The development and treatment of periprosthetic leakage after prosthetic voice restoration: a literature review and personal experience. Part II: conservative and surgical management

Abstract

In the past 30 years, the use of voice prostheses has become the gold standard for voice rehabilitation after total laryngectomy. The placement of a voice prosthesis is a simple procedure that is associated with only a minor increase in operating time and a low rate of complications. Most problems with voice prostheses are minor and can be easily managed. Enlargement of the tracheo-oesophageal fistula, however, can be a severe complication. Approximately 25 % of all patients with voice prostheses develop periprosthetic leakage with aspiration within 1-4 years after the placement of a voice prosthesis. Depending on the severity of fistula enlargement, treatment ranges from conservative approaches to maximally invasive procedures. In some cases, however, these measures prove unsuccessful. The causes of treatment failure and fistula enlargement are not yet fully understood. Apart from a discussion of treatment options, an algorithm for the management of this complication is presented on the basis of the literature and the experience that we have accumulated at our institution during the past 20 years in the treatment of 232 laryngectomised patients.

GERD und adjuvante Radiochemotherapie prädisponieren für rezidivierende Stimmprotheseninsuffizienz

“…Bei einer geringen Zunahme des Shuntdurchmessers kann in manchen Fällen die Versorgung mittels einer Silikon-Unterlegscheibe [16] oder einer Prothese mit einem größeren Flansch [17] erfolgen. Sollte sich die periprothetische Leckage mit diesen Maßnahmen nicht beherrschen lassen, empfiehlt es sich, zunächst die spontane Schrumpfung des Stimmprothesenlagers abzuwarten.…”

“…Sollte sich die periprothetische Leckage mit diesen Maßnahmen nicht beherrschen lassen, empfiehlt es sich, zunächst die spontane Schrumpfung des Stimmprothesenlagers abzuwarten. Dazu wird die Stimmprothese entfernt, eine orale Nahrungskarenz mit Ernährung via nasogastraler Sonde oder parenteraler Ernährung verordnet und der Patient mit einer geblockten Trachealkanüle versorgt, um einer Aspiration vorzubeugen [16]. Da Patienten mit gastroösophagealem Reflux ein erhöhtes Risiko für eine Erweiterung des Stimmprothesenshunts zeigen, sollte zusätzlich eine Therapie mit Protonenpumpenhemmern begonnen bzw.…”

Management of leaking tracheoesophageal puncture with hyaluronic acid injection

“…Placement of an enlarged esophageal and/or tracheal flange on the voice prosthesis has resulted in considerable success. Lewin et al had a 77% success rate in preventing leaks by customizing voice prostheses for patients with enlarged TEPs. Additionally, they cite an 80% long‐term success rate using this method to avoid permanent gastrostomy, aspiration pneumonia, and surgical TEP closure.…”

“…These options include injection of the tracheoesophageal wall to increase bulk and to prevent any leakage. This has been described with autologous fat injection, hyaluronic acid, polydimethylsiloxane elastomer injection, and granulocyte‐macrophage colony‐stimulating factor . There are no clear guidelines for management, despite varied treatments.…”

“…Hyaluronic acid has been approved for this use in our institution. This injectable was chosen because of its previously reported high success rate in similar cases …”