A tracheoesophageal puncture (TEP) is a surgical procedure to restore speech following a total laryngectomy, the complete removal of the larynx. This method of voice rehabilitation creates a new pathway for sound production, allowing individuals who have lost their voice box to speak again.
The Post-Laryngectomy Anatomical Landscape
A total laryngectomy fundamentally alters the anatomy of the neck, creating a new arrangement for breathing and swallowing. During the procedure, the larynx is removed, and the connection between the trachea and the mouth is permanently severed. Surgeons then create a permanent opening at the front of the neck called a stoma, connecting the top of the trachea directly to the skin.
This new configuration results in two distinct pathways. The first is the respiratory path, where air enters and exits the lungs exclusively through the stoma. The second is the digestive path, where food and liquid travel from the mouth, down the pharynx and esophagus, and into the stomach as they did before.
An individual who has undergone a laryngectomy can no longer breathe through their nose or mouth. This separation of the airway from the digestive tract is the reason a new method for voice production is necessary.
The Tracheoesophageal Puncture Site
The tracheoesophageal puncture is a small, surgically created channel, or fistula, that connects the trachea to the esophagus. The procedure can be performed either at the same time as the initial laryngectomy surgery (a primary puncture) or in a separate procedure later (a secondary puncture).
This puncture passes through the wall of tissue that separates the posterior, or back, wall of the trachea and the anterior, or front, wall of the esophagus. This shared wall, sometimes called the tracheoesophageal party wall, is the thinnest point between the two structures, making it an ideal location.
The puncture itself is small, about the size of a pencil eraser. Its purpose is to create a direct conduit from the airway into the food pipe, which is not left open but is designed to hold a special prosthesis.
Anatomy of the Voice Prosthesis
The tracheoesophageal puncture is kept open by a small medical device known as a voice prosthesis, most commonly made of medical-grade silicone. This device is inserted into the fistula to maintain the channel between the trachea and the esophagus. The prosthesis has several distinct parts that work together for speech while protecting the airway.
The device is held in place by two flanges, which are wider, disc-like ends. The tracheal flange sits against the back wall of the trachea, visible from within the stoma. The esophageal flange rests against the front wall of the esophagus, anchoring the device within the digestive tract.
Connecting the two flanges is a central barrel or shaft that passes through the puncture site. The length of this barrel is selected carefully to match the thickness of the tissue wall between the individual’s trachea and esophagus. Inside this barrel is a one-way valve.
This valve is designed to open only under pressure from air moving from the trachea towards the esophagus. When not in use for speaking or during swallowing, the valve remains closed. This prevents anything from the esophagus, such as food or liquids, from leaking back into the trachea and lungs.
The Functional Anatomy of TEP Speech
The production of a new voice using a TEP brings together the altered anatomy and the prosthesis in a coordinated sequence. The process begins with the person taking a breath in through their stoma. They then occlude, or cover, the stoma opening with a finger or a specialized valve, preventing the exhaled air from escaping.
With the stoma covered, the individual exhales. The air travels up the trachea from the lungs but cannot exit through the blocked stoma. This redirection of airflow increases the pressure inside the trachea, and the path of least resistance becomes the voice prosthesis.
The pressurized air pushes open the one-way valve inside the prosthesis and is shunted into the upper part of the esophagus. This column of air causes the soft tissues of the pharyngoesophageal (PE) segment—the area where the throat meets the esophagus—to vibrate. This vibration creates a raw, buzzing sound, which serves as the new sound source.
This raw sound then travels up through the pharynx and into the oral cavity. From this point on, the process of forming words is nearly identical to typical speech. The tongue, lips, teeth, and palate articulate and shape the sound into recognizable words and sentences. The resulting voice is often intelligible and allows for conversational speech.