Unlocking tracheoesophageal speech from pharyngoesophageal spasm: preliminary results of a videofluoroscopic-guided botulinum toxin A injection technique.

PURPOSE: The tracheoesophageal puncture for the voice prosthesis (VP) placement is the recognized gold standard in post-laryngectomy voice rehabilitation. Despite the development of specific intraoperative techniques, a subset of patients will suffer from poor functional outcomes due to pharyngoesophageal spasms (PES). This paper evaluates the functional outcomes after transcutaneous botulinum toxin type A (BTX-A) infiltration for PES with a videofluoroscopy-guided technique. METHODS: Since 2022, eight consecutive patients with VP and affected by PES were treated with BTX-A injection by a standard videofluoroscopic guided technique at the European Institute of Oncology, IRCCS (IEO) in Milan. A lidocaine test was performed pre-operatively to evaluate the potential effect of chemical neurectomy. All patients with positive lidocaine tests were injected with 50 IU of BTX-A (Allergan, Irvine, CA) according to the sites marked during the videofluoroscopy. Reported symptoms (VHI, SECEL), perceptual (INFVo), aerodynamic (MPT) and manometric parameters were collected before and after treatment. RESULTS: In all cases, BTX-A was performed as an outpatient procedure without complications. For seven patients, only one BTX-A injection was needed, while one patient required a re-injection. Subjective and perceptive improvement after BTX-A was significant for VHI, SECEL and INFVo. MPT showed significant improvement after a chemical neurectomy. After a mean follow-up of 6 months, all patients maintained a good TES quality. CONCLUSION: The videofluoroscopic guided BTX-A injection of the pharyngoesophageal tract showed to be a feasible and reproducible technique in all cases. The pharyngoesophageal videofluoroscopy allows defining of patients' anatomical landmarks that help the surgeon to perform a homogeneous injection, empowered by post-injection massage.

An experimental model of the pharyngoesophageal segment in tracheoesophageal phonation.

Tracheoesophageal (TE) speech is an important method of speech rehabilitation for those who undergo a total laryngectomy. Despite the many advantages over other methods, there is still room for improvement in terms of the overall quality of the TE voice as well as its success rate. These points could be greatly assisted by an improved knowledge on the mechanics of TE speech. Here, an experimental model of the pharyngoesophageal segment (PES), based on the idea of a collapsible tube, is proposed. To implement the model, considerable simplifications had to be made, most notably in the use of a thin flexible tube to represent the PES. The model was used to assess the minimum amount of tonicity required for the onset of phonation in terms of the flow rate and longitudinal tension. Additionally, comparisons with a mathematical model [Tourinho, da Silva, dos Santos, Thomaz, and Vieira, J. Acoust. Soc. Am. 149, 1979-1988 (2021)] have been made, yielding similar trends for sufficiently large flow rates. The measurements also suggest that the phonation frequency is most affected by the tonicity of the PES, which highlights the question of which physiological mechanism is responsible for the control of the fundamental frequency of phonation.

An acoustic study of Cantonese alaryngeal speech in different speaking conditions.

Esophageal (ES) speech, tracheoesophageal (TE) speech, and the electrolarynx (EL) are common methods of communication following the removal of the larynx. Our recent study demonstrated that intelligibility may increase for Cantonese alaryngeal speakers using clear speech (CS) compared to their everyday "habitual speech" (HS), but the reasoning is still unclear [Hui, Cox, Huang, Chen, and Ng (2022). Folia Phoniatr. Logop. 74, 103-111]. The purpose of this study was to assess the acoustic characteristics of vowels and tones produced by Cantonese alaryngeal speakers using HS and CS. Thirty-one alaryngeal speakers (9 EL, 10 ES, and 12 TE speakers) read The North Wind and the Sun passage in HS and CS. Vowel formants, vowel space area (VSA), speaking rate, pitch, and intensity were examined, and their relationship to intelligibility were evaluated. Statistical models suggest that larger VSAs significantly improved intelligibility, but slower speaking rate did not. Vowel and tonal contrasts did not differ between HS and CS for all three groups, but the amount of information encoded in fundamental frequency and intensity differences between high and low tones positively correlated with intelligibility for TE and ES groups, respectively. Continued research is needed to understand the effects of different speaking conditions toward improving acoustic and perceptual characteristics of Cantonese alaryngeal speech.

