Tracheo oesophageal puncture

Tracheo oesophageal puncture is a surgical procedure performed to rehabilitate a patient who has undergone total laryngectomy. This involves creation of a fistula between trachea and oesophagus. A prosthetic valve is introduced through this fistula. This procedure enables the patient to regain his ability to speak. The commonly used valve was devised by Blom and Singer in 1979.

Indications
This procedure is reserved for patients who have failed to acquire oesophageal voice after total laryngectomy.

The prosthesis used is a one way valve. Through the fistula air enters the oesophagus from the trachea. Thus the force of expired air entering the oesophagus vibrates the pharyngo oesophageal membrane causing speech.

Classification
Tracheo oesophageal puncture is of two types:
 * Primary Tracheo oesophageal puncture: This procedure is performed along with total laryngectomy. After creation of tracheostome, a small opening is created through the posterior wall of trachea to reach the oesophagus. 19 gauge Ryles tube is introduced through this opening to reach the oesophagus. This tube is utilised for feeding the patient during the immediate post operative field. After 6 weeks this Ryles tube is removed and a valve based prosthesis (Blom Singer prosthesis) is introduced through this opening. The main advantage of this procedure is that a second sitting surgery is avoided and the patient will be able to speak within 6 weeks after total laryngectomy. Only contraindication for this procedure is the patient's inability to maintain the valve due to advancing age.
 * Secondary Tracheo oesophageal puncture: Is performed 6 weeks after total laryngectomy. These patients must be given adequate time for acquiring oesophageal voice. Electronic larynx option must also be exhausted before proceeding with secondary tracheo oesophageal puncture. The size of the stoma created is also important. The diameter of the stoma should at least be 2cm. Anything less than this would be considered to be suboptimal.

Patient selection
For tracheo oesophageal puncture to be successful the following factors should be considered:
 * The patient should be motivated
 * The patient should have good manual dexterity to maintain prosthesis
 * Patient should not have cricopharyngeal spasm
 * A trans nasal oesophageal insufflation test must be performed before the procedure. This test will identify those patients who are likely to fail this procedure because of the  cricopharyngeal muscle spasm which prevent air from entering the pharynx .  Cricopharyngeal muscle is present at the junction of pharynx and oesophagus.  It has to relax before swallowing could take place to enable food to pass into the oesophagus.