Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Tracheosophageal Puncture Approximately 11,000 to 12,000 new cases of laryngeal cancer are diagnosed each year, many of which require total laryngectomy to control the neoplastic process. The resultant loss of the ability to communicate verbally is probably the most devastating aspect of this disease. Ever since the first successful total laryngectomy was performed by Billroth in 1873, multitudes of surgical procedures and prosthetic devices have been devised in attempts to restore speech to the laryngectomy patient. Until recently, these attempts at vocal rehabilitation have had only limited success and were often fraught with troublesome complications. Although esophageal speech would seem to be an ideal mode of alaryngeal speech, since it requires no additional surgical procedures or prosthetic devices, its acquisition frequently takes several months of training, and less than 50% of patients ever acquire esophageal speech. The entire field of vocal rehabilitation after laryngectomy was revolutionized in 1979 when Drs. Singer and Blom described an endoscopic voice restoration procedure that involved creating a fistula between the trachea and esophagus. The fistula was then stented with a silastic device that maintained the patency of the fistula, shunted air from the lungs to the hypopharynx for sound creation, and prevented aspiration with a one-way valve. They reported the acquisition of fluent tracheoesophageal speech in 90% of their patients regardless of whether or not they had undergone radical neck dissection or radiation therapy. They reported virtually no complications, and the time required for speech rehabilitation was very short. Tracheoesophageal speech is produced when the force of expired air entering the esophagus from the trachea causes the pharyngoesophageal membranes to vibrate. The apposition of the vibrating membranes produces sound, and the sound is converted into speech through articulation by the mouth and oropharynx. The vibratory segment is located in the lower cervical region in the majority of tracheoesophageal speakers, corresponding to C5 through C7. The cricopharyngeus and the inferior and middle constrictor muscles contribute to the formation of the vibratory segment. Several studies comparing tracheoesophageal speech to other forms of alaryngeal speech have been performed. Acoustic analyses have revealed that the fundamental frequency and rate of tracheoesophageal speech are considerably higher than that of esophageal speech. This reflects the fact that tracheoesophageal speakers use pulmonary air to sustain voice production. The intensity and periodicity of tracheoesophageal speech are also greater than that of esophageal speech, again because of the advantage of pulmonary air support. Multiple perceptual studies have also been carried out comparing tracheoesophageal speech to esophageal speech and to artificial laryngeal speech. Some generalized conclusions can be drawn from these studies. First, the rate of tracheoesophageal speech is significantly faster than that of esophageal speech. In addition, TE speech is more intelligible than artificial laryngeal speech and is less monotonous than either esophageal or artificial laryngeal speech. It is also important to point out that the use of an artificial larynx can be distracting to the listener and is inconvenient for the patient, who must carry around the device at all times in order to communicate. Although tracheoesophageal puncture is relatively easy to perform and frequently yields excellent results, this procedure is not suitable for all patients. Careful patient selection is crucial to high long-term success rates. During the preoperative evaluation of a patient for TE puncture, assessment of the patient's motivation and compliance is of prime importance. He must understand what is involved with using and caring for the prosthesis and be willing to do so. Family members cannot be responsible for the maintenance of the prosthesis. The patient must also have reasonably good manual dexterity and visual acuity in order to successfully use and maintain the prosthesis. The patient must also have adequate pulmonary reserve and be in good overall health. If a hypopharyngeal