The French way of voice rehabilitation post total laryngectomy: current clinical practices and tendencies.

BACKGROUND: Vocal rehabilitation post total laryngectomy (TL) lacks clinical guidelines, especially with the presence of multiple modalities. OBJECTIVES: To describe the tendencies of vocal rehabilitation post TL in France and compare it with other countries. We try to identify the most practiced modalities and recognize statistically significant influencing factors. MATERIALS AND METHODS: An electronic anonymous survey was answered by 75 ENT surgeons from France. The survey outlined the common practiced vocal rehabilitation modalities and had two versions depending on if the participant practices the tracheoesophageal speech (TES) or not. RESULTS: 96% use TES in their practice. Single modality TES and double modality TES with esophageal speech (ES) are the two most practiced modalities. 99% agreed that there is no age limit for the TES. Single modality ES was offered 92% more when more than 10 TL were performed per year (p < .05). No influencing factors found for single modality TES or double modality TES with ES (p > .05).Conclusion: In line with tendencies from other countries, the TES is the most practiced modality of vocal rehabilitation coupled or not with the ES. TES has no age limit as per our participants. The least practiced modality is the singe modality ALS.

Voice Restoration and Quality of Life in Larynx Cancer.

Voice restoration following laryngectomy has a significant influence on quality of life (QOL). Three main techniques exist to provide voice: esophageal speech (ES), artificial larynx (electrolarynx [EL]), and tracheoesophageal puncture (TEP). Although the EL was historically the most used technique, TEP has quickly become the gold standard. ES remains the least frequently used technique in developed countries. Technique selection must be made on an individual basis, considering the patient's cancer history and comorbidities. Ultimately, the choice in voice-restoration technique requires joint decision making with the surgeon, speech pathologist, and patient.

Olfactory function in laryngectomised patients: tracheo-oesophageal versus oesophageal speech.

Objective: This study aimed to evaluate olfactory function in patients rehabilitated with oesophageal (ES) voice or tracheo-oesophageal (TES) prosthesis to further verify whether there were differences in smell alterations depending on voice rehabilitation modality. Methods: A total of 40 patients who had undergone total laryngectomy participated in the study. Speech rehabilitation was achieved through TES in 20 patients (Group A) or ES in 20 patients (Group B). Olfactory function was evaluated using the Sniffin' Sticks test. Results: At olfactory evaluation, in Group A, 4/20 patients (20%) were anosmic, whereas 16/20 patients (80%) were hyposmic; in Group B, 11/20 patients (55%) were anosmic whereas 9/20 patients (45%) were hyposmic. A significant difference (p = 0.04) was found at global objective evaluation. Conclusions: The study shows that the rehabilitation with TES contributes to maintaining a functioning, albeit limited, sense of smell.

Voice-Related Quality of Life Outcomes from Pneumatic Artificial Laryngeal and Esophageal Speakers.

The self-reporting voice-related quality of life (V-RQOL) instrument has been viewed as a modular index of quality of life for speakers using tracheoesophageal, esophageal (ES), or electrolaryngeal speech. However, V-RQOL has never been studied with pneumatic artificial laryngeal (PA) individuals. This study attempted to quantify the self-assessed voice-related performance of PA and ES speakers in Taiwan via the V-RQOL questionnaire, and further to compare the results for PA and ES speakers. METHODS: V-RQOL was assessed in 79 PA and 25 ES speakers undergoing total laryngectomy without using tracheoesophageal puncture. Data were collected from members of Taiwan's Association of Laryngectomees. RESULTS: There was no significant difference between PA and ES participants in social-emotional, physical functioning and total scores, suggesting both may consider their quality of life comparable with each other. In ES participants, there was a significant effect of time after total laryngectomy in physical functioning and total scores. CONCLUSIONS: PA speakers did not exhibit more dissatisfaction or disability than ES speakers on 10 statements in the V-RQOL, but after total laryngectomy the ES have been shown to improve over time. Information on the experience of PA and ES speakers could be used by clinicians to inform patients of potential outcomes, and help them select suitable rehabilitation techniques.

Has Esophageal Speech Returned as an Increasingly Viable Postlaryngectomy Voice and Speech Rehabilitation Option?

