Tracheoesophageal Puncture Periprocedural Care

Patient instructions

Educating the patient on expectations of voice following tracheoesophageal puncture (TEP), as well as the need for speech therapy and long-term maintenance of the valve, is important. Speech therapy to develop coherent and understandable speech is necessary and should be planned prior to the procedure. ^{[4, 7]}  As described, maintenance of the valve, and methods for improving the life of the valve and the puncture site are also important parts of education and patient selection. The patient must also be counseled on what to do if the prosthesis comes out for an extended period of time, to prevent closure of the TEP.

Elements of informed consent

The informed consent for this procedure varies by physician but should make mention of the risk of infection, valve incompetence or leakage around the valve, poor speech outcome, need for further procedures including revision of the puncture site, stenosis or closure of the TEP site, and migration of the valve.

Depending on whether a primary or secondary tracheoesophageal puncture (TEP) is being performed, different equipment is necessary.

For a primary TEP, the instruments required for the total laryngectomy also suffice for the TEP. Specifically this includes the following:

• Right-angle clamp

• No. 15 blade

If the prosthesis is going to be placed at the time of puncture (primary placement), the prosthesis itself and any prosthesis-specific equipment is also necessary. Otherwise a catheter (red rubber or Foley) is used to stent the puncture until prosthesis placement at a later time in the office setting (secondary placement).

For a secondary TEP, the equipment necessary depends on the specific prosthesis device used.

Under general anesthesia the following equipment is used:

• Cervical esophagoscope

• No. 18 gauge needle

• Dilating catheter with guidewire

If this is performed under local anesthesia, various kits are available to assist with placement. Generally speaking, the items needed include the following:

• Inserting needle/trochar

• Dilating catheters/tubes

Again, whether in the office or the operating room, if the prosthesis is not going to be placed at the time of puncture, a catheter should be used to stent the puncture site until prosthesis placement.

Patient-maintained prostheses

Patient-maintained prostheses come in two types, duckbill and low-pressure, both based on the original Blom-Singer valve. These valves are designed to be removed and cleaned or replaced by the patient every 3-4 days. The duckbill prosthesis has the advantage of being a longer-lasting valve than the low-pressure prosthesis but requires more respiratory effort due to increased airway resistance.

Indwelling prostheses

Indwelling prostheses are placed by the clinician at the time of tracheoesophageal puncture (TEP) or in-office replacement, and can stay in place for years if properly maintained. They allow for patients with less manual dexterity to have prostheses, so long as they are able to clean the prosthesis with flushing.

Management of complications

Complication management in TEP requires good and prompt communication between the laryngectomy patient and the clinician, either a physician or speech pathologist. Aspiration of the prosthesis is a medical emergency, and should be treated as such, with prompt presentation to the emergency department and management to include retrieval of the foreign body in the airway.

Displacement of the prosthesis without aspiration is also a time sensitive complication, as the puncture site has the ability to close quickly. Prompt presentation to the clinician is important. If already narrowed, a smaller soft catheter may be able to be placed through puncture to prevent complete stenosis, with immediate or delayed dilation back to appropriate size for TEP prosthesis placement. The largest sized catheter that can fit comfortably through the puncture should be used. Additionally, the external portion of the catheter should be secured to the patient's neck to prevent the patient from aspirating the catheter. The catheter can also be used for feeding without worrying about aspiration.

Placement of a new prosthesis is then indicated if desired, with resizing. A prosthesis may also need to be resized if leakage occurs due to an improperly sized prosthesis or enlargement of the TEP. ^[21] Mechanical failure of the valve due to blockage from secretions or fungal growth, or simple wear from use, may require placement of a new valve. ^[20]

Closure of the TEP, either primarily through ligation of the tract, or secondarily, through removal of the prosthesis with subsequent stenosis, is an option. This usually occurs when a patient is unhappy with the TEP or when there are complications best managed by allowing the TEP to close and be performed again at a later date. Chone et al describes that some patients in their study elected for removal of the voice prosthesis after establishing esophageal speech. ^[17]

Stenosis of the TEP may be treated with dilation or surgical opening, including repuncture. Stenosis of the neopharynx or esophagus may also be treated with dilation, as well as cricopharyngeal myotomy, if the stenosis is due to muscular spasm or hypertrophy. Granulation around the site should be treated with resection of the granulation tissue, which can be performed with silver nitrate cautery. Additionally, pathologic evaluation of this tissue may be necessary to rule out recurrence of the primary tumor.

Patients should be educated on how a TEP prosthesis works as well as associated costs. In the United States, most insurers do not cover the complete cost of a TEP prosthesis and as such, patients should be aware of the potential for out-of-pocket costs prior to the procedure. Given the need for routine replacement of these devices, patients should understand the potential annual "maintainence" cost associated with a TEP prosthesis.

No specific physician monitoring or follow-up is necessary, however, it is important that the patient is sufficiently educated regarding the care and maintainence of the TEP prosthesis (including daily cleaning).

The patient should follow up with a speech-language pathologist (SLP) who has specific experience and training with TEP prostheses and TEP speech. Their expertise is important to rehabilitating these patients and optimizing speech outcomes with TEP speech. This may involve discussing breathing and relaxation exercises to avoid excess tension with speech.

Additional follow up with the physician or SLP may be necessary to manage prosthesis replacement and troubleshooting if there are concerns for leak or fungal colonization.