Page 80 - Prosthetic voice rehabilitation-5th edition

5.4.2 TEP tract infection/hypertrophy 5.4.2.1 Local infection 5.4.2.1.1 VP still OK Redness and tenderness of the TEP tract around the VP are signs of local infection. In most cases there is also edema and granulation tissue formation. However, if these latter symptoms are not occurring, and the prosthesis still seems of the right length and functions properly, treatment with broad-spectrum antibiotics with or without corticosteroids can be sufficient to control this infection. An example of such an infection can be seen in the top figure, with the result of antibiotic treatment after 2 weeks in the lower figure. However it is of utmost importance to verify that the prosthesis really is of the right length, since undue pressure of the prosthesis onto the mucosa of the party wall will further increase the edema. Upsizing of the prosthesis is then required. 5.4.2.1.2 VP displaced In most cases of infection around the VP, granulation formation and/or edema will occur to the extent that the TEP tract becomes longer. As a result, the device may be drawn inwards and disappear under the tracheal mucosa, or conversely, it may be pushed out of the TEP tract due to overgrowth of the mucosa on the esophageal side. This last phenomenon is schematically shown in the animation to the right. The patient notices such an infection by a slightly increased effort in voicing. The figure shows an example of such a case of excess tissue formation on the esophageal side, which prolapsed slightly after removal of the prosthesis. A pseudo-diverticulum, also called esophageal pouch, is the result. This should not be considered a separation of the party wall, as sometimes is assumed. Replacement of the VP with a longer version is then advisable. Keep in mind that the VP should be overshot in order to ensure that the esophageal flange is properly placed in the esophagus and that the excess tissue is encompassed between both flanges. Treatment with broad-spectrum antibiotics with or without corticosteroids is often adequate to control this infection. And, obviously, reflux treatment should be started forthwith.99 If the infection is not cured by this treatment with the VP in situ, the device should be removed and further healing should be awaited. If by this process the TEP tract closes spontaneously, secondary re-puncture for insertion of a new VP may be required (see Surgery chapter 3.2 Secondary prosthetic voice rehabilitation). 80