PURPOSE: The literature on postlaryngectomy voice and speech rehabilitation is long-standing. Although multiple rehabilitation options have existed over the years, the acquisition and use of esophageal speech (ES) has decreased significantly over the past 40 years. This reduction coincides with the increased application of tracheoesophageal puncture (TEP) voice restoration. The literature suggests that voice acquisition failures observed secondary to TEP may represent a similar phenomenon that led to ES acquisition failures. METHOD: A comprehensive review of the literature on ES and TEP voice/speech was conducted. Specific attention was directed toward information on ES and TEP speech failures. Information on pharyngoesophageal segment (PES) spasm in the context of ES and TEP voicing failures was of specific importance. RESULTS: Similarities between voicing failures with both ES and TEP were identified. In order to resolve spasm in TEP speech, proactive efforts to eliminate it were undertaken, and regardless of the method used, voicing improvements were observed. These data suggest that both ES and TEP speech acquisition failures may be related to the same control mechanisms influencing the PES. CONCLUSIONS: The elimination of PES spasm provides evidence that justifies the reconsideration of ES. Consequently, ES may return as an increasingly viable postlaryngectomy voice and speech rehabilitation option.

Acoustic Analysis of Taiwanese Tones in Esophageal Speech and Pneumatic Artificial Laryngeal Speech.

PURPOSE: This study examined the acoustic properties of Taiwanese (Southern Min) lexical tones produced in esophageal speech (ES) and pneumatic artificial laryngeal speech (PAL), including onset fundamental frequency (F0), slope of F0 contour, duration, and amplitude (intensity) of the vowel portion of syllables carrying seven Taiwanese tones. METHOD: Seven ES speakers, seven PAL speakers, and 18 normal laryngeal (NL) speakers (all male) read aloud target syllables carrying the tones in monosyllables, disyllables, and sentences. Acoustic features were measured with Praat. RESULTS: Acoustic analysis revealed (a) no significant effects of linguistic level on acoustic parameters except for duration, which generally significantly decreased from monosyllables to disyllables to sentences for Tones 1 and 5; (b) significant differences across the speaker groups in onset F0 (PAL > ES > NL), duration (PAL > NL and PAL > ES for all tones), and mean amplitude (PAL > NL > ES); and (c) no significant difference in mean slope of F0 contour across the speaker groups. CONCLUSIONS: These preliminary data on acoustic properties of Taiwanese tones produced by ES and PAL speakers could facilitate the design of therapeutic strategies for improving the intelligibility of alaryngeal lexical tones. Further studies are recommended to examine the relative perceptual importance of the acoustic parameters.

Chaos Behavior Analysis of Alaryngeal Voices Including Esophageal and Tracheoesophageal Voices.

HYPOTHESIS/OBJECTIVES: This study's objective was to develop a method to evaluate the chaotic characteristic of alaryngeal speech. The proposed method will be capable of distinguishing between normal and alaryngeal voices, including esophageal (SE) and tracheoesophageal (TE) voices. It has been previously shown that alaryngeal voices exhibit chaotic characteristics due to the aperiodicity of their signals. The proposed method will be applied for future use to quantify both chaos behavior (CB) and the difference between SE and TE voices. STUDY DESIGN: A total of 74 voice recordings including 34 normal and 40 alaryngeal (26 SE and 14 TE) were used in the study. Voice samples were analyzed to distinguish alaryngeal voices from normal voices and to investigate different chaotic characteristics of SE and TE speech. METHODS: A chaotic distribution detection-based method was used to investigate the CB of alaryngeal voices. This CB was used to detect the difference between SE and TE voice types. Quantification of the CB parameter was performed. Statistical analyses were used to compare the results of the CB analysis for both the SE and TE voices. RESULTS: Statistical analysis revealed that CB effectively differentiated between all normal and alaryngeal voice types (p < 0.01). Subsequent multiclass receiver operating characteristic (ROC) analysis demonstrated that CB (area under the curve) possessed the greatest classification accuracy relative to correlation dimension (D2). CONCLUSIONS: The CB metric shows strong promise as an accurate, useful metric for objective differentiation between all normal and alaryngaeal, SE and TE voice types. The CB calculations showed expected results, as SE voices have significantly more CB than TE voices, constituting substantial improvement over previous methods and becoming the first SE and TE classification method. This metric can help clinicians obtain additional acoustic information when monitoring the efficacy of treatment for patients undergoing total laryngectomies.

Neural Correlates of Esophageal Speech: An fMRI Pilot Study.

