This document discusses the management of laryngeal cancers. It covers evaluation by a multidisciplinary team and treatment options depending on the location and stage of the cancer. For early glottic cancers, options include radiation therapy, endoscopic laser resection, or open partial laryngectomy. More advanced cancers typically require total laryngectomy, with postoperative chemoradiation an option. Voice rehabilitation after laryngectomy can involve esophageal speech, an electrolarynx, or tracheoesophageal puncture. Close follow-up is important after any treatment to monitor for recurrence.

1. LARYNGEAL CARCINOMA- MANAGEMENT
Dr Vikas

2. MANAGEMENT OF LARYNGEAL CANCERS
 Multidisciplinary teams
 Minimum team defined by British Association of Otolaryngologist,-
head and neck surgeon is an otolaryngologist, a
radiotherapist/oncologist, nurse, speech and swallowing therapist

3. CARCINOMA IN SITU
 Is replacement of the full depth of epithelium by malignant cells,
without those transgressing the basement epithelium
 Tis should be regarded as part of the continuum of early laryngeal
cancer and managed as T1 carcinoma
 High possibilities of recurrent disease suggests holding back use of
radiotherapy for those leisions where resection would lead to
significant functional defecits and use of surgical technique wherever
possible

4. GLOTTIC CANCER
Carcinoma in situ
 Trans oral endoscopic CO2 laser
 Microlaryngoscopic cord stripping
 Regular follow up is essential
Glottic T1NO
 Narrow field Radiotherapy
 Voice conservation surgery

5. Type of surgery depends upon location of lesion within glottis
Mid cord lesion
 Trans oral Endoscopic cordectomy/ CO2 laser cordectomy
 >90% cure rates
 Good voice quality
 Very short treatment period
 Tracheostomy is avoided
 Laryngofissure with cordectomy-
 >90% cure rates
 slightly inferior voice quality
 Temporary tracheostomy is required

6. Cord lesion extending to the anterior commissure-
 Radiation therapy
 Vertical frontolateral laryngectomy
 Endoscopic CO2 laser excison (experience required)
Pure anterior commissure lesion
 May cause early cartilage invasion ( absence of inner perichondrium)
 May involve base of epiglottis or cricothyroid membrane without
causing cord fixity.
 T3/T4 lesion may clinically be Under staged as T1/T2 lesion
 Cure rates will be drastically compromised with radiotherapy
 Surgery is preferred modality.

8. GLOTTIC T2 N0
 Includes –
 Superficial tumors where vocal cords are freely mobile but the suface
extension is beyond glottis( T2a)
 Infiltrative tumors causing impaired cord mobility(T2b)
 For T2a lesions Radiotherapy should be Treatment of choice
 Voice is near normal
 Regular follow up is required
 Salvage surgery on failure of radiotherapy
 T2b lesions being more infiltrative
 Best Treated with VPL or supracricoid laryngectomy with CHEP.
 Voice remains hoarse

9.  Results of randomized controlled trial of surgery versus radiotherapy
for early glottic laryngeal cancer.
Surgery Radiotherapy
 Five-year survival T1 100 91.7
T2 97.4 88.8
 Five-year disease-free Tl 100 71.1
Survival T2a 78.7 60.1

11. GLOTTIC T3, T4
 Fixation of vocal cord is grave prognostic sign
 Results with surgery are far superior to those with surgery alone.
 Alternative is radical radiotherapy with surgery reserved for salvage of
radiotherapy failures.
 Strict follow up is required
 Detection of recurrences
 Harwood et al, registered a surgical salvage rate of 60%
 In india due to extremely poor follow up total laryngectomy is
preferred.

12. SUPRA GLOTTIC CANCER
Mobile cords and No cartilage invasion-
 Chief determinants of choice of therapy are-
 Status of cervical lymph nodes
 Age
 Pulmonary status
 Subsite within supraglottis
.

13. Minimal or no neck disease N0/ N1
 Lesion of infrahyoid epiglottis
 Surgery claims superior cure rates in comparison to radiotherapy
 If pulmonary status is poor radiotherapy is preferred (no involvement of pre-
epiglottic space on CT/MRI )
 Involvement of pre-epiglottic space- near total laryngectomy is preferred.
 Lesions of suprahyoid epiglottis
 Generally exophytic
 Unlikely to involve pre-epiglottic space
 Respond well to radiotherapy
 Neck is included in radiation field
 Small localized lesions best resected endoscopically with CO2 laser
 Neck dissection may be carried out after 2 weeks if required.

