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SummaryInsertion of voice rehabilitation devices (VRD) via tracheoesophageal punctures (TEP) post laryngectomy is considered the standard of care. The management of periprosthetic leakage from the puncture site in a zone of previous neck dissection and or radiotherapy is problematic when it results in a tracheoesophageal fistula (TOF), as simple surgical closure and use of tissue for flaps carries a high risk of failure. We share our clinical experience in 3 of 42 patients who had a laryngectomy and VDR, who developed an expanding TEP with failure of free flaps in two, and the utility of a narrow pectoralis major myofascial flaps (PMMF) as a universally successful salvage or primary procedure.

Background: Voice prosthesis is the current standard for post laryngectomy rehabilitation. Several clinical factors can affect the functional outcomes of voice prosthesis. Various complications are recorded with voice prosthesis. Objective: This study aimed to compare the results of primary and secondary provox insertion in patients with advanced laryngeal carcinoma undergoing total laryngectomy. Patients and Methods: Randomized-controlled clinical study included 24 patients with provox voice prosthesis rehabilitation 12 had primary tracheoesophageal puncture and 12 had secondary tracheoesophageal puncture. All patients were evaluated for successful voice restoration and complications rates. Results: Short-term success rate was 92% in the primary group and 83% in the secondary group. Long-term success rate was 83% in the primary group and 75% in the secondary group. Success rates were higher in the primary group but without statistically significant difference. Complications rate in the primary group was 58.3% and in the secondary group 66.6%. Complications rate was higher in the secondary group but without statistically significant difference. Conclusion: Provox voice prosthesis provides consistent and good voice results, which improve with time. Primary provox insertion had better success rates and fewer complications. Periprosthetic leak is the most common complication.

To evaluate the postoperative surgical wound infection prevalence rates of patients undergoing SL, identify the causative organism and determine predisposing factors leading to infection. A retrospective study of all consecutive patients who underwent salvage total laryngectomy at our unit between 2015 and 2020 was performed. The following parameters were also analyzed: age, smoking history, pre and postoperative albumin level, history of radio and chemo-radiotherapy, reconstruction with pectoralis flap, intraoperative tracheoesophageal puncture, and tumor stage. A total of 12 of the 21 patients (57%) experienced a postoperative infection after SL during the study period. 82% of those patients whose preoperative albumin level below 3gm/dl developed postoperative infection. There is a significant increase (p

Background Gastric pull-up is a reconstructive option for circumferential defects after resection of advanced laryngopharyngeal malignancy. Voice loss is expected and vocal rehabilitation remains a challenge. Our study objectives were to investigate the feasibility of secondary tracheoesophageal puncture following gastric pull-up and to analyze voice outcomes. Methods This was a prospective cohort study of patients with advanced laryngopharyngeal malignancies who underwent gastric pull-up and secondary tracheoesophageal puncture between 1988 and 2017 at a tertiary-care academic institution. Objective acoustic measures included fundamental frequency and vocal intensity. Perceptual analysis was performed using voice recordings (“Rainbow Passage”) randomly presented in a blinded fashion to four clinicians using the validated GRBAS scale. Speech intelligibility was assessed in a blinded fashion using a validated 7-point scale. Additionally, the Voice Handicap Index-10 was administered as a validated patient self-reporting tool. Results Ten patients (7 male, 3 female) were included, all of whom preferentially used tracheoesophageal puncture for communication. These patients had abnormal median fundamental frequency of 250 (interquartile range (IQR) 214–265) Hz and a limited median vocal intensity of 65.8 (IQR 64.1–68.3) dB. Perceptual analysis (GRBAS) revealed a median ‘moderate’ degree of impairment [grade 2 (IQR 2–3), roughness 2 (IQR 2–3), breathiness 3 (IQR 2–3), asthenia 2 (IQR 1–2), strain 2 (IQR 1–2)] as did median intelligibility scores [median 5 (IQR 4–7)]. Most patients self-reported an abnormal voice handicap-10 [median 26.5 (IQR 22.8–35.0)]. Conclusion Secondary tracheoesophageal puncture is a safe and feasible option for voice rehabilitation after gastric pull-up. Although analyses demonstrated moderate subjective and objective impairment, tracheoesophageal puncture provided patients with a self-reported means of functional verbal communication and was their preferred method of communication. Graphical abstract

Tracheoesophageal puncture for voice prosthesis placement is often used in vocal rehabilitation of patients undergoing total laryngectomy. Although its closure can occur spontaneously, some patients require a surgical procedure. We propose a surgical technique, without flap interposition, that begins with careful separation of the esophagus and trachea and identification of the site of tracheoesophageal fistula. After continuous suture closure of the esophagus, the anterior segment of the first tracheal rings is vertically incised to facilitate tracheal closure in a suture without tension. Finally, a small pectoral skin flap is made and mobilized to suture to the free edges of the sectioned tracheal rings, thus reducing the risk of tracheal stenosis. Four patients underwent this procedure with uneventful postoperative evolution and permanent closure of the fistula.

BackgroundWith the increasing necessity for total laryngectomy (TL) after prior (chemo)radiotherapy, prosthetic vocal rehabilitation outcomes might have changed.MethodsRetrospective cohort study including all patients laryngectomized between 2000 and 2012 with a voice prosthesis (VP) in the Netherlands Cancer Institute.ResultsMedian device lifetimes of the standard Provox2 and Vega VPs are 63 and 66 days, respectively, and for the problem-solving ActiValve Light and Strong VPs 143 and 186 days, respectively. In multivariable analysis, salvage TL and TL for a dysfunctional larynx (compared to primary TL) were associated with a shorter device lifetime. Almost half of the patients (48%) experienced tracheoesophageal puncture tract-related problems, and this concerned 12% of all VP replacements.ConclusionsCompared to historical cohorts, device lifetimes of regular Provox2 and Vega voice prostheses have decreased. Complications are not occurring more frequently but affect more patients. Nevertheless, the clinical reliability and validity of prosthetic voice rehabilitation is still sound.

