Secondary voice prosthesis insertion in patients without direct access to the upper esophagus

Abstract

After total laryngectomy, voice rehabilitation can be achieved by use of voice prosthesis insertion (e.g. Blom-Singer®, Inhealth Technologies, USA; Provox®, Atos Medical, Sweden; Tracoe®, Tracoe Medical, Germany), esophageal voice or assistive digital speech device (e.g. Servox®, Servox AG, Germany). Various studies have shown that insertion of a voice prosthesis leads to superior rehabilitation results compared to other voice methods 1,2 and has become standard of care in many countries. However, insertion of voice prosthesis requires tracheo-esophageal puncture (TEP) which normally is performed during laryngectomy procedure or secondarily as an elective procedure following adjuvant therapy. Primary TEP allows almost direct visualization of the proposed TEP site and protection of the posterior esophageal wall by a rigid pharyngoscope or by the therefore introduced pharynxprotector (e.g. Provox Pharynx Protector®, Atos Medical, Sweden) In case of secondary puncture, the use of rigid scopes to protect the posterior pharyngeal wall and verify correct position of the prosthesis requires sufficient head reclination and mouth opening to ascertain adequate exposure of the upper esophagus and correct placement of the trocar. However, due to degenerative changes of the cervical spine, trismus, pharyngeal reconstruction (e.g. microvascular free tissue transfer), scar tissue formation in postirradiated patients or most often a combination of these factors, the upper esophagus sometimes cannot directly be accessed by rigid instruments. Alternative techniques for secondary TEP comprehend a special wire-guided TEP using a flexible scope 3, transnasal esophagoscopy with air insufflation 4 and a fiberoptic laryngoscope inserted in the cuffed part of an endotracheal tube for visualizing the puncture site 5. Even though these fiberoptic guided methods allow access to the upper esophagus and the puncture site can be directly visualized, safe TEP is compromised by the lack of a rigid abutment protecting the posterior esophagus wall and in some cases, air insufflation can lead to pneumomediastinum and mediastinitis due to a created “via falsa”. In our experience sufficient protection of the posterior esophagus wall is one of the key factors in preventing from possible TEP-complications, such as mediastinitis and sepsis 6. With regard to these few patients, who don’t qualify for secondary TEP by using rigid optic control, we opted for a simple, cheap and safe method to insert voice prosthesis after laryngectomy.