Page 37 - Prosthetic voice rehabilitation-5th edition

3.2.3 Secondary TEP and direct fit of the voice prosthesis The instruments needed for this procedure were besides the contents of the original Provox (1) package, i.e. the voice prosthesis (of a proper length), the guide wire and the scalpel, or in case the Provox2 device is used, a prosthesis with the proper length and a separately packed guide wire, a short rigid esophagoscope with a light source, the Provox trocar and cannula and 2 curved non-toothed hemostats (Figure right). Since the introduction of the fully disposable Provox Vega Puncture Set (PVPS; figure right), this Seldinger type instrument set has largely replaced the traditional Provox instruments, guide wire and hemostats. It should be kept in mind, though, that the pharynx protector in the PVPS is NOT used during secondary TEP, and can be discarded right away. Pharynx protection with the PVPS should be accomplished with the rigid esophagoscope, or another intraluminal tube/instrument. All secondary TEPs should be performed under peri-operative 24-hours broad- spectrum antibiotic prophylaxis. If carried out under general anesthesia, the laryngectomized patient is intubated. The short rigid esophagoscope is introduced and moved towards the tracheostoma (Figures right). In case of a stenosis, it might be helpful to introduce a thin nasogastric tube first, to facilitate the introduction of the scope and to guide the dilatation, which should be carried out first. When the tip of the esophagoscope reaches the tracheostoma, the scope is swiveled 1800, turning the oblique open side of the esophagoscope upwards. After proper oxygenation, often the ventilation tube can be removed for several minutes by the anesthetist, which gives a clear view into and open access to the tracheostoma. It also makes it somewhat easier to palpate the proper position of the scope with a finger. At this stage, selection of the proper size of the prosthesis should be made. The thickness of the tracheoesophageal party wall can also judged with the palpating finger on top of the esophagoscope or another intraluminal protection device. Four lengths of the Provox voice prostheses are available: 4.5, 6, 8 and 10 millimeters, with two additional lengths (12.5 and 15 mm) in case of Provox2. 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. In case the traditional Provox instruments are used, the trocar and cannula is then placed in the midline of the tracheoesophageal wall, 5-10 mm below the muco- cutaneous junction, and a TEP is created through a 37