Introduction Tracheoesophageal puncture (TEP) with voice prosthesis (VP) is considered the gold standard in vocal rehabilitation of total laryngectomized patients, for generating better speech intelligibility and good vocal result. The aspects of aging that may be related to the success of this method of rehabilitation are rarely discussed in the literature. Objective To describe the factors that influence the rehabilitation outcome of the total laryngectomized older patients with voice prosthesis. Methods A retrospective cohort study enrolled in the Head and Neck Cancer Surgery Section of the Brazilian National Cancer Institute. Secondary data were collected through physical and electronic medical records of patients undergoing vocal rehabilitation using tracheoesophageal prosthesis, from 2006 to 2019. Descriptive analysis presented the distribution of the demographic and clinical characteristics of this population. Results Thirty patients rehabilitated with VP over 70 years old (mean age: 73.7 years), of which 93.3% were male. Married (73.3%), with low education (70%) and had a tumor of size T4a (60%). Adjuvant radiotherapy was performed in 66.7% of patients, 16.7% to previous radical radiotherapy, Complication rate was 53.3%, (68.7% granuloma and 18.7% shunt enlargement). All patients with shunt enlargement removed the prosthesis, whereas the prevalence of removal among those patients without complications was 14.3%. Logistic regression indicated that secondary TEP had 96% less chance of failure for phonation than primary TEP. Conclusions Patients with more complications are more likely to have phonation issues and to remove the prosthesis. Older patients with larger tumors and who underwent salvage laryngectomy or were submitted to a primary puncture seem to be more likely to have complications and/or aphonia.

Autologous tissue-assisted regenerative procedures have been considered effective to close different types of fistula, including the leakage around tracheoesophageal puncture. The aim of this study was to retrospectively review 10 years of lipotransfer for persistent periprosthetic leakage in laryngectomized patients with voice prosthesis. Clinical records of patients who experienced periprosthetic leakage from December 2009 to December 2019 were reviewed. Patients receiving fat grafting were included. The leakage around the prosthesis was assessed with a methylene blue test. Twenty patients experiencing tracheoesophageal fistula enlargement were treated with fat grafting. At the one-month follow-up, all patients were considered improved with no leakage observed. At six months, a single injection was sufficient to solve 75% of cases (n 15), whereas 25% (n 5) required a second procedure. The overall success rate was 80% (n 16). Results remained stable for a follow-up of 5.54 ± 3.97 years. Fat grafting performed around the voice prosthesis, thanks to its volumetric and regenerative properties, is a valid and lasting option to solve persistent periprosthetic leakage.

Objectives This study aims to describe a new secondary tracheoesophageal puncture technique with voice prosthesis insertion under local anesthesia with a low-cost device and evaluate its outcome. Methods With a transoral flexible transillumination device of aluminum of 2.3 mm with fiberoptic light, the esophagus’s anterior wall is visualized through the tracheostomy. A tracheoesophageal fistula is made with a blade and passed through the fistula. Then a bent trocar is introduced into the lumen using the device as a guidewire. Once in the lumen, a thin guide wire is passed through up to the mouth. The voice prosthesis is positioned with retrograde insertion. Then, the patient is discharged without hospitalization. Results 15 patients submitted to this technique had a successful surgical outcome. There were no complications as pneumothorax, esophageal perforation, bleeding, or hospitalization. Conclusion The new device is feasible under local anesthesia.

Closure of a tracheoesophageal puncture site performed during voice prosthesis implantation may sometimes be required. Besides local techniques, more elaborate procedures, such as closure by means of free microvascular flaps, have been advocated. In this report, we describe a case of local treatment of a hard-to-heal fistula with local application of autologous platelet-rich fibrin matrix in a 77-year-old male patient. At one-week follow-up, the size of the fistula had decreased dramatically but some leakage remained when drinking. After one month, the patient was able to drink and eat normally without any leakage. There was no recurrence of the leakage at two years' follow-up. In summary, local application of platelet-rich fibrin seems to be a simple, safe and effective procedure for tracheoesophageal fistula closure.

Background To present an effective and easily applicable method for tracheoesophageal puncture (TEP) closure by using a localized annular flap instead of bulky and distant flaps. Methods The medical records of patients who underwent TEP closure surgery with the annular mucosal flap technique between July 2012 and August 2018 were retrospectively reviewed. Fistula size, indication for closure, duration of surgery, radiotherapy status, and surgery results were analyzed. Results We have used our technique in nine patients. No postoperative bleeding, wound infection, esophageal stenosis, and tracheostoma stenosis occurred. In all these patients except one, successful closure was achieved. None of the patients had a recurrence of the TEP. Conclusion The annular mucosal flap technique for TEP closure is easy and quick to apply. The patient's oral feeding at the sixth hour after procedure without using a nasogastric tube makes the technique preferable as a priority.

