Secondary voice prosthesis insertion in patients without direct access to the upper esophagus.

INTRODUCTION After total laryngectomy, voice rehabilitation can be achieved by use of voice prosthesis insertion (e.g., BlomSinger, InHealth Technologies, Carpinteria, CA; Provox, Atos Medical, H€orby, Sweden; Tracoe, Tracoe Medical, Frankfurt, Germany) or an esophageal voice or assistive digital speech device (e.g., Servox, Servox AG, Troisdorf, Germany). Various studies have shown that insertion of a voice prosthesis leads to superior rehabilitation results compared to other voice methods and has become the standard of care in many countries. However, insertion of a voice prosthesis requires tracheoesophageal puncture (TEP), which normally is performed during a laryngectomy procedure or secondarily as an elective procedure following adjuvant therapy. Primary TEP allows almost direct visualization of the proposed TEP site and protection of the posterior esophageal wall by a rigid pharyngoscope or by the pharynx protector (e.g., Provox Pharynx Protector; Atos Medical). In the case of secondary puncture, the use of rigid scopes to protect the posterior pharyngeal wall and verify the correct position of the prosthesis requires sufficient head reclination and mouth opening to ascertain adequate exposure of the upper esophagus and correct placement of the trocar. However, due to degenerative changes of the cervical spine, trismus, pharyngeal reconstruction (e.g., microvascular free tissue transfer), scar tissue formation in postirradiated patients, or most often a combination of these factors, the upper esophagus sometimes cannot directly be accessed by rigid instruments. Alternative techniques for secondary TEP include a special wire-guided TEP using a flexible scope, transnasal esophagoscopy with air insufflation, and a fiberoptic laryngoscope inserted in the cuffed part of an endotracheal tube for visualizing the puncture site. Even though these fiberoptic-guided methods allow access to the upper esophagus, and the puncture site can be directly visualized, safe TEP is compromised by the lack of a rigid abutment protecting the posterior esophagus wall, and in some cases air insufflation can lead to pneumomediastinum and mediastinitis due to accidental esophageal perforation. In our experience, sufficient protection of the posterior esophagus wall is one of the key factors in preventing possible TEP complications such as mediastinitis and sepsis. With regard to the few patients who do not qualify for secondary TEP using rigid optic control, we opted for a simple, inexpensive, and safe method to insert a voice prosthesis after laryngectomy.