Journal of Otology & RhinologyISSN: 2324-8785

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Short Communication, J Otol Rhinol Vol: 6 Issue: 2

Stylet-Guided Secondary Tracheo-esophageal Puncture: A Safe and Simple Method

Bawab IT*, Jacobs JR and Mutchnick S
Department of Otorhinolaryngology-Head and Neck Surgery, Wayne State, USA
Corresponding author : Ibrahim Bawab, MD
Head and Neck Surgery Fellow-Detroit Medical Center, WSU Deptartment of Oto HNS, 4201 St. Antoine, 5E UHC, Detroit, MI 48201, USA
Tel:
313-3294430
E-mail: [email protected]
Received: January 12, 2017 Accepted: March 02, 2017 Published: March 10, 2017
Citation: Bawab IT, Jacobs JR, Mutchnick S (2017) Stylet-Guided Secondary Tracheo-esophageal Puncture: A Safe and Simple Method. J Otol Rhinol 6:2. doi: 10.4172/2324-8785.1000311

Abstract

Prior to the 1970s, rehabilitation of aphonia following a total laryngectomy was accomplished using esophageal speech or through the use of mechanical or electrical devices. First described in 1980 by Singer and Blom, tracheoesophageal puncture (TEP) with prosthesis placement affords the clarity of esophageal speech without the volitional need to ingest and expel air. Deciding between a primary or secondary tracheoesophageal puncture (TEP) can depend on multiple factors. Pou describes that a primary TEP is absolutely contraindicated if the party wall between the trachea and esophagus have been separated, either as a consequence of surgeon technique or secondary to the degree of oncologic resection. Relative contraindications include conditions precluding adequate use of the prosthesis such as poor pulmonary function, poor manual dexterity, or bilateral hearing loss. Pou notes that preoperative or the need for postoperative radiation are not contraindications to primary TEP When comparing primary TEP to secondary TEP, the literature shows no significant difference in outcomes initially or at later follow-up, with success rates in the 75-90% range after 2 years.
 

Keywords: Tracheo-esophageal Puncture; bilateral hearing loss; laryngectomy

Introduction

Prior to the 1970s, rehabilitation of aphonia following a total laryngectomy was accomplished using esophageal speech or through the use of mechanical or electrical devices.
First described in 1980 by Singer and Blom, tracheoesophageal puncture (TEP) with prosthesis placement affords the clarity of esophageal speech without the volitional need to ingest and expel air [1].
Deciding between a primary or secondary tracheoesophageal puncture (TEP) can depend on multiple factors. Pou describes that a primary TEP is absolutely contraindicated if the party wall between the trachea and esophagus have been separated, either as a consequence of surgeon technique or secondary to the degree of oncologic resection. Relative contraindications include conditions precluding adequate use of the prosthesis such as poor pulmonary function, poor manual dexterity, or bilateral hearing loss [2,3]. Pou notes that preoperative or the need for postoperative radiation are not contraindications to primary TEP [3] When comparing primary TEP to secondary TEP, the literature shows no significant difference in outcomes initially or at later follow-up, with success rates in the 75-90% range after 2 years [4,5].
On the other hand, a secondary TEP is performed after the total laryngectomy has had time to heal, and some advocate performing the procedure after a radiation course, if prescribed, has been completed.
Adjuvant radiotherapy and salvage post-chemoradiotherapy laryngectomy patients present a troublesome population for TEP placement using the standard rigid esophagoscopy technique because of the potential of scarring and neck stiffness and limited neck extension which would make neopharyngeal instrumentation and visualization cumbersome.
We describe a technique for blind secondary TEP placement that would be beneficial for “difficult” TEP candidates.

Materials and Methods

The post-laryngectomy patient is placed in the supine position, under general anesthesia and endotracheal stomal intubation, The Glide Rite Rigid Stylet (Verathon Medical; Bothel, WA) is placed in the oral cavity and advanced caudally until the blunt end is palpated at the stomal tracheoesophageal wall (Figure 1A). Using a 15 blade, the tracheoesophageal wall is pierced directly over the blunt end of the GlideRite stylet approximately 1cm below the superior edge of the common party wall (Figure 1B). The Stylet is advanced through the puncture. A 8-french foley catheter is sutured using a 2-0 silk tie to the blunt edge of the Stylet (Figure 1C). The stylet is retracted and removed from the oral cavity pulling with it the cuffed end of the 8-french foley catheter (Figure 2). At this point the 2-0 silk suture is cut and the cuff inflated with 2 cc of normal Saline. The foley catheter is now retracted through the tracheoesophageal puncture until the cuff is lying on the esophageal side of the puncture site (Figure 1D). Hemostasis around the stoma is now achieved using silver nitrate rods. The Foley is taped or sutured to the chest and the patient extubated after anesthetic reversal.
Figure 1: Schematic Sagittal View of the Stylet-Guided Tracheoesophageal Puncture Procedure.
Panel A- Palpation of the stylet through the tracheostoma Panel B- Puncture using a 15 blade through the party wall Panel C- The Foley Catheter is tied using a 2-0 silk stitch to the ball tip end of the stylet Panel D- Final positioning of the Foley Catheter after cuff inflation Panel E- Introduction of the Voice Prosthesis after 48 hours.
Figure 2: Foley Catheter threaded through the puncture site.
After 48 hours of the procedure, the patient is referred to the speech pathologist. The cuff of the foley catheter would be deflated, and the catheter removed. The newly created tracheoesophageal puncture is now canalized using valve prosthesis (Figure 1E).

