Sunday, April 27, 2014

Tracheal-esophageal Prothesis!

About a month ago I had the opportunity to travel to Indiana for the Blom-Singer Tracheal-esophageal Prothesis course! First, I just have to say WOW! This was such a fantastic course, and to have the opportunity to learn from Dr. Blom and his colleagues was nothing short of awesome! I am amazed with the creativity and inginuity in the makings of the various prothesis.

When I first started in this field my knowledge base of a laryngectomy was limited. When I started working at my outpatient facility I was inspired to continue expanding my knowledge base due to our population. To understand the tracheal-esophageal prothesis (TEP) we first must ask, what is it? Why does a person need it? How is it used? 

Why would someone need a TEP?
After a person is diagnosed with a laryngeal cancer they are typically offered one, more or all of the following options:

1. Surgery to remove tumor
2. Radiation
3. Chemo
4. Partial laryngectomy
5. Full laryngectomy

When a person has a laryngectomy there larynx is removed. When the larynx is removed this means that the vocal folds are removed. A stoma is created into the enterance of the trachea so the patient now has a new airway.

Now without vocal folds it is pretty difficult to communicate but there are options such as...

1. Esophageal speech
2. Electrolarynx
3. Tracheal esophageal prothesis
4. Other AAC options

What is it?/How does it work?
A TEP is placed above the stoma site (see below). This in essence is a fistula created through the tracheal wall into the esophgeal wall (a shared wall). A prothesis is placed that has a valve. The patient now can take a breath, digitally occlude (finger occlude) their stoma and the air will now be directed through the prothesis in order to then create a voice through the new vibratory source, the esophagus.

Stoma with no TEP

Stoma with TEP

Lateral view of tracheal-esophageal shared wall.

Now you might be thinking, why the need for a valve? You need the valve in order to eat. If you do not have a prothesis in (or a prothesis that is just open - no valve) and a patient drinks or eats the food/drink will then fall through the fistula and then into the airway. Food into the airway equals an increased chance of choking and pneumonia. The above image is fantastic for the new airway flow when the stoma is covered.

Learning how to correctly place a TEP.
There are several important factors in placing a TEP but the two I wanted to share is in regards to size and are so very critical for appropriate placement. First you will hear the terms "16 French" "20 French" and possibily even a "23.5 French." This is in regards to the diameter of the prothesis. A concept that was emphasized at the conference was "bigger is not always better." You must respect the fistula that has been placed. This is tissue that has been through trauma and the least amount of bother one is to the tissue the better. Many place a larger TEP - 20 French and up thinking that the receiver will then have a better vocal quality. This is not always the case. I was so fortunate to meet a woman at this conference who volunteered for us to practice TEP placements with. She had a 16 French placement and had a very clear AND feminine voice! 

The next size concern is the depth of tracheal-esophageal wall tissue. How long does the TEP need to be? It is important not to have it too tight and especially not too lose (leakage). You use a measuring tool/dialator (below) in order to determine the correct size.

The dilator looks something like this...

Keep in mind that patient's that are just post laryngectomy and TEP/fistula placement, they will be sore and swollen. It will take time for this tissue heal.  Dr. Blom recommends for a secondary TEP patient (a patient that had a laryngectomy and then decided they wanted a TEP and when back later for their surgery) could be placed with the TEP 2-3 days post surgery. They would then be able to start vocalizing as soon as the TEP was placed. They may need to come back in 2-3 weeks for a new prothesis due to recovery of tissue. 

There are also two major types of TEP's - indwelling and non-indwelling. An indwelling must be replaced by a medical professional, a non-indwelling can be replaced by the patient. Just because a patient has a non-indwelling that doesn't mean they do not need to continue to work with a medical professional. The TEP site can change and so does the needs of the patient.

Problem solving is a big part of placing TEP's. I highly recommend going to a TEP course and that being said this blog post should not be considered enough education to go and do a TEP placement - going to a course first is recommended.

What is your experience with TEP's? What courses do you recommend?

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