stricture is suspected, a preoperative barium swallow may be helpful. Stoma size and depth must also be assessed, since a narrow stoma can be occluded by the TEP prosthesis and a very large stoma may be difficult to occlude. Stomal revision or stomaplasty may be required prior to puncture. Finally, air insufflation testing should be performed on all patients prior to secondary TE puncture. This tests the patient's ability to sustain speech with esophageal insufflation in attempt to detect the presence of pharyngeal constrictor spasm. Pharyngoesophageal spasm accounts for the vast majority of tracheoesophageal speech failures. If spasm is detected by air insufflation, pharyngeal constrictor myotomy should be considered prior to performing. TE puncture. Parapharyngeal nerve blockade can help predict those who will be successful TE speakers after myotomy. With respect to the timing of surgery, there has currently been a trend favoring the performance of tracheoesophageal puncture at the time of laryngectomy to avoid a second operative procedure and avoid delay in speech rehabilitation. This practice is somewhat controversial, and the controversy, surrounds whether or not there is an increased risk of complications after primary tracheoesophageal puncture. Possible complications after pri-mary TE puncture could theoretically be cellulitis, mediastinitis, pharyngocutaneous fistulas, and aspiration pneumonia. It has been suggested that such complications can be avoided by preserving the integrity of the tracheoesophageal partie wall at the time of surgery. A review of the recent literature has in fact shown no increased risk of such complications after primary TE puncture, with success rates in terms of vocal rehabilitation comparable to those after secondary TE puncture. Only tracheostomal stenosis has been noted to occur with a significantly higher frequency after primary puncture. Another important consideration is vocal rehabilitation of tracheoesophageal speech failures.Seventy-nine percent of such failures are the result of pharyngoesophageal spasm; the remainder of failures are the result of hypopharyngeal stricture formation and other structural problems. Of interest is that the proportion of speech failures that are due to pharyngoesophageal spasm has rather dramatically increased over the years. A large part of this increase can probably be attributed to the increased application of primary TE puncture, during which there is obviously no way to predict who will subsequently develop pharyngoesophageal spasm. In an attempt to minimize postoperative spasm after primary TE puncture, several modifications of total laryngectomy technique have been employed, but none of these techniques have been shown to be significantly more effective than another. Such techniques include not reapproximating the pharyngeal constrictor muscles, performing a posterolateral constrictor myotomy in conjunction with a classic, three-layer pharyngeal closure, or performing a pharyngeal plexus neurectomy without any myotomy at all. Case Presentation A 40-year-old African American male underwent total laryngectomy with a right modified radical neck dissection at Ben Taub General Hospital for a T2,NO,MO squamous cell carcinoma of the right pyriform sinus. He did not undergo radiation therapy. Despite intensive speech therapy, he was unable to develop fluent esophageal speech and relied upon the use of an artificial larynx. An air insufflation test was performed, during which he was capable of producing sustained esophageal speech. He subsequently underwent tracheoesophageal puncture at an outlying hospital, but he returned to Ben Taub for placement of the prosthesis. However, after the 14 French catheter was removed from the tracheoesophageal fistula, he was unable to produce an adequate voice. Attempts to place a speech prosthesis were unsuccessful due to deviation of the tract with misalignment of the fistula, and the fistula was allowed to close. Because the patient strongly desired tracheoesophageal speech, a second tracheoesophageal puncture was performed. He has since developed strong, fluent, tracheoesophageal speech. Bibliography Andrews JC, Mickel RA, Ward PH, et al: Major complications following tracheoesophageal puncture for voice