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• W2009223932 abstract "The tracheoesophageal puncture technique for voice restoration described by Singer and Blom 1. remains the optimal means of voice rehabilitation after total laryngectomy. Since the initial description, numerous prosthesis types have been introduced. 2.-5. With the initial Blom-Singer prosthesis technique, the method for prosthesis placement and replacement was based on an antegrade approach; the prosthesis was placed into the puncture site from the tracheal side to the esophageal side. This allowed for the necessary maintenance and prosthesis changes required with the earlier designs. Subsequent prosthetic designs, such as the Groningen 4. and the initial Provox 5. prostheses, required placement and replacement of the specific prosthesis to be completed in a retrograde fashion. With this method, the prosthesis is pulled from the esophageal side through to the tracheal side and then secured. This retrograde technique was found to be safe and effective but often associated with patient discomfort. Also, specialized instrumentation was required to allow successful placement. These prostheses required the retrograde approach to secure proper positioning of the flanges, which are larger than those on the original Blom-Singer prosthesis. The most recent modification of the Blom-Singer prosthesis, the indwelling prosthesis, 6. has larger flanges than the original and is designed to remain in place for longer periods. Again, it relies on antegrade placement of the prosthesis using a Gel-Cap technique. Occasionally, prosthesis placement in the standard antegrade fashion may not be achievable because of a variety of factors: a tortuous tract, disadvantageous placement of the puncture site in stoma, or the inserting device being held up by the posterior esophageal wall or spine. We describe a technique of retrograde placement of the Blom-Singer indwelling prosthesis for challenging cases. The stoma is thoroughly cleaned and anesthetized with topical 4% lidocaine spray. This is also applied to the oropharynx. The puncture tract is inspected for patency and assessment of its trajectory and depth. Because accurate sizing for the prosthesis can be limited by the same factors that limit antegrade placement, the choice of prosthesis size is estimated based on the patient's anatomy and history of previous prosthesis size, if one exists. Oversizing is favorable, because placement can be secured and optimal size can be determined by measurement of the excess prosthesis on the tracheal side. Patency of the tract is always assessed with a trial of open tract phonation. After failure of the standard replacement attempts, a dilator or soft rubber stenting catheter is placed through the tract. This is removed and a No. 12 French red rubber catheter is placed through the tract and oriented in a cephalad direction. The catheter is passed superiorly until it is seen within the mouth. The catheter is grasped with a clamp and pulled through the mouth. The tab on the external flange of the prosthesis is sutured to the tip of the catheter with a 2-0 silk suture (Fig. 1). The catheter is pulled back through the puncture site until the tab exits through the puncture site. The suture is released, and the prosthesis is grasped with a hemostat (Fig. 1). The prosthesis is further advanced from the esophageal side to the tracheal side in a careful manner until the external flange snaps into place on the trachea side. Retrograde placement of the indwelling prosthesis. The prosthesis, which is attached to a rubber catheter, is pulled through the puncture site. The pull-through is aided by grasping the flange with an instrument. Once placement is secured, the flange is trimmed. Optimal placement can be assessed by examining the lumen of the prosthesis for proper orientation, by fiberoptic nasopharyngoscopy, and by trial of phonation. The tab is trimmed when placement is verified (Fig. 1). When there is difficulty directing the red rubber catheter in a superior direction secondary to orientation of the puncture tract, a Coude urinary catheter may be used, orienting the angled tip superiorly. We have used this technique on 25 occasions when standard placement of the indwelling prosthesis was not possible. Choice to use the indwelling prosthesis was made on an individual basis with considerations of factors such as airflow requirements, a patient's inability to maintain routine care of a standard prosthesis because of visual, physical, or social limitations, or a desire by the patient to have a longer-lasting prosthesis. All retrograde placements were successful, and no complications were encountered. Optimal placement of a voice restoration prosthesis is essential to successful rehabilitation. Prosthesis replacement should not only be atraumatic and tolerable to the patient, but should also maintain the integrity of the puncture tract with secure placement of the prosthesis. The antegrade method originally described by Singer and Blom 1. has been well tolerated by patients in large clinical experiences with surgical voice restoration. Some prostheses, such as the Provox 1, which were originally placed in a retrograde manner, have been modified to be placed in antegrade fashion. Still, clinical situations do arise that make antegrade placement difficult, if not impossible. We have found this a rare but vexing problem. Rather than proceeding with further unsuccessful and traumatic placement attempts or allowing the tracheoesophageal tract to close, requiring subsequent repuncture, an alternative method of prosthesis placement is desirable. Such a method should be safe, should not involve specialized or unattainable materials, and should be easily mastered by caregivers participating in voice rehabilitation after laryngectomy. We have found the retrograde technique described above to fulfill all of these criteria. This technique involves the use of no further incisions or invasive maneuvers. The added materials required to achieve retrograde placement consist only of a hemostat, an appropriate catheter, and a silk suture. Likewise, the technique is straightforward and has the potential to be used by most practitioners familiar with tracheoesophageal prosthesis placement. Granted, retrograde placement of the indwelling voice prosthesis is slightly more difficult for the patient than traditional antegrade placement. When this is balanced against potential loss of the tracheoesophageal tract and subsequent loss of voice, retrograde placement is a safe and favorable option." @default.
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• W2009223932 modified "2023-09-27" @default.
• W2009223932 title "Outpatient Retrograde Placement of the Indwelling Voice Prosthesis" @default.
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