Secondary tracheoesophageal puncture (TEP) performed in the office on total-laryngectomy patients, using transnasal esophagoscopy, yielded good results, researchers have reported.
Nearly all of the 39 procedures reviewed in the retrospective study were successful, and speech results were also good, said Brad LeBert, MD, of the Department of Otolaryngology-Head and Neck Surgery at the Louisiana State Health Sciences Center in Shreveport, in a presentation at the 2009 annual meeting of the American Head and Neck Society, held as part of the Combined Otolaryngology Spring Meeting.
The patient was able to avoid the risk of general anesthesia, and this also offered a decreased cost of the procedure, not only to the patient, but also to the hospital, Dr. LeBert said.
In-office tracheoesophageal prosthesis placement with the use of transnasal esophagoscopy [TNE] is a very viable procedure to be done by any otolaryngologist familiar with TNE techniques, said Amy Hessel, MD, Assistant Professor of Head and Neck Surgery at the University of Texas M. D. Anderson Cancer Center (MDACC) in Houston, and one of the surgeons who performed the procedures. This procedure utilizes principles and procedures that all otolaryngologists are familiar with-endoscopy and Seldinger technique.
She cautioned that there are key points that must not be forgotten. While this procedure is technically easy and provides an excellent service for those patients rendered aphonic from laryngectomy, there are a few aspects that must not be overlooked, she said. It is absolutely imperative that these patients be supported by a speech pathology group who are familiar with TEP and are able to assist with initial candidate assessment, TEP placement, vocal instruction, and maintenance of the prosethesis.
Background on TEP
Tracheoesophageal puncture, introduced in 1980, can be done either at the time of the total laryngectomy, as a primary procedure, or later as in a secondary procedure. Using TNE for the procedure was introduced in 2003 by Bach, Postma, and Koufman (Laryngoscope 2003;113: 173-6).
The procedure used in the study presented by Dr. LeBert, performed at LSU Health Sciences Center and M. D. Anderson Cancer Center, involves keeping the patient awake without any sedation, using only local anesthesia. TNE is used for endoscopic guidance. The puncture is made either using a direct puncture method or the Seldinger technique, in which a hollow needle is used to make the puncture, allowing a guidewire to be passed through.
There are several scopes available for transnasal esophagoscopy. The one used in this study was the Olympus model. They all have varying benefits associated with them, Dr. LeBert said. They all share the common factor that they have a very small diameter of about 5 millimeters. This allows for easy passage through the nose and into the nasopharynx. A traditional esophagascope has an average diameter of 13 mm.
The retrospective review covered 39 patients receiving the treatment from January of 2004 to December of 2008. Their average age was 65, ranging from 47 to 83. Eighty-two percent were male.
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.
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.
Mark Persky, MD, Chair of the Department of Otolaryngology at Beth Israel Medical Center in New York, said that the findings were encouraging, and might be another step into the expanding array of in-office procedures.
He said it was especially nice to see that the procedures in the office worked well for patients who had had reconstructive surgeries beforehand. Performing a prosthetic procedure on a patient at the same time as reconstruction is done is often not ideal because of the added strain.
It’s a good point to bring out, Dr. Persky said. I think that this can be done even in patients who you’re reluctant to do it on as an initial approach. You do it as a delayed procedure, and the fact that they can do it in the office under local anesthesia, I think, is a wonderful thing.
He said that he does not currently perform these procedures in the office, but said, I could see doing it after this, sure.
Having the procedure done in the office is less stressful on the patient-and on the bottom line, he said. Most patients would like to avoid an inpatient experience if they could, he said. I think that for the patient experience, it works out well. For cost consciousness, it works out very well also.
©2009 The Triological Society