Tracheoesophageal (TE) Prosthesis

What It Is

Why It Is Used

Mechanism of Action

1. The patient occludes the tracheostoma with a thumb or finger (or a hands-free heat-moisture exchanger valve)
2. Exhalation forces air through the one-way prosthesis valve into the upper esophagus
3. The air vibrates the esophageal walls (similar to a belch), generating a tone
4. The patient articulates this tone into speech using the lips, tongue, and palate

Timing of Placement

• Primary TEP: Created at the time of laryngectomy (if wound-healing complications are not anticipated)
• Secondary TEP: Created as an outpatient procedure ~4 weeks post-resection, using a flexible esophagoscope to guide puncture placement
• Primary and secondary TEP have similarly high complication rates; the extent of pharyngeal reconstruction (not prior radiation) is a more important factor in timing selection

Types of Prostheses

Complications

1. Leakage (most common)

• Around the valve (peri-prosthetic): due to enlargement of the TEF fistula - fluid tracks around the outside of the prosthesis
• Through the valve lumen: valve dysfunction/failure
• Confirmed by having the patient drink a colored liquid (e.g., grape juice) while inspecting the prosthesis
• Risk: aspiration pneumonia
• Management: Remove prosthesis, insert a Foley catheter (uninflated) to maintain fistula patency until specialist follow-up. Do NOT attempt catheter placement if the tract is <2 weeks old (risk of false passage)

2. Valve aspiration/extrusion

• Prosthesis dislodges and can be aspirated
• Symptoms: persistent cough, dyspnea, respiratory distress
• Diagnosis: chest radiograph (prosthesis is radiopaque)
• The TEF tract closes within 24-48 hours of dislodgement - a Foley or red rubber catheter must be inserted promptly to maintain patency
• Requires otolaryngology consultation

3. Biofilm formation

• Candida colonization on silicone degrades the valve, causing it to fail
• Limits prosthesis lifespan
• Antifungal prophylaxis (nystatin, amphotericin lozenges) and antifungal-impregnated prostheses have been studied to reduce biofilm

4. Cricopharyngeal spasm

• Can impair sound production / fluency
• Managed with botulinum toxin injection into the cricopharyngeus (percutaneous or endoscopic)
• A test block with 1% lidocaine infiltration can predict response

5. Stenosis of the TEF tract

• Can develop post-operatively; may present as difficulty producing speech in addition to dysphagia

Emergency Management Summary (TE Prosthesis in the ED)

Role of the Speech-Language Pathologist (SLP)

• Pre-operative counseling on speech options
• Prosthesis sizing and fitting
• Voice training post-insertion
• Long-term compliance and troubleshooting

Recent Evidence

1. Biofilm strategies on voice prostheses (Tsikopoulos et al., J Voice 2025, PMID 37625903) - reviews approaches to inhibit Candida/bacterial biofilm on silicone, which is the primary driver of prosthesis failure.
2. TE voice therapy post-laryngectomy (Sparks et al., J Voice 2026, PMID 38000962) - systematic review confirming the importance of structured voice therapy in optimizing outcomes after TE prosthesis placement.

Terminal / Palliative Care of Head and Neck Cancer Patients

Overview and Scope

• The disease and its treatments profoundly impair functions essential to human identity - communication, swallowing, and breathing
• The boundary between "radical" and "palliative" treatment is blurred (e.g., major resections with limited prognosis)
• Functional deficits lead to social isolation and depression
• Histological confirmation of recurrence can be difficult after prior treatments

An estimated 20% of head and neck cancer patients qualify for palliative care input at the time of initial diagnosis, with an average survival of 5 months within this cohort.

When to Refer for Palliative Care

• Unresectable locoregional disease and/or distant metastasis at initial presentation
• Recurrent unresectable disease and/or distant metastasis after treatment
• Patients unable to tolerate anticancer treatment due to disease stage, comorbidity, functional status, or patient preference

Symptom Prevalence in Terminal Head and Neck Cancer

1. Pain Management

• Nociceptive pain - from local compression or invasion by the tumour
• Neuropathic pain - from peripheral/central nervous system dysfunction (due to tumour or prior treatment)
• Mixed presentations are common

• Step 1: Non-opioids (e.g., regular paracetamol)
• Step 2: Add weak opioid (e.g., codeine)
• Step 3: Substitute strong opioid - morphine remains the drug of choice for moderate-to-severe pain

• First-line: anti-convulsant (gabapentin) or anti-depressant (amitriptyline)
• Nerve compression: trial of dexamethasone (corticosteroid)
• Refractory: methadone, ketamine, interventional pain procedures

• Defined as transient exacerbation despite stable background analgesia
• Use short-acting opioid preparations: oral morphine (oramorph/oxynorm)
• Newer formulations: fentanyl (sublingual, buccal, intranasal) - equal efficacy, faster onset, but reserved for movement-related or sudden short-lived pain; requires baseline of ≥60 mg oral morphine equivalent

• Myoclonus, visual hallucinations, confusion, drowsiness
• Management: reduce dose if pain controlled, check renal function (metabolites accumulate), or opioid switch (e.g., morphine → oxycodone / hydromorphone)
• If renal impairment: use renally-independent opioids e.g., alfentanil

• Oral route often unavailable - use PEG/gastrostomy tube (note: do NOT crush sustained-release preparations - use Zomorph granules or MST Continus suspension)
• Transdermal fentanyl patches: changed every 72 hours; suitable only once pain is stable; less flexible for titration
• Subcutaneous infusion via syringe driver is often preferred in the terminal phase