15. Bulky nodal disease N2/N3
 Responds poorly to radiation
therapy
 TOC- primary surgery with
post operative radiotherapy.

16. VOCAL CORD FIXITY / CARTILAGE INVASION
 Total or Near total laryngectomy is indicated.

17. SURGERY
Advantages:
1.Treatment in single sitting
2.Minimal absence from employment
3.Certainty of removal of specimen & ability to assess margin surgically
4.Allows further laryngeal surgery or radiotherapy in case of recurrence

18. Disadvantages
 Affect voice quality
 Access sometimes difficult
 Requires general anaesthesia & may need repeated operations for
which patient may not be fit

19. RADIATION –
ADVANTAGES
 Functional preservation.
 Patient's preference
 No Post Operative complication
 Deals effectively with the microscopic invasion into the adjacent
lymphatic and venous channels

20. DISADVANTAGES
 Ineffective at the necrotic centre of tumor so ineffective against large
bulky tumors
 Relatively ineffective against Radio resistant tumors
 Post radiation reactions
 Morbidity

21. TRANSORAL LASER SURGERY

22. INCLUSIONAL CRITERIA
Complete endoscopic visualization of the carcinoma
Tumor extension to the contralateral VC < 3mm
Absence of arytenoid involvement (except vocal
process)
Subglottic extension < 5mm
Supraglottic extension no further than lateral
extension of ventricle
Mobile vocal folds
No cartilage involvement

23. ADVANTAGES
 Good voice quality
 Good swallowing
 Lower complications rates
 Lower costs
 Shorter hospitalization
 Tracheostomy and NG tubes not routinely required

24. OPERATIVE CONSIDERATIONS
 Increased difficulty in identification of recurrent carcinoma in
irradiated tissue leads to routine use of frozen section
 All margins to be confirmed by permanent section post-op.
 Strict follow-up with fibroscopic examination and serial imaging
allowing early detection of recurrence
 The use of CO2 laser excision after radiation failure does not
preclude its use for persistent or multiple recurrent disease

25. OUTCOMES
 In 40% of cases more than one laser-assisted surgery was
required
 Local control rate was 51-87% (Mean 65%)
 Subsequent total laryngectomy was necessary in 25%
 Overall control rate including those requiring total
laryngectomy was 80-100% (Mean 83%)

26.  Complications
Complication rates are <5% and from most to least common include:
 Granuloma formation
 Laryngeal edema
 Laryngeal stenosis
 Chondronecrosis

27. PARTIAL LARYNGECTOMY
 Aim
 Is to perform oncological clearance of tumour with as much
preservation of normal voicing and swallowing as possible
 Emphasis should be given to
 Survival is more important than voice
 Partial laryngectomies require experience and training
 Patient must have good pulmonary reserve
 More radical PL should be avoided in patients who have been
previously irradiated

28. VERTICAL PARTIAL LARYNGECTOMY

29.  Cordectomy- resection of the entire cord up to the vocal process of the
arytenoid, may be achieved by an open approach via a laryngofissure
 Frontolateral laryngectomy- extends cordectomy to take in that part of the
thyroid cartilage into which the anterior commissure inserts
 Anterior frontal laryngectomy- removes this region together with part of
both cords
 Hemilaryngectomy-removes a vertical block of larynx to include one cord
(occasionally including arytenoid) and the anterior two-thirds of the ipsilateral thyroid
cartilage.

