|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 3 | Page : 303-304
A rare case of tracheoesophageal puncture with party wall necrosis
JR Anam, S Kannan, DA Chaukar, AK D’cruz
Department of Head and Neck Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||18-Feb-2016|
J R Anam
Department of Head and Neck Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Anam J R, Kannan S, Chaukar D A, D’cruz A K. A rare case of tracheoesophageal puncture with party wall necrosis. Indian J Cancer 2015;52:303-4
Tracheoesophageal prosthesis (TEP) is considered to be the gold standard in postlaryngectomy voice rehabilitation. Presently TEP has a success rate of around 90%.,,,, TEP is associated with fistula-related complications, which leads to periprosthetic leak, displacement, and so on. The treating clinician should be aware of thetse complications and manage them appropriately to achieve high success rate. Herewith we report one of the rare complications of TEP, pressure necrosis of party wall, and techniques to manage and prevent it. In the literature, to our knowledge only one other case of pressure necrosis of tracheoesophageal fistula has been reported.
A 43-year-old gentleman, known diabetic and hypertensive, presented with hoarseness for 2 months. He was diagnosed to have carcinoma of the left vocal cord. He received 68 Gy radiations in 34 fractions with a curative intent. Four months later he had a biopsy confirmed recurrence, which on computed tomography scan showed cartilage erosion.
He underwent total laryngectomy (TL) with primary trachoesophageal puncture, a Provox I, 8 mm prosthesis was inserted. Surgery and postsurgical stay were uneventful. Final histopathology report confirmed residual viable moderately differentiated squamous carcinoma with tumor involving laryngeal skeleton.
Postsurgery speech therapy was started after 20 days. The patient had good speech (4 as per mean voice quality (MVQ) scoring system) (5). First TEP change was done at 23 months in view of peri-TEP leak. Provox II, 8 mm was used. Second TEP change was done at 26 months again due to a peri-TEP leak, using Provox II, 8 mm. The patient was asymptomatic for 12 months, this time when he had a peri-TEP leak it was changed to Provox II, 6 mm. He presented at 7th month with discharge and loosening of TEP. On examination, the esophageal flange was protruding outside, with mucosa in between both flanges. There was pressure necrosis of party wall; TEP was only partly attached, from 7'o clock to 11'oclock position [Figure 1]. TEP was removed, detached mucosa was found between the two flanges. Red rubber catheter was passed throughfistula, and the patient was started on ryle's tube feeds [Figure 2]. Upper gastrointestinal endoscopy was done to rule out new pathology. A new TEP of longer size, that is, Provox II, 8 mm, was put after 2 days. The leak stopped and he could speak comfortably. On his next visit after 4 months, he still had redundant mucosa around the flange, which was trimmed using laser and TEP replaced back [Figure 3]. The patient has been on follow-up for the past 18 months without any further complaints.
|Figure 1: Tracheoesophageal prosthesis with party wall necrosis and granulation tissue|
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|Figure 2: Red rubber tube passed after removal of tracheoesophageal prosthesis|
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First laryngectomy was performed by Theodre Billroth in 1886. The credit of first tracheoesophageal puncture goes to a postlaryngectomy patient who attempted suicide with an ice pick in 1931. The tracheoesophageal prosthesis was introduced by Dr. Bloom and Singer in 1980. Since then after a number of refinements, the present day prosthesis is low pressure, indwelling, and easy to replace.
It is important to understand the pathophysiology of the trouble-shooting events/complication and manage them appropriately. The most common complication of TEP is leakage of fluid either through the prosthesis (central TEP leak) or around the prosthesis (periprosthetic leak). The complications associated with TEP can be classified as prosthesis related or fistula related, such as periprosthetic leak, displacement of the prosthesis, granulation, infection, and underreported pressure necrosis of the party wall.
Pressure necrosis of the party wall
Cause: Whenever small size prosthesis is fitted to a patient, it causes pressure-induced ischemic injury to the party wall. It leads to tear in the party wall, hence the prosthesis gets separated with a redundant mucosa in between.
Prevention: Always use appropriate size prosthesis, when in doubt, it is always better to insert larger size prosthesis, if needed a sailastic ring can be inserted at a later stage.
Treatment: Remove the detached prosthesis, and insert a longer prosthesis, reassess after 1-3 months. If residual redundant mucosa persists then it can be removed or if any granulation found can be laser fulgurated.
Alternatively, insert a Ryles tube and a cuffed tracheastomy tube, fistula is allowed to settle for 5-7 days. Reassess and trim the redundant mucosa. Insert longer size prosthesis.
In the literature, to our knowledge only one other case of pressure necrosis of TEP tract has been reported.
Pressure necrosis of the party wall can be prevented by using appropriate size of the prosthesis during the change.
| » References|| |
Hilgers FM, Schouwenburg PF. A new low-resistance, self maintaining prosthesis (Provox™) for voice rehabilitation after total laryngectomy. Laryngoscope 1991;100:1202-7.
Yoshida GY, Hamaker RC, Singer MI, Blom ED, Charles GA. Primary voice restoration at laryngectomy: 1989 update. Laryngoscope 1989;99:1093-5.
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[Figure 1], [Figure 2], [Figure 3]