Voice Restoration After Total Laryngectomy

Introduction

Although nonsurgical methods such as electrolarynx and esophageal speech are available for patients, tracheoesophageal puncture (TEP) is considered the best means of voice restoration after total laryngectomy (TL). A TEP allows a patient to channel air from the lungs through a puncture site in the posterior wall of the trachea, into the esophagus up through the pharynx, where the mucosa acts as a vibrating apparatus and into the oral cavity, where the air is modulated by articulatory mechanisms to produce phonation. TEP has gained in popularity over the past several decades due to the superior speech produced when compared with other methods of communication for laryngectomy patients. Studies in numerous patients who have had a TL reveal that functional indwelling voice prostheses greatly improve the quality of life for the patient, possibly even to a level higher than for those who undergo organ-preservation protocols. Currently, there are several companies that manufacture the prostheses, with InHealth (Carpinteria, CA) making the Blom-Singer device, which is the most widely used in the United States, and Atos Medical (Malmo, Sweden) manufacturing the Provox devices, which are more widely used internationally.

The procedure can be performed either primarily during the TL or secondarily after the patient has healed well, each carrying its own advantages. Primary TEP, performed at the time of the TL, avoids a second operation and allows for more rapid return of phonation. Secondary TEP is often chosen if the patient is considered at high risk for postoperative fistula formation or wound breakdown, which can be complicated by the insertion of an indwelling foreign body into the fistula tract in the newly created stoma. Often, the considerations are multifactorial and depend on the comfort level and guiding practices of the surgeon, speech language pathology (SLP) team, and patient.

Historically, the TEP was performed as a secondary procedure under anesthesia with the insertion of a catheter to establish the tract, followed by the prosthesis being inserted a week or two late, after the fistula had sufficiently matured. However, techniques have evolved, with well-established evidence supporting primary and secondary insertion of the prosthesis immediately at the time of puncture and the ability to perform a secondary puncture in an office setting to avoid anesthesia and save costs. Thus there are few TEP exclusion criteria for TL patients: (1) physical limitations (i.e., stroke, musculoskeletal disorders, amputations) that preclude manipulation and covering the stoma during phonation, (2) financial considerations with reimbursement and care/maintenance of the prosthesis, (3) access to an speech language pathologist (SLP) who is comfortable with TEP voicing instruction, teaching care for the puncture site, and replacing the prosthesis, and (4) need for concomitant total glossectomy. The author believes that TEP should be offered to all TL patients who do not meet the exclusion criteria because voice restoration with TEP is superior to both electrolarynx and esophageal speech and can dramatically improve the TL patient’s quality of life (QOL), function, and psychosocial well-being.

Key Operative Learning Points

• TEP can be done primarily or secondarily.

  • The primary approach is preferred if the patient is undergoing primary surgical management for advanced-stage cancer.

  • Secondary can be used if there are concerns for healing in patients who have had radiation therapy to the neck.

• Insertion of the prosthesis at the time of puncture allows for immediate voicing and avoids the possible dislodgement of the catheter used to keep the fistula patent.

• SLP consultation is essential to achieving and sustaining functional phonation with the TEP.

• Direct visualization of the puncture or placement of a pharyngeal protector is important for avoiding inadvertent violation of the posterior esophageal wall.

Preoperative Period

TEP was traditionally performed as a secondary procedure after the patient had healed from the TL because of concern for increased fistula formation and wound breakdown with a primary puncture. Healing issues are especially prevalent in the salvage setting, where pharyngocutaneous fistula rates can be as high as 33%. However, recent data suggest that the placement of vascularized tissue as part of the pharyngeal reconstruction can reduce fistula formation. More current studies have suggested there are not increased complications with primary TEP placement, regardless of whether the surgery is being performed primarily or in a salvage setting and that TEPs can be used and are still effective when microvascular tissue or rotational flap reconstructions are used. However, if the surgeon and his or her team are more comfortable with secondary placement, the procedure can easily be performed in the operating room or office, depending on the availability of equipment, anesthetic risk due to medical comorbidities, and patient financial/travel constraints. For the office setting, a transnasal esophagoscope (TNE) is an absolute requirement to obtain adequate visualization via insufflation. To perform the procedure in the operating room, the patient must be able to tolerate general anesthesia from a cardiopulmonary standpoint.

The first step in decision making should involve an assessment by both the surgeon and the SLP regarding the patient’s candidacy. If the patient will be unable to care for and/or use his or her prosthesis due to physical or financial limitations, a TEP should not be undertaken. Although the need for using the thumb to occlude the stoma can be avoided with a secondary valve that covers the stoma, the patient needs to have the ability to adequately clean and care for his or her prosthesis and stoma. The procedure does carry a minimal chance of significant complications, including the risk of aspiration and death from an enlarging, nonhealing fistula and should be avoided if the patient is not a good candidate. Although changing prostheses can be done by either the surgeon or the SLP, having an SLP who is trained in working with TEPs and TL patients is tantamount to achieving phonation. Before the TL itself, having the SLP meet with the patient and discuss what is involved with using and maintaining the prosthesis is essential for obtaining informed consent. In addition, showing patients pictures and a video helps to establish realistic expectations and eases anxiety about having the larynx removed.

The next step is to decide whether a primary or secondary puncture will be performed. I prefer to perform primary TEP insertion for all TL patients and strongly supports using this approach when a primary TL is being done, as opposed to the salvage setting where the decision can be left to surgeon preference. For a secondary puncture, if the patient is at high risk for complication from general anesthesia or has poor access secondary to trismus, poor neck extension, or other anatomic limitations, then an in-office procedure has been demonstrated to be very effective. If the surgeon does not have a TNE scope available or the patient cannot tolerate the in-office procedure due to anxiety, then performing the procedure in the operating room (OR) can be undertaken. I prefer to place the actual prosthesis at the time of the puncture, regardless of whether in the primary or secondary setting, because this decreases the risk of dislodgement and need for a repeat procedure.

Operative Period