30. Removal of:
 One vocal fold - from anterior commissure to vocal
process
 ½ of opposite vocal fold may also be removed if involved
 Ipsilateral false vocal cord
 Ventricle
 Paraglottic space (and overlying thyroid cartilage)

31. CONTRAINDICATIONS
 Large T3 or any T4 lesion
 Intrarytenoid or cricoarytenoid joint involvement
 Bilateral arytenoid cartilage involvement or bilaterally
diminished vocal cord mobility
 Thyroid cartilage penetration
 Supraglottic extension exceeding 10mm at the anterior
commissure or 5mm at the vocal process of the arytenoid
 Poor pulmonary function

32. OPERATIVE CONSIDERATIONS
The use of intraoperative frozen sections is imperative
for maximal local control
All margins should be confirmed with permanent
section postoperatively
In the event of failure of salvage VPL total
laryngectomy remains an option and this will not
ultimately affect local control. 8
The use of bipedicled flaps of strap muscles to
replace excised intralarygeal soft tissue may facilitate
post-op rehabilitation 13

33.  Outcomes
Meta-analysis showed:
 Local control rate 50-100% (mean 78%)
 Approximately 15% of patients require completion laryngectomy for
second recurrence

34.  Complications
Early - generally tracheostomy related
Infection
Aspiration and dysphonia
Late
Aspiration
Chondritis
Laryngeal stenosis (Must rule out local recurrence)
Severe hoarseness
Granulation tissue
Tumor recurrence

35. SUPRACRICOID LARYNGECTOMY
Removal of:
Entire thyroid cartilage
Bilateral true and false vocal cords
Ventricles
Paraglottic and Preepiglottic spaces
Epiglottis
Hyoid bone
One arytenoid (may spare both if not involved)
- At least one arytenoid must be spared to preserve
phonation and sphincter functions

36. SUPRACRICOID LARYNGECTOMY

37. CONTRAINDICATIONS
Infiltration of both aryntenoid cartilages
Infiltration of cricoarytenoid joint or inter-arytenoid region
Subglottic extension >1cm below the vocal fold
Extension to the glossoepiglottic valecula
Major preepiglottic space invasion
Hyoid bone invasion
Invasion of outer perchondrium of thyroid cartilage
Extra-laryngeal spread

38. COMPLICATIONS
 Swallowing disorders are the most common in the short term
 Voice quality is hoarse, rough, breathy but with acceptable
intelligibility.
 Aspiration Pneumonia is the most frequent complication (17.5%)
 Neo-laryngeal edema

39. OUTCOMES
 Disease-free survival 84.5%
 Of the 15.5% failure of SCL, 66.7% successfully treated with Total
laryngectomy
 3 year survival rate of 80 -100%
 5 year survival rate of 69.4 -100%

40. SUPRAGLOTTIC LARYNGECTOMY
 Following tracheostomy and raising of flaps, the supraglottis is
excised en block with cuts through both valleculae, aryepiglottic folds
and ventricles
 Removal of upper half of thyroid cartilage and all the epiglottis

41. SUBTOTAL LARYNGECTOMY
 Operation popularised by Biller & Lawson
 Three- quarter laryngectomy combining supraglottic laryngectomy with
vertical hemilaryngectomy on the side of the tumour
Indication
 Supraglottic cancer which involve an arytenoid &/or vocal cord on one
side only
 Tumour should be no longer than 2cm in maximum diameter
 Should not extend in subglottis

42. NEAR- TOTAL LARYNGECTOMY
 Described by Pearson
 Technically complex procedure to create a physiological voice shunt
based on mobile arytenoid
 No significant gains over total larygectomy

43. TOTAL LARYNGECTOMY
 Mainstay of treatment for advanced laryngeal cancer
 Fistly performed by Billroth in 1870
 Curative as well as palliative.
 The current 5 yr. survival rate of patients following total Laryngectomy
is about 80%

44. CHEMOTHERAPY
 Palliative
 Adjunctive
Chemoradiation
Surgery followed or preceded by
Chemoradiation

45. MANAGEMENT OF THE NECK
 Main predictor of survival in squamous cell carcinoma is the presence,
number and extracapsular spread of lymph node metastases

46.  N0
Elective neck dissection is commonly performed for management of
node negative T2-4 supraglottic cancer
Risk (Shah et a1.)--
 Supraglottic -16-43%
 Transglottic – 11-52%
 Subglottic – 19-65%
Elective neck irradiation

47. N+ NECK IN LARYNGEAL CANCER
 N1
 modified neck dissection is procedure of choice
 N2a or N2b
 Choice of either MRND or RND followed by postoperative
radiotherapy or chemotherapy

48.  N3
 Whether or not to operate depends upon
 staging of disease
 presence or absence of fixation & what node is fixed to
 experience of surgeon
 need of patient