OBJECTIVE/HYPOTHESIS Tracheoesophageal diversion (TED) can prevent damage to the respiratory system in patients with swallowing disorders and/or repetitive aspiration pneumonia; however, TED may cause the loss of phonation. Our previous study demonstrated that TED with tracheoesophageal puncture (TEP) prevents aspiration while retaining phonation. In this study, we aimed to further evaluate the feeding status and phonation of patients who underwent TED with TEP to verify the reproducibility of this procedure. STUDY DESIGN Case series study. METHODS We retrospectively reviewed the medical records of 11 patients who underwent TED with TEP for intractable aspiration from February 2017 to August 2019 at Fukuoka Sanno Hospital. We evaluated the preoperative penetration aspiration score (PPAS), daily activities, preoperative and postoperative food intake level scale (FILS) score, nutrition route, maximum phonation time(MPT), and postoperative communication method. RESULTS The study population included 10 men and 1 woman (mean age, 66 years; range, 44-81) with a PPAS of 6.8 ± 1.0. The FILS score changed from 2.1 ± 0.5 preoperatively to 7.5 ± 2.0 postoperatively (paired t-test, P

Summary Objective In a postlaryngectomy patient, tracheoesophageal (TE) speech is considered to be the most effective and preferred method of communication. Previous research has demonstrated that despite an appropriately sized TE prosthesis placement at the time of puncture, there are a portion of patients that require resizing postoperatively. The purpose of this study was to report on the variability of the tracheoesophageal prosthesis length. Study design Retrospective chart review. Setting Tertiary care academic medical center. Methods This was a retrospective chart review of 62 patients who underwent secondary tracheoesophageal puncture (TEP) at a tertiary care academic medical center from January 2008 to November 2019. Patient demographic information, average changes in prosthesis length, number of prosthesis adjustments, and timing of prosthesis exchanges were collected. Results 62 patients met criteria for study inclusion. Mean age was 61.96 years old with 49 being male (79%) and 13 (21%) females. Overall change in prosthesis length was - 3.85 mm ± 3.58 with time to first prosthesis change at 2.29 months ± 2.73. There was an average of 4.37 changes ± 3.43 before reaching a stable length. Twenty-six patients (41.9%) had increases in their prosthesis length resulting in closure of the tracheoesophageal fistula requiring seven patients (11.3%) to return to the operating room for repuncturing. History of smoking (P = 0.02), Blom-Singer prosthesis type (P = 0.03), and larger diameter (P = 0.01) appeared to be predisposing factors for a fluctuating prosthesis length. Conclusion Tracheoesophageal prosthesis length decreases over time for secondary punctures, requiring adjustments with a speech language pathologist. There are a clinically significant portion that have fluctuations in prosthesis length resulting in an increased risk for requiring re-puncturing.

Objectives Despite the advances in surgical and non-surgical organ preservation treatments, total laryngectomy (TL) remains the most effective treatment in advanced larynx cancer and as salvage procedure in chemoradiation failure. One of the most devastating sequel after TL is loss of voice. Voice prosthesis (VP) is currently the preferred choice for voice rehabilitation. The purpose of this study is to identify VP complications, its lifespan and factors that influence the longevity of the VP. Methods We performed a retrospective study at a Tertiary University Hospital. Medical records of patients that underwent total laryngectomy, between January 1st of 2008 and 31st of December of 2017 were analyzed. Results Of the 84 patients that underwent laryngectomy, 60 had VP. The average age at the time of surgery 60.2 years old and there was a male preponderance (57:3). The mean lifespan of the prosthesis was 7.53 months. Leakage through the prosthesis was the most common reason for replacement of the prosthesis, followed by leakage around the prosthesis. Follow up time and manual suture were associated with prosthesis replacement. There was no significant relationship between the staging, tumor location or adjuvant radiotherapy and number of prosthesis replacement or its lifespan. Conclusions Rehabilitation after TL is of major importance to improve quality of life after surgery. Tracheoesophageal puncture with voice prosthesis is a safe procedure for vocal rehabilitation and was performed in the majority of patients in our study. Follow-up time and type of suture were the main determinants of the lifespan of the prosthesis.

Purpose Tracheoesophageal puncture with voice prosthesis placement remains the gold standard for voice restoration following total laryngectomy, but may cause various complications. This study aims to summarize patient-related and device-related adverse events associated with tracheoesophageal puncture and voice prosthesis placement. Materials and methods The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of adverse events related to tracheoesophageal puncture with voice prosthesis placement from January 1, 2010, to April 30, 2020. Data were extracted from reports pertaining to tracheoesophageal prostheses. Results Seventy-seven reports involving tracheoesophageal voice prostheses were identified, from which 111 adverse events were extracted. Of these, 58 (52.3%) were patient-related, while 53 (47.7%) were device-related. The most frequently reported patient-related adverse events were aspirated prosthesis (24 [41.4%]), foreign body during placement (11 [19.0%]), aspiration pneumonia (9 [15.5%]), and aspirated brush tip (8 [13.8%]). The most common device-related adverse events were detached brush tip (15 [28.3%]), leak (14 [26.4%]), and torn esophageal flange (11 [20.8%]). Conclusions While tracheoesophageal puncture with voice prosthesis placement has revolutionized voice rehabilitation following total laryngectomy, the procedure may be associated with adverse events both at the time of placement and later. Interventions aimed at improving both physician and patient education may help reduce adverse events attributed to improper use. Further research is needed to clarify optimal approaches to education.

