Page 46 - Prosthetic voice rehabilitation-5th edition

3.4 TEPtractclosure 3.4.1 Indications Closure of the TEP tract can be indicated when there are problems such as widening of the tract causing periprosthetic leakage, not responding to conservative measures (e.g. use of a voice prosthesis with an extended esophageal flange, such as the Provox Vega XtraSeal, and/or use of an additional flange at the tracheal side, such as the Provox XtraFlange, or temporary removal of the device). Also a prolapse and/or infection of the TEP tract, spontaneous extrusion of the prosthesis, postoperative wound infection problems around the stoma, severe hypopharyngeal stenosis or a too low or high position of the TEP can be indications for TEP tract closure. If the TEP tract exists longer than 6 months surgical closure is mostly needed. If the TEP is present less than 6 months or in patients with spontaneous extrusion of the prosthesis or infection of the tract, spontaneous closure can be expected. 3.4.2 Surgical technique The aim of the surgical procedure is to close the TEP tract in layers and to strengthen the posterior tracheal party wall. If the stoma needs revision, this can be accomplished at the same time (see the following chapter on stoma revision). The figure right is showing a case of a hypertrophic, too low situated TEP tract, which caused persistent leakage around the prosthesis. An incision is made horizontally on either side of the stoma, and curved posterior to encompass the posterior line of the stoma and a superiorly based skin and platysma flap is created (figure below left). The figure below right shows the posterior tracheal wall is dissected away from the esophagus, revealing the TEP tract. The TEP tract is then completely dissected free to enable a hemostat being passed underneath (figure below left). The tract is opened and cut completely (figure below right). 46