rehabilitation. Laryngoscope 97:562-7, 1987. Arsian M: Reconstructive laryngectomy. Ann Otol Rhinol Laryngol 81:479-86, 1972. Asai R: Laryngoplasty after total laryngectomy. Arch Otolaryngol 95:114-9, 1972. Baggs TW, Pine SJ: Acoustic characteristics: tracheoesophageal speech. J Communic Disord 16:299-307, 1983. Baugh RF, Lewin JS, Baker SR: Vocal rehabilitation of tracheoesophageal speech failures. Head Neck 12:69-73, 1990. Brown RG: A simple but effective artificial larynx. J Laryngol Otol 40:793-7, 1925. Conley JJ, DeAmesti F, Pierce MK: A new surgical technique for the vocal rehabilitation of the laryngectomized patient. Ann Otol Rhinol Laryngol 67:655-64, 1958. Donegan JO, Gluckman JL, Singh J: Limitations of the Blom-Singer technique for voice restoration. Ann Otol Rhinol Laryngol 90:495-7, 1981. Guttman MR: Rehabilitation of the voice in laryngectomized patients. Arch Otolaryngol 15:478-9, 1932. Ho CM, Wei WI, Lam KH, et al: Tracheostomal stenosis after immediate tracheoesophageal puncture. Arch Otolaryngol Head Neck Surg 117:662-5, 1991. Hoffman HT, Baker SR: Tracheostoma diverticulum following tracheoesophageal puncture. Arch Otolaryngol Head Neck Surg 116:1074-6, 1990. Hurbis CG, Tiesenga JE, Wenig BL, et al: A new instrument for the simplification of tracheoesophageal puncture. Otolaryngol Head Neck Surg 104:410-6, 1991. Johns ME, Cantrell RW: Voice restoration of the total laryngectomy patient the Singer-Blom technique. Otolaryngol Head Neck Surg 89:82-6, 1981. Juarbe C, Shemen L, Eberie R, et al: Primary tracheoesophageal puncture for voice restoration. Am J Surg 152:464-6, 1986. Kolson H, Glasgold A: Tracheo-esophageal speech following laryngectomy. Trans Am Acad Ophthalmol Otolaryngol 71:421-5, 1967. Komorn RM: Vocal rehabilitation in the laryngectomized patient with a tracheoesophageal shunt. Ann Otol Rhinol Laryngol 83:445-51, 1974. Lavertu P, Scott SE, Wood BG, et al: Secondary tracheoesophageal puncture for voice rehabilitation after laryngectomy. Arch Otolaryngol Head Neck Surg 115:350-5, 1989. Lopez MJ, Kraybill W, Guerra O, et al: Voice rehabilitation practices among head and neck surgeons. Ann Otol Rhinol Laryngol 96:261-3, 1987. Maniglia AJ, Lundy DS, Swim SC, et al: Speech restoration and complications of primary versus secondary tracheoesophageal puncture following total laryngectomy. Laryngoscope 99:489-91, 1989. Maves MD, Lingeman RE: Primary vocal rehabilitation using the Blom-Singer and Panje voice prostheses. Ann Otol Rhinol Laryngol 91:458-60, 1982. McConnel FMS, Duck SW: Indications for tracheoesophageal puncture speech rehabilitation. Laryngoscope 98:1065-8, 1986. Mehle ME, Lavertu P: Sternoclavicular arthritis and manual pressure necrosis: two potential complications of tracheoesophageal puncture. Otolaryngol Head Neck Surg 105:130-3, 1991. Merwin GE, Goldstein LP, Rothman HB: A comparison of speech using artificial larynx and tracheoesophageal puncture with valve in the same speaker. Laryngoscope 95:730-4, 1985. Milford CA, Perry AR, Cheesman AD, et al: A British experience of surgical voice restoration as a primary procedure. Arch Otolaryngol Head Neck Surg 114:1419-21, 1988. Modica LA: Hypertrophic scarring of tracheoesophageal fistula causing vocal failure. Arch Otolaryngol Head Neck Surg 114:1324-5, 1988. Mohr RM, Padock BH, Boehler J: An adaptation of tracheoesophageal puncture. Laryngoscope 93:1086-8, 1983. Moon JB, Sullivan J, Weinberg B: Evaluations of Blom-Singer tracheoesophageal puncture prostheses performance. J Speech Hear Res 26:459-64, 1983. Moon JB, Weinberg B: Aerodynamic and myoelastic contributions to tracheoesophageal voice production. J Speech Hear Res 30:387-95, 1987. Ossoff RH, Lazzarus CL, Sisson GA: Tracheoesophageal puncture for voice restoration: modification of the Blom-Singer technique. Otolaryngol Head Neck Surg 92:418-22, 1984. Panje WR, Vandemark D, McCabe BF: Voice button prosthesis rehabilitation of the laryngectomee. Ann Otol Rhinol Laryngol 90:503-5, 1981. Pauloski BR, Fisher HB, Blom ED, et al: Statistical differentiation of tracheoesophageal speech produced under four prosthetic/occlusion speaking conditions. J Speech Hear Res 32:591-9, 1989. Pretsfelder LH, Izzo KL, Mohr R: Speech rehabilitation outcome after Blom-Singer tracheoesophageal