2. Respiratory Tract Secretion Management

• Balance: reduce secretions without making them too tenacious
• If oral/gastrostomy route unavailable: transdermal hyoscine hydrobromide (Scopoderm) patches

3. Communication Difficulties

• Alternative aids: electronically generated speech devices, written communication
• Loss of communication subtleties has a profound psychological impact
• Advance care planning (ACP) becomes especially important early, while patients can still communicate
• Open-ended discussions about goals of care and future complications should be proactive

4. Terminal Haemorrhage ("Carotid Blowout")

• Rupture of the carotid artery system occurs in an estimated 3-5% of patients who have undergone major head and neck resections

• Tumour-related: proximity to the carotid artery
• Treatment-related: previous radical neck dissection and/or radiotherapy; post-operative wound healing problems
• Systemic: coagulopathy; age >50; 10-15% weight loss; comorbidities (e.g., diabetes)

• A herald (sentinel) bleed may precede the fatal haemorrhage
• Visible ballooning or pulsation of the carotid

• Review and stop anticoagulants (warfarin, heparin)
• Review drugs affecting platelet function: NSAIDs, aspirin, SSRIs
• If sentinel bleed occurs: arterial embolization by interventional radiology can delay or abrogate further bleeding

• Goal of midazolam: reduce patient's awareness and distress; provides retrograde amnesia if the patient survives
• Opioids are generally not needed unless haemorrhage is not terminal and patient reports pain
• At home: full MDT discussion required; community healthcare teams and ambulance service must be briefed in advance

5. Airway Obstruction

• Retention of secretions
• Tumour encroachment into the airway or tracheostomy

• Decision-making about escalation must be pre-planned
• Palliative surgical options: tracheostomy or tumour debulking in the airway (if appropriate)
• Stridor: high-dose dexamethasone 8-16 mg subcutaneously may reduce peritumour oedema
• Pre-emptive prescription of midazolam (anxiolytic) for the terminal event

6. Holistic / Psychosocial Care

Depression

• Highly prevalent; independently predicts poorer quality of life
• Head and neck cancer patients have a disproportionately higher suicide risk than the general cancer population (linked to male predominance, tobacco/alcohol use, limited social support)
• Screen with brief tools: anhedonia (loss of interest/pleasure) and low mood
• Treatment: psychotherapy + antidepressants
  • SSRIs first-line over tricyclics (better tolerability)
  • Caution: SSRIs increase GI bleeding risk - significant consideration in this group
  • Mirtazapine: useful if appetite stimulation and sedation are acceptable (give at night)

Spiritual Care

• Explore meaning, purpose, hope, and coping at every consultation
• Example questions: "What gives you hope and strength?" / "How are you coping?"

Ethical Issues

1. Autonomy - patient's right to decide
2. Beneficence - act to provide benefit
3. Non-maleficence - avoid harm
4. Justice - fair use of resources

• Provision of artificial nutrition and hydration as death approaches (especially when patient preference is unclear)
• Communication difficulties making patient-centred decision-making harder - forward planning while patients can still communicate is essential

Multidisciplinary Team

• Specialist palliative care physician and nurses
• Otolaryngologist / head and neck surgeon
• Speech-language pathologist
• Dietitian
• Clinical psychologist / psychiatrist
• Chaplain / spiritual care
• Social worker
• Community nursing / hospice teams
• Ambulance service (for home-based terminal events)

Note on recent evidence: A 2024 review on ethics and palliation in head and neck surgery (Hochfelder & Shuman, Surg Oncol Clin N Am 2024, PMID 39244287) addresses the ethical complexities in this population and supports early, integrated palliative involvement.

Masked Mastoiditis

Definition

Two things are key to its successful diagnosis and management:

1. Mastoid disease is not always reflected by the appearance of the tympanic membrane
2. Chronic mastoiditis is a surgical condition, regardless of the tympanic membrane appearance

• Cummings Otolaryngology

Pathogenesis / Why It Is "Masked"

1. Antibiotics partially treat the middle ear and most of the mastoid
2. A focal area of persistent infection in the mastoid does not respond - typically behind a blocked aditus
3. Granulation tissue blocks the aditus ad antrum, creating an anaerobic pocket
4. Anaerobic organisms (Peptococcus spp., Bacteroides spp.) thrive in this low-virulence environment
5. An indolent osteitis develops, causing little or no pain - hence the disease is "masked"
6. Meanwhile, bone destruction continues and complications develop insidiously

Clinical Features

Diagnosis

• Shows localized opacification in an otherwise aerated mastoid (focal disease, not diffuse)
• Identifies bone destruction, coalescence, and extent of disease

• CT with IV contrast is recommended when intracranial or vascular complications are suspected (to look for thrombophlebitis, epidural or intracranial involvement)
• A low threshold for CT should be maintained in any child with persistent ear symptoms following antibiotic treatment

Complications

• Subperiosteal abscess (can be painless)
• Labyrinthitis (acute suppurative)
• Petrous apicitis (Gradenigo's syndrome: otorrhoea, ipsilateral abducens palsy, retro-orbital pain)
• Sigmoid sinus thrombosis
• Bezold's abscess (spread to digastric triangle)

Treatment

• Cortical mastoidectomy is typically performed to eradicate the diseased air cell system
• Surgical excision eliminates symptoms and resolves the focal infection
• If a subperiosteal abscess is present, drainage is performed at the same time
• IV antibiotics are given perioperatively and directed by culture results

Chronic mastoiditis is a surgical condition - antibiotics alone will not eliminate the disease, and their continued use simply perpetuates the "masking" effect.

Key Teaching Points