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Objectives: To evaluate the outcome of primary vs secondary tracheoesophageal puncture (TEP), in particular the effects of preoperative and postoperative radiotherapy on success and complication rates in primary TEPs, and to highlight modified surgical and management techniques. Design: Retrospective study of case series. Setting: Chevalier Jackson-Norris Center–Department of Otorhinolaryngology and Bronchoesophagology at Temple University Health Sciences Center Hospital, Philadelphia, Pa. Patients: One hundred six consecutive patients underwent primary TEPs and 30 underwent secondary TEPs for voice restoration after laryngectomy for cancer over a period of 8 years with follow-ups ranging from 6 months to 8.5 years. The group given primary TEP also includes 19 patients who received radiation for cure and salvage laryngectomy and 75 who received full-course postoperative radiotherapy. Intervention: Tracheoesophageal puncture and Blom-Singer prosthesis. Main Outcome Measures: Speech measures including (1) voice intensity, (2) pitch of speech, (3) duration of sustained phonation, and (4) rate of speech. Results: A success rate of 93% was achieved in the group of patients given primary TEP regardless of radiotherapy. An 83% success rate was achieved with patients given secondary TEP. There were no major complications related to TEPs. Conclusions: Primary TEP for patients requiring total laryngectomy is highly recommended since a second operative procedure can be avoided and speech obtained rapidly. Postoperative radiotherapy does not increase the complication rate from TEP. (Arch Otolaryngol Head Neck Surg. 1994;120:301-307)

• The incidence of tracheostomal stenosis in a group of patients after total laryngectomy with or without pharyngectomy plus immediate tracheoesophageal or tracheogastric puncture was compared with that of a control group without puncture. The stenosis rate of the puncture group was significantly higher than that of the control group (19% vs 6%). The other probable etiologic factors for stomal stricture were similar in both groups. Analysis of the risk factors in the puncture group suggested a higher tendency of stenosis in females (43% vs 16%) and in patients receiving postoperative radiotherapy (29% vs 14%), although the difference failed to reach statistical significance. (Arch Otolaryngol Head Neck Surg. 1991;117:662-665)

Objectives: To investigate the speech and swallowing outcomes of patients undergoing near-total laryngectomy and to determine those perioperative factors that are associated with success. Design and Setting: Retrospective analysis of a case series obtained from a hospital-based academic tertiary care center. Participants and Intervention: Records of all patients who underwent near-total laryngectomy at this institution were reviewed. Outcome Measures: Wound healing problems, quality of speech, degree of aspiration, and need for shunt revision were recorded. Results: Thirty-nine patients during a 10-year period underwent near-total laryngectomy. Good speech was obtained in 30 (76%). Severe aspiration was a complication in eight patients (21%), necessitating reversal of the shunt in four (10%). Certain technical aspects of this procedure that produce a "hooded" myomucosal shunt were crucial to proper shunt function. Severe aspiration and poor voice outcome were most likely in patients who experienced a postoperative pharyngocutaneous fistula. These fistulas tended to occur at the junction of the pharynx and the upper end of the myomucosal shunt. When this region broke down, the hooding of the shunt was disrupted and its function impaired. Conclusions: Careful patient selection is crucial to the creation of a functional myomucosal speaking shunt after near-total laryngectomy. In patients at high risk for developing a pharyngocutaneous fistula, where irreversible aspiration through the shunt is then likely, this operation should be avoided and a total laryngectomy with tracheoesophageal puncture considered instead. (Arch Otolaryngol Head Neck Surg. 1996;122:473-475)

At the 1989 Triological Society meeting in San Francisco, Calif, Drs Richard J. Lipton, Thomas McCaffrey, and Kerry D. Olsen, Rochester, Minn, and Bruce Pearson, Jacksonville, Fla, presented their findings regarding electroglottographic voice analysis of patients following near total laryngectomy. The presentation opened with a brief description of the rationale for near total laryngectomy, and the requirements necessary for successful postoperative voice production. Electroglottography was used to analyze the frequency and power spectrum produced by normal male patients, as well as the group under study. A single patient who had successfully undergone tracheoesophageal puncture, as well as a successful esophageal speaker, were included. These patients were evaluated with the electroglottograph for a 16-second time period of contextual speech. This was an attempt to ascertain how these patients functioned in a social setting. Normal male subjects were noted to have a rather narrow frequency band centered around 130 Hz. Those patients

