"My Voice"

Order a paperback or Kindle Edition or e-book of "My Voice: A Physician's Personal Experience with Throat Cancer," the complete 282 page story of Dr. Brook's diagnosis, treatment, and recovery from throat cancer.

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Obtain and/or view a video presentation, a slide presentation and an instructive manual how to ventilate laryngectomees and neck breathers (free). A self examination guide for detection of primary and recurrent head and neck cancer is available.

Tracheo-esophageal voice prosthesis use and care

Restoring speech communication using a voice prosthesis was a significant medical advancement in laryngectomees. It enables the laryngectomee to create sound again immediately after its insertion. A voice prosthesis is inserted through a previously created tracheoesophageal puncture (TEP) connecting the trachea and esophagus in those wishing to speak through tracheo-esophageal speech. It enables the individual to exhale pulmonary air from the trachea into the esophagus through a silicone prosthesis that connects the two; the vibrations are generated by the lower pharynx.


Types of voice prosthesis

There are two types of voice prosthesis: an indwelling one that is installed and changed by a speech and language pathologist (SLP) or otolaryngologist and a patient-changed one. 

The indwelling prosthesis generally lasts a longer time than the patient managed device. However, prosthesis eventually leak mostly because yeast and other microorganisms grow into the silicone leading to incomplete closure of the valve flap.  When the valve flap does not close tight anymore, fluids can pass through the voice prosthesis (see below in Causes of voice prosthesis leak section).

An indwelling prosthesis can function well for weeks to months. However, some SLPs believe that it should be changed even when it does not leak after six months because, if left for a longer time, it can lead to dilatation of the puncture.   


The patient managed voice prosthesis allows greater degree of independence. It can be changed by the laryngectomee on a regular basis (every 1-2 weeks). Some individuals change the prosthesis only after it starts leaking. The old prosthesis can be cleaned and reused several times. 

A number of factors determine an individual's ability to use a patient managed voice prosthesis:

  • The location of the puncture should be easily accessible; the site of the puncture may, however, migrate over time, making it less accessible.
  • The laryngectomee should have adequate eyesight and good dexterity, enabling him/her to perform the procedure, and capable of following all the steps involved. An indwelling voice prosthesis does not need to be changed as frequently as a patient managed one.

Two videos made by Steve Staton explain how to replace a patient-changed prosthesis:  Prosthesis installation 1 and prosthesis installation 2.

The main difference between the clinician-changed and patient-changed voice prosthesis is the size of the flanges. The larger size flanges on the clinician-changed devices make it harder to accidentally dislodge it. Another difference is that the insertion strap should not be removed from the patient-changeable prosthesis because its helps to anchor the prosthesis. There is generally no difference in voice quality between a clinician-changed and a patient-changed device.

           
                          

                                            A voice prosthesis (Vegae TM Atos Medical)





Potential contra-indications for having voice prosthesis

Not every laryngectomee is able to use voice prosthesis. Relative contra indications for voice prosthesis include:
  • Poor dexterity
  • Poor eye sight
  • Poor pulmonary function
  • Impaired mental status
  • Lack of motivation
  • Inability to manage associated care of stoma and voice prosthesis
  • Voicing difficulties
  • Recurrent aspiration and dislodging of the TEP
  • Difficulty in occluding the stoma
  • Proximity of speech pathologist or otolaryngologist
  • Lack of support system
  • Potential cost and lack of reimbursement







What to do if the prosthesis leaks or is dislodged?

If the prosthesis leaks or has become dislodged or has been removed accidentally, a patient-changed prosthesis can be inserted by those who carry an extra device. Alternatively, a red rubber catheter can be inserted into the TEP which can close within a few hours, to prevent closure.  Inserting a catheter or a new prosthesis can prevent the need for a new TEP. Leakage of the prosthesis from the center (lumen) can be temporarily handled by inserting a plug (specific to the type and width of the prosthesis) until it can be changed. It is therefore advisable that individuals using voice prosthesis carry a prosthesis plug and catheter.


Dislodging of the TEP usually occurs when patients attempt to clean or replace the device and a cough is stimulated.  Sudden inspiratory effort increases the risk of aspirating the device when it is not secure at the trachea. When the TEP is dislodged, one of three possibilities may occur:

1.       The patient may cough it out.
2.       It may fall into the esophageal side of the fistula tract and get swallowed where it will eventually pass through the digestive tract.
3.       It may fall into the trachea and become aspirated. This will immediately generate intense coughing that may expel the prosthesis though the stoma.  If this occurs the patient must seek medical attention immediately, as this can be life-threatening. It is important to have the inhaled prosthesis removed from the lungs.


