Tracheo oesophageal Puncture by drtbalu

Tracheo - Oesophageal Puncture

By

Dr. T. Balasubramanian M.S. D.L.O.

This is a rehabilitation procedure performed for patients who have undergone total laryngectomy to restore their ability to speak. Before performing a TEP procedure the following facts must be borne in mind:

1. There should not be any oncological compromise
2. The patient must have normal swallowing without aspiration
3. This procedure is cheap and easy to perform
4. The patient must have good pulmonary reserve

Primary TEP:

This procedure can be performed along with total laryngectomy in the same sitting. When performed along with total laryngectomy it is known as primary tracheo oesophageal puncture. Major advantage of Primary TEP is that it can be performed in the same sitting as total laryngectomy. The patient has 90% chances of regaining his ability to speak. 3. It is safer than secondary TEP because it does not involve mediastinal dissection and the posterior wall of trachea is safe from injury.

Secondary TEP:
If TEP is performed 6 weeks after performing total laryngectomy it is known as secondary TEP.
Advantages of secondary TEP:
1. It can be performed if the patient fail to develop oesophageal speech
2. It can be performed under local anesthesia

A transnasal oesophageal insufflation test should be performed before deciding on a TEP. The test is performed using a disposable kit consisting of a 50-cm long catheter and tracheostoma tape housing with a removable adaptor. The catheter is placed through the nostril until the 25-cm mark is reached, which should place the catheter in the cervical esophagus adjacent to the proposed TEP. The catheter and the adaptor are taped into place. The patient is then asked to count from 1 to 15 and to sustain an ‘‘ah’’ for at least 8 seconds without interruption. Multiple trials are performed to allow the patient to produce a reliable sample. The responses obtained are the following:

1. Fluent sustained voice production with minimal effort

2. A breathy hypotonic voice indicating a lack of cricopharyngeal muscle tone

3. Hypertonic voice

4. Spastic voice due to spasm of cricopharyngus muscle

TEP fails commonly in patient with cricopharyngeal spasm / gastro oesophageal reflux disease. If oesophageal insufflation test suggests cricopharyngeal spasm then cricopharyngeal myotomy must be performed in addition to TEP. If the patient has gastro oesophageal reflux disease then it must be treated before performing TEP.

Procedure: A fistulous opening is created between the trachea and oesophagus at the level of permanent tracheostome after performing total laryngectomy. The level of the fistula is ideally situated at 12 o clock postion of tracheostome. Classically a direct laryngoscope is introduced into the hypopharynx and its illumination is utilised to identify the area where stoma is to be created. This area is perforated using a 11 blade. A 16 guage Ryles tube is introduced through this opening into the oesophagus to keep the fistula patent. After a week the Ryles tube is removed and a Blom singer valve speaking prosthesis is introduced through this opening. When the patient expires air enters the cervical oesophagus through this fistula and gets expelled into the hypopharynx. Vibrating mucosa in the area of hypopharynx and oral cavity causes the patient to generate voice.

In the video clipping below a new innovative way of performing TEP is shown. Here instead of using a direct laryngoscope to identify the site of TEP a Yanker's suction is introduced into the hypopharynx through the oral cavity. The tip of the Yanker's suction tube is easily seen over the tracheostome. A 11 blade / 15 blade is used to perforate the trachea. In the video clipping below a Miles retrograde gouge is used to perforate the trachea. After perforating the trachea a 16 guage Ryles tube is introduced through the stoma to keep it patent till a prosthesis is introduced.
This procedure can be performed under local anesthesia. It needs no special equipment. It can be performed under out patient setting and is safe.