Video laryngoscopy-assisted secondary tracheoesophageal puncture placement for the patient with severely limited neck extension


  • Emily E. Crozier MD,

    1. Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, U.S.A
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  • Kevin Klein MD,

    1. Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, U.S.A
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  • Janis Deane CCC-SLP,

    1. Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, U.S.A
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  • Laura E. Toles CCC-SLP,

    1. Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, U.S.A
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  • Larry L. Myers MD, FACS

    Corresponding author
    1. Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, U.S.A
    • Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9035
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  • The authors have no funding, financial relationships, or conflicts of interest to disclose.


Secondary tracheoesophageal puncture (TEP) placement in patients with severe limitations in neck extension is challenging. Visualization of the hypopharynx with traditional rigid endoscopy may not be possible. We report using the C-MAC (Karl Storz, Tuttlingen, Germany) video laryngoscope to successfully place a secondary TEP in patient with severe radiation fibrosis at a tertiary referral center. A 59-year-old male with severe radiation fibrosis of the neck underwent total laryngectomy for a nonfunctioning larynx. His primary TEP dislodged in the early postoperative period and the patient requested secondary TEP and voice prosthesis. The result was a successful, properly positioned, placement of a secondary TEP. Videolaryngoscopy should be included in the surgeon's armamentarium of techniques to effectively and safely perform secondary TEP in anatomically difficult patients.


Tracheoesophageal puncture (TEP) is an effective and preferred method for postlaryngectomy voice restoration.1 It can be performed primarily at the time of ablation or as an elective procedure following postoperative adjuvant therapy. Traditionally, TEP is performed with rigid endoscopy for direct visualization of the proposed TEP site with the patient under general anesthesia.

One of the most challenging problems facing head and neck surgeons is placement of a secondary TEP in the postirradiated patient with severe soft tissue fibrosis where extension of the cervico-mental angle is severely limited. Rigid endoscopy may be difficult, or even impossible, in this patient population and is often exacerbated by trismus, full dentition, or macroglossia. Techniques for secondary TEP in these patients include unsedated office-based TEP using guidewire,2 in-office transnasal esophagoscopy,3 or blind technique.4

We describe using the C-MAC video laryngoscope (Karl Storz, Tuttlingen, Germany) to visualize the neopharynx for secondary TEP placement in a patient with severe radiation fibrosis of the neck.


A 59-year-old male completed combined chemoradiation therapy for advanced hypopharynx cancer 5 years prior to presentation. At the time of treatment, he received a tracheotomy and a gastrostomy tube (G-tube). He complained of severe dysphagia for 4 years after decannulation and was G-tube dependent. The clinical and radiographic work-up for locoregional and distant disease was negative. After extensive preoperative consultations over several months, the patient opted for removal of his nonfunctioning larynx to resume oral nutrition. He subsequently underwent a narrow-field laryngectomy with primary TEP. Intraoperative findings included severe radiation fibrosis of the skin and soft tissues of the neck. The neopharynx was reconstructed with a right, internal, mammary artery perforator faciocutaneous rotation flap tunneled under the upper chest and neck skin. His postoperative course was complicated by the development of a minor pharyngocutaneous fistula that was successfully treated with conservative measures and by the dislodgment of the TEP catheter. He desired replacement of the TEP for voice prosthesis.

Prior to the secondary TEP procedure, an esophageal air insufflation test was performed by the speech pathologist for objective identification of the vibratory potential of the pharyngoesophageal segment. The patient was deemed a good candidate for placement of a secondary TEP because he attained phonation of up to 10 words per one breath.

The patient was subsequently taken back to the operating room and placed under general anesthesia. The initial attempts to adequately visualize the distal neopharynx with a rigid esophagoscope were unsuccessful due to severe limitations in neck extension. The C-MAC video laryngoscope was inserted into the oral cavity down to the hypopharynx for real-time digital image visualization. The curved needle from the Blom-Singer tracheoesophageal puncture set (InHealth Technologies, Carpenteria, CA) was inserted 7 mm inferior to the mucocutenous junction of the posterior tracheal wall into the neopharynx (Fig. 1). The Seldinger technique was used to insert the 14-French catheter at the TEP site. The catheter was inserted from the posterior tracheal wall into the neopharynx. The distal end of the tube was cut and placed distally in the esophagus using a Fraenkel laryngeal forceps (Fig. 2). The tube was secured in place to the left anterior chest with interrupted figure-of-eight sutures of 2-0 nylon. There were no intraoperative complications. The patient was then awoken from anesthesia and taken to the recovery room extubated in stable condition.