OBJECTIVES: The esophageal speech is one of the possible alaryngeal voices resulting after total laryngectomy. Its production is made by the regurgitation of the air coming from the esophagus, sonorized through the passage from the walls of the upper esophageal sphincter. The neural correlates of this voice have never been investigated, while the neural control of laryngeal voice has been already documented by different studies. METHODS: Four patients using esophageal speech after total laryngectomy and four healthy controls underwent functional magnetic resonance imaging. The fMRI experiment was carried out using a "Block Design Paradigm." RESULTS: Comparison of the phonation task in the two groups revealed higher brain activities in the cingulate gyrus, the cerebellum and the medulla as well as lower brain activities in the precentral gyrus, the inferior and middle frontal gyrus and the superior temporal gyrus in the laryngectomized group. CONCLUSIONS: The findings in this pilot study provide insight into neural phonation control in laryngectomized patients with esophageal speech. The imaging results demonstrated that in patients with esophageal speech, altered brain activities can be observed. The adaptive changes in the brain following laryngectomy reflect the changes in the body and in the voice modality. In addition, this pilot study establishes that a blocked design fMRI is sensitive enough to define a neural network associated with esophageal voice and lays the foundation for further studies in this field.

The Effect of Clear Speech on Cantonese Alaryngeal Speakers' Intelligibility.

BACKGROUND/AIM: The purpose of this study was to provide preliminary data concerning the effect of clear speech (CS) on Cantonese alaryngeal speakers' intelligibility. METHODS: Voice recordings of 11 sentences randomly selected from the Cantonese Sentence Intelligibility Test (CSIT) were obtained from 31 alaryngeal speakers (9 electrolarynx [EL] users, 10 esophageal speakers and 12 tracheoesophageal [TE] speakers) in habitual speech (HS) and CS. Two naïve listeners orthographically transcribed a total of 1,364 sentences. RESULTS: Significant effects of speaking condition on speaking rate and CSIT scores were observed, but no significant effect of alaryngeal communication methods was noted. CS was significantly slower than HS by 0.78 syllables/s. Esophageal speakers demonstrated the slowest speech rate when using CS, while EL users demonstrated the largest decrease in speaking rate when using CS compared to HS. TE speakers had the highest CSIT scores in HS (listener 1 = 81.4%; listener 2 = 81.3%), and esophageal speakers had the highest CSIT scores in CS (listener 1 = 87.5%; listener 2 = 89.7%). EL users experienced the largest increase in intelligibility while using CS compared to HS (9.1%) followed by esophageal speakers (8.9%) and TE speakers (1.4%). CONCLUSION: Preliminary data indicate that CS may significantly affect Cantonese alaryngeal speakers' speaking rate and intelligibility. However, intelligibility appeared to vary considerably across speakers. Further research involving larger, heterogeneous groups of speakers and listeners alongside longer and more refined CS training protocols should be conducted to confirm that CS can improve Cantonese alaryngeal speakers' intelligibility.

Influence of position and angulation of a voice prosthesis on the aerodynamics of the pseudo-glottis.

The use of a tracheoesophageal valve, also known as voice prosthesis, is currently the most appealing solution for recovering the ability to speak in subjects who have undergone a total laryngectomy. The prosthesis allows the passage of air from the trachea to the esophagus, thereby promoting the flow-induced vibration of the subject's pharyngoesophageal segment. In turn, the pharyngoesophageal segment modulates the air flow from the lungs into the subject's vocal tract, acting as an alternative source of acoustic energy to generate voice. The vibration of the pharyngoesophageal segment will likely depend on the aerodynamic forces acting on its wall, which will be defined by the flow characteristics downstream from the valve's outlet. Previous works have investigated the pressure drop across different prosthesis designs with both in-vitro and in-vivo experiments. Nevertheless, the aerodynamic aspects of the flow in the tracheoesophageal region have only been investigated experimentally in an idealized geometry. This work investigates the influence of the prosthesis position on the aerodynamic behavior of the pharyngoesophageal segment in terms of wall pressure distribution and characteristics of the velocity field. The investigations were carried out with a static model of the tracheoesophageal region based on the finite volume method and a Reynolds-averaged Navier-Stokes solver. The geometry of the system was based on computed tomography images obtained from laryngectomized subjects during phonation at different voice registers and included the geometry of a commercially available voice prosthesis. The results suggest that the position and angulation of the voice prosthesis have a minor influence on the pressure loss along the tracheoesophageal segment and on the pressure distribution on the pharyngoesophageal segment's wall.

