Delayed Pneumothorax and Progressive Laryngeal Edema Following Rib-Including Pectoralis Major Osteomyocutaneous Flap for Mandibular Reconstruction in a Patient With Post-Chemoradiation Head and Neck Cancer

Do-Won Kwon; Myung Chul Lee; Young Chang Lim; Joon Yong Park

doi:10.3342/kjorl-hns.2025.00374

Abstract

We report a rare case of delayed pneumothorax and persistent laryngeal edema following mandibular reconstruction using a rib-including pectoralis major osteomyocutaneous flap in a high-risk post-chemoradiation patient. A 53-year-old cachectic male with a history of chemoradiotherapy for hypopharyngeal carcinoma developed a second primary squamous cell carcinoma of the right buccal mucosa with mandibular invasion. Due to multiple comorbidities and prior radiation, he underwent segmental mandibulectomy and reconstruction using a pectoralis major flap incorporating a vascularized fifth rib segment. The postoperative course was complicated by delayed right-sided pneumothorax requiring chest tube drainage and progressive laryngeal edema requiring tracheostomy and enteral feeding. These complications were likely due to prior irradiation, rib harvesting, and impaired healing. This case demonstrates the feasibility of rib-including pectoralis major flaps for salvage mandibular reconstruction when free-flap surgery is contraindicated, and highlights the importance of prolonged multidisciplinary surveillance of delayed thoracic and airway complications in previously irradiated patients.

Key words: Head and neck neoplasms ㆍ Postoperative complications ㆍ Reconstructive surgical procedures

Introduction

Mandibular reconstruction following oncological resection of oral cavity cancers remains a major challenge in head and neck surgery. Segmental mandibulectomy for buccal mucosal squamous cell carcinoma (SCC) results in composite defects requiring restoration of both bone and soft tissue to preserve essential functions such as mastication, swallowing, speech, and aesthetics. Reconstructive success is directly tied to the postoperative quality of life and is thus a crucial component of surgical planning.

The fibular osteocutaneous free flap is the gold standard for mandibular reconstruction because of its consistent vascular anatomy, sufficient bone length, and suitability for dental implantation [1]. Alternatives such as the scapular free flap offer excellent chimeric design flexibility and are favorable for curved or lateral defects [2], whereas the radial forearm osteocutaneous flap provides a thinner, pliable soft tissue coverage with lower donor-site morbidity [3].

However, microvascular techniques are not always feasible in patients with prior radiation, poor nutritional status, or comorbidities. Pedicle flaps, particularly the pectoralis major osteomyocutaneous flap (PMOMCF) with a vascularized rib, provide a single-stage reconstruction without microvascular anastomosis [4].

Despite its utility, data on PMOMCF use in previously irradiated patients and related complications remain limited. We report a case of mandibular reconstruction using a PMOMCF in a cachectic patient with prior chemoradiotherapy. The case highlights complications including delayed pneumothorax and persistent laryngeal edema, emphasizing the need for long-term vigilance.

Case

A 53-year-old male with prior hypopharyngeal SCC (cT2N2cM0), treated with definitive chemoradiotherapy (70 Gy in 33 fractions with cisplatin), presented with a right buccal mucosa mass. He had liver cirrhosis, coronary artery disease, and a 30-year smoking history. He remained disease-free for 4 years.

Biopsy revealed moderately differentiated SCC. Imaging showed a 3.0 cm lesion with mandibular cortical erosion but no nodal or distant metastasis. The preoperative CT imaging and endoscopic findings are shown in Fig. 1. Initially, definitive radiotherapy was considered; however, given the patient’s relatively young age and strong preference for curative surgical treatment, operative management was planned.

The patient underwent wide excision, segmental mandibulectomy, right elective neck dissection (levels I-III), and temporary tracheostomy. Given his prior radiation, cachexia (body mass index [BMI]: 13 kg/m²), and comorbidities, free flap reconstruction was deemed high-risk. A PMOMCF with a 5th rib segment (5×1.5 cm) and a 5×6.5 cm skin paddle was used. The rib segment was harvested following the technique described by Shunyu, et al. [4], with careful preservation of the intercostal vessels and periosteal perforators arising from the internal thoracic artery. Dissection was performed in a subperiosteal plane to ensure vascular integrity. This approach minimizes pleural injury and enhances graft viability without requiring microvascular anastomosis. A titanium plate secured the defect. The flap was used to reconstruct the buccal mucosa and floor of the mouth. Intraoperative photographs of the mandibulectomy defect, flap design, and reconstruction are shown in Fig. 2.

Postoperative recovery was initially uneventful. Tracheostomy was decannulated at 2 weeks. However, on postoperative day (POD) 26, follow-up CT revealed screw loosening, which was corrected the next day under local anesthesia.