49. VOICE REHABILITATION FOLLOWING
LARYNGECTOMY

50. INTRODUCTION
 TEP (Tracheo-oesophageal puncture) is considered gold standard
among various voice rehabilitation procedures
 A good percentage of patients undergoing total Laryngectomy regain
esophageal voice

51. FUNCTIONAL ALTERATIONS FOLLOWING TOTAL
LARYNGECTOMY
 Loss of speech.
 Changes in normal swallowing mechanism
 Changes in the pattern of respiration
 Tracheostome problems;
 Problems with loss of glottal occlusion, e.g. lifting;
 Problems with airway diversion, e.g. loss of olfaction;
 Body image/psychological/social problems.

52. REQUIREMENTS FOR NORMAL PHONATION
 Active respiratory support
 Adequate glottic closure
 Normal mucosal covering of vocal cord
 Adequate vocal cord length and tension control
Components of phonation
e
Lung (Bellows)
Larynx
(Vibrator)
Articulators
(Lips,
tongue,
teeth)

53. METHODS OF SPEECH FOLLOWING LARYNGECTOMY
 Esophageal speech
 Electro larynx
 TEP (Tracheo-oesophageal puncture)

55. ESOPHAGEAL SPEECH
 All pts. Develop some degree of esophageal speech following
Laryngectomy
 All alaryngeal speech modalities are compared with this modality
 Till 1970’s this was the gold standard for all other post Laryngectomy
speech rehabilitation procedures

56. ESOPHAGEAL SPEECH - PHYSIOLOGY
 Air is swallowed into cervical esophagus
 This swallowed air is expelled out causing vibrations of pharyngeal
mucosa
 These vibrations along with articulations of tongue cause speech to
occur
 The exact vibrating portion of pharynx is the pharyngo-oesophageal
segment
 The vibrating muscles and mucosa of cervical oesophagus and
hypopharynx cause speech

57. ESOPHAGEAL SPEECH – PE SEGMENT
 This segment is made up of musculature and mucosa of lower
cervical area (C5-C7 segments).
 Vibration of this segment causes speech in pts. Without larynx
 Cricopharyngeal area is important
 Cricopharyngeal spasm in these pts. Can lead to failure in developing
esophageal speech
 Cricopharyngeal myotomy may help these pts. in developing
esophageal speech

58. PUMPING AIR INTO CERVICAL OESOPHAGUS
 Injection method
 Inhalational method

59. INJECTION METHOD
 Enough positive pressure is built inside oral cavity to force air into
cervical oesophagus
 Lip closure and tongue elevation against palate causes increase
intraoral pressure
 Air is injected into the cervical oesophagus by voluntary swallowing
 This method is also known as tongue pumping / glossopharyngeal
press / glossopharyngeal closure

60. INHALATIONAL METHOD
 Uses the negative pressure used in normal breathing to allow air to
enter cervical oesophagus
 Air pressure in the cervical oesophagus below Cricopharyngeal
sphincter is the same negative pressure as that of thoracic cavity
 Pts. learn how to relax Cricopharyngeal sphincter during inspiration
allowing air to flow into cervical oesophagus as it enters the lungs
 Pts. are encouraged to consume carbonated drinks which facilitates
air entry into cervical oesophagus helping in generation of esophageal
speech

61. ESOPHAGEAL SPEECH - ADVANTAGES
 Patient’s hands are free
 No additional surgery / prosthesis needed. Hence no extra cost for
the pt.
 Pts. Get easily adapted to esophageal voice

62. ESOPHAGEAL SPEECH - DISADVANTAGES
 Nearly 40% of pts fail to develop esophageal speech
 Quality of voice generated is rather poor
 Pt. may not be able to continuously speak using esophageal voice
without interruption. They will be able to speak only in short bursts
 Significant training is necessary
 Loudness / pitch control is difficult
 Fundamental frequency of esophageal speech is 65 Hz which is lower
than that of male and female frequencies

63. CAUSES FOR FAILURE
 Presence of cricopharyngeal spasm
 Presence of reflux esophagitis
 Abnormalities involving PE segment – like thinning of muscle wall in
that area
 Denervation of muscle in the PE segment
 Poorly motivated patient

