Tracheo-oesophageal puncture
Tracheo-esophageal puncture | |
---|---|
ICD-9-CM | 31.95 |
A tracheo-esophageal puncture (or tracheoesophageal puncture) is a surgically created hole between the
A laryngectomized person is required to breathe through a permanent breathing hole in the neck, called a tracheostoma. When a laryngectomized person occludes the tracheostoma, completely blocking exhaled air to leave the body through that pathway, exhaled air is directed through the voice prosthesis. This air enters the esophagus and escapes through the mouth. During this process, as the air passes through the upper tissues of the esophagus and lower throat, it allows for vibration of the tissues of the pharyngoesophageal segment (also called PE-segment, neoglottis or pseudoglottis). This vibration creates a sound that serves to replace the sound the vocal cords previously produced. Other methods of alaryngeal speech (speech without vocal cords) are esophageal speech, and artificial larynx speech. Studies show that tracheoesophageal speech is found to be closer to normal speech than esophageal speech[1][2][3] and is often reported to be better, both in terms of naturalness as well as how well it is understood, when compared to esophageal speech[4][5] and electrolarynx speech.[6] The first report on a tracheoesophageal puncture dates back to 1932[7] when a laryngectomized patient was said to use a hot ice pick to create a tracheoesophageal puncture in himself. This enabled him to speak by forcing air through the puncture when closing off the tracheostoma with a finger.
Puncture procedures
There are two tracheo-esophageal puncture procedure types: Primary and secondary puncture. Initially, the procedure was described as a secondary procedure[8] and later also as a primary procedure.[9]
Primary tracheoesophageal puncture
This procedure is performed during the total laryngectomy surgery. After removal of the larynx and creation of the tracheostoma, the puncture is made through the back wall of the trachea into the front wall of the esophagus. The main advantages of a primary puncture are: 1) that a second surgery to create the puncture is avoided (including the related costs and risks) and: 2) that the patient will be able to speak within a few weeks after total laryngectomy.[10][11]
There are cases where a primary procedure cannot be performed. For example, this procedure cannot be used when there is complete separation of the tracheoesophageal wall where the puncture would otherwise be placed (for example, in case a portion of the esophagus is removed requiring an anastomosis, or “reconnection” of structures in the region). In that case, a sufficient period of recovery and wound healing would be required. A secondary puncture could then be placed.[citation needed]
Secondary tracheoesophageal puncture
This procedure refers to a puncture that is placed anytime after the total laryngectomy surgery. The decision to use a primary or secondary puncture can vary greatly. Secondary puncture can be performed when: 1) primary puncture was not possible, 2) for re-puncture after closure of a previous tracheoesophageal puncture, 3) because of physician or patient preference, and 4) in case failure of esophageal or electrolarynx speech if this was chosen as the initial speech option.[citation needed]
Placement of the voice prosthesis
There are two different methods that can be used to place the voice prosthesis: Primary placement: A voice prosthesis is placed into the puncture[12][13] immediately after it is created. During the immediate postoperative period, the patient is fed through a feeding tube, either inserted directly into the stomach or through a more temporary version than extends from the nose into the stomach. This tube is removed when the patient is able to eat enough by mouth to maintain nutritional needs; this can be as early as the second day following surgery.[11] Speech production with the voice prosthesis is initiated when the surgical area has healed, after clearance by the surgeon. The advantages of this method are: 1) the voice prosthesis stabilizes the TE wall, 2) the flanges of the device protect the puncture against leakage of fluids, stomach acids and other stomach contents, 3) there is no irritation or pressure from a stenting catheter, used to maintain the puncture opening until a voice prosthesis can be placed, 4) patients become quickly familiar with their prosthesis care as they receive instructions while hospitalized, 5) the patient will not have to undergo an outpatient procedure during which the voice prosthesis needs to be fitted, 6) many patients can learn to speak before the start of any post-operative radiation therapy (if indicated) 7) the patient can focus on voice production immediately, as wound healing allows.[11]
Another advantage is that generally, the voice prosthesis placed at the time of surgery lasts relatively long and requires no early frequent replacements.[14][15] The only disadvantage is that the patient will need to use a feeding tube for a few days.
Delayed placement: Instead of the voice prosthesis, a catheter (red rubber, Silastic Foley catheter,
Indications
Indications include voice rehabilitation for patients who are undergoing a total laryngectomy (primary puncture) or patients who have had a total laryngectomy in the past (secondary puncture).
References
- PMID 6571180.
- PMID 3352438.
- PMID 6716991.
- PMID 8182320.
- S2CID 20134241.
- PMID 3624525.
- ^ Guttman MR (1932). "Rehabilitation of the voice in laryngectomized patients". Arch Otolaryngol. 15: 478–488.
- S2CID 10447001.
- S2CID 27689897.
- ^ PMID 15163599.
- ^ a b c Hilgers FJ, van den Brekel MW. "Ch. 113: Vocal and Speech Rehabilitation Following Laryngectomy". In Flint Haughey, Richardson, Robbins, Thomas, Niparko, Lund (eds.). Cummings Otolaryngology: Head and Neck Surgery (5th ed.). Philadelphia: Elsevier. pp. 1594–1610.
- PMID 2233085.
- PMID 6544851.
- S2CID 45017821.
- PMID 11074828.
- S2CID 23076024.
External links
- Tracheoesophageal puncture entry in the public domain NCI Dictionary of Cancer Terms