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A Multidisciplinary Approach to Secondary Tracheoesophageal Puncture for Voice Prosthesis Insertion Using Flexible Esophagoscopy

      Abstract

      Background

      Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP.

      Methods

      Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications.

      Results

      We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks.

      Conclusion

      Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.

      Key Words

      Abbreviations:

      CRE (controlled radial expansion), ENT (Ear, Nose, and Throat), FDG (fluorodeoxyglucose), PET (positron emission tomography), SP (speech pathologist), TEP (tracheoesophageal puncture), UGI (upper gastrointestinal), UGIS (upper gastrointestinal surgeon), VP (voice prosthesis)
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      References

        • Tang C.
        • Sinclair C.
        Voice restoration after total laryngectomy.
        Otolaryngol Clin North Am. 2015; 48: 687-702https://doi.org/10.1016/j.otc.2015.04.013
        • De Coul B.
        • Hilgers F.
        • Balm A.
        • et al.
        A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single Institution's experience with consistent application of provox indwelling voice prostheses.
        Arch Otolaryngol Head Neck Surg. 2000; 126: 1320-1328https://doi.org/10.1001/archotol.126.11.1320
        • Kaye R.
        • Tang C.
        • Sinclair C.
        The electrolarynx: voice restoration after total laryngectomy.
        Med Devices (Auckl). 2017; 10 (DOI: 10.2147/MDER.S133225): 133-140
        • Padhya T.
        • Athavale S.
        • Morgan J.
        • et al.
        An alternative approach for secondary tracheoesophageal puncture in the difficult laryngectomy neck.
        Laryngoscope. 2008; 118: 266-269https://doi.org/10.1097/MLG.0b013e318158e437
        • Costa C.
        • Abrahão M.
        • Cervantes O.
        • et al.
        New endoscopic secondary tracheoesophageal voice prosthesis placement technique.
        Otolaryngol Head Neck Surg. 2003; 128: 686-690https://doi.org/10.1016/s0194-5998(03)00196-7
        • Pelosof A.
        • Seraphim A.
        • Sztokfisz C.
        • et al.
        Alternative technique in secondary tracheoesophageal puncture using flexible endoscope and overtube in patients with difficult post-laryngectomy abnormalities.
        Appl Cancer Res. 2017; 37: 42https://doi.org/10.1186/s41241-017-0048-2
        • Tkaczuk A.
        • Taylor R.
        • Wolf J.
        A novel device for placement of a secondary tracheoesophageal voice prosthesis: a preliminary feasibility study.
        ORL J Otorhinolaryngol Relat Spec. 2018; 80: 36-40https://doi.org/10.1159/000485513
        • Le Bert B.
        • McWhorter A.
        • Kunduk M.
        • et al.
        Secondary Tracheoesophageal Puncture With In-Office Transnasal Esophagoscopy.
        Arch Otolaryngol Head Neck Surg. 2009; 135: 1190-1194https://doi.org/10.1001/archoto.2009.166
        • Emerick K.
        • Tomycz L.
        • Bradford C.
        • et al.
        Primary versus secondary tracheoesophageal puncture in salvage total laryngectomy following chemoradiation.
        Otolaryngol HeadNeck Surg. 2009; 140: 386-390
        • Neto J.
        • Dedivitis R.
        • Aries F.
        Comparison between primary and secondary tracheoesophageal puncture prosthesis: a systematic review.
        ORL J Otorhinolaryngol Relat Spec. 2017; 79: 222-229https://doi.org/10.1159/000477970
        • Chakravarty P.
        • McMurran A.
        • Banigo A.
        • et al.
        Primary versus secondary tracheoesophageal puncture: systematic review and meta-analysis.
        J Laryngol Otol. 2018; 132: 14-21
        • Ricci E.
        • Riva G.
        • Dagna F.
        • et al.
        In-clinic secondary tracheoesophageal puncture and voice prosthesis placement in laryngectomees.
        Eur Ann Otorhinolaryngol Head Nec Dis. 2018; 135: 349-352
        • Ng R.
        • Lam P.
        • Wong B.
        Insertion of Provox2 voice prosthesis using the anterograde technique immediately after the secondary tracheoesophageal puncture.
        J Laryngol Otol. 2005; 119: 988-990
        • Geterud A.
        • Bove M.
        • Ruth M.
        Hypopharyngeal acid exposure: an independent risk factor for laryngeal cancer?.
        Laryngoscope. 2003; 113: 2201-2205https://doi.org/10.1097/00005537-200312000-00030
        • Copper M.
        • Smith C.
        • Stanojcic L.
        • et al.
        High incidence of laryngopharyngeal reflux in patients with head and neck cancer.
        Laryngoscope. 2000; 110: 1007-1011https://doi.org/10.1097/00005537-200006000-00023
        • Ward E.
        • Bishop B.
        • Frisby J.
        • et al.
        Swallowing outcomes following laryngectomy and pharyngolaryngectomy.
        JAMA Otolaryngol Head Neck Surg. 2002; 128: 181-186https://doi.org/10.1001/archotol.128.2.181
      1. American Speech-Language-Hearing Association. (2004). Roles and responsibilities of speech-language pathologists with respect to evaluation and treatment for tracheoesophageal puncture and prosthesis [Position Statement]. Available from www.asha.org/policy. doi:10.1044/policy.PS2004-00107