64. ELECTROLARYNX
 These are battery operated vibrating devices
 It is held in the submandibular region
 Muscle contraction and changes in facial muscle tension causes
rudiments of speech
 Initial training to use this equipment should begin even before surgery

65. ELECTROLARYNX - TYPES
 There are two types of electrolarynx
 An external type that is placed against the neck
(the most common). Hypoesthesia of neck
during early phases of post op period can cause
difficulties
 An oral type (intraoral placement device)
External type (Neck type)

66. INTRAORAL ARTIFICIAL LARYNX
 Intraoral devices are used for patients who
cannot achieve adequate sound
conduction on the skin.
 Intraoral cup should form a tight seal over
the stoma. There should not be any air
leak
 Oral tip should be placed in the oral cavity
 Pts exhaled air rattles the cup placed over
the stoma
 Changes in exhaled pressure can vary the
quality of sound generated

67. ELECTROLARYNX - ADVANTAGES
 Can be easily learnt
 Immediate communication is possible
 Additional surgery is avoided
 Can be used as a interim measure till the patient masters the
technique of esophageal speech or gets a TEP inserted

68. ELECTROLARYNX - DISADVANTAGES
 The main disadvantages include the mechanical, monotonous and
robot-like sound quality.
 Expensive to maintain
 The necessity to use a hand to operate the controls and dependence
on batteries.
 Difficult while speaking over telephone

69. TYPES OF VOICE RESTORATION SURGERIES
 Neoglottic reconstruction
 Shunt technique

70. NEOGLOTTIC PROCEDURE
 Trachea hyoidopexy
 This can restore voice function in alaryngeal patients
 Abandoned due to increased incidence of complications like
aspiration

71. SHUNT TECHNIQUE
 Developed by Guttmann in 1930
 Involves creation of shunt between trachea and esophagus
 Lots of modifications of this procedure is available, Basic aim is to
divert air from trachea into the esophagus

72. TYPES OF SHUNTS
 High trachea-esophageal shunt (Barton)
 Low trachea-esophageal shunt (Stafferi)
 TEP shunts (Guttmann)

73. CAUSES OF FAILURE OF SHUNT PROCEDURE
 Aspiration through the fistula
 Closure of the fistula
 To avoid these problems prosthesis was introduced

74. TYPES OF PROSTHESIS

75. Figure- The sequence of events in respect of creating a
tracheo-esophqgeal fistula and insertion of a speaking
valve as a primary procedure.
(a) A stab incision is made in the back wall of the trachea
and the guide wire and applicator are introduced.
(b) The short esophagoscope is removed, the valve
is attached to the guide wire and pulled into place.

76. TEP
 Was first introduced by Blom and Singer in 1979
 One way silicone valve is introduced via the fistula
 This valve served as one way conduit for air into esophagus while
preventing aspiration
 This prosthesis has two flanges, one enters the esophagus while the
other rests in the trachea. It fits snugly into the trachea-esophageal
wound
 Indwelling prosthesis have more rigid flanges when compared to that
of non indwelling ones
 A medallion ring is attached to the non indwelling prosthesis to
prevent aspiration

77. TYPES OF TEP
 Primary TEP – Performed during total laryngectomy
 Secondary TEP – Performed 6 months after surgery

78. ANATOMICAL STRUCTURES TEP
 TEP is performed in midline (Less bleeding)
 Structures that are penetrated during TEP- membranous posterior
wall of trachea, esophagus and its 3 muscle layers and esophageal
mucosa
 Interconnecting tissue in the trachea-esophageal space

79. ADVANTAGES OF TEP
 Can be performed after laryngectomy / irradiation / chemotherapy /
neck dissection
 Fistula can be used for esophago-gastric feeding during immediate
PO period
 Easily reversible
 Speech develops faster than esophageal speech
 High success rate
 Closely resembles laryngeal speech
 Speech is intelligible

80. COMPARISON BETWEEN LARYNGEAL, OESOPHAGEAL AND
TRACHEO-OESOPHAGEAL SPEECH.
Physical requirements Laryngeal speech Oesophageal speech Jracheo-rqesophageai
speech
initiator Lungs 500 mL Oesophageal air 40-70
mL
Lungs 500 mL
Vibrator Vocal cords Pharyngo-oesophageal
segment
Pharyngo-oesophageal
segment
Articulators Tongue, teeth, lips, soft
palate
Tongue, teeth, lips, soft
palate
Tongue, teeth, lips, soft
palate