OBJECTIVES/HYPOTHESIS To evaluate the long-term swallowing outcomes after surgical treatment for chronic aspiration in patients treated with radiotherapy for head and neck cancer. STUDY DESIGN This was a retrospective study. METHODS The data of patients who underwent radiotherapy for head and neck cancer and who subsequently required a laryngectomy or a tubed supraglottic laryngeal closure (TSLC) for recurrent aspiration pneumonia between 2004 and 2017 were retrieved from a tertiary referral hospital dysphagia clinic. The Functional Oral Intake Scale (FOIS) and the Swallowing Performance and Status Scale (SPSS) were used to assess swallowing function. RESULTS Of the 17 patients who required surgery for chronic aspiration secondary to radiotherapy for head and neck cancer, two underwent a laryngectomy and 15 a TSLC. During a mean follow-up of 77 months, the FOIS and SPSS scores significantly improved at 12, 24, and 36 months after laryngectomy and TSLC relative to the baseline (P

Acquired benign tracheoesophageal fistula (TOF) is a rare medical condition that usually results from trauma, foreign bodies or granulomatous infections. This is an unusual presentation of a male patient with a history of laryngectomy who has had over a period of several years inappropriately and vigorously used valve cleaning brushes to clean tracheal secretions, which has led to the formation of a TOF. Due to the patient’s obsessive habit, we could not manage him using conventional surgical methods. Instead, we opted for the placement of a salivary bypass tube, which yielded good results and recovery. To the best of our knowledge, no other case of similar aetiology has been published. We would like to highlight the importance of appropriate patient selection and education prior to performing a tracheoesophageal puncture to avoid developing life-threatening complications as demonstrated in our case report.

Background/Aims: The tracheoesophageal prothesis (TEP) has become the primary modality for laryngeal communication after total laryngectomy due to high success rates, minimal morbidity, and more natural pulmonary driven speech. Fibrosis, kyphosis, and post-radiation contracture may preclude TEP placement through rigid esophagoscopy, and certain patients may not tolerate an in-office awake procedure. For such patients, a technique for flexible esophageal stenting and TEP placement is necessary. Methods: We performed a retrospective review of 3 patients who underwent TEP placement through endotracheal-tube esophageal stenting at the Massachusetts Eye and Ear Infirmary. Results: All 3 patients underwent laryngectomy after prior chemoradiotherapy for laryngeal cancer with resulting neck contracture and fibrosis preventing rigid esophagoscopy. All patients underwent successful TEP placement through endotracheal stenting without complication and developed excellent tracheoesophageal speech. Specific technical details are highlighted. Conclusions: In patients with anatomical constraints preventing traditional TEP placement through rigid esophagoscopy, fiberoptic guidance through an endotracheal tube stent provides a safe and efficient approach for TEP placement.

A tracheoesophageal voice prosthesis is very effective for improving speech after total laryngectomy. Although it is generally a safe method, it may be necessary to close the tracheoesophageal fistula due to complications such as prosthesis-related cellulitis, granulation tissue formation, tracheoesophageal fistula necrosis, or salivary leakage around the prosthesis. Surgical and non-surgical methods for closure have been described. In this article, a method for closing the tracheoesophageal fistula with a butterfly cartilage graft is described. The butterfly cartilage technique is safe and efficient in terms of anatomical closure of the fistula. This study shows that the method can be easily applied, with low morbidity, using an auto-graft material with local anesthesia in an outpatient setting.

OBJECTIVES/HYPOTHESIS Tracheoesophageal puncture (TEP) can be performed at the time of laryngectomy (primary) or postoperatively (secondary). Prior studies demonstrate safe and earlier voice acquisition and rehabilitation with primary TEP. The objectives of this study were to assess national trends in primary TEP and identify factors associated with its use. STUDY DESIGN Retrospective review. METHODS Retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2010 to 2014 was performed. The NIS was queried for patients who underwent total laryngectomy (TL) (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] 30.3-30.4) and primary TEP (ICD-9-CM 31.95). Patient demographics, comorbidities, and factors known to influence the decision to perform TEP were characterized. Factors associated with primary TEP were identified by multivariable regression. RESULTS A total of 15,410 patients underwent TL during the study period. Of this cohort, 1,124 patients (7.3%) underwent primary TEP. Among patients who underwent primary TEP, 80.9% had laryngeal cancer, 16.4% had pedicled or free-flap reconstruction at the time of TL, 4.2% underwent partial pharyngectomy, and 48.0% underwent cricopharyngeal myotomy (CPM). The majority of primary TEPs were performed at urban teaching hospitals (90.6%). In multivariable regression, patients who underwent CPM were at significantly increased odds of primary TEP (odds ratio: 3.79, P

Background:Tracheoesophageal puncture represents the ‘gold standard’ for voice restoration following laryngectomy. Tracheoesophageal puncture can be undertaken primarily during laryngectomy or in a separate secondary procedure. There is no current consensus on which approach is superior. The current evidence comparing primary and secondary tracheoesophageal puncture was assessed.Methods:A systematic review and meta-analysis of articles comparing outcomes for primary and secondary tracheoesophageal puncture after laryngectomy were conducted. Outcome measures were: voice success, overall complication rate and pharyngocutaneous fistula rate.Results:Eleven case series met the inclusion criteria, two prospective and nine retrospective. Meta-analysis did not demonstrate statistically significant differences in overall complication rate or voice outcomes, though it suggested a significantly increased risk of pharyngocutaneous fistula in primary compared to secondary tracheoesophageal puncture.Conclusion:Primary tracheoesophageal puncture is a safe and efficient approach for voice rehabilitation. However, secondary tracheoesophageal puncture should be preferred where there is a higher risk of pharyngocutaneous fistula.

Objectives To identify differences in postoperative wound complications associated with a primary tracheoesophageal puncture (TEP) at the time of laryngectomy versus no TEP. Study Design Retrospective review of large national data set. Setting Academic and nonacademic health care facilities in United States, contributing de-identified, risk-adjusted clinical data to the American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods The National Surgical Quality Improvement Program data set for years 2006 to 2012 identified 430 patients who underwent total laryngectomy with or without a primary TEP. Patients who underwent a TEP at the time of laryngectomy (n = 68) were compared with patients who underwent laryngectomy without a TEP (n = 362). Postoperative wound complications and secondary outcomes, including medical complications and length of hospitalization, were compared between the groups. Results The incidence of "superficial" and "deep or organ space" surgical site infection, medical complications, return to the operating room, and length of hospitalization were similar between the groups. Patients in the TEP group had a higher overall wound complication rate (relative risk, 2.02; 95% CI = 1.06-3.84; attributable risk, 8.17%; number needed to harm, 12). Conclusions Performance of a primary TEP concurrent to total laryngectomy contributed to a small increase in attributable risk for overall wound complications but did not add substantial risk for "superficial" or "deep or organ space" surgical site infection, medical complications, or increased burden for resource utilization. These data may help inform patient choice and physician recommendations for primary alaryngeal speech rehabilitation.

