Page 84 - Prosthetic voice rehabilitation-5th edition

5.4.3 Other TEP-tract issues 5.4.3.1 VP replacement with hemorrhage Slight hemorrhage from the edges of the TEP tract may occur during replacement of the VP. This is the result of removal of the old device when some granulations are present and not caused by the insertion of the new VP. This hemorrhage will normally cease spontaneously with the insertion of the new VP. Patients undergoing anticoagulant therapy should be carefully evaluated for the risk of hemorrhage prior to placement or replacement of the VP. It is also advisable to reassure the patient that the traces of blood they might notice in the sputum in the first few days after replacement of the VP are not worrisome and no sign of a pulmonary malignancy. Obviously, if they keep seeing these traces of blood they should be stimulated to make an earlier clinic appointment in order to establish whether further examination is needed. 5.4.3.2 VP missing 5.4.3.2.1 VP ingested? Accidental ingestion of a VP may occur. This is, not surprisingly, more frequently seen with non-indwelling VPs, because of their retention is much lower than that of the indwelling VPs with their much sturdier flanges.101 It should also be noted that, in case of dislodgment of an indwelling Provox prosthesis, the likelihood of VP ingestion is higher than that of aspiration, because the esophageal flange is sturdier than the tracheal flange. Possible causes can be a local infection of the TEP tract or the constant pressure of a trachea cannula onto the VP, causing gradual overgrowth of tracheal mucosa. The animation to the left shows a possible course of events. In case of disappearance of the VP, it should be verified whether the device is indeed ingested and not just is hidden under the mucosa. As with any other foreign body, the symptoms caused by ingestion depend largely on the size, location, degree of obstruction (if any), and the length of time it has been present. The ingested component in the lower esophagus may be removed through esophagoscopy or observed for a short period of time. The object may pass spontaneously into the stomach, and as most foreign bodies usually do, pass the intestinal tract. Surgical removal of foreign bodies in the intestinal tract must be considered if bowel obstruction occurs, bleeding is present, perforation occurs, or if the object fails to pass through the intestinal tract. In case a reinsertion of the VP is considered, proper measures should be taken to avoid reoccurrence of the ingestion (see Periprosthetic leakage, chapter 5.4.1). 101. Hancock K, Houghton B, van As-Brooks CJ, Coman W. First clinical experience with a new non-indwelling voice prosthesis (Provox NID) for voice rehabilitation after total laryngectomy. Acta Otolaryngol 2005; 125:981-990. 84