Page 30 - Prosthetic voice rehabilitation-5th edition

3.1.2 Primary TEP and direct fit of the voice prosthesis At this stage of the surgical procedure the primary tracheoesophageal puncture (TEP) is carried out. No temporary stenting of the TEP tract is needed with the Provox system. First, the proper size of the voice prosthesis should be selected. For this reason, the thickness of the tracheoesophageal party wall should be judged with a palpating finger. The original Provox prosthesis is available in four lengths: 4.5, 6, 8, and 10 millimeters, the Provox2 device in two additional lengths, 12.5 and 15 mm. The Provox Vega prosthesis has 4, 6, 8, 10, 12.5, and 15 mm versions, and is not only in the 22.5 Fr version, we prefer, but also in these 6 lengths with a 20 Fr or a 17 Fr diameter. In most patients an 8 or 10-millimeter long voice prosthesis is appropriate. In case of doubt, the longer prosthesis should be used to allow for postoperative swelling and edema at the puncture site. Until recently, for performing the TEP the use of the special Provox Trocar and Cannula (Figures left) and Pharynx Protector (Figure middle) was recommended, but since the availability of the Provox Vega Puncture Set (Figure right), which enables a Seldinger dilation type of TEP and insertion procedure, this has become the preferred method/instrument. During the original TEP technique, the Pharynx Protector is placed through the open pharynx into the cervical esophagus and positioned just cranially of the tracheostoma. The Trocar and Cannula is recommended for the actual TEP. If this instrument is not available, a non-cutting sharp trocar is preferred over any cutting device, e.g. a scalpel, because this could result in an oval shaped TEP tract prone to peripheral leakage. The Trocar is placed in the midline of the trachea back wall 5-10 mm below the upper tracheal mucosa rim. The 5 mm diameter Trocar and Cannula is directed perpendicular towards the opening of the Pharynx Protector to create a straight tract in the tracheoesophageal party wall. Next the Trocar is removed, leaving the Cannula in situ. Thereafter, a special guide wire is passed through the Cannula into the pharynx, where the voice prosthesis is attached. With the help of the guide wire, the voice prosthesis is then pulled into the TEP tract and the tracheal flange is pulled and rotated in place into the trachea with the help of two hemostats. Finally the introduction string at the tracheal flange is cut off, and the voice prosthesis is rotated in its proper position with the oval side of the flange pointing downwards. The traditional primary TEP procedure is shown in the figures and video below. 30