Objectives/Hypothesis This study compares the overall durability, phonation effort, and speech quality achieved by the Blom-Singer Dual Valve prosthesis to the same characteristics achieved by the single-valve prosthesis used in a select population of total laryngectomy patients who have demonstrated single-valve prosthesis failure within 3 months of placement. Study Design Prospective phase IV study. Methods Fourteen patients who had previously experienced early valve failure using a single-valve prosthesis had a Dual Valve placed by a speech language pathologist. A total of seventeen Dual Valves were inserted during routine clinical visits for valve replacement. Time intervals from insertion to replacement of the Dual Valve, as well as the average lifespan of patients’ three previous single valves were collected. Subjective, categorical responses to speech quality and phonation effort for the Dual Valve compared to the single valve were collected on a questionnaire upon failure of the device. Results The mean duration of the single valve was 60 days, with a median of 51 days, whereas the mean duration of the Dual Valve was 164 days, with a median duration of 84 days. Both sets of data were statistically significant, with a P value of .0131. Valve life was increased in 86% of patients, with 43% experiencing greater than 150 days improvement in valve duration when using the Dual Valve. Phonation effort was increased in 14% of patients, and speech quality was not significantly affected in any patients. Conclusions In this select population, the Dual Valve offers improved durability over the single valve without sacrificing speech quality, making it a preferred prosthesis option for patients experiencing single-valve failure in less than 3 months. Level of Evidence 4. Laryngoscope, 128:422–426, 2018

With the COVID-19 pandemic, there has been significant changes and challenges in the management of oncology patients. One of the major strategies to reduce transmission of the virus between patients and healthcare workers is deferral of follow-up visits. However, deferral may not be possible in total laryngectomy patients. Urgent procedures may be necessary to prevent complications related to ill-fitting tracheoesophageal puncture (TEP) voice prostheses, such as aspiration or loss of voicing. In this paper, we describe the Princess Margaret Cancer Center’s approach to managing this unique patient population.

Pharyngoesophageal stenosis (PES) is a common and serious complication of head and neck cancer treatments such as radiation therapy, chemotherapy, tracheoesophageal puncture placement, and total laryngectomy surgery. Dilation-resistant stenosis requires surgical reconstruction, often with a radial forearm free flap (RFFF). With the present technique, the authors refine their previous bipaddled free flap design used to reconstruct a persistent tracheoesophageal fistulae (TEF) in combination with PES. Accordingly, we present a novel bipaddled triangular RFFF design ideally suited to address the shape of the defect in the posterior tracheal wall that results when the TEF is opened and the esophageal and tracheal components are restored.

Objectives/hypothesis To evaluate the demographics, clinical features, management, and prognostic indicators of tracheoesophageal puncture complications in patients undergoing placement of voice prosthesis following cancer treatment. Study design Retrospective analysis. Methods A retrospective analysis was conducted of cases from a tertiary referral center diagnosed between 1996 and 2015. Multivariate logistic regression was used to determine factors associated with tracheoesophageal puncture (TEP) and voice prostheses-complication-free survival (TEP/VP-CFS). Results One hundred fourteen cases were identified. Most patients were males (92.9%) with pT3 (26.8%) or pT4 (58.1%) N+ (53.6%) tumors. All patients received laryngectomy as the primary treatment, with 75% of patients receiving adjuvant radiation therapy or chemoradiotherapy. Complications with TEP were common (65.2%). The most frequent problem was salivary leakage (50.0%), which at the same time was the most common reason for changing the prosthesis. On univariate regression analysis, prosthesis placement time after adjuvant radiotherapy (hazard ratio [HR]: 4.17, 95% confidence interval [CI]: 2-8.69), secondary prosthesis placement after primary surgery (HR: 3.97, 95% CI: 1.99-7.9), and laryngectomy with flap reconstruction (HR: 1.96, 95% CI: 0.99-3.89) were significant prognosticators for complications. Multivariate regression analysis revealed secondary prosthesis placement after adjuvant radiotherapy (HR: 3.66, 95% CI: 1.39-9.68) or after primary surgery (HR: 2.57, 95% CI: 0.92-7.2) to be the strongest predictors of reduced TEP/VP-CFS. Conclusions Secondary prosthesis placement after primary surgery, placement after previous irradiation, and laryngectomy with flap reconstruction are predictors of poor TEP/VP-CFS. Planned adjuvant radiotherapy is not a contraindication for TEP with prosthetic placement, but it is very important to place the prosthesis during the primary surgery or at least before scheduled radiotherapy. Level of evidence 4 Laryngoscope, 2020.

Tracheoesophageal puncture with voice prosthesis placement is used to restore vocal function after total laryngectomy. However, closure of the fistula is sometimes needed. At our department, a simple and effective technique for closure was developed. It does not require interposed tissues or materials. Moreover, our procedure allows for a short rehabilitation time for swallowing and a short hospitalization. We describe advantages, pitfalls, and errors to avoid. This technique should not be performed for patients who are irradiated and those with large fistulas.

