Objectives/Hypothesis Tracheoesophageal puncture (TEP) can be performed at the time of laryngectomy (primary) or postoperatively (secondary). Prior studies demonstrate safe and earlier voice acquisition and rehabilitation with primary TEP. The objectives of this study were to assess national trends in primary TEP and identify factors associated with its use. Study Design Retrospective review. Methods Retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2010 to 2014 was performed. The NIS was queried for patients who underwent total laryngectomy (TL) (International Classification of Diseases, Ninth Revision, Clinical Modification ICD‐9‐CM 30.3–30.4) and primary TEP (ICD‐9‐CM 31.95). Patient demographics, comorbidities, and factors known to influence the decision to perform TEP were characterized. Factors associated with primary TEP were identified by multivariable regression. Results A total of 15,410 patients underwent TL during the study period. Of this cohort, 1,124 patients (7.3%) underwent primary TEP. Among patients who underwent primary TEP, 80.9% had laryngeal cancer, 16.4% had pedicled or free‐flap reconstruction at the time of TL, 4.2% underwent partial pharyngectomy, and 48.0% underwent cricopharyngeal myotomy (CPM). The majority of primary TEPs were performed at urban teaching hospitals (90.6%). In multivariable regression, patients who underwent CPM were at significantly increased odds of primary TEP (odds ratio: 3.79, P < .0001). Flap reconstruction, partial pharyngectomy, age, gender, history of laryngeal cancer, hospital region, and teaching status were not associated. Conclusions Primary TEP is associated with earlier voice restoration after TL but is infrequently performed. The majority of primary TEPs are performed in teaching hospitals, and primary TEP is associated with concurrent cricopharyngeal myotomy. Future studies should investigate practice patterns associated with primary TEP. Level of Evidence 4. Laryngoscope, 128:2320–2325, 2018