Important considerations when choosing between primary and secondary tracheoesophageal puncture (TEP)

Patients and surgeons share common goals post-surgery that should guide the decision on primary and secondary tracheoesophageal puncture:

  • Allow early voice rehabilitation with positive psycho-social impact
  • Successful voice rehabilitation
  • Avoid second surgical procedure
  • Minimize complications and tissue trauma

Primary punctures allow for earlier voice rehabilitation

Patients who underwent primary puncture achieved fluent speech 62 days earlier than patients who underwent secondary puncture(1).

Primary punctures allow for successful voice rehabilitation

Clinical evidence shows overall success rates and voice outcomes were similar between primary and secondary TEP(2-6).

No difference in complication rates between primary and secondary punctures

Systematic review shows primary puncture is not associated with higher complication rates compared to secondary puncture. With primary placement no TEP catheter is needed, potentially minimizing tissue trauma(2-5).

No increased risk of pharyngocutaneous fistula with primary punctures

Clinical evidence shows no increased risk of developing pharyngocutaneous fistula with primary puncture compared to secondary or no puncture(7).

Watch the animation below to see a primary puncture of the TE wall during the procedure of a total laryngectomy, and the placement of a Provox Vega Voice Prosthesis with the Provox Vega Puncture Set (Instructional animation for clinicians).

Provox Vega Puncture Set- Primary Puncture and Prosthesis Placement

Always read the Instructions for use before starting to use any of the products. For Instructions for
use, please visit


1 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(3):386-90.
2 Luu K, Chang BA, Valenzuela D, Anderson D. Primary versus secondary tracheoesophageal puncture for voice rehabilitation in laryngectomy patients: A systematic review. Clin Otolaryngol. 2018.
3 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(7):1436-40.
4 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(4):262, 4-, 7.
5 Boscolo-Rizzo P, Maronato F, Marchiori C, Gava A, Da Mosto MC. Long-term quality of life after total laryngectomy and postoperative radiotherapy versus concurrent chemoradiotherapy for laryngeal preservation. Laryngoscope. 2008;118(2):300-6.
6 Iype EM, Janardhanan D, Patil S, Suresh S, Varghese BT, Thomas S. Voice Rehabilitation After Laryngectomy: A Regional Cancer Centre Experience and Review of Literature. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2020;72(4):518-23.
7 Lansaat L, van der Noort V, Bernard SE, Eerenstein SEJ, Plaat BEC, Langeveld T, et al. Predictive factors for pharyngocutaneous fistulization after total laryngectomy: a Dutch Head and Neck Society audit. Eur Arch Otorhinolaryngol. 2018;275(3):783-94