By the third week, the patient began a liquid diet, but developed throat pain and reduced oral intake. Laryngoscopy revealed progressive diffuse supraglottic swelling. Dexamethasone administration resulted in a partial improvement in symptoms; however, the edema worsened after the discontinuation of corticosteroids.

Approximately 2 months after surgery, while preparing for postoperative chemoradiation therapy, the patient developed acute dyspnea and right-sided chest pain. Imaging confirmed delayed right pneumothorax on POD 64, which was managed with immediate chest tube drainage. Given the patient’s history of radiation, rib harvesting, and chronic coughing, a delayed pleural defect was suspected. The chest tube was removed on POD 91 after nearly 1 month of maintenance.

Despite no radiological or endoscopic evidence of tumor recurrence, laryngeal edema aid fibrosis progressed and became functionally significant. Adjuvant intensity-modulated radiotherapy (60 Gy delivered in 30 fractions) without chemotherapy was initiated on POD 69. However, beginning on POD 92, the patient experienced recurrent aspiration pneumonia with cultures revealing Pseudomonas and Candida species, prompting a respiratory medicine consultation. On POD 106, a second tracheostomy was performed due to secretion retention and airway compromise. After stabilization and antibiotic therapy, the patient was discharged on POD 127. Follow-up photographs were taken showing the right lower facial region and the intraoral flap site. These images demonstrate favorable healing of the surgical site and successful mucosalization of the flap (Fig. 3).

At the latest follow-up (POD 240), there was no clinical or radiological evidence of tumor recurrence. However, persistent laryngeal edema and fibrosis continued to compromise airway and swallowing functions. The patient remained dependent on tracheostomy and nasogastric tube (Levin tube) feeding. Fig. 4 shows delayed complications, including a right pneumothorax on POD#64 (Fig. 4A) and progressive supraglottic edema on postoperative laryngoscopy (Fig. 4B).

This study was approved by the Institutional Review Board (IRB) of Konkuk University Medical Center (IRB No. KUMC 2025-05-041), and informed consent was waived.

Discussion

Mandibular reconstruction following oncologic resection in previously irradiated patients with head and neck cancer presents substantial challenges owing to compromised vascularity, poor wound healing, and increased surgical morbidity. Although osteocutaneous free flaps of the fibula, scapula, and radial forearm remain the gold standard for mandibular reconstruction owing to their structural and functional advantages [1-3], patients with significant systemic comorbidities, prior high-dose radiotherapy, or severe cachectic status may be unsuitable candidates for microvascular procedures.

Pedicle flaps are viable alternatives in such cases. The PMOMCF incorporating a vascularized rib segment, although infrequently used in current practice, provides a one-stage reconstruction option capable of restoring both bony continuity and soft tissue volume without requiring microsurgical expertise [4]. In our case, this flap was selected because of the patient’s poor surgical profile, including liver cirrhosis, prior chemoradiotherapy, and a BMI of 13 kg/m².

A unique and instructive complication in this patient was the development of delayed pneumothorax approximately 2 months postoperatively. Although intraoperative pleural tears during rib harvesting are documented risks [4], delayed presentation is extremely rare and, to the best of our knowledge, has not been reported in the context of reconstructive surgery. Rib harvesting, particularly from the 5th or 6th rib, poses a risk of subclinical pleural injury owing to the anatomical proximity of the parietal pleura. Even in the absence of intraoperative signs of pleural violation, microtears may remain undetected initially, leading to slow air leakage or delayed pneumothorax.

Although thoracic radiation was not administered to this patient, the delayed resolution may have been influenced by local pleural disruption from the rib harvest, chronic coughing, and the patient’s cachectic state, all of which impaired tissue healing and pleural adhesion formation. Similar prolonged pleural space pathology has been described in the trauma literature [5,6].

Importantly, delayed pneumothorax has been observed in patients with minor rib fractures, often several days after trauma. In a large cohort, fractures of the third to ninth ribs were significantly associated with delayed pulmonary complications, including pneumothorax [7]. Another study identified subcutaneous emphysema, as a predictor of delayed pneumothorax, even when initial imaging was unremarkable [8]. These findings suggest that microinjuries, even in atraumatic or controlled surgical settings, may manifest with a significant delay. In our patient, the fifth rib harvest site may have served as a latent point of pleural weakness, which was gradually exacerbated by the chronic cough and poor healing.

Another critical complication was persistent and progressive laryngeal edema that emerged postoperatively and ultimately required long-term tracheostomy and tube feeding. While chronic radiation-induced lymphedema or fibrosis is a well-documented late effect, the sudden onset of symptoms following airway manipulation raises the possibility of a radiation recall-like phenomenon or a “second hit” reaction. The “second hit” hypothesis posits that previously irradiated tissues, although clinically quiescent, remain biologically primed for exaggerated responses to physiologic stress [9].