• Reconstruction of the pharyngoesophagus after total laryngectomy avoids the development of salivary fistulae and restores satisfactory swallowing. Successful techniques for closure include multiple layers of tissue, selected suture materials, the application of postoperative radiation therapy, and modified neck dissection. In addition, vocal rehabilitation has been traditionally associated with the formation of a pharyngoesophageal segment capable of producing sound after air insufflation. A three-year experience with 129 patients after they underwent a total laryngectomy and tracheoesophageal shunt showed that 16 patients (12%) failed to achieve satisfactory speech after tracheoesophageal puncture because of pharyngoesophageal spasm. Response to percutaneous block of the pharyngeal plexus and subsequent myotomy of the cricopharyngeus and pharyngeal constrictor muscles was assessed in 14 patients. Increased pharyngoesophageal tone after total laryngectomy seems to be an important factor in the failure to acquire esophageal voice. ( Arch Otolaryngol 1981;107:670-673)

• It has been the aim of surgeons since Billroth first described laryngectomy to restore speech to the patient. However, a substantial percentage of patients fail to develop esophageal speech. Many authors have confirmed the success of the tracheoesophageal fistula procedure as a means of surgical voice restoration as a secondary procedure. We have performed tracheoesophageal puncture as a primary procedure at the time of laryngectomy in 36 patients, with a success rate of 89%. We believe that primary puncture is the method of choice for surgical voice restoration following laryngectomy. (Arch OtolaryngolHead Neck Surg 1988;114:1419-1421)

• The Singer-Blom tracheoesophageal puncture (TEP) technique is an effective and safe surgical method for speech rehabilitation of the alaryngeal patient. The silicone prosthesis, which is fitted in the TEP tract, allows pulmonary air to be used for voice production but prevents aspiration. In a series of 63 patients, 56 (89%) were able to develop fluent speech, but only 45 patients (71%) currently use tracheoesophageal speech as their prime mode of communication. Of the 18 patients (29%) who no longer use tracheoesophageal speech, 11 experienced either inadvertent dislodgement of the prosthesis or were noncompliant, five patients failed to develop fluent speech after adequate trial, and two patients failed because of aspiration. Almost all of the successful patients have voice quality and fluency that are as good or better than accomplished esophageal speakers, despite the fact that most of these patients were unable to learn esophageal speech. Since the Singer-Blom technique has eliminated most of the problems associated with other forms of surgical speech rehabilitation, it is considered to be the best surgical technique presently available for restoring speech in the alaryngeal patient. ( Arch Otolaryngol 1981;107:674-676)

• Current methods of pharyngoesophageal reconstruction have in common the creation of an epithelial lined pharynx. We performed eight cases of pharyngoesophageal reconstruction with a pectoralis major muscle flap. In the first six cases, split-thickness skin was quilted onto the muscle. In the last two cases, pectoralis major muscle alone was used, allowing epithelialization to occur from adjacent mucosa. The results with this simplified technique have been as good as when a skin-grafted muscle flap was used. We prefer a pectoralis major muscle flap, with or without split-thickness skin, to a pectoralis myocutaneous flap. There is no hair growth, it is easy to tube, and a thinwalled pharynx is produced. This is an advantage for the development of an esophageal voice, and tracheoesophageal puncture can be easily performed if no voice is achieved. All of our patients received full-dose, preoperative radiotherapy. One patient developed a fistula that closed spontaneously. There have been no strictures at the pharyngoesophageal junction. All patients quickly established a good oral intake. ( Arch Otolaryngol 1985;111:375-376)

