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Tracheoesophageal Puncture

Background

Prior to the 1970s, rehabilitation of aphonia following a total laryngectomy (TL) was accomplished using esophageal speech or through the use of mechanical or electrical devices.

Esophageal speech requires the patient to volitionally swallow air via the neopharynx and emit the air while articulating, as with normal speech. This produces a belchlike understandable speech.
Instead of using the vocal fold vibration as the sound source, this is replaced by the vibration of the pharyngeal walls. Many patients are able to teach themselves to speak to a degree in this manner, but fluency remains a challenge. Working with a speech pathologist can increase the fluency and clarity of their speech. The major advantage of this technique is the lack of any necessary prostheses or external devices.

In contrast, the mechanical larynx has been a mainstay in voice restoration. The early pneumatic devices were supplanted by electrical vibratory electrolarynges in the 1940s. Using these devices, speech is generated via an external vibration of the air column within the upper aerodigestive tract, combined with speech articulations, as in esophageal speech. The early learning period for this technique is short, and a reproducibly understandable voice can be quickly accomplished. The downsides to using an electrolarynx include an unnatural, mechanical, and often monotonal quality to the voice, as well as the necessity of a device itself. The device relies on battery power, may break, and may not be covered by the patient’s insurance.

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. Their simple technique involves the surgical placement of a one-way valve between the tracheostoma and neopharynx, which allows air to be shunted on demand through the neopharynx and produce speech similar to esophageal speech. The one-way valve prevents retrograde flow from neopharynx to the trachea and prevents aspiration. Multiple advances have been made in prosthesis design and construction (including the advent of hands-free adjuvant devices), surgical technique, as well as in the timing of the procedure over the past 3 decades.

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