Figure 1.

Visualization of the distal neopharynx during insertion of the curved needle and catheter. [Color figure can be viewed in the online issue, which is available at]

Figure 2.

Use of Fraenkel forceps to redirect the TEP catheter down the esophagus toward the stomach. [Color figure can be viewed in the online issue, which is available at]

Postoperatively, the patient was seen as an outpatient for placement of the TE speech prosthesis. The speech pathologist placed a 12-mm, 16-French Blom-Singer low-pressure voice prosthesis. Following instruction on digital occlusion of the stoma, the patient attained clear and fluent speech independently.


Since the first successful laryngectomy was performed by Billroth in 1873, there has been a desire to find an effective means of alaryngeal speech. In 1899, Taptas is credited as the first to devise and apply an external prosthesis to a patient after total laryngectomy.5 The patient produced completely understood words in a strong whispering voice and did not aspirate. The philosophy underlying the function of his device constituted the basic idea of modern speaking valves. The modern day TEP was first introduced as a method of postlaryngectomy voice restoration in 1980 by Blom and Singer.6 They proposed the use of a one-way valved prosthesis through a TEP site as an alternative to use of an electrolarynx or failed acquisition of esophageal speech. TEP speech is powered by the lungs and is thus more natural and sustainable. The prosthesis allows movement of air from the trachea into the esophagus and neopharynx; air is released from this reservoir and vibrates within the soft tissues to create speech. At the same time, the one-way valve prevents aspiration of secretions from the pharynx into the trachea. Their original prosthesis had a beak-like slit opening to allow airflow into the pharynx. This prosthesis required high pressures to open, and subsequent modifications of the prosthesis allowed for lower air pressure to open the valve and deliver air to the pharynx for voicing.

Although primary TEP has been accepted as the procedure of choice for voice rehabilitation after standard laryngectomy,1, 7 secondary TEP may be required for several patient groups. Indications for secondary TEP include lack of placement of TEP at initial surgery, failures of non–prosthesis-assisted esophageal voice, accidental dislodgement of the catheter keeping the TEP site patent, suboptimal placement of primary TEP, and/or primary TEP-related problems.

Secondary TEP placement in the postirradiated patient with severe soft tissue fibrosis presents several challenges. A woody neck that disallows neck extension renders effective rigid endoscopy nearly impossible. Trismus, full dentition, or macroglossia may exacerbate the inability to perform traditional rigid endoscopy for secondary TEP placement. Insertion of the rigid esophagoscope may cause lacerations of the posterior pharyngeal wall mucosa, resulting in bleeding, poor visualization, fistula, or even mediastinitis.

Video laryngoscopy-assisted TEP placement (VLATEPP) avoids the difficulty of placing a rigid endoscope in the neopharynx and esophagus. It can be performed without hyperextension of the neck. The curved blade of the video laryngoscope follows the contour of the base of the tongue and is more easily inserted in patients with radiation fibrosis, limited neck extension, or other anatomic variations that limit placement of a rigid scope. The video laryngoscope limits the risk of posterior wall pharyngeal mucosa lacerations and subsequent bleeding that may impair visualization. The video laryngoscope lifts the tongue, and once inserted, it provides a clear image of the neopharynx and posterior tracheal wall at the proposed puncture site. The TEP needle and catheter can be placed through the posterior tracheal wall, with full visualization of the puncture site, in contrast to blind techniques.

VLATEPP is easily mastered because it uses techniques familiar to both surgeons and anesthesiologists. It can be performed as a combined effort between the anesthesiologist and the surgeon and does not require a second surgeon to manipulate the esophagoscope. If the anesthesiologist does not have a video laryngoscope, the surgeon may request that the hospital obtain the video laryngoscope components prior to performing elective secondary TEP placement.


VLATEPP provides excellent visualization of the hypopharynx in patients with extensive radiation fibrosis of the neck resulting in severely limited neck extension. This technique should be added to the armamentarium of procedures to place secondary TEPs in this anatomically challenging patient population.