Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy

Abstract

Background Enlarged tracheoesophageal puncture (TEP) is a challenging complication of surgical prosthetic voice restoration. Prevention of this complication requires identification of high risk individuals, as well as surgical and prosthetic correlates of TEP enlargement. Methods Multivariable logistic regression methods were used to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP in a 5-year retrospective cohort. Results Enlarged TEP only occurred in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced (N2 or N3) nodal disease (ORadjusted: 4.3, 95% CI: 1.0-19.1), postoperative stricture (ORadjusted: 3.2, 95% CI: 1.2-8.6), and diagnosis of locoregional recurrence or distant metastasis after laryngectomy (ORadjusted: 6.2, 95% CI: 2.3-16.4) increased risk of enlarged TEP. Extended resection and preoperative nutritional status were also significantly associated with enlarged TEP. Prosthetic parameters did not significantly correlate with enlargement. Conclusions Development of enlarged TEP is a multifactorial process related to both baseline and postoperative factors.

Early Risk Factors for Enlargement of the Tracheoesophageal Puncture After Total Laryngectomy

“…Consistent with previously published results, 4 patients with N + primary disease were 6.6-fold more likely to develop an enlarged TEP than patients with N0 primary disease. However, neck dissections, which are more commonly performed in patients with node-positive disease, did not significantly increase the risk of an enlarged TEP.…”

“…A detailed description of this cohort has been previously published. 4 A summary of patient characteristics is provided in Table 1.…”

“…Extended resections and postoperative radiotherapy are also predisposed to TEP enlargement. 4 Many of the risk factors identified in this earlier analysis, including tumor recurrence and stricture, emerge well into the postoperative course. However, early identification of high-risk individuals is important to inform decisions about candidacy for the TEP procedure and prosthetic management.…”

“…The primary dependent variable was a diagnosis of an enlarged TEP during the study period, defined by leakage around the voice prosthesis that was unresponsive to standard prosthetic management. 4 Potential early risk factors included patient demographics, tobacco and alcohol history, medical comorbidities, disease characteristics, extent of surgery, and preoperative radiotherapy and chemotherapy. Patient demographics included sex, age at time of laryngectomy, self-reported race or ethnicity at time of registration, marital status at time of registration, and institutional pay code at time of registration as an indicator of socioeconomic status.…”

Outcomes of Elective Total Laryngectomy for Laryngopharyngeal Dysfunction in Disease‐Free Head and Neck Cancer Survivors

“…Salvage TL was required for radionecrosis or intractable aspiration in only 1.4% of patients (7/517) randomized to laryngeal preservation regimens for advanced stage squamous carcinoma in the Radiation Therapy Oncology Group 91-11 trial, 8 and accounted for only 3% to 8% of laryngectomies reported in two published cohort studies. 9,10 A review of the literature yields no summary of outcomes after elective TL for dysfunction in disease-free HNC survivors, but there is evidence from a single case-study that swallowing physiology remains impaired despite the fact that aspiration is controlled after TL. 4 The intent of the current study was not to confirm the known fact that TL relieves intractable aspiration.…”