Semon Lecture: 'Laryngectomy Practice Based on Personal Research', Royal Society of Medicine, 5 November 2020, London, UK.

I wish to thank the Semon Committee for inviting me to deliver the 2020 Semon lecture. This is a very special honour, as is evidenced by the list of distinguished lecturers dating back to the inaugural lecture delivered at University College London in 1913. I am not the first South African to deliver the Semon lecture, having been preceded by my previous chairman Sean Sellars in 1993, and by Jack Gluckman in 2001, who was South African raised and educated and who subsequently became the chairman of otolaryngology in Cincinnati, USA.

The Mandarin Voice Handicap Index for Laryngectomees With Pneumatic Artificial Laryngeal and Esophageal Speech.

Purpose The Voice Handicap Index (VHI) questionnaire assesses the impact of total laryngectomy on voice-related quality of life. This study evaluates the Mandarin VHI, including its internal consistency, test-retest reliability, content validity, and differences in scores for Mandarin alaryngeal patients with pneumatic artificial laryngeal (PA) and esophageal (ES) speech. Method Translation and validation of the VHI questionnaire was performed through the forward-backward translation technique. This study used a sample of 78 PA and 23 ES participants from Taiwan who completed the Mandarin VHI. Forty-two of the alaryngeal participants completed the Mandarin VHI twice over a period of 7-63 days. Results The measurement of the internal consistency of the Mandarin VHI showed a high Cronbach's alpha coefficient for the total score (.975) and the functional (.930), physical (.939), and emotional (.938) subscales. Based on the results of the intraclass correlation coefficients, good test-retest reliability for the total and domain scores was found (intraclass correlation coefficient = .827-.863). Conclusion The Mandarin VHI was validated as an instrument with proper internal consistency and reliability, which supports the Mandarin VHI as a valid instrument for the self-evaluation of handicaps related to voice problems in PA and ES speakers.

Dynamic Study of Oesophageal Function during Phonation: Simple but Effective.

Secondary aphonia significantly affects the quality of life of the laryngectomy patient despite the excellent success of the operation. Vocal rehabilitation often does not achieve the desired results, given the innumerable prognostic variables. Tracheo-oesophageal speech is considered the standard gold method of voice restoration, but a possible spasm of pharyngo-oesophageal segment is the prominent cause of rehabilitation failure. However, the phenomenon is difficult to identify and underestimated, and diagnostic methods are inquisitive or expensive. To propose a phonatory and swallowing evaluation essay of pharynx-oesophageal segment disorders, we conducted a retrospective study from 2012 to 2017 by selecting 6 patients who underwent total laryngectomy and voice prosthesis implantation that suffered from aphonia after surgery. All patients underwent dynamic phonation videofluoroscopy and plexus bath control test with lidocaine hydrochloride. All patients were then referred for treatment with neurotoxin blocker. In all cases, the analysed patients presented an air-trapping phenomenon with the formation of a spasmodic block upstream of an interrupted aerial column. The control test with lidocaine hydrochloride resulted in a transient improvement in speech performance. The neurotoxin block therapy subsequently performed ultimately led to an improvement in the patient's rehabilitation process with a recovery of the phonatory performance. We describe the new use of a barium bolus as a diagnostic tool for identifying neopharynx disorders. Appropriately selected patients with pharynx-oesophageal segment disorders could benefit from a neurotoxin-blocking treatment to improve oesophageal speech.

A study on tracheoesophageal phonation based on a collapsible channel model.

Laryngeal cancer afflicts a large number of people worldwide, and some will need surgery to contain the disease. Currently, tracheoesophageal (TE) speech is a common method of voice rehabilitation for patients who have had their larynges excised. However, despite the relatively high success rate, not everyone is capable of producing the TE voice, usually due to the tonicity of the pharyngoesophageal segment (PES). The present work studies how the tonicity of the muscles of the PES affects TE phonation, focusing mainly on hypotonicity. A simplified collapsible channel model is used. Steady-state solutions are obtained and a linear stability analysis is performed. It is then shown that the steady-state solutions of the model are similar to the wide variety of possible PES configurations that are reported in the literature. The linear stability analysis results provide a simple expression for the estimation of the minimum tonicity required for self-sustained oscillations of the PES.

Listener impressions of alaryngeal communication modalities.