Discussion

The classic method of performing a secondary puncture involves the use of a cervical rigid esophagoscope. The esophagoscope is inserted into the neopharynx and advanced to the level of the party wall and positioned with the bevel facing anteriorly, thus protecting the posterior esophageal wall. Under direct visualization, a needle or trochar can be inserted through the party wall, approximately 8-10 mm below the superior edge of the posterior tracheal wall into the bevel of the esophagoscope.
A catheter or wire is then fed through the puncture site or trochar until it is visualized out of the oral end of the esophagoscope. Deschler describe a Teflon catheter that is fed over the puncturing needle. The tract can then be dilated either via a Seldinger technique or via serially larger red-rubber catheters. The final catheter can be then reduced back into the esophagus for future TEP prosthesis placement or the prosthesis itself can be placed. Early complications are related to the procedure itself, and include bleeding, pain, stricture, and abscess formation or infection of nearby structures [6].
Late complications include enlargement of the puncture site, with displacement of or leakage around the prosthesis (approximately 19% of patients) [7,8] Migration of the prosthesis is reported to occur in 2% of patients [6] Careful planning and monitoring of the site can help to prevent these complications. In particular, correct sizing of the prosthesis, in order to prevent pistoning of the prosthesis during use, decreases the amount of enlargement of the TEP [3,9].
Another method of performing a secondary puncture includes flexible esophagscopy. Bach et al describe the use of the transnasal esophagoscope to place the puncture under local anesthesia in a clinic setting.
Under fiberoptic visualization with insufflation of the esophagus, the proposed puncture site is identified using a blunt instrument, and then an 18-gauge needle is advanced through the posterior tracheal wall into the esophageal lumen. Afterwards a cruciate incision is made at the site and dilating catheters are passed through the puncture site into the esophagus [10].
Some had advocated the use of a “blind” technique for puncturing the tracheoesophageal partition using Yankauer Suction. The Hand piece angulation would be ideal for access to the neopharynx and tracheoesophageal partition. The Yankauer tube is carefully passed through the mouth and into the pharynx, allowing the hand piece to curve anteriorly beyond the tongue base. The Yankauer tip is felt at the stoma, the tracheoesophageal wall is punctured around 7mm below the superior aspect of the stoma. Through the puncture site, a 8-french foley catheter is introduced and threaded in the lumen of the Yankauer Suction hand piece. The Yankauer is the retrieved through the oral cavity, the foley catheter cuff inflated and retracted through the tracheoesophageal puncture until the cuff is lying on the esophageal side of the puncture site. Although this technique provides a safe and fast technique in blunt localization and positioning of the puncture site in secondary TEP, it might prove to be cumbersome in patients with stiff necks or neopharyngeal scarring since the Yankauer suction tube is of limited flexibility and of significant diameter of 10mm.
Our technique provides a simple and safe technique for tracheoesophageal puncture without the need of direct visualization using rigid esophagoscopy which would prove technically difficult in the post-radiotherapy population complaining of neck rigidity and trismus. The anterior angulation of the Glide Rite as well as its blunt end ensures adequate access and reach to the proximal tracheoesophageal party wall. The average operative time for the technique is 7 minutes. The Foley cuff would present a Tamponade at the puncture site that would minimize entry of esophageal content into a false passage through the puncture to the trachea (Figure 3). Another advantage of the technique is the minimal requirement of instrumentation (Figure 4) and the relative ease of spatial orientation using bimanual palpation. Overinflation of the Foley catheter cuff might present a potential pitfall that would result in dysphagia and odynophagia in the immediate postoperative period; this could be avoided by inflation of the cuff with 1-2cc of normal saline.
Figure 3: Endoscopic View of the inflated Foley catheter cuff lodged in the Neopharynx.
Figure 4: Material Required for the Procedure.

Conclusion

GlideRite Rigid Stylet aided tracheoesophageal puncture offers a fast, cheap, simple and safe technique for the otolaryngologist and would add to the armamentarium in dealing with the “difficult” insertion candidates.

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