81. DISADVANTAGES OF TEP
 Pt should manually cover the stoma during voicing
 Good pulmonary reserve is a must
 Additional surgical procedure is needed to introduce it
 Posterior esophageal wall can be breached
 Catheter can pass through the posterior wall

82. TEP – PATIENT SELECTION
 Motivated patient
 Patient with stable mind
 Patient who has understood the anatomy & physiology of the process
 Patient should not be an alcoholic
 Good hand dexterity
 Good visual acuity
 Positive esophageal air insufflation test
 Patient should not have pharyngeal stricture / stenosis
 Stoma should be of adequate depth and diameter
 Intact trachea-esophageal wall

83. CONTRAINDICATIONS OF TEP
 Extensive surgery involving pharynx, larynx with separation of
trachea-esophageal wall
 Inadequate psychological preparation
 Patient with doubtful ability to cope up with prosthesis
 Impaired hand dexterity
 Suspected difficulty during PO irradiation

84. PRIMARY - TEP
 Hamaker first performed in 1985
 Primary TEP should be attempted where ever possible
 In this procedure puncture is performed immediately after
laryngectomy and prosthesis is inserted
 Primary tracheo-oesophageal puncture is now accepted as the
optimal method for voice rehabilitation.
 Prosthesis of sufficient length should be used

85. ADVANTAGES OF PRIMARY TEP
 Risk of separation of trachea – esophageal wall is minimized
 Tracheo – esophageal wall is stabilized to some extent by the
prosthesis
 Flanges of prosthesis protects trachea from aspiration
 Stomal irritation is less
 Patient becomes familiar with prosthesis immediately following
surgery
 Post op irradiation is not a contraindication

86. PRIMARY TEP - PROCEDURE
 Because of exposure following laryngectomy it is easy to perform
 Ideally performed before pharyngeal closure
 Puncture is performed through pharyngotomy defect
 Ryles tube can be introduced via the fistula to provide gastric feeding
in the post op period

87. SECONDARY TEP
 Usually performed 6 weeks following laryngectomy
 This allows pt time to develop esophageal speech
 Area of fistula is identified using rigid esophagoscope
 Prosthesis can be inserted immediatly

88. MODIFIED SECONDARY TEP PROCEDURE
 Performed under local anesthesia
 Patient placed in recumbent position with mild extension of neck with
a shoulder roll
 Tracheostomy tube is removed
 12 0’ clock position of tracheostoma visualized and infiltrated using
2% xylocaine with 1 in 100,000 adrenaline
 Yanker’s suction tube is inserted into the oral cavity till it hitches
against 12-0 clock position of tracheostome
 This area is incised using 11 blade and widened using curved artery
forceps
 Blom singer prosthesis is then introduced through this fistula

89. 12 – 0 CLOCK POSITION OF TRACHEOSTOMA

90. YANKER’S SUCTION TUBE INSERTED

91. TEP - INCISION

92. TEP - WIDENED

93. PROSTHESIS INTRODUCED

94. PROSTHESIS USED IN TEP
 Blom-Singer prosthesis
 Panje button
 Gronningen button
 Provox prosthesis

95. various tracheooesophageal voice prostheses:
(a) Blom-Singer 'duck bill' prosthesis with
introducer ;
(b) indwelling Provox prosthesis with introducer;
(c) Groningen low resistance prosthesis;
(d) indwelling Blom-Singer prosthesis, introducer
and 'gel cap'.

