Long-term problems in patients with tracheoesophageal puncture

The Dynamic Tracheoesophageal Prosthesis Length

OBJECTIVE

In a postlaryngectomy patient, tracheoesophageal (TE) speech is considered to be the most effective and preferred method of communication. Previous research has demonstrated that despite an appropriately sized TE prosthesis placement at the time of puncture, there are a portion of patients that require resizing postoperatively. The purpose of this study was to report on the variability of the tracheoesophageal prosthesis length.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care academic medical center.

METHODS

This was a retrospective chart review of 62 patients who underwent secondary tracheoesophageal puncture (TEP) at a tertiary care academic medical center from January 2008 to November 2019. Patient demographic information, average changes in prosthesis length, number of prosthesis adjustments, and timing of prosthesis exchanges were collected.

RESULTS

62 patients met criteria for study inclusion. Mean age was 61.96 years old with 49 being male (79%) and 13 (21%) females. Overall change in prosthesis length was - 3.85 mm ± 3.58 with time to first prosthesis change at 2.29 months ± 2.73. There was an average of 4.37 changes ± 3.43 before reaching a stable length. Twenty-six patients (41.9%) had increases in their prosthesis length resulting in closure of the tracheoesophageal fistula requiring seven patients (11.3%) to return to the operating room for repuncturing. History of smoking (P = 0.02), Blom-Singer prosthesis type (P = 0.03), and larger diameter (P = 0.01) appeared to be predisposing factors for a fluctuating prosthesis length.

CONCLUSION

Tracheoesophageal prosthesis length decreases over time for secondary punctures, requiring adjustments with a speech language pathologist. There are a clinically significant portion that have fluctuations in prosthesis length resulting in an increased risk for requiring re-puncturing.

Indications and complications of secondary tracheoesophageal puncture in Chinese laryngectomees

BACKGROUND

Although there are many literatures about secondary tracheoesophageal puncture (TEP) for voice prosthesis. Most of the description of indications is not specific and the description of complications is not so vivid, which is not of great value for novice doctors.

OBJECTIVE

To show specific indications and vivid complications of secondary TEP with typical clinical pictures for novice doctors.

MATERIAL AND METHODS

The clinical data of 20 patients undergoing secondary TEP for Provox Vega voice prosthesis in our hospital were analyzed. The surgical indications and the prevention and treatment of common perioperative complications were summarized.

RESULTS

The surgical indications included: no obvious stenosis of the stoma and the entrance of esophagus; no obvious scar constitution, mouth opening restriction and backward restraint of the neck, etc. The common postoperative complications included: TEP fistula infection (2 cases), bleeding of the fistula (1 case), deep neck abscess (1 case), granulation hyperplasia at the inner side of the fistula (1 case), invagination of the voice prosthesis (2 cases) and leakage (2 cases).

CONCLUSIONS AND SIGNIFICANCE

The secondary TEP for Provox Vega voice prosthesis is clinically safe, but certain indications should be mastered. Common postoperative complications can be solved through preventive and remedial treatment schemes.

Factors influencing the longevity and replacement frequency of Provox voice prostheses

INTRODUCTION

This study aimed to assess the factors that influence the longevity and replacement frequency of Provox voice prostheses following their placement.

METHODS

The medical records of 27 patients who received Provox voice prostheses after total laryngectomy and attended follow-up regularly between 1998 and 2012 were retrospectively reviewed. The success rate of the Provox voice prostheses (i.e. whether speech was achieved), quality of speech achieved, number and type of complications encountered, frequency of prostheses replacement and reasons for prostheses replacements were evaluated.

RESULTS

All 27 patients were men and their mean age was 63.0 (range 43-78) years. The mean follow-up period was 60.3 (range 1-168) months. Fluent and understandable speech was achieved in 85.0% of the patients. The mean duration before prosthesis replacement had to be performed was 17.1 (range 1-36) months. The most frequent complication was fluid leakage through the prosthesis. There was a strong positive correlation of 77.1% between the longevity of prostheses and postoperative follow-up duration (r = 0.771; p < 0.01).