Tyrosine kinase inhibitors (TKIs) aid in prolonging life in patients with advanced locoregional thyroid malignancy. Such patients may undergo total laryngectomy for local disease control and tracheoesophageal puncture (TEP) for speech rehabilitation. Enlargement of TEP fistulas is usually attributed to wound healing issues and leads to major complications. Four laryngectomies with TEP were performed between 2015 and 2016 and subsequently placed on a TKI. Three patients developed a complication after TKI treatment, and 2 patients had a tracheoesophageal fistula. Patients should be counseled about possible wound healing risks associated with TKIs.

Purpose Post-radiation therapy salvage surgeries are challenging for surgeons due to tissue fibrosis. The woody hardness classification is valuable in differentiating the degree of neck stiffness, but its clinical utility has not been evaluated. We applied it to patients undergoing salvage laryngectomy to study the impact of woody hardness on postoperative outcomes. Materials and methods A retrospective observational study was performed on patients undergoing salvage laryngectomy between 2014 and 2019. Patients were assigned into the A (extremely woody hard), B (moderately woody hard), or C (mildly woody hard) woody hardness class. The primary outcome was pharyngoesophageal stricture development. Secondary outcomes included time to pharyngoesophageal stricture, pharyngocutaneous fistula development, time to pharyngocutaneous fistula, development of post-operative complications, and tracheoesophageal puncture complications. Results Fifty-one patients were included in the study: Class A 1 patient, Class B 30 patients, and Class C 20 patients. The single Class A patient was grouped with the Class B patients. The development of a pharyngoesophageal stricture shows consistent negative association with woody hardness despite most analyses not reaching statistical significance. These associations are robust to a number of confounding variables in multivariate logistic and time to event analyses. Furthermore, the time to event analysis controlling for squamous cell carcinoma diagnosis led to a statistically significant association between woody hardness (i.e., A/B higher risk) and time to stricture (HR=5, p=0.02). Conclusions This study suggests that this classification may be useful in predicting pharyngoesophageal stricture formation in salvage laryngectomy patients and could be used to implement stricture preventive measures.

Contains fulltext : 177852.pdf (Publisher’s version ) (Closed access) BACKGROUND: Diagnostic and therapeutic office-based procedures under topical anesthesia are emerging in the daily practice of laryngologists and head and neck surgeons. Since the introduction of the transnasal esophagoscope, office-based procedures for the esophagus are increasingly performed. METHODS: We conducted a systematic review of literature on office-based procedures under topical anesthesia for the esophagus. RESULTS: Transnasal esophagoscopy is an extensively investigated office-based procedure. This procedure shows better patient tolerability and equivalent accuracy compared to conventional transoral esophagoscopy, as well as time and cost savings. Secondary tracheoesophageal puncture, esophageal dilatation, esophageal sphincter injection, and foreign body removal are less investigated, but show promising results. DISCUSSION: With the introduction of the transnasal esophagoscope, an increasing number of diagnostic and therapeutic office-based procedures for the esophagus are possible, with multiple advantages. Further investigation must prove the clinical feasibility and effectiveness of the therapeutic office-based procedures.

Objectives/Hypothesis A total laryngectomy (TL) is performed as a primary or salvage therapy for laryngeal carcinoma. Pharyngotomy closure after TL is typically performed using manual sutures. Automatic stapling devices are routinely used in thoracoabdominal surgery, but have not been widely accepted for use in pharyngotomy closure. Previously described closed stapling techniques of pharyngeal closure do not allow direct evaluation of surgical margins and are limited to endolaryngeal disease. We describe an open technique for pharyngotomy closure using a mechanical stapling device. Study Design Retrospective review. Methods A review was conducted of 16 total laryngectomies performed from May 2008 to August 2015 utilizing an Ethicon Endopath ETS Compact-Flex 45 stapler. Results Sixteen patients (15 male, one female), mean age 69 years, received open TL (14 salvage, two primary) with endostapler pharyngeal closure and primary tracheoesophageal puncture (TEP). Surgical time averaged 218 minutes. Median time to swallowing was 4 days (range, 2–240 days) and mean hospital stay 6 days (range, 3–10 days). Fistula incidence was 31% (5/16) overall and 36% (5/14) in the postradiation patients. Conclusions Mechanical stapling is a simple method for postlaryngectomy open pharyngotomy closure. This technique allows evaluation of margins, easy primary TEP, and the opportunity for early swallowing and shorter hospital stays. In addition, it can be performed for closure of salvage laryngectomies with rates of fistula formation similar to that found in the literature using suture closure techniques. Future studies are necessary to compare oncological results and surgical complications between the open and closed stapling techniques and to traditional suture closure. Level of Evidence 4 Laryngoscope, 2016

The tracheoesophageal puncture (TEP) restores verbal communication after total laryngectomy using a one-way valved voice prosthesis (VP). Microbial colonization can shorten VP device life. Our aims were to investigate patterns of prosthetic and oral colonization, and record changes in VP device life after targeted decontamination. We conducted a retrospective review of TEP clinic patients who underwent microbial analysis of the VP between 01/2003 and 07/2013. Two subgroups were analyzed: (1) patients with microbial analysis of the VP and the mouth were analyzed to identify patterns of common contamination, and (2) patients who were prescribed targeted oral decontamination on the basis of the microbial analysis of the VP were analyzed to evaluate effects on device life. Among 42 patients, 3 patients had only fungal, 5 only bacterial, and 33 had polyspecies fungal and bacterial colonization. In the TEP-oral microflora subgroup (n = 15), 7 had common microorganisms in the mouth and on the VP. Among the decontamination subgroup (n = 23), 6 patients received broad spectrum rinse, 16 antifungal agents and 13 antibiotics, or a combination thereof. After targeted decontamination, the median device life of prostheses improved from 7.89 to 10.82 weeks (p = 0.260). The majority of patients with a suboptimal VP device life in this pilot had polyspecies bacterial and fungal colonization. VPs rarely had fungal contamination alone (3 %), and non-albicans fungal species were more common than expected. For these reasons, we are exploring the use of targeted decontamination regimens that were associated with 1.4-fold improvement in VP duration.

