Tracheoesophageal Puncture (TEP)

Considerations

• • Secondary placement of TEP prosthesis

Preparation

• • Ensure you have properly size the TE prosthesis to fit the patient's trachea

    • Start with 20 French 8 mm - fits most patients well

    • If too small, use 22 French 10 mm 

  • Plan TEP site to allow ease of access while cleaning and changing prosthesis

  • Check TEP dilator and prosthesis is secured

  • Equipment 

    • Esophagoscopy / Laryngoscopy tray

    • Provox kit 

Procedure

• • Once patient is intubated, turn table 90 degrees in preparation for esophagoscopy / laryngoscopy 

  • Apply upper tooth guard

  • Insert esophagoscope into esophagus

  • Using non-operative hand, palpate the esophagoscope through the posterior wall of trachea

  • While palpating, slowly retract esophagoscope until the tip is palpable at TEP insertion site

  • Rotate esophagoscope 180 degrees so that flange is posterior and providing a safe guard for the trocar

  • Insert the puncture needle through the TEP site until tip reaches the inner wall of and is visible through the esophagoscope

    • Optional: Use the Hopkins rod with camera to indirectly visualize the puncture through the esophagoscope 

  • Insert the guidewire through the puncture needle until it is reachable at the cranial end of esophagoscope, and secure

  • Remove the esophagoscope while keeping guidewire in place

  • Slide the puncture dilator onto the guidewire from the cranial side, and secure the end of the guidewire to the dilator

  • Advance the dilator by pulling the guidewire smoothly from the tracheal side until it is showing through the puncture site

  • Applying counter pressure with your other hand, continue pulling the guidewire to advance the dilator until the prosthesis flange is unfurled and seated in the correct position

  • Turn the prosthesis into correct position

  • Cut the safety strap to release the prosthesis from the dilator

  • Optional: Use the Hopkins rod with camera to document proper placement in the esophagus through the esophagoscope 

Sample operative report

Findings:

Status post total laryngectomy on ***

Placed Provox Vega TEP for voice rehabilitation 

Procedure in Detail:

@NAME@ was transported to the OR where {HE/SHE:30451} was positioned supine. The laryngectomy stoma was intubated with an armored ETT. Bed turned 90 degrees. Maxillary *** teeth *** gums protected.

Rigid Jesberg esophagoscope placed to the level of the laryngectomy stoma. Puncture completed in the posterior midline stoma wall, 10 mm inferior to the mucocutaneous junction. Guidewire threaded; Puncture trocar and esophagoscope removed. Dilator followed by device placed with tracheal phalanges fully exposed. Device extension secured to skin with steri-strip.

Extubated without issue. Stoma vent replaced. *** Gums *** teeth intact. Transported to PACU without issue.

Post-op

• • Medications 

    • Nystatin 100,000 unit/mL Oral Susp

    • Apply the suspension to clean the prosthesis through the stoma 2 times daily; If there is visible fungus, then clean 4 times daily AND SWALLOW 1 TEASPOONFUL (5 ML) ORALLY 2-4 TIMES A DAY

  • Diet

    • Resume diet as tolerated 

  • Follow up

    • ST clinic in 1-2 weeks 

    • HNS clinic PRN 

    • The TEP can be changed by ST or MD every 3 months or earlier as needed 

  • Complications 

    • Damage to teeth / related structures 

    • Leak from the TEP requires replacement 

    • Leak from around the TEP also requires replacement, can be more challenging since there may be an issue with the fit

    • Fungal colonization is a common nuisance, can be managed with Nystatin but also usually requires replacement  

Pearls & Pitfalls

High-Yield

Links

• eMedicine - Tracheoesophageal Puncture

• Atos Medical - Provox® Vega™ Puncture Set

• WebWhispers (International Internet support group) - TEP