CONCLUSION

The voice prosthesis is a tool that can be delivered in a practical fashion and replaced easily with no serious complications. It is a means by which speech can be restored, with a high success rate, after total laryngectomy. In the present study, we found that postoperative follow-up duration was the most important factor influencing the longevity of the Provox voice prosthesis.

Role of Computed Tomography and Bronchoscopy in Speech Prosthesis Aspiration

Tracheoesophageal puncture prostheses (TEPPs) are an integral aspect of speech rehabilitation for many patients who have undergone total laryngectomy. Because one flange of the prosthesis sits in the trachea and the other in the esophagus, these devices can be aspirated or swallowed if dislodged. Five cases of prosthesis aspiration that occurred in 4 veterans within a 16-month period are described. The 5 aspirated TEPPs resulted in highly variable clinical presentations ranging from complaints of “lost” TEPPs in asymptomatic patients to near-asphyxiation. Furthermore, the aspirated TEPPs were not reliably demonstrated on chest radiographs, often leading to delayed diagnosis. Aspiration of TEPPs may be more common than formerly recognized, and chest computed tomography or bronchoscopy is indicated in cases of missing TEPPs not demonstrated on plain films.

Longitudinal Tracheoesophageal Puncture Size Stability

Objective

The purpose of this study is to investigate prosthesis size stability over time and determine which factors influence need for change in size.

Study Design

Retrospective chart review.

Setting

Teaching hospital.

Subjects and Methods

Retrospective chart review was performed on all individuals who had previously undergone total laryngectomy and tracheoesophageal puncture and had a minimum of 3 years of consistent and consecutive follow-up data after their prosthesis was initially placed. Data reviewed included demographic variables of age at time of tracheoesophageal puncture, ethnicity, and sex.

Results

Fifty patients were identified who met criteria for study inclusion with a mean age of 64.7 years (range, 43-86 years) with 41 (82%) men and 9 (18%) women. Surgical management was equally divided between those who underwent total laryngectomy (n = 25) as primary treatment vs those who had salvage laryngectomy (n = 25) for persistent or recurrent disease. Prosthesis size was stable, with no change in diameter or length, in only 5 (10%) patients and unstable in 45 (90%), as they were changed at least once. The only factor that demonstrated statistical significance was sex (Fisher exact test = 0.035), with women being more likely to have a stable prosthesis size over time.

Conclusions

The results of this study demonstrate that 90% of patients who underwent total laryngectomy and tracheoesophageal puncture required a change in their prosthesis size beyond the first 3 months of expected healing. These results support the need for continual reassessment of the fistula tract when changing the prosthesis to ensure appropriate fit.

Autologous fat injection to treat leakage around tracheoesophageal puncture

PURPOSE

To evaluate prospectively autologous fat injection as a treatment for leakage around tracheoesophageal puncture.

PATIENTS AND METHODS

For ten patients who exhibited leakage of saliva or liquid around their tracheoesophageal puncture, autologous fat injection was carried out into the tracheoesophageal wall around the maintained prosthesis. Short-term success was evaluated at one month, and long-term follow-up was continued as long as the patients remained alive. The effectiveness of the procedure was evaluated based on the presence or absence of leakage around the puncture as the patient swallowed methylene blue liquid. Patients were adjudged completely improved when no leakage of blue liquid was observed, partially improved when a slight stasis was evident, or unimproved when a marked leakage of blue liquid was noted.

RESULTS

Short-term success was achieved for 6 patients, 2 patients partially improved, and the procedure failed for 2 others. Long-term success (from 10 to 65 months) was achieved in all 4 of the completely improved patients who were free of disease, including 1 patient who required an additional injection. Removal of the puncture was later carried out in the 2 others for cervical node metastases or tracheal tumor. Definitive or transitional puncture closure or removal of the prosthesis was required in 3 partially or unimproved patients, whereas 1 partially improved patient died of lung metastasis 3 months later.