Background We evaluated the impact of radiation, reconstruction, and timing of tracheoesophageal puncture (TEP) on complications and speech outcomes. Methods Retrospective review identified 145 patients who underwent TEP between 2003 and 2007. Results Ninety-nine patients (68%) had primary and 46 (32%) had secondary TEP, with complications occurring in 65% and 61%, respectively (p = .96). Twenty-nine patients (20%) had major complications (18 primary and 11 secondary; p = .42). Ninety-four patients (65%) had pre-TEP radiation, 39 (27%) post-TEP radiation, and 12 (8%) no radiation. With patients grouped by TEP timing and radiation history, there was no difference in complications, fluency, or TEP use. With mean 4.7-year follow-up, 82% primary and 85% secondary used TEP for primary communication (p = .66). Free-flap patients used TEP more commonly for primary communication after secondary versus primary TEP (90% vs 50%; p = .02). Conclusion Primary and secondary tracheoesophageal speakers experience similar high rates of complications. Extent of pharyngeal reconstruction, rather than radiation, may be more important in selection of TEP timing. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1765–1771, 2016

Although associated with significant morbidity including fistula, stricture, poor voice rehabilitation, and even death, salvage laryngectomy and laryngopharyngectomy will remain as important surgical procedures as long as transoral surgery and chemoradiation therapy continue to be employed primarily in the treatment of laryngeal malignancy. Multi-institutional retrospective analyses indicate that onlay pectoralis myofascial flaps may reduce the incidence of post-operative fistula to 10–15 % compared to 30 % associated with primary closure alone. Regional and distant fasciocutaneous flaps have limited morbidity and their use may minimize the rates of stricture. Employment of salivary bypass tubes appears to reduce the incidence of fistula to less than 10 %. Voice rehabilitation outcomes with tracheoesophageal puncture are equivalent between fasciocutaneous flaps and primary closure, and better than the voice quality attained with enteric flaps or pectoralis flaps. Pectoralis onlay flaps are a viable option in select patients undergoing primary closure who are aware of the associated morbidity and voice outcomes. Free tissue transfer, in particular the anterolateral thigh flap, used in conjunction with salivary bypass tubes offers an ideal balance of donor site morbidity, post-operative fistula, and voice rehabilitation, and should be considered for appropriate patients.

Objective:To evaluate the utility of the hybrid tracheoesophageal puncture procedure in stapler-assisted laryngectomy.Methods:Patients who underwent total laryngectomy at a single institution from 2009 to 2015 were reviewed. The interventions assessed were surgical creation of a tracheoesophageal puncture and placement of a voice prosthesis. The outcomes measured included voicing ability and valve failure.Results:Thirty-nine patients underwent total laryngectomy or pharyngolaryngectomy. Of these, nine underwent stapler-assisted laryngectomy; seven of the nine patients underwent concurrent stapler-assisted laryngectomy, cricopharyngeal myotomy and a hybrid tracheoesophageal puncture procedure. These seven patients were the focus of this review. Successful voicing and oral alimentation was achieved in all patients. Mean time to phonation was 30 days (range, 7–77 days) and mean time to first valve change was 90 days (range, 35–117 days).Conclusion:Primary tracheoesophageal puncture with concurrent voice prosthesis placement and cricopharyngeal myotomy is easily performed with stapler-assisted laryngectomy. The hybrid tracheoesophageal puncture procedure is a simple method that enables a single operator to achieve primary tracheoesophageal puncture and valve placement; in addition, it facilitates concurrent cricopharyngeal myotomy.

Objectives/Hypothesis Demonstrate that biofilm formation will be reduced on tracheoesophageal prostheses when vibratory stimulus is applied, compared to controls receiving no vibratory stimulus, in a dynamic in vitro model of biofilm accumulation simulating the interface across the tracheoesophageal puncture site. Study Design Prospective, randomized, controlled, crossover in university laboratory. Methods Ex vivo tracheoesophageal prostheses were obtained from university-affiliated speech language pathologists at Indiana University School of Medicine, Indianapolis. Prostheses demonstrating physical integrity and an absence of gross biofilm accumulation were utilized. Sixteen prostheses were cleansed and sterilized prior to random placement by length in two modified Robbins devices arranged in parallel. Each device was seeded with a polymicrobial oral flora on day 1 and received basal artificial salivary flow continuously with three growth medium meals daily. One device was randomly selected for vibratory stimulus, and 2 minutes of vibration was applied to each prosthesis before and after meals for 5 days. The prostheses were explanted and sonicated, and the biofilm cultured for enumeration. This process was repeated after study arm crossover. Results Tracheoesophageal prostheses in the dynamic model receiving vibratory stimulus demonstrated reduced gross biofilm accumulation and a significant biofilm colony forming unit per milliliter reduction of 5.56-fold compared to nonvibratory controls (P < 0.001). Significant reductions were observed within length subgroups. Conclusion Application of vibratory stimulus around meal times significantly reduces biofilm accumulation on tracheoesophageal prostheses in a dynamic in vitro model. Further research using this vibratory stimulus method in vivo will be required to determine if reduced biofilm accumulation correlates with longer device lifespan. Level of Evidence N/A. Laryngoscope, 2016

