Twenty-three (59%) of the patients had had previous radiation therapy and had a salvage total laryngectomy performed. Sixteen patients (41%) had had some type of flap reconstruction performed-two involving the pectoralis major myocutaneous flap, five involving the radial forearm free flap, eight involving the anterior lateral thigh free flap, and one other that wasn’t specified. Seventeen patients (44%) had had a previous tracheoesophageal puncture.
Explore This IssueNovember 2009
Special care must be taken with patients who have had reconstruction performed, Dr. Hessel said. [For] any patient who has a free flap reconstruction, it is important that the patients being considered for TNE/TEP have some sort of imaging to confirm that the neopharynx and cervical esophagus are indeed lined up behind the trachea, she said. The extensive nature of a laryngopharyngectomy with flap may cause the anatomy to shift and the cervical esophagus may not be directly behind the tracheal stoma. At MDACC, we typically get a modified barium swallow in these patients to evaluate the anatomy before the TEP procedure.
The patients had the understandability of their speech analyzed. They were categorized as understandable all the time, understandable most of the time, usually understandable but with face-to-face contact necessary, difficult to understand, or never understandable.
In 38 of the 39 patients (97%) the puncture was performed successfully. There was some kind of technical difficulty in seven of the patients, with scar formation in four, and one instance each of nasopoharyngeal stenosis, a tight esophageal inlet, a tortuous pharyngoesophageal segment, and difficulty defining the puncture tract. But there were no complications, either major or minor, associated with the procedure.
The time until prosthesis placement was an average of 4.3 days. The type of reconstruction that had been used for pharyngeal closure had no statistical effect on outcome.
The 31 patients still using their prosthesis for speech at the time of their last clinical visit performed well. Twenty of these patients (61%) had speech that was rated as understandable all the time. Eight patients (25%) had speech rated as understandable most of the time, and three had speech rated as usually understandable or worse.
The success with voice results in secondary tracheoesophageal puncture patients in the study dovetailed with findings in other studies. A 2006 study (Cheng et al. Ear Nose Throat 2006; 85:262) reported that successful voice restoration in secondary TEP patients ranged from 56% to 94%.
Value of In-Office Procedures
Dr. Hessel said that the in-office option might be a valuable one. Transnasal tracheoesophageal fistula formation is a very viable procedure that, in the right patients, can be realistically done in any ENT office, she said. It is a billable procedure that allows the patient to forgo another anesthetic and to re-establish speech without significant problems.