Introduction
Speech restoration is of great significance for the social and economic welfare of patients who undergo total laryngectomy. As outlined in Chapter 75 , Voice Restoration After Total Laryngectomy, speech restoration is most often accomplished with the use of the electrolarynx or by placement of a primary or secondary tracheoesophageal puncture (TEP), allowing for esophageal speech. More than 80% of patients with a TEP develop intelligible speech and voice restoration with a TEP, and is of superior quality to that of the electrolarynx. Although most patients do well with their tracheoesophageal speech, there are certain problems associated with the valve :
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Poorly fitting valve leading to frequent displacement
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Spontaneous closure of the fistula following loss of the valve
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Aspiration of the valve into the tracheobronchial tree
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Leakage of saliva and food into the tracheobronchial tree
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Aspiration pneumonia from severe leakage, which could be life threatening in patients with pre-existing chronic lung disease
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Yeast infection of the valve
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Lack of patient acceptance of the valve
Many of these problems can be successfully managed with medical therapy, adjustment of the prosthesis itself, or by narrowing the tracheoesophageal fistula with injectable materials. In the minority of patients, the decision is made to remove the TEP due to continued complications related to the valve or fistula or simply patient preference. Given that a well-formed tracheoesophageal fistula is epithelialized circumferentially, the tract does not necessarily close spontaneously after prosthesis removal, especially when the fistula is large or in the patient who has been radiated, is malnourished, or continues to smoke heavily. This chapter describes the technique for definitive closure of the fistula after valve removal.
Key Operative Learning Points
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Conservative measures of closure for salivary leakage such as TEP site injections and size adjustments of the prosthesis should be tried before definitive surgical closure.
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Efforts to improve swallowing and voicing by pharyngoesophageal dilation, cricopharyngeus myotomy, or Botox treatment should be exhausted before closing the TEP in patients who are dissatisfied with their voice or swallowing ability.
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Patients need to be counseled about alternative methods of communication such as the electrolarynx and esophageal speech.
Preoperative Period
History
History of Present Illness
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The patient who has had a total laryngectomy generally has long-term care with the head and neck surgeon and speech language pathologist.
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The patient will often present in follow-up with speech or swallowing problems, a prosthesis that repeatedly becomes dislodged, or a history of recurrent aspiration pneumonias.
Past Medical History
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Past medical history
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Prior interventions for improvement of speech, swallowing, and leakage
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Serious comorbidities
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Cancer treatment history
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Date of total laryngectomy and TEP placement
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Use of radiation therapy before or after total laryngectomy
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Social history
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Continued alcohol and tobacco use
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Assess voice use goals in social and professional settings.
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Medications
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Use of anticoagulants
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Use of herbal products
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Physical Examination
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A complete examination of the head and neck is performed to rule out peristomal recurrence or second primary malignancies as a cause for TEP site complications.
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Evaluation of the fit of the TEP, often performed in conjunction with the speech language pathologist
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Evaluate the size of the laryngectomy stoma and the relative location of the TEP.
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Assess the quality of the peristomal tissues, especially in the radiated patient.
Imaging/Diagnostics
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No imaging is indicated if the patient is undergoing closure of the tracheoesophageal fistula for leakage.
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A fluoroscopic evaluation of the pharynx and esophagus may be useful in evaluation of the total laryngectomy patient with difficulty voicing and/or swallowing.
Indications
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The absolute indication for closure of the TEP is severe leakage with aspiration. Most salivary leakage responds to conservative measures such as reduction in the size of the valve to allow shrinkage of the fistulous tract. Cauterization of the fistula has also been used to promote shrinkage of the tract.
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Another indication for surgical closure of a TEP is poor voicing refractory to optimal teaching, therapy, and treatment of underlying etiologies. Poor voicing may be caused by spasm of the cricopharyngeus muscle or pharyngeal stenosis. Treatment for these conditions includes Botox injection of the cricopharyngeus muscle, cricopharyngeal myotomy, cervical neurectomy, dilation, and pharyngoplasty ( Chapter 54 ).
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We have also encountered a few patients who have none of the previously listed problems but simply wanted the fistula closed because they either did not like the idea of a fistula and the valve or just did not like the quality of their voice.
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We have been doing primary TEPs at the time of total laryngectomy since shortly after the introduction of the Singer-Blom valve. We try to carefully select patients who we feel would not succeed with a Singer-Blom valve, such as those who have poor manual dexterity (e.g., rheumatoid arthritis), low level of motivation, chronic neurologic syndrome, and inability to maintain the prosthesis.
Contraindications
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Proceeding to closure of the TEP without prior attempts to troubleshoot leakage, speech, and swallowing problems more conservatively. Patients whose stoma has been heavily radiated
Preoperative Preparation
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Patients who are candidates for closure of the TEP should be counseled by the speech language pathologist about the use of alternative methods of communication, such as the electrolarynx or esophageal speech.
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If the stoma is quite small, then stomaplasty should be included at the time of the closure of the TEP. The technique of stomaplasty, which includes creation of a small local flap in the superior aspect of the stoma, is described in Chapter 83 . If the size of the fistula is quite large or the TEP is located superiorly near the cutaneous junction, then stomaplasty with a flap is not feasible. Patients who have a stoma that has been heavily radiated present a unique problem. These patients do not tend to do well when stomaplasty is performed and have marked difficulty in healing.
Operative Period
Anesthesia
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Local anesthesia
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General anesthesia with small flexible endotracheal tube (anode tube)
Positioning
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Supine, shoulder roll to improve visualization
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Prep and drape the neck.
Perioperative Antibiotic Prophylaxis
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No antibiotics are indicated.
Monitoring
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No routine monitoring is indicated.
Instruments and Equipment
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Standard head and neck set
Key Anatomic Landmarks
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Tracheostoma
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Tracheoesophageal party wall
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Tracheoesophageal fistula tract
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Esophagus
Prerequisite Skills
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Total laryngectomy
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TEP ( Chapter 25 )
Operative Risks
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Failure of closure to heal, especially in the radiated patient
Surgical Technique
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The area that surrounds the superior aspect of the tracheostoma is infiltrated with 1% lidocaine with epinephrine 1:100,000.
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An incision is made in the mucocutaneous junction of the tracheal stoma from the 9-o’clock to the 3-o’clock position ( Fig. 26.1 ).
