Placement of a tracheoesophageal prosthesis using intraoperative ultrasound: A novel technique

Introduction

Patients who undergo a total laryngectomy experience significant functional difficulties involving their speech and swallowing, which, in turn, may lead to emotional, mental and social hurdles. Concerning their speech, several options have been available over the years to provide some return of phonation including electrolarynx, oesophageal speech and a tracheoesophageal prosthesis (TEP).

Since the early 1980s when first published, TEP placement has become the gold standard for restoring the ability to phonate in total laryngectomy patients. ¹ TEP can either be performed primarily in the same instance as a total laryngectomy or completed secondarily at some interval after the initial resection. This is a topic of debate as a primary TEP negates the need for subsequent surgeries and patients are able to vocalise several weeks following surgery. However, secondary TEP has been shown to decrease the risk of post-surgical complications such as pharyngocutaneous fistula formation. ²

Secondary TEP placement most often occurs within the operating room under general anaesthesia although in-office techniques have been described. ³ TEP placement consists of utilising a rigid oesophagoscope introduced through the oral cavity to the cervical oesophagus to provide direct visualisation when inserting the TEP. However, in cases of pharyngeal stenosis, it may not be possible to perform oesophagoscopy due to physical barriers created by fibrosed tissues. In cases not amenable to utilisation of rigid esophagoscopy, revision surgeries are undertaken to correct the stenosis, requiring an additional operation with exposure to general anaesthesia and delaying placement. However, novel techniques may be employed to obviate the need for revision surgeries and allow for immediate placement of TEP, even when significant stenosis is present. We describe a case in which a patient presented with significant stenosis of his oesophagus preventing the passage of a rigid oesophagoscope to perform a TEP. In this scenario, ultrasonography was utilised to visualise the pharyngoesophageal segment and assist in performing a successful TEP.

Case report

Eight months prior to ultrasound-guided TEP placement, a mid-70s male presents to the emergency department of a tertiary medical centre due to dyspnoea, orthopnoea and haemoptysis for several days. Evaluation included a thorough otolaryngologic examination and computed tomography (CT) neck, which revealed a transglottic mass with extralaryngeal extension into the right lateral neck and right strap muscles. The patient was diagnosed with cT4aN0MX laryngeal cancer and was scheduled for surgery.

Three days later, the senior author and a colleague performed a total laryngectomy with left anterolateral thigh (ALT) free flap reconstruction and bilateral neck dissection. The procedure was successful, and no complications were noted in the post-operative period. Two months following surgery, the patient started on adjuvant radiation via intensity-modulated radiation therapy (IMRT) for which he completed a total of 66 Gy in 33 fractions. Three days prior to placement of his TEP, the patient had a scheduled outpatient follow-up for routine cancer surveillance. A post-treatment positron emission tomography (PET)/CT scan demonstrated no evidence of residual or metastatic head and neck carcinoma. His swallowing function was adequate, and he wished to undergo tracheoesophageal puncture with prosthesis placement for restoration of voice.

On the day of TEP placement, the patient was prepped and draped in a standard sterile fashion. A stomal revision was first done by creating circumferential radial incisions and a rim of skin excised. Flaps were advanced and sutured using horizontal mattress 4-0 Vicryl sutures. At that point, attention was then paid to performing the tracheoesophageal puncture. A rigid oesophagoscopy was attempted but was unable to be performed due to significant scarring from radiation therapy. The senior author then utilised two-dimensional (2D) ultrasound to visualise the pharyngoesophageal segment and insertion of a hollow bore needle (Figure 1). Once safely in place, a guidewire was passed through the needle which was thin enough to pass through the patient’s oesophagus and mouth. A 20 French, 10 mm prosthesis was then placed successfully, and the patient was transferred to anaesthesia for extubation. There were no complications during or following the procedure.

OPEN IN VIEWER

Figure 1.

Transverse view of the patient’s cervical neck utilising two-dimensional ultrasound (2DUS). The oesophageal segment is visualised (outlined with white arrows) with the anterior aspect of the vertebral body just posterior (circled). Constant visualisation of the needle (not seen) and oesophageal lumen on 2DUS will ensure accurate tracheoesophageal puncture.

Discussion

There is little information available on the number of TEPs performed at any given time. However, according to a national population-based study within the United States, there are approximately 3000 laryngectomies performed annually. ⁴ Due to removal of the vocal cords during the procedure, patients require one of several strategies for return of phonation, TEP being the gold standard. Although post-operative radiation has been a part of the mainstay of treatment for total laryngectomy patients with head and neck cancer, there are obvious side effects from adjuvant treatments such as xerostomia, dysphagia, shortness of breath and oesophageal stenosis, to name a few. In fact, one study found that of those who undergo a total laryngectomy with adjuvant radiation, 33% developed oesophageal stenosis, which has implications for the completion of a TEP as the current technique stands. ⁵

Patients who present with significant stenosis in whom routine oesophagoscopy cannot be performed present a challenge to surgeons in the operating room. Previously, surgeons often had to halt the operation and plan for revision surgery instead of placing the TEP at that time. However, this case illustrates the use of ultrasound-guided TEP placement as an effective alternative to the traditional approach for successful TEP placement, which eliminates the need for repeat procedures requiring additional anaesthesia exposure and saves the patient from risks thereof. Furthermore, the ability to perform the TEP despite significant stenosis avoids the toll that delaying return of phonation would have on emotional, mental and social wellbeing.

Conclusion

This case demonstrates that even in the face of significant stenosis and inability to perform oesophagoscopy as is typically done, TEP can still be performed using ultrasound, which, to our knowledge, is a novel technique that has not previously been applied in TEP placement.