Tracheoesophageal Puncture

Prior to the 1970s, rehabilitation of aphonia following a total laryngectomy (TL) was accomplished using esophageal speech or through the use of mechanical or electrical devices.

Esophageal speech requires the patient to volitionally swallow air via the neopharynx and emit the air while articulating, as with normal speech. This produces a belchlike understandable speech. ^[1] Instead of using the vocal fold vibration as the sound source, this is replaced by the vibration of the pharyngeal walls. Many patients are able to teach themselves to speak to a degree in this manner, but fluency remains a challenge. Working with a speech pathologist can increase the fluency and clarity of their speech. The major advantage of this technique is the lack of any necessary prostheses or external devices.

In contrast, the mechanical larynx has been a mainstay in voice restoration. The early pneumatic devices were supplanted by electrical vibratory electrolarynges in the 1940s. Using these devices, speech is generated via an external vibration of the air column within the upper aerodigestive tract, combined with speech articulations, as in esophageal speech. The early learning period for this technique is short, and a reproducibly understandable voice can be quickly accomplished. The downsides to using an electrolarynx include an unnatural, mechanical, and often monotonal quality to the voice, as well as the necessity of a device itself. The device relies on battery power, may break, and may not be covered by the patient’s insurance.

First described in 1980 by Singer and Blom, ^[2] tracheoesophageal puncture (TEP) with prosthesis placement affords the clarity of esophageal speech without the volitional need to ingest and expel air. Their simple technique involves the surgical placement of a one-way valve between the tracheostoma and neopharynx, which allows air to be shunted on demand through the neopharynx and produce speech similar to esophageal speech. The one-way valve prevents retrograde flow from neopharynx to the trachea and prevents aspiration. Multiple advances have been made in prosthesis design and construction (including the advent of hands-free adjuvant devices), surgical technique, as well as in the timing of the procedure over the past 3 decades.

Patients undergoing total laryngectomy (TL) or those that are status post TL are candidates for tracheoesophageal puncture (TEP) with prosthesis placement. ^{[3, 4, 5]}

Contraindications to tracheoesophageal puncture (TEP) are few, and most are relative. Absolute contraindications include a subtotal laryngectomy, such as a cordectomy, hemilaryngectomy, supraglottic laryngectomy, or near-total laryngectomy. Additionally, separation of the space between the esophagus and tracheostoma (party wall), or a total laryngopharyngoesophagectomy with gastric pull-up ^[4] are contraindications for a primary tracheoesophageal puncture because this necessarily creates a potential space for infection or abscess.

Relative contraindications include poor pulmonary function, ^{[4, 5]} which decreases the ability to use the prosthesis due to the need for relatively higher positive pressures in the trachea; a strong alcohol drinking habit, ^[5] which increases the possibility of aspiration and complications; and an inability to maintain the prosthesis, ^{[4, 5]} either due to a lack of manual dexterity or impaired mental status. Concerns for maintenance of the prosthesis may also be noted for the uninsured, poorly-insured, or those with financial limitations, due to the ongoing costs of caring for and replacing the prosthesis.

Best practices

Both primary (time of TL) and secondary (another procedure after TL) tracheoesophageal puncture (TEP) are viable options, and each has its positive and negative aspects. ^[6] The main advantage to primary TEP is that it does not require an additional procedure that may produce associated comorbidities (including possibly a second general anesthetic). Negative aspects are mostly stoma-related problems, including possible difficulties due to delayed stenosis of the stoma and interference with the use or cleaning of the TEP prosthesis. Other issues may include difficulty with wound healing of the fistula in light of preoperative or postoperative radiation, risk of leakage and aspiration in the early postoperative period, and the inability to try pure esophageal speech (although prelaryngectomy esophageal speech may be practiced). ^[1]

Secondary TEP allows for the ability to attempt esophageal speech if desired, as well as maturation of the stoma after radiation and other adjuvant therapies before placement of the TEP.

The prosthesis can also be placed in a primary (at the time of puncture placement) or secondary (after puncture placement) fashion. The major manufacturers of TEP prostheses now have "kits" that facilitate primary prosthesis placement. In cases where the prosthesis is placed in a delayed fashion (secondarily), a red rubber catheter is often used to stent the puncture site and the prosthesis is placed in-office in a delayed fashion.