Radiation recall is a well-recognized but poorly understood inflammatory reaction in previously irradiated tissues triggered by systemic agents, mechanical stimuli, or other stressors. Although it most commonly affects the skin, mucosal and deeper tissues such as the larynx can also be affected, manifesting as edema, pain, or ulceration [10]. Proposed mechanisms include dysfunctional stem cell repair, persistent subclinical inflammation, dysregulated cytokine release, and vascular or autonomic dysregulation. These factors may explain why seemingly stable laryngeal tissues exhibit exaggerated edema after surgical manipulation or intubation in previously irradiated patients.

Although our patient exhibited partial steroid responsiveness, this should not be interpreted as a definitive reversibility. Previous studies have suggested that radiation-related laryngeal edema may demonstrate fluctuating steroid sensitivity, with long-term outcomes determined more by structural tissue changes than by acute inflammation. In rare instances, this phenomenon has been described as radiation recall supraglottitis, in which the previously irradiated laryngeal tissue becomes inflamed after minor surgical or airway stimuli [11].

In a retrospective cohort of patients with post-radiation head and neck cancer, 54% developed chronic laryngeal edema, with approximately 9% requiring tracheostomy due to persistent airway compromise [12]. These findings underscore the need for proactive airway surveillance, early anti-inflammatory intervention, and multidisciplinary care planning in high-risk surgical candidates with a history of head and neck irradiation. Furthermore, several clinical studies have highlighted the increased incidence of postoperative airway complications such as laryngeal edema and dysphagia in patients with prior head and neck radiotherapy, especially when procedures such as transoral surgery, endoscopic resection, or tracheal anastomosis are performed [13-15].

This case underscores the need for long-term multidisciplinary surveillance of high-risk patients undergoing nonmicrovascular reconstruction, particularly when rib harvesting or airway manipulation is involved. Thoracic and airway complications may arise with significant delays even in the absence of intraoperative events, requiring prompt recognition and sustained management.

In conclusion, PMOMCF can be a feasible reconstructive option for patients ineligible for free-flap surgery. Surgeons should anticipate delayed thoracic and airway complications, particularly in post-radiation settings. Comprehensive perioperative planning and monitoring is critical for optimizing outcomes.

Notes

Acknowledgments

None

Author Contribution

Conceptualization: Joon Yong Park. Data curation: Do-Won Kwon, Joon Yong Park. Formal analysis: Joon Yong Park. Investigation: Do-Won Kwon. Methodology: Joon Yong Park. Project administrations: Joon Yong Park. Supervision: Young Chang Lim, Joon Yong Park. Validation: Young Chang Lim, Joon Yong Park. Visualization: Joon Yong Park. Writing—original draft: Do-Won Kwon, Joon Yong Park. Wrting—review & editing: Myung Chul Lee, Young Chang Lim, Joon Yong Park.

Fig. 1.

Preoperative imaging and endoscopic findings. A: Axial view of contrast-enhanced neck CT shows a soft tissue mass involving the right buccal mucosa (red arrow), consistent with buccal squamous cell carcinoma. B: Coronal view of non-contrast neck CT reveals cortical bone erosion of the right mandibular body (yellow arrow), indicating tumor invasion. C: Laryngoscopic image demonstrates mucosal irregularity and discoloration on the right buccal mucosa (green arrow), correlating with the primary tumor site.

Fig. 2.

Intraoperative procedure and flap design for mandibular reconstruction. A: Intraoperative view following segmental mandibulectomy shows the composite defect involving the right buccal mucosa, mandibular body, and floor of mouth. B: Preoperative skin marking for the planned pectoralis major myocutaneous flap (PMMC) including a vascularized fifth rib segment. C: Immediate postoperative view after inset of the osteomyocutaneous PMMC flap and fixation of a titanium reconstruction plate bridging the mandibular defect.

Fig. 3.

Postoperative follow-up photographs after mandibular reconstruction using pectoralis major osteomyocutaneous flap. A: External view of the right lower face and neck showing healed surgical scars and reconstructed contour at 2 months postoperatively. B: Intraoral endoscopic view demonstrating mucosalized flap covering the buccal mucosa and reconstructed floor of mouth at 8 months postoperatively.

Fig. 4.

Radiologic and endoscopic findings of delayed complications. A: Chest X-ray (posteroanterior view) obtained on postoperative day 64 reveals right-sided pneumothorax prior to intervention. Arrows show the visceral pleural line of the collapsed lung in pneumothorax. B: Laryngoscopic image showing significant supraglottic mucosal edema and fibrosis compromising the airway.

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