96. PANJE VOICE BUTTON
 Biflanged tube with one way
valve
 Can be inserted through the
fistula created for this purpose
 It is supplied with an introducer
which makes insertion simple
 Should be removed and cleaned
every two days
 Can be removed, cleaned and
reinserted by the patient

97. GRONNINGEN BUTTON
 Introduced by Gronningen in
Netherlands in 1980
 It causes high airflow resistance
delayed speech in some
patients
 Now low air flow resistance
tubes have been introduced

98. BLOM-SINGER PROSTHESIS
 Introduced by Blom and Singer in 1978
 Commonly used prosthesis
 This prosthesis acts as one way valve
allowing air to pass into the esophagus
and prevents aspiration
 This prosthesis is shaped like a duck bill
hence known as “Duck bill prosthesis”
 The duck bill end should reach up to
oesophagus
 It is an indwelling prosthesis can be left
in place for 3 months
 This prosthesis is available in varying
lengths

99. PROVOX PROSTHESIS
 Indwelling low air flow pressure
prosthesis
 It has extended life time. Can
last a couple of yeas if used
properly
 Insertion is easy

100. INDWELLING VERSUS NON INDWELLING PROSTHESIS
Indwelling prosthesis Non indwelling prosthesis
Can be left in place for 3-6 months Should be removed and cleaned every couple of
days
Requires specialist to do the job Pt. Can do it themselves
Less maintenance Periodical maintenance
Stoma should be greater than 2 cms Stoma should be greater than 2 cms
Oesophageal insufflation test should be positive Oesophageal insufflation test should be positive

101. PROBLEMS WITH TEP INSERTION
 Leak through the prosthesis
 Leak around the prosthesis
 Immediate aphonia / dysphonia
 Hypertonicity problems
 Delayed speech

102. OESOPHAGEAL INSUFFLATION TEST
 Should be performed before TEP
 Assesses cricopharyngeal muscle response to esophageal distention
 A catheter is placed through the nostril up to 25 cm mark. This
indicates probable site of puncture
 Pt is asked to count numbers or vocalize “Ah”

103. INSUFFLATION TEST INTERPRETATION
 Fluent voice on minimal effort – normal
 Breathy voice indicating -hypotonic cricopharyngeal muscle
 Hypertonic voice – “Cricopharyngeal spasm”
 Spasmodic voice – “Extreme cricopharyngeal spasm”

104. COMMON PROBLEMS WITH TEP
 Improper location of puncture
 Inappropriate size of puncture
 Presence of cricopharyngeal spasm
 Leakage through and around the prosthesis

105. LOCATION OF TEP
 12-0,’clock position of stoma
 About 1-1.5 cms from trachea-cutaneous junction
 If located superiorly pt may find it difficult to occlude
 If located deep into the trachea then it becomes difficult to introduce
the prosthesis

106. MANAGEMENT OF LEAK THROUGH THE PROSTHESIS
Cause Solution
Valve in contact with posterior wall of
esophagus
Replace prosthesis with different length and size
Prosthesis length too short for the puncture
“Pinched valve”
Remeasure the puncture and replace with appropriate
size prosthesis
Valve deterioration Replace valve
Fungal colonization of valve with yeast Treat with nystatin
Back pressure High resistant prosthesis
Mucous / food lodgment Prosthesis to be cleaned

107. MANAGEMENT OF LEAK AROUND THE PROSTHESIS
Cause Solution
TEP location Remove prosthesis allow puncture to close
and repuncture
Unnecessary dilatation during valve placement To be avoided
Thin trachea-esophageal wall 6 mm or less Choose custom prosthesis
Prosthesis of incorrect length and size Choose correct length
Poor tissue integrity due to irradiation Custom prosthesis

108. TRACHEOSTOMAL PROBLEMS
•Patients who have undergone total laryngectomy will have a permanent tracheostomy with the
usual potential problems of increased chest infections, crusting and stenosis.
•Surgical attention to detail when fashioning the stoma with access to nebulization and
humidification devices can reduce these. The current trend is to use hands free occlusion for
speech and moisture conservation devices applied directly to the stoma.
Figure - Heat moisture exchange devices. (a)
Stomvent (Gilbeck); (b) Trachenaze Plus with shower
protector (Kapitex); (c)Trachenaze (Kapitex); (d)
Provox (Atos Medical).

109. RECENT ADVANCES
 In 1998 , Strome et al, performed the first true laryngeal transplant in
Cleveland, USA.
 In 2010 UC Davis Medical Center, California performed another
successful laryngeal transplant.
 Recently, Delaere et al. have developed a procedure using tracheal
autotransplantation, with vascularity provided by a radial forearm free-
flap. Thirty-six patients have been treated with reportedly excellent
results.