosis, and Management.

IMPORTANCE:Significant international variations exist for prevention methods, diagnostic, and management criteria for pharyngocutaneous fistula. OBJECTIVE:To formulate best practice management guidelines for pharyngocutaneous fistula after total laryngectomy. DESIGN:Modified Delphi consensus study conducted between January 2024 and November 2025 using two rounds of a structured survey. Levels of consensus were evaluated through a 9-point Likert scale and predefined cutoffs: strong consensus (≥ 80% in 7-9 range, median ≥ 9), consensus (≥ 80% in 7-9 range, median 8-9), near-consensus (≥ 70% in 7-9 range), or no-consensus (< 70% agreement). SETTING:International multicenter study. Participation of experts from 18 countries of America, Europe, Asia, South America, and Oceania, under the guidance of the International Federation of Oto-rhino-laryngological Societies (IFOS). PARTICIPANTS:A multidisciplinary international panel of 36 experts in head and neck surgery, otolaryngology, radiation oncology, radiology, and plastic surgery. The panelists were chosen for their clinical expertise in the area of total laryngectomy and pharyngocutaneous fistula management; published work in the form of peer-reviewed publications, as well as geographical representation. MAIN OUTCOMES AND MEASURES:The level of consensus in 59 statements regarding fistula definition and classification, preoperative risk factors, prevention strategies, diagnostic modalities, conservative management protocols, surgical intervention criteria, nutritional support, and patient outcomes. RESULTS:A consensus or strong consensus was reached on 30 of 59 statements (50.8%). Strong consensus levels were reached for preoperative nutrition optimization (median 9.0), postoperative enteral feeding support (median 9.0), standardized surveillance protocols (median 9.0), and revision surgery for persisting fistulae (median 9.0). Consensus was also achieved for the use of vascularized tissue reinforcement in selected high-risk settings, although the preferred reconstructive strategy varied according to flap type and clinical scenario. Of the 29 statements, 5 (8.5%) were excluded at Round 1 as a result of conceptual repetition as highlighted by panel feedback, and 24 (40.7%) did not reach consensus after both rounds, including fistula classification systems, prophylactic salivary bypass tubes, time to resume oral feeding postoperatively and negative pressure wound therapy. CONCLUSIONS AND RELEVANCE:This Delphi study from an international panel provides areas of agreement and ongoing equipoise across the prevention, diagnosis, and management of PCF, while demonstrating significant practice variability in terms of their classification, the use of prophylactic interventions, and conservative therapies.