CONCLUSIONS

Fat injection around a voice prosthesis is a procedure that may be conducted as an alternative to other conservative techniques to decrease the size of the puncture. Close endoscopic observation is required however to eliminate secondary tumor that might expand the size of the puncture.

Voice restoration after laryngectomy: experience with the Blom-Singer extended-wear indwelling tracheoesophageal voice prosthesis

BACKGROUND

The Blom-Singer tracheoesophageal voice prosthesis has undergone continuous design modifications during the last 18 years to make it more effective, anatomically compatible, and easier to use. This evolution continues with the recent introduction of an indwelling-style voice prosthesis intended for use by individuals who are unable or disinclined to use a self-removable-style voice prosthesis. The a priori self-lifespan goal of the indwelling prosthesis was 180 days.

METHODS

The present investigation describes the experience of 81 consecutive participants who used a total of 206 indwelling voice prosthesis. Selection criteria included total laryngectomy and either primary (n = 35) or secondary (n = 46) tracheoesophageal puncture. All participants had external-beam radiotherapy either pre- or postlaryngectomy. Specifically, lifespan of the prosthesis, the effects and clinical management of fungal colonization, and participant satisfaction with this style prosthesis were studied.

RESULTS

A prosthesis use rate of 90% was observed. Group 1 prostheses (without fungal colonization and without Nystatin therapy) exhibited a lifespan significantly longer than did group 2 prostheses (with fungal colonization and prior to Nystatin therapy) (sample mean [mean] = 185.6 days versus 80.6 days; p < .05). Group 3 prostheses (following Nystatin therapy) also exhibited a lifespan significantly longer than that of group 2 prostheses (mean = 156.1 days versus 80.6 days; p < .05). Lifespans of group 1 and group 3 prostheses were not significantly different (p < .05).

CONCLUSIONS

The extended-wear, indwelling voice prosthesis achieved its a priori lifespan goal of 180 days (6 months) with almost uniform patient preference and without risk of increased complications. When fungal colonization was present. Nystatin therapy significantly prolonged prosthesis lifespan.

In situ lifetime, causes for replacement, and complications of the Provox voice prosthesis

One hundred Provox voice prostheses consecutively inserted in 37 patients and replaced only when phonation was impaired or complications noted were analyzed for in situ lifetime, causes for replacement, and complications. The mean in situ lifetime was 311 days. Actuarial analysis (Kaplan-Meier method) of the in situ lifetime revealed that 65.9%, 23.7%, and 16.4% of the voice prosthesis were still in situ by the 6th, 12th, and 18th postinsertion month. Cause for replacement was salivary leakage through the prosthesis valve, salivary leakage around the prosthesis, deterioration of the prosthesis, and excessive crusting resulting in increased airflow resistance in 33%, 27%, 24%, and 16% of cases, respectively. Complications included granulation tissue formation, cervical cellulitis, necrosis of the tracheoesophageal puncture, tracheostomal stenosis, and swallowing impairment in six, two, one, three, and one patient, respectively.

Prosthetic voice restoration with the tracheostomal valve: a clinical experience

INTRODUCTION

Tracheoesophageal puncture (TEP) and use of a voice prosthesis is not a panacea for all laryngectomies. This report presents results of longitudinal treatment of 24 patients with secondary TEP followed longitudinally for 10 years in a private practice setting. Unique to this report is a focus on the use of the entire voice restoration system including both the voice prosthesis and the automatic tracheostomal valve.

METHODS

All patients referred for secondary TEP between 1982 and 1992 are included. Voice quality and the longevity of vocal restoration were ascertained. Clinical problems and their solutions are reported.

RESULTS

Immediate vocal restitution was achieved in 19 of 24 patients. Voicing was produced in two more patients within a few weeks. Four patients were not available for long-term follow-up because of death due to recurrent disease. Overall, 60% of patients were rated excellent and 5% rated fair in communication over a long-term period. Thirty-five percent were rated failure.

DISCUSSION

TEP and the use of the voice restoration system enabled both hands to be free during speaking and is achieved by many laryngectomies. Patient evaluation, training, and follow-up with team problem-solving may increase success rates using this approach.