Procedure planning

Patient selection is important in planning for TEP. To minimize complications, patients should be motivated, have enough dexterity to clean their prosthesis, and be counseled on the complications and therapy involved to use their prosthesis safely and correctly. The patient must be appropriately counseled regarding the care and maintenance required, along with incumbent costs, prior to the procedure. ^{[1, 5, 7]} Consideration should be given to the relative contraindications as previously described.

The esophageal insufflation test was developed to preoperatively predict tracheoesophageal voice outcomes, ^[8] in order to determine those patients who were more likely to experience difficulty passing air through the neopharynx due to hypertonicity or spasm. Subsequent studies have shown that these tests are more predictive of short-term outcomes, but that long-term outcomes are not well predicted by insufflation testing. ^[9]

Complication prevention

Prevention of complications largely relies on good patient counseling and training. Maintenance of the prosthesis is the most important aspect of preventing complications. This includes cleaning the prosthesis to remove mucous, food, and prevent microbial growth, especially yeast. ^{[1, 10]} Monitoring of the prosthesis through close follow-up for damage to the valve and leakage around the prosthesis is also important. Prosthesis life can be increased by medical management, such as reducing reflux by antireflux medications and elevating the head of the bed at night. ^[10]

The prophylactic use of antifungal medications may also be indicated. Studies have shown that prosthesis life can be nearly doubled when antifungals such as miconazole or fluconazole are prescribed either prophylactically or after colonization by fungal organisms. ^{[11, 12]} Ameye et al studied the effects of a daily buccal slow release nystatin tablet compared to routine prosthesis cleaning with a nystatin solution with a control group and found a significant increase in the lifetime of the prosthesis using the daily tablets. ^[13] Additionally, prostheses have been designed with silver oxide within the lumen and have been shown to extend the life of the prosthesis and possibly prevent fungal growth. ^[14]

Multiple studies since the development of tracheoesophageal puncture (TEP) have shown that the speech produced by TEP alaryngeal speech is superior to that of both electrolarynx and esophageal speech ^{[4, 15, 16]} in both understandability and acceptability to the speaker. TEP speech has been rated the closest to laryngeal speech of all the available options. ^[16] The ability to learn and use the prosthesis successfully occurs in 50–90% of patients, ^{[3, 4]} whereas as few as 23% of patients are able to learn esophageal speech. ^[4]

When comparing primary TEP to secondary TEP, the literature shows no significant difference in outcomes initially or at later follow-up, with success rates in the 75–90% range after 2 years. ^{[17, 18, 19]} Although Chone et al have shown a possibly decreased failure rate in primary versus secondary TEP, the sample size in the study was small. ^[17] The similarity in outcomes is even true in those patients who underwent free flap reconstruction or postoperative radiation, which are often reasons stated for forgoing a primary TEP.

Reasons for poor speech outcomes with TEP include increased pharyngeal spasm, pressure, hypertonicity, or presence of a stricture in the pharyngoesophageal segment. Some of these issues can be managed by pharyngeal myotomy or pharyngeal neurectomy.

However, early complications are related to the procedure itself, and include bleeding, pain, stricture, and abscess formation or infection of nearby structures. ^[20] Late complications include enlargement of the puncture site, with displacement of or leakage around the prosthesis (approximately 19% of patients). ^{[21, 22, 23]} Conversely, stenosis or granulation and polyp formation around the stoma and puncture site can block the prosthesis or make it nonusable and can happen in approximately 20% of patients. ^[20] Migration of the prosthesis is reported to occur in 2% of patients. ^[20] Careful planning and monitoring of the site can help to prevent these complications. In particular, correct sizing of the prosthesis, in order to prevent pistoning of the prosthesis during use, decreases the amount of enlargement of the TEP. ^{[4, 16]} A feeling of fullness in the neopharyngeal segment or esophagus may also be present and is a common complication of TEP, typically attributed to thepresence of the prosthesis or either stenosis or hypertonicity of the region. ^[1]

The valve must be monitored for wear and replace it as it begins to leak. This can happen anywhere from 3 weeks to years after placement. The life of the valve can be extended, as described above, by careful cleaning and monitoring. Valves have also been developed that use magnets to aid in valve closure even in the presence of secretions. Leakage through or around the valve presents opportunity for aspiration of secretions, food, or both. In addition, a loose valve itself may be aspirated.