        • Silver F.
        • Gluckman J.
        • Donegan J
        Operative complications of tracheoesophageal puncture.
        Laryngoscope. 1985; 95: 1360-1362https://doi.org/10.1288/00005537-198511000-00013
        • Morrison M.
        • Chheda N.
        • Postma G.
        The tough tracheoesophageal puncture.
        Am J Otolaryngol. 2012; 33: 113-115https://doi.org/10.1016/j.amjoto.2011.04.006
        • Bach K.
        • Postma G.
        • Koufman J.
        In-Office tracheoesophageal puncture using transnasal esophagoscopy.
        Laryngoscope. 2003; 113: 173-176
        • Britt C.
        • Lippert D.
        • Kammer R.
        • et al.
        Secondary tracheoesophageal puncture in-office using Seldinger technique.
        Otolaryngol Head Neck Surg. 2014; 150: 808-812
        • Gazzini L.
        • Laura E.
        • Molteni G.
        • et al.
        Secondary tracheoesophageal puncture with the blind technique: 10 years’ experience.
        Eur Arch Otolaryngol. 2021; 278: 4459-4467
        • Parrilla C.
        • Longobardi Y.
        • Galli J.
        • et al.
        Periprosthetic leakage in tracheoesophageal prosthesis: Proposal of a standardized therapeutic algorithm.
        Otolaryngol Head Neck Surg. 2021; 165: 446-454https://doi.org/10.1177/0194599820983343
        • Lorenz K.
        The development and treatment of periprosthetic leakage after prosthetic voice restoration. A literature review and personal experience part I: the development of periprosthetic leakage.
        Eur Arch Otorhinolaryngol. 2015; 272: 641-659https://doi.org/10.1007/s00405-014-3394-7
        • Lorenz K.
        The development and treatment of periprosthetic leakage after prosthetic voice restoration: a literature review and personal experience. Part II: conservative and surgical management.
        Eur Arch Otorhinolaryngol. 2015; 272: 661-672https://doi.org/10.1007/s00405-014-3393-8
        • Hutcheson K.
        • Lewin J.
        • Sturgis E.
        • et al.
        Enlarged tracheoesophageal puncture after total laryngectomy: a systematic review and meta-analysis.
        Head Neck. 2011; 33: 20-30https://doi.org/10.1002/hed.21399
        • Starmer H.
        • Agrawal N.
        • Koch W.
        • et al.
        Does prosthesis diameter matter? The relationship between voice prosthesis diameter and complications.
        Otolaryngol Head Neck Surg. 2011; 144: 740-746https://doi.org/10.1177/0194599810395362
        • Hutcheson K.
        • Lewin J.
        • Sturgis E.
        • et al.
        Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy.
        Head Neck. 2012; 34: 557-567https://doi.org/10.1002/hed.21777
        • Norsuhazenah P.
        • Baki M.
        • Yunus M.
        • et al.
        Complications following tracheoesophageal puncture: a tertiary hospital experience.
        Ann Acad Med Singap. 2010; 39: 565-568
        • Dragicevic D.
        • Jovic R.
        • Kljajic V.
        • et al.
        Complications following secondary voice prosthesis insertion and impact of previous irradiation on their appearance.
        Niger J Clin Pract. 2021; 24: 470-475https://doi.org/10.4103/njcp.njcp_549_19