Outcomes and adverse events of enlarged tracheoesophageal puncture after total laryngectomy

Objectives/Hypothesis: Enlargement of the tracheoesophageal puncture (TEP) results in aspiration around the voice prosthesis (VP) and may lead to pneumonia. The primary objective was to summarize control of leakage around the VP after conservative management of enlarged TEP. Study Design: Retrospective cohort study. Methods: This 5-year cohort included 194 patients who underwent total laryngectomy (with or without pharyngectomy) and TEP at the University of Texas MD Anderson Cancer Center. Control of leakage around the VP was analyzed at last follow-up after enlarged TEP. Adverse events were compared in patients with and without enlarged TEP. Results: The incidence of enlarged TEP was 18.6% (36 of 194, 95% confidence interval [CI]: 13.0%-24.1%). Conservative methods commonly attempted in lieu of complete TEP closure included placement of an enlarged-flange VP (34 of 36, 94%), temporary VP removal (14 of 36, 39%), and TEP-site injection (8 of 36, 22%). At last follow-up, conservative methods controlled leakage around the VP in 81% (29 of 36) of patients. Only two patients required complete TEP closure due to persistent leakage after enlarged TEP. Unresolved leakage was more common in patients with recurrent cancer after laryngectomy (P =.081) and irregular TEP contour (P =.003). Relative to controls without TEP enlargement, patients with enlarged TEP had a three-fold higher risk of pneumonia (relative risk: 3.4, 95% CI: 1.9-6.2) and aspiration of the prosthesis (relative risk: 3.3, 95% CI: 0.8-14.1). Conclusions: Although the rate of enlarged TEP is relatively low, the complication significantly elevates risk of pneumonia. Prosthetic leakage related to TEP enlargement can often be managed conservatively to avoid complete closure of the TEP.