A census survey of the records of the Department of Otolaryngology. The Ohio State University, Columbus, identified 108 patients with tracheoesophageal puncture (TEP) for voice restoration. Fifty-one patients received radiation therapy in the management of the disease, 50 did not, and seven were unavailable for follow-up. The records were reviewed and chi 2 tests applied to identify possible effects of radiation therapy on the achievement of TE speech and on TEP-related complications. Results of a census indicate that, with the exception of radiotherapy, the two groups of patients were highly similar with respect to ultimate achievement of TE speech and to the frequency with which complications occurred, eg, stoma stenosis or leakage via TE fistula. These findings support the incorporation of TEP with the total laryngectomy procedure, even for patients for whom radiation therapy is indicated.

Hans Zenner, Wurzburg, West Germany, reported his experience with the Eska-Herrmann Wurzburg tracheoesophageal puncture prosthesis at the January 1988 meeting of the Eastern Section of the Triological Society held in New York. His technique for both primary and secondary voice restoration includes placing a siliconized stent into the puncture. The stent remains in place for two weeks. He has employed this technique for primary voice restoration in patients who have undergone myocutaneous flap reconstruction, gastric pull-up, and jejunal free-graft reconstruction. Because of problems with the original Blom-Singer duckbill prosthesis, Dr Zenner has designed the Wurzburg prosthesis in cooperation with Herrmann. This prosthesis has a convex stem that is placed into the hypopharynx to prevent aspiration and is self-retaining secondary to the use of two retention collars. To improve the percentage of voice production, a dorsal myotomy is routinely performed. A stoma valve has been designed for use with this prosthesis

In Reply .—I appreciate Singer's comments and respectfully acknowledge his pioneering efforts and continuing leadership in this area. I was mistaken to include hematoma and esophageal reflux in my table of complications of tracheoesophageal puncture for vocal restoration without a footnote indicating that these are actually complications of the adjunctive procedure of cricopharyngeal myotomy. It was not my intention to misrepresent the findings of Singer's article, and I apologize to him. It is not clear why Singer denies cervical spine fracture and esophageal perforation as complications of the puncture procedure. Both complications are reported by others as a consequence of this procedure, without concurrent myotomy. 1,2 My experience shows that if examined carefully in the early postoperative period, the majority of my patients are found to have minor leakage of saliva, with aspiration, which is evidenced by direct inspection and cough. Generally, this resolves in about 1 week and is

Debra Mandel, MD, and coworkers, Long Island Jewish Hospital, New Hyde Park, NY, presented a retrospective analysis of the development of alaryngeal speech after laryngectomy in hearing-impaired patients. Their findings were reported at the January 1988 Eastern Section meeting of the Triological Society, held in New York. Of 35 patients examined, 19 had hearing loss greater than 35 dB; most of these losses were sensorineural. Speech quality was determined for each patient. There were seven patients who spoke through the esophagus, nine patients with tracheoesophageal puncture, and 19 patients who used an electrolarynx. Of the 19 patients who used an electrolarynx, only five developed proficient speech. No patients with significant hearing loss developed esophageal speech; one patient with unilateral hearing loss developed esophageal speech. This may be secondary to the volume of esophageal speech being 10 dB less than laryngeal speech, causing difficulty in the patient's monitoring his own

—We appreciate the opportunity to respond to Drs Blom and Singer. Their letter begins with the statement "As originators of three of the four prostheses that were the subject of Weinberg and Moon's recent article..." This statement is simply not true. For example, one of the four prostheses, the Voice Button, was developed by William Panje and is marketed by Xomed, Inc. A second prosthesis, the BIVONA Low Resistance device, was not designed by Blom or Singer. We have been evaluating tracheoesophageal puncture prostheses since their inception. 1-6 Our evaluations have consisted of both empirical testing and mathematical modeling. They have largely been directed toward specifying the opposition such devices offer to airflow through them. We personally shared the results of our earlier evaluations of duckbill devices with Blom. 3 In fact, our results led to our suggesting that Blom and Singer consider internalizing a valve and altering the