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Primary versus secondary tracheoesophageal puncture: systematic review and meta-analysis

  • P D Chakravarty (a1), A E L McMurran (a2), A Banigo (a3), M Shakeel (a3) and K W Ah-See (a3)...
Abstract Background:

Tracheoesophageal puncture represents the ‘gold standard’ for voice restoration following laryngectomy. Tracheoesophageal puncture can be undertaken primarily during laryngectomy or in a separate secondary procedure. There is no current consensus on which approach is superior. The current evidence comparing primary and secondary tracheoesophageal puncture was assessed.


A systematic review and meta-analysis of articles comparing outcomes for primary and secondary tracheoesophageal puncture after laryngectomy were conducted. Outcome measures were: voice success, overall complication rate and pharyngocutaneous fistula rate.


Eleven case series met the inclusion criteria, two prospective and nine retrospective. Meta-analysis did not demonstrate statistically significant differences in overall complication rate or voice outcomes, though it suggested a significantly increased risk of pharyngocutaneous fistula in primary compared to secondary tracheoesophageal puncture.


Primary tracheoesophageal puncture is a safe and efficient approach for voice rehabilitation. However, secondary tracheoesophageal puncture should be preferred where there is a higher risk of pharyngocutaneous fistula.

Corresponding author
Address for correspondence: Dr Patrick Daragh Chakravarty, Department of Otolaryngology, Head and Neck Surgery, Ward 11B, Queen Elizabeth University Hospital, Glasgow G51 4TF, Scotland, UK E-mail:
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1 Singer MI, Blom ED. An endoscopic technique for restoration of voice after total laryngectomy. Ann Otol Rhinol Laryngol 1980;89:529–33
2 Roxburgh J, Perry A. Use of a “hands-free” tracheostoma valve in patients with laryngectomy and tracheoesophageal puncture. Ann Otol Rhinol Laryngol 2004;113:565–70
3 Emerick KS, Tomycz L, Bradford CR, Lyden TH, Chepeha DB, Wolf GT et al. Primary versus secondary tracheoesophageal puncture in salvage total laryngectomy following chemoradiation. Otolaryngol Head Neck Surg 2009;140:386–90
4 Chone CT, Gripp FM, Spina AL, Crespo AN. Primary versus secondary tracheoesophageal puncture for speech rehabilitation in total laryngectomy: long-term results with indwelling voice prosthesis. Otolaryngol Head Neck Surg 2005;133:8993
5 Kao WW, Mohr RM, Kimmel CA, Getch C, Silverman C. The outcome and techniques of primary and secondary tracheoesophageal puncture. Arch Otolaryngol Head Neck Surg 1994;120:301–7
6 Cocuzza S, Bonfiglio M, Grillo C, Maiolino L, Malaguarnera M, Martines F et al. Post laryngectomy speech rehabilitation outcome in elderly patients. Eur Arch Otorhinolaryngol 2013;270:1879–84
7 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377–84
8 Maniglia AJ, Lundy DS, Casiano RC, Swim SC. Speech restoration and complications of primary versus secondary tracheoesophageal puncture following total laryngectomy. Laryngoscope 1989;99:489–91
9 Lukinović J, Bilić M, Raguz I, Zivković T, Kovac-Bilić L, Prgomet D. Overview of 100 patients with voice prosthesis after total laryngectomy--experience of single institution. Coll Antropol 2012;36:99102
10 Boscolo-Rizzo P, Zanetti F, Carpené S, Da Mosto CM. Long-term results with tracheoesophageal voice prosthesis: primary versus secondary TEP. Eur Arch Otorhinolaryngol 2008;265:73–7
11 Bozec A, Poissonnet G, Chamorey E, Demard F, Santini J, Peyrade F et al. Results of vocal rehabilitation using tracheoesophageal voice prosthesis after total laryngectomy and their predictive factors. Eur Arch Otorhinolaryngol 2010;267:751–8
12 Cheng E, Ho M, Ganz C, Shaha A, Boyle JO, Singh B et al. Outcomes of primary and secondary tracheoesophageal puncture: a 16-year retrospective analysis. Ear Nose Throat J 2006;85:262–7
13 Geraghty JA, Wenig BL, Smith BE, Portugal LG. Long-term follow-up of tracheoesophageal puncture results. Ann Otol Rhinol Laryngol 1996;105:501–3
14 Moon S, Raffa F, Ojo R, Landera MA, Weed DT, Sargi Z et al. Changing trends of speech outcomes after total laryngectomy in the 21st century: a single-center study. Laryngoscope 2014;124:2508–12
15 Morrison MD, O'Grady M. Primary tracheo-esophageal puncture voice restoration with laryngectomy. J Otolaryngol 1986;15:6973
16 Serra A, Di Mauro P, Spataro D, Maiolino L, Cocuzza S. Post-laryngectomy voice rehabilitation with voice prosthesis: 15 years experience of the ENT Clinic of University of Catania. Retrospective data analysis and literature review. Acta Otorhinolaryngol Ital 2015;35:412–19
17 Shenoy AM, Ashok H, Premalata BS, Prasad AV, Nanjundappa K, Kumar S. Surgical speech restoration by tracheo-oesophageal puncture--Kidwai experience. Indian J Cancer 2000;37:2731
18 Wenig BL, Mullooly V, Levy J, Abramson AL. Voice restoration following laryngectomy: the role of primary versus secondary tracheoesophageal puncture. Ann Otol Rhinol Laryngol 1989;98:70–3
19 Centre for Evidence-Based Medicine. OCEBM Levels of Evidence. In: [6 November 2017]
20 Sayles M, Grant DG. Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. Laryngoscope 2014;124:1150–63
21 Rentschler GJ, Mann MB. The effects of glossectomy on intelligibility of speech and oral perceptual discrimination. J Oral Surg 1980;38:348–54
22 Gitomer SA, Hutcheson KA, Christianson BL, Samuelson MB, Barringer DA, Roberts DB et al. Influence of timing, radiation, and reconstruction on complications and speech outcomes with tracheoesophageal puncture. Head Neck 2016;38:1765–71
23 Sinclair CF, Rosenthal EL, McColloch NL, Magnuson JS, Desmond RA, Peters GE et al. Primary versus delayed tracheoesophageal puncture for laryngopharyngectomy with free flap reconstruction. Laryngoscope 2011;121:1436–40
24 Dowthwaite SA, Penhearow J, Szeto C, Nichols A, Franklin J, Fung K et al. Postlaryngectomy pharyngocutaneous fistula: determining the risk of preoperative tracheostomy and primary tracheoesophageal puncture. J Otolaryngol Head Neck Surg 2012;41:169–75
25 Parikh SR, Irish JC, Curran AJ, Gullane PJ, Brown DH, Rotstein LE. Pharyngocutaneous fistulae in laryngectomy patients: the Toronto Hospital experience. J Otolaryngol 1998;27:136–40
26 Dedivitis RA, Aires FT, Cernea CR, Brandão LG. Pharyngocutaneous fistula after total laryngectomy: systematic review of risk factors. Head Neck 2015;37:1691–7
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The Journal of Laryngology & Otology
  • ISSN: 0022-2151
  • EISSN: 1748-5460
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