The objectives of this study were to demonstrate that the length of the tracheoesophageal voice prosthesis changes over time and to determine whether the prosthesis length over time increased, decreased, or showed no predictable change in size. A retrospective chart review was performed at a tertiary care referral center. Patients who underwent either primary or secondary tracheoesophageal puncture between January 2006 and August 2014 were evaluated. Patients were excluded if the tracheoesophageal prosthesis size was not consistently recorded or if they required re-puncturing for an extruded prosthesis. Data analyzed included patient demographics and the length of the tracheoesophageal voice prosthesis at each change. A total of 37 patients were identified. The mean age was 64 years. Seventy-six percent were male. 24 % underwent primary tracheoesophageal puncture and 76 % underwent secondary tracheoesophageal puncture. The length of the prosthesis decreased over time (median Kendall correlation coefficient = -0.60; mean = -0.44) and this correlation between length and time was significant (p = 0.00085). Therefore, in conclusion, tracheoesophageal prosthesis length is not constant over time. The tracheoesophageal wall thins, necessitating placement of shorter prostheses over time. Patients with a tracheoesophageal voice prosthesis will require long-term follow-up and repeat sizing of their prosthesis. Successful tracheoesophageal voicing will require periodic reevaluation of these devices, and insurers must, therefore, understand that long-term professional care will be required to manage these patients and their prostheses.

We report the case of a patient who developed an epidural abscess several months following primary TEP. Tracheoesophageal puncture (TEP) is a common procedure used for speech rehabilitation in total laryngectomy (TL) patients. Epidural abscess after TEP placement is a rare complication but there are several cases reported in the literature. Patients typically present with neck pain and/or dysphagia, in addition to signs and symptoms of infection. Her case was unusual in that she presented initially with paraplegia without neck pain or dysphagia. Surgical evacuation of the abscess was performed urgently, however the patient developed osteomyelitis of the cervical spine with persistent cord compression and irreversible paraplegia. She subsequently expired from sepsis. Epidural abscess after TEP placement is a serious but rare complication. Early detection and treatment are imperative to avoid poor long-term outcomes.

Background: Tracheoesophageal puncture (TEP) with voice prosthesis (VP) placement is considered the standard for vocal rehabilitation after total laryngectomy (TL). This study aimed to compare the success rate of primary and secondary TEP and to evaluate the impact of clinical factors on functional outcome.Methods: A retrospective medical chart review was conducted in patients who underwent TL or pharyngolaryngectomy (PLT) and TEP. Variables collected included age, gender, comorbidities, tumor location and stage, extension of surgical resection, reconstruction, neck dissection, radiation therapy, salvage surgery, device lifetime, postoperative complications and successful voice restoration.Results: A total of 186 patients were enrolled in this study, 164 patients (88.2%) underwent primary TEP and 22 (11.8%) secondary TEP. Successful voice rehabilitation was achieved in 76.9% of patients and there was no difference between primary and secondary TEP groups (76.2% vs. 81.8%, p=0.76). A poorer voice restoration outcome was found in patients who underwent radiation therapy (p=0.01) or salvage surgery (p=0.03). Adjuvant radiation was the only independent prognostic factor for functional success (OR=4.7, IC 95%= 1.4-15.9, p=0.04). VP related complications occurred in 65.7% of patients, with higher incidence in secondary TEP group (90.9% vs. 67.7%, p=0.03). Overall device lifetime was similar between primary and secondary groups (9.2 vs. 8.7 months, p=0.89).Conclusions: Voice rehabilitation outcome was similar with primary and secondary TEP. However, TEP related complications were more common in secondary procedures. Primary TEP allows earlier voice restoration, avoiding a second surgical intervention. Functional success rate was poorer for patients who underwent radiation therapy.

Enlargement of tracheoesophageal puncture (TEP) is seen in 1-29% of laryngectomee/laryngopharyngectomee using tracheoesophageal voice. It predisposes patient for recurrent aspiration pneumonia. Surgical closure of TEP is required in 30-67% of patients not responding to conservative measures. Surgical closure of an enlarged TEP using a flap may be time consuming, complex, and logistically challenging to organize. A novel technique of Fascia lata graft closure of an enlarged TEP is presented here. This technique can be useful in carefully selected patients with an enlarged TEP.

High dose of radiation to bone may cause necrosis. Osteoradionecrosis of the cervical vertebrae is a rare adverse event of radiotherapy in patients treated for head and neck cancer. The risk on osteoradionecrosis will increase with doses exceeding 60 Gy. Minimal trauma of the overlying mucosa of the heavily irradiated cervical spine causes subsequent infections or instability may cause neck pain and severe neurological disability. In four patients the cervical spine received up to 100 Gy due to reirradiation. Clinically the patients presented with neck pain. All patients had defects in the pharyngeal posterior wall and cervical instability due to osteoradionecrosis of several cervical vertebrae. Despite optimal conservative treatment the patients developed sensory and motor function loss of the upper extremities. Laminectomies were performed and the cervical spine was stabilized. The pharyngeal posterior wall defects could not be reconstructed. All patients received lifelong antibiotic treatment. Pain and neurological deficits declined after surgery and initiating antibiotics. Eventually all patients could take up their daily activities. Three patients died between 6 months and 2 years after surgery. The cause of death was not related to the osteoradionecrosis. In case of cervical osteoradionecrosis, with secondary infections, stability of the spine should be restored even when the integrity of the pharyngeal posterior wall cannot be restored. Our cases demonstrate that even when an anterior approach is impossible, due to irradiation changed tissue structures of the pharyngeal posterior wall, a combination of lifelong antibiotic treatment and posterior stabilization is a good alternative. The vertebrae affected by osteoradionecrosis and secondary infection can be left in situ. This intervention leads to improvement in quality of life.