Purpose: Following a total laryngectomy in which the larynx is completely removed, individuals in the USA have three primary options for alaryngeal verbal communication including tracheoesophageal speech (TES), oesophageal speech (ES) and electrolarynx (EL). Using a large sample of participants from across the USA, this study investigated listener impressions of each primary type of alaryngeal communication. As these are the individuals more likely to be participating in social interactions and in positions of hiring for employment, the general public's impressions of TES, ES and EL may be a vital consideration during the treatment process.Method: A total of 381 individuals rated eight speech samples, including samples from speakers of each alaryngeal communication modality as well samples from age and sex matched laryngeal speakers, with regards to three outcome measures: intelligence, likability and employability.Result: Listener impressions of alaryngeal speech samples were modulated by the type of communication mode. Further, the patterns of results differed by speaker sex, with ES speech rated consistently more favourable for female speakers across all outcome measures and TES rated consistently more favourable for male speakers across all outcome measures.Conclusion: An overall preference for laryngeal speech was noted, particularly with male speakers. The female ES stimuli, interestingly, was the highest rated alaryngeal communication modality. Regardless of speaker sex, all alaryngeal modes greatly affected impressions of employability relative to impressions of likeability and intelligence.

The use of the Lombard Effect in Improving Alaryngeal Speech.

OBJECTIVE: The present study examined and compared the Lombard effect among laryngeal and alaryngeal speakers including esophageal, tracheoesophageal, pneumatic artificial laryngeal, electrolaryngeal speakers of Cantonese. The subsequent change in intelligibility was also examined. METHODS: A total of 52 native Cantonese-speaking laryngeal and alaryngeal speakers (10 laryngeal , 8 laryngeal , 13 electrolaryngeal , 11 esophageal, and 10 tracheoesophageal) participated in a reading task involving three 10-syllable Cantonese sentences under 10 background conditions: quiet, 60 dB, 65 dB, 70 dB, 75 dB, 80 dB, 85 dB, 90 dB, 95 dB, and 100 dB white background noise. Speech intelligibility associated with speaking conditions were evaluated by five naïve Cantonese speakers. RESULTS: Output intensity was significantly increased in all speaker types under all nine noisy background conditions when compared with the quiet condition. However, the amount of increase was different for different modes of phonation. In addition, significant difference in speech intelligibility between laryngeal and alaryngeal speakers was found at all conditions, but not among any alaryngeal speech. DISCUSSION AND CONCLUSION: The Lombard reflex is still present after total laryngectomy. Yet, different alaryngeal speech was associated with different amount of loudness change, and subsequent improvement in intelligibility was not observed.

Assessment of Factors Impacting Long-Term Utilization of Tracheoesophageal Speech Among Laryngectomees.

OBJECTIVE(S): To evaluate complication rate and abandonment rate after tracheoesophageal puncture and to assess factors associated with these outcome measures. METHODS: Retrospective review of laryngectomy patients seen at a single academic institution between 1/1/2003 and 12/1/2018. Charts reviewed for demographics, medical comorbidities, tumor characteristics, surgical data, adjuvant treatment history, and complications related to laryngectomy or tracheoesophageal puncture. Complications were divided into minor and major. RESULTS: A total of 293 laryngectomees met inclusion criteria. Of these, 69 patients (23.5%) underwent tracheoesophageal puncture. Average follow up was 64.6 months (SD 58.3). Overall laryngectomy complication rate was 43.3%. Overall tracheoesophageal puncture complication rate was 73.9%, with 39.1% of patients having major complications and 34.8% having minor complications only. Total abandonment rate for tracheoesophageal puncture was 34.8%. No associations were seen between tracheoesophageal puncture complication or abandonment rates based on age, gender, race, or insurance status. An increased rate of laryngectomy complications was seen after primary tracheoesophageal puncture (76.5% vs 41.3%, P = .005). CONCLUSION: Tracheoesophageal puncture outcomes were similar in patients with varied demographic, medical, and treatment backgrounds. When considering timing, our findings suggest that patients should be counseled on the possibility of increased complication risk after primary tracheoesophageal puncture. In those in whom the surgeon already has concerns about wound healing, it may be prudent to avoid primary tracheoesophageal puncture. The relatively high abandonment rate emphasizes the value of this measure of tracheoesophageal puncture outcome and highlights the need for appropriate patient counseling and prospective studies assessing the decision to abandon.