Secondary tracheoesophageal puncture: Factors predictive of voice quality and prosthesis use

Abstract

Objective To identify factors predicting prosthesis use and final speech quality in patients undergoing secondary tracheoesophageal puncture (TEP) for voice restoration after laryngectomy. Methods We undertook a retrospective study of 168 patients who underwent secondary TEP at the Cleveland Clinic between June 1980 and October 1993. Factors examined were: patient demographics, extent of initial surgery, method of pharyngeal preparation, history of irradiation, insufflation test results, pharyngeal stricture, and concurrent medical conditions. Univariate and multivariate statistical analyses were performed to identify predictive factors. Results At last evaluation, 73.8% (124) of the patients were still using the prosthesis. Quality of speech was the only predictor of prosthesis use (p < .001). Phonation on the first day was achieved in 90% (151) of patients. Speech result improved significantly over the first 6 months (p < .001). Univariate analysis found that the need for reconstruction at laryngectomy (p = .04), the presence of pharyngeal stricture (p = .001), and continued prosthetic use (p < .001) were associated with the speech result. There was no significant advantage to the lack of approximation of the pharyngeal constrictors (p = .31). Stepwise logistic regression showed that only the absence of pharyngeal stricture was associated with a better‐quality voice (p = .001). Conclusion Tracheoesophageal puncture is a reliable method for restoring voice after laryngectomy. Prosthesis use decreases with time, and good voice quality is the only predictor of continued prosthesis use. In this series the absence of pharyngeal stricture was the only significant predictor of good to excellent speech. HEAD & NECK 1996;18:393–398 © 1996 John Wiley & Sons, Inc.

Reabilitação fonatória do laringectomizado total: utilização de toxina botulínica na voz tráqueo-esofágica com prótese fonatória

“…The true need for myotomy in TEP is a controversial issue in the literature, varying from 9% to 79% in TL patients. [1][2][3][4][5][6][7][8][9][10][11][12][13] In secondary TEP, myotomy is associated with a 10% to 20% incidence of salivary fistulae, 26 with the same consequences mentioned above. Using the BT for the treatment of PES spasm makes it possible to restrict myotomy for those patients that truly require this method for treating the PES; this avoids unnecessary procedures in the remaining patients, and reduces their surgery time and complication rate.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13] Altered PES motor activity in these cases is a reflex initiated by air entering the esophagus, blocking air from progressing to the pharynx. Consequently, the pharyngeal mucosa does not vibrate, and there is no phonation.…”

“…Consequently, the pharyngeal mucosa does not vibrate, and there is no phonation. 1,[3][4][5][7][8][9]13,18 Spasm may be seen in videofluoroscopy done during phonation with the PP; 5,7,8,15,24 it is absent during swallowing when the PES relaxes. During constriction there is no relaxation when swallowing.…”

“…17 It should be borne in mind that even after myotomy of the middle and lower pharyngeal constrictor muscles, there may be spasm by reapproximation of muscle fibers. 1,7,10,11,17 In such cases, the BT may also be used.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13] There are three approaches for the treatment of PES alterations: myotomy of the middle and lower constrictors of the pharynx, neurectomy of the pharyngeal plexus, and the recently described chemical denervation of the PES with the botulinum toxin (BT). 6,7,8,10,11,[14][15][16][17][18][19][20][21][22][23] The BT is a presynaptic blocker of acetylcholine release at the neuromuscular junction.…”