Page 82 - Prosthetic voice rehabilitation-5th edition

5.4.2.1.4 Difficult anterograde VP insertion In case anterograde insertion is difficult due to local infection, it is advisable is to first dilate the TEP tract with a properly sized dilator (to the right an example). After 5-10 minutes insertion will be easier and overshooting the VP into the esophageal lumen and pulling it back into the right position with the help of two hemostats will be possible in most instances. 5.4.2.2 Tissue interfering with VP 5.4.2.2.1 Granulation tissue Granulation tissue around the TEP tract has been reported at a rate of approximately 5%.2 Mostly this is seen in conjunction with a local infection and treatment of such an infection will result in spontaneous disappearance of the granulation, as shown above. However, it also can be a sign of reflux, as already mentioned repeatedly.79,83,84 It is sometimes advisable to (temporarily) put in a longer prosthesis. If this is not the case or if immediate treatment is required in order to improve the voice, some sort of cauterization (electro-, chemo-, laser) of the granulation may be considered. In conjunction with this, treatment with a broad-spectrum antibiotic is advisable. The figures to the right give an example of this: above prior to NdYAG laser excision, below the situation 2 weeks later. It is also advisable to treat possible reflux with properly dosed PPIs twice daily. 2. Op de Coul BM, Hilgers FJ, Balm AJ, Tan IB, van den Hoogen FJ, van TH. A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single Institution's experience with consistent application of provox indwelling voice prostheses. Arch Otolaryngol Head Neck Surg 2000; 126:1320-1328. 79. Lorenz KJ, Grieser L, Ehrhart T, Maier H. Role of reflux in tracheoesophageal fistula problems after laryngectomy. Ann Otol Rhinol Laryngol 2010; 119:719-728. 83. Boscolo-Rizzo P, Marchiori C, Gava A, Da Mosto MC. The impact of radiotherapy and GERD on in situ lifetime of indwelling voice prostheses. Eur Arch Otorhinolaryngol 2008; 265:791-796. 84. Pattani KM, Morgan M, Nathan CA. Reflux as a cause of tracheoesophageal puncture failure. Laryngoscope 2009; 119:121-125. 82