puncture. Arch Phys Med Rehabil 66:814-7, 1985. Recher G, Pesavento G, Ferlito A, et al: Italian experience of voice restoration after laryngectomy with tracheoesophageal puncture. Ann Otol Rhinol Laryngol 100:206-10, 1991. Robbins J, Blom EC, Singer MI: A comparative acoustic study of normal, esophageal, and tracheoesophageal speech production. J Speech Hear Disord 49:202-210, 1984. Robbins J, Christensen J, Kempster G: Characteristics of speech production after tracheoesophageal puncture: voice onset time and vowel duration. J Speech Hear Res 29:499-504, 1986. Robbins J, Fisher HB, Singer MI: Selected acoustic features of tracheoesophageal, esophageal, and laryngeal speech. Arch Otolaryngol 110:670-2, 1984. Ruth H, Davis WE, Renner G: Deep neck abscess after tracheoesophageal puncture and insertion of a voice button prosthesis. Otolaryngol Head Neck Surg 93:809-11, 1985. Silver FM, Gluckman JL, Donegan JO: Operative complications of tracheoesophageal puncture. Laryngoscope 95:1360-2, 1985. Singer MI, Blom ED: An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 89:529-33, 1980. Singer MI, Blom ED: Selective myotomy for voice restoration after total laryngectomy. Arch Otolaryngol 107:870-3, 1981. Singer MI, Blom ED, Hamaker RC: Applications of the voice prosthesis during laryngectomy. Ann Otol Rhinol Laryngol 98:921-5, 1989. Singer MI, Blom ED, Hamaker RC: Further experience with voice restoration after total laryngectomy. Ann Otol Rhinol Laryngol 90:498-502, 1981. Singer MI, Blom ED, Hamaker RC: Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation. Laryngoscope 96:50-4, 1986. Singer MI, Hamaker RC, Blom ED: Revision procedure for the tracheoesophageal puncture. Laryngoscope 99:761-3, 1989. Spiro JD, Spiro RH: Retropharyngeal abscess and carotid hemorrhage following tracheoesophageal puncture and voice prosthesis insertion: a case report. Otolaryngol Head Neck Surg 102:762-3, 1990. Stewart IA, Sherwen PJ: Tracheoesophageal puncture simplified. Laryngoscope 97:639-40, 1987. Taub S: Air bypass voice prosthesis for vocal rehabilitation of laryngectomies. Ann Otol Rhinol Laryngol 84:45-8, 1975. Trudeau MD, Schuller DE, Hall DA: The effects of radiation on tracheoesophageal puncture. Arch Otolaryngol Head Neck Surg 115:1116-7, 1989. Vincent ME, Robbins AH, Walsh M, et al: Evaluation of Blom-Singer voice prosthesis. Am J Roentgenol 143:745-50, 1984. Weinberg B, Moon J: Aerodynamic properties of four tracheoesophageal puncture prostheses. Arch Otolaryngol 110:673-5, 1984. Weinberg B, Moon JB: Airway resistances of Blom-Singer and Panje low pressure tracheoesophageal puncture prostheses. J Speech Hear Disord 51:169-72, 1986. Weinberg B, Moon JB: Impact of tracheoesophageal puncture prosthesis airway resistance on in-vivo phonatory performance. J Speech Hear Disord 51:88-91, 1986. Wenig BL, Levy J, Abramson AL, et al: Voice restoration following laryngectomy: the role of primary versus secondary tracheoesophageal puncture. Ann Otol Rhinol Laryngol 98:70-3, 1989. Wetmore SJ, Johns ME, Baker SR: The Singer-Blom voice restoration procedure. Arch Otolaryngol 107:674-6, 1981. Wetmore SJ, Krueger K, Wesson K, et al: Long-term results of the Blom-Singer speech rehabilitation procedure. Arch Otolaryngol 11:106-9, 1985. Wetmore SJ, Krueger K, Wesson K: The Singer-Blom rehabilitation procedure. Laryngoscope 91: 1109-17, 1981. Wetmore SJ, Ryan SP, Montague JC, et al: Location of the vibratory segment in tracheoesophageal speakers. Otolaryngol Head Neck Surg 93:355-60, 1985. Williams SE, Watson JB: Differences in speaking proficiencies in three laryngectomee groups. Arch Otolaryngol 111:216-9, 1985. Williams SE, Watson JB: Speaking proficiency variations according to method of alaryngeal voicing. Laryngoscope 97:737-9, 1987. Wolf CL, Cheney ML, Blair PA: Tracheoesophageal puncture for voice restoration after laryngectomy. J La State Med Soc 138:11-14, 1986. Wood BG, Tucker HM, Levine HL: Tracheoesophageal puncture for alaryngeal voice restoration. Ann Otol Rhinol Laryngol 90: 492-4, 1981. Zanoff DJ, Wold D, Drummond S, et al: Tracheoesophageal speech: with and without tracheostoma stoma valve. Laryngoscope 100:498-502, 1990. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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