The most common location for device impaction is at the level of the upper right main stem bronchus and carina. This usually is well tolerated, but an uncomfortable shortness of breath (dyspnea) is present. Because of the potential lethal consequences of an aspirated prosthesis, it should always be considered and evaluated whenever a prosthesis is lost.





Axial CT with contrast, showing TEPwithin the stomach





Causes of voice prosthesis leak

There are two patterns of voice prosthesis leak - leak through the prosthesis and leak around it.

Leakage through the voice prosthesis is predominantly due to situations in which the valve can no longer close tightly. This may be due the following:  colonization of the valve by fungus; the flap valve may get stuck in the open position; a piece of food, mucus or hair (in those with a fee flap) stuck on the valve; or the device coming in contact with the posterior esophageal wall. Inevitably, all prostheses will fail by leaking through, whether from Candida colonization or simple mechanical failure.

If there is continuing leakage through the prosthesis from the time it is inserted, the problem is generally caused by the flap's valve remaining open because of negative pressure generated by swallowing. This can be corrected by using a prosthesis that has a greater resistance. The trade-off is that having such a voice prosthesis may require more effort when speaking. It is nevertheless important to prevent chronic leakage that can lead to aspiration into the lungs.


Leakage around the voice prosthesis is less common and is mainly due to TEP tract dilation or the inability to grip the prosthesis. It has been linked to shorter prosthesis life time. It may occur when the puncture, that houses the prosthesis widens. During insertion of the voice prosthesis, some dilation of the puncture takes place, but if the tissue is healthy and elastic, it should shrink back after a short time. The inability to contract back can be associated with gastroesophageal reflux, poor nutrition, alcoholism, hypothyroidism, improper puncture placement, incorrectly fitted prosthesis, TEP tract trauma, local granulation tissue, recurrent or persistent local or distant cancer, past radiation treatment and radiation necrosis.

Leakage around the prosthesis can also occur if the prosthesis is too long for the user’s tract. Whenever this occurs, the voice prosthesis moves back and forth in the tract (pistoning) thereby dilating the tract. The tract should be measured and a prosthesis of more appropriate length should be inserted. In this circumstance leakage should resolve within 48 hours. If the tissue around the prosthesis does not heal around the shaft within this time period, comprehensive medical evaluation is warranted to determine the cause of the problem.
  
Another cause of leakage around the prosthesis is the presence of narrowing (stricture) of the esophagus. The narrowing of the esophagus forces the laryngectomee to swallow harder, with greater force so that the food/liquid goes through the stricture. The excess swallowing pressure pushes the food/liquid around the prosthesis.

Several procedures have been used to treat persistent leakage around the prosthesis. These include temporary removal of the prosthesis and replacement with a smaller-diameter catheter to encourage spontaneous shrinkage; using customized prostheses; placing a purse-string suture around the puncture; injection of gel, collagen or micronized AlloDerm® ( LifeCell, Branchburg, N.J. 08876); cautery with silver nitrate or electrocautery; autologous fat transplantation;  inserting a larger prosthesis to stop the leak, and surgical or non-surgical (removing the prosthesis allowing closure to occur) closure of the puncture. Treatment of reflux (the most common cause of leakage) can allow the esophageal tissue to heal. Granulation tissue can be removed by cauterization (electro-, chemo-, laser-).  

Increasing the diameter of the prosthesis is generally not recommended. Generally a larger diameter TEP is heavier than a smaller one, and the weakened tissue is often not able to support a bigger device, making the problem even worse. 

Some, however, believe that using a larger diameter prosthesis reduces the speaking pressure (larger diameter allows better airflow) which allows greater tissue healing to occur while when the underlying cause (most often reflux) is treated.

The use of a prosthesis using a larger esophageal and/or tracheal flange may be helpful, as the flange acts as a washer to seal the prosthesis against the walls of the esophagus and/or trachea, thus preventing leakage.

Both types of leakage can cause excessive, strenuous, coughing which may even lead to development of abdominal wall and inguinal hernias. The leaked fluid can enter the lungs, causing aspiration pneumonia. Any leakage can be confirmed by direct visualization of the prosthesis while drinking colored liquid. If leakage occurs and cannot be corrected after brushing and flushing the voice prosthesis, it should be changed as soon as possible.

With the passage of time, a voice prosthesis generally tends to last longer before it begins to leak. This is because the swelling and increased mucus production are reduced as the airway adapt to the new condition. Improvement is also due to better prosthesis management by laryngectomees as they familiarize themselves with their device.

Patients with a TEP need to be followed by an SLP because of normal changes in the tracheo-esophageal tract. Re-sizing of the tract may be needed as it can change in length and diameter with time. The length and diameter of the prosthesis' puncture generally change over time as the swelling generated by creation of the fistula, surgery and radiation gradually decreases. This require repeated measurements of the length and diameter of the puncture tract by the SLP who can select a properly sized prosthesis.

One of the advantages of having a voice prosthesis is that it can assist in dislodging food stuck in a narrow throat. When food get stuck above the prosthesis, trying to speak or blowing air through the voice prosthesis can sometimes force the stuck food upward and relieve the obstruction.

The prosthesis may have to be changed if there is an alteration in the quality of the voice especially when the voice becomes weaker or one needs more respiratory effort to speak. This may be due to yeast growth which interferes with the opening of the valve.








A voice prosthesis inside the tracheo-esophageal puncture 







What to do if the indwelling voice prosthesis leaks


Persistent leakage of the voice prosthesis into the trachea induces cough especially when liquids are ingested. The leakage carries several risks which include:
  • Development of aspiration pneumonia
  • Clogging of HME
  • Social embarrassment
  • Anxiety
  • Temporary increase of blood pressure and pulse
  • Avoiding food and liquid intake causing dehydration and weight loss
  • Emergence of inguinal hernia
  • Urinary incontinence ( involuntary leakage of urine)
A leak can take place when a piece of dry mucus, a food particle, or hair (in those with a free flap) prevents a complete closure of the prosthesis's valve. Cleaning the prosthesis by brushing and flushing it with warm water (see previous section) can remove these obstructions and stop the leakage. 

If the leakage through the voice prosthesis happens within three days after its insertion it may be due to a defective prosthesis or one that was not placed correctly. It takes some time for the yeast to grow.  If the prosthesis leaks when new, it is due to another cause. In addition to brushing and flushing with warm water, cautiously rotating the prosthesis a couple of times to dislodge any debris may help. If the leak persists the voice prosthesis should be replaced.

The easiest way of temporarily stopping the leak until the voice prosthesis can be changed is use a plug. A plug is specific for the type and width of each voice prosthesis. It is a good idea to obtain a plug from the prosthesis' manufacturer and have it handy. Sealing the prosthesis will prevent speaking but it allows eating and drinking without leakage. The plug can be removed after eating and drinking and reinserted as needed. Some individuals use a small cotton swab inserted into the prosthesis lumen to absorb the leaking fluid. This method runs the risk of dropping the swab into the trachea. These are temporary solutions until the voice prosthesis is replaced.

It is important to stay well hydrated despite the leakage. Avoiding fluid losses in hot weather through perspiration by staying in an air-conditioned environment and ingesting liquids in a way that is less likely to leak are helpful. Speaking while drinking can reduce or even prevent the liquids to leak inside the trachea. Drinks that contain caffeine increase urination and should be avoided.
.
Viscous (thickened) fluids tend not to leak and consuming them can provide essential liquids despite the leak. Many food items that contain large amount of liquids are more viscous (i.e., jelly, soup, oat meal, toast dipped in milk, yogurt) and are therefore less likely to leak through the prosthesis. On the other hand coffee and carbonated drinks are more likely to leak. Fruits and vegetables (e.g., watermelon, apples, etc.) contain large amount of water. The way to find out what works is to cautiously try any of these.

Another method to reduce the leak until the prosthesis can be changed which may work for some individuals is to try and swallow the liquid as if it is a food item. Such maneuver is less likely to lead to fluid leakage through the voice prosthesis. 

These measures can be used to keep well-hydrated and nourished until the voice prosthesis can be changed. 





A Provox voice prosthesis 



Cleaning the voice prosthesis and preventing leaking

It is very important to keep the voice prosthesis clean to insure their proper function and durability. When not cleaned properly the prosthesis can leak, and the ability to speak can be compromised or weakened. It is recommended that the voice prosthesis be cleaned at least twice a day (morning and evening), and preferably after eating because this is the time when food and mucus can become trapped. Cleaning is especially helpful after eating sticky foods or whenever one’s voice is weak.  A prosthesis cleaning brush and flushing bulb are used in cleaning the prosthesis.

It is advisable to clean the voice prosthesis' inner lumen at least twice a day and after each meal.


                                               

Maintenance and prevention of leakage guidelines are:


  1. Before using the brush provided by the manufacturer, dip it in a cup of hot water and leave it there for a few seconds. 
  2. Insert the brush into the prosthesis (not too deep) and twist it around a few times to clean the inside of the device. 
  3. Take the brush out and rinse it with hot water and repeat the process 2-3 times until no material is brought out by the brush. Because the brush is dipped in hot water one should be careful not to insert it beyond the voice prosthesis inner valve to avoid traumatizing the esophagus with excessive heat.
  4. Flush the voice prosthesis twice using the bulb provided by the manufacturer using warm (not hot!) potable water. To avoid damage to the esophagus sip the water first to make sure that the water temperature is not too high.
  5. Prevent yeast growth (see below)

Warm water works better than room temperature water in cleansing the prosthesis probably because it dissolves the dry secretions and mucus and perhaps even flushes away (or even kills) some of the yeast colonies that had formed on the prosthesis.


Initially the mucus around the prosthesis should be cleaned using tweezers preferably with rounded tips. Following that the manufacturer-provided brush should be inserted into the prosthesis and twisted back and forth. The brush should be thoroughly washed with warm water after each cleaning. The prosthesis is then flushed twice with warm (not hot) water using the manufacturer’s provided bulb.

The flushing bulb should be introduced into the prosthesis opening while applying slight pressure to completely seal off the opening. The angle that one should place the tip of the bulb varies between individuals. (The SLP can provide instructions how to choose the best angle.) Flushing the prosthesis should be done gently because using too much pressure can lead to splashing of water into the trachea. If flushing with water is problematic, the flush can also be used with air.


The manufacturers of each voice prosthesis brush and flushing bulb provide directions of how to clean them and when they should be discarded. The brush should be replaced when its threads become bent or worn out.



The prosthesis brush and flushing bulb should be cleaned with hot water, when possible, and soap and dried with a towel after every use. One way to keep them clean is to place them on a clean towel and expose them to sunlight for a few hours, on a daily basis. This takes advantage of the antibacterial power of the sun’s ultraviolet light to reduce the number of bacteria and fungi.

Placing 2-3 cc of sterile saline in the trachea at least twice a day (and more if the air is dry), wearing an HME 24/7 and using a humidifier can keep the mucus moist and reduce the clogging of the voice prosthesis.




A voice prosthesis cleaning brush (Atos Medical )




A voice prosthesis flushing bulb (Atos Medical)





A sterile saline vial for respiratory tract use ("Saline bullet")



Preventing yeast growth in the voice prosthesis

Overgrowth of yeast is one cause of a voice prosthesis leaking and thus failing. Nevertheless, it takes some time for yeast to grow in a newly installed voice prosthesis and form colonies that prevent its valve’s from closing completely. Accordingly, failures immediately after voice prosthesis installation are unlikely due to yeast growth.

The presence of yeast should be established by the person who changes the failing voice prosthesis  This can be done by observing the typical yeast (Candida) colonies that prevent the valve from closing and, if possible, by sending a specimen from the voice prosthesis for fungal culture.


Mycostatin (an antifungal agent) is often used to prevent voice prosthesis failure due to yeast. It is available with a prescription in the form of a suspension or tablets. The tablets can be crushed and dissolved in water. There is anecdotal information that apple cider vinegar that is known to inhibit candida growth can be used to gargle and be swallowed to prevent yeast growth on the TEP.

Automatically administering anti-fungal therapy (i.e., mycostatin) just because one assumes that yeast is the cause of voice prosthesis failure may be inappropriate without proof. It is expensive, may lead to the yeast developing resistance to the agent, and may cause unnecessary side effects. 

There are, however, exceptions to this rule. These include the administration of preventive anti-fungal agents to diabetics; those receiving antibiotics; chemotherapy or steroid; and those where colonization with yeast is evident (coated tongue etc.).

There are several methods that help prevent yeast from growing on the voice prosthesis:


  • Reduce the consumption of sugars in food and drinks, brush your teeth well after consuming sugary food and/or drinks.
  • Brush your teeth well after every meal and especially before going to sleep.
  • Clean your dentures daily.
  • Diabetic should maintain adequate blood sugar levels.
  • Take antibiotics and corticosteroids only if they are needed.
  • After using an oral suspension of an antifungal agent, wait for 30 minutes to let it work and then brush your teeth. This is because some of these suspensions contain sugar.
  • Dip the voice prosthesis brush in a small amount of mycostatin suspension or vinegar and brush the inner voice prosthesis before going to sleep. (A homemade suspension can be made by dissolving a quarter of a mycostatin tablet in 3-5 cc water). This would leave some of the suspension inside the voice prosthesis  The unused  suspension should be discarded. Do not place too much mycostatin or vinegar in the prosthesis to prevent dripping into the trachea. Speaking a few words after placing the suspension will push it towards the inner part of the voice prosthesis. 
  • Consume probiotics by eating active-culture yogurt and/or a probiotic preparation.
  • Gently brush the tongue if it is coated with yeast (white plaques) 
  • Replace the toothbrush after overcoming a yeast problem to prevent re colonizing  with yeasts
  • Keep the prosthesis brush clean






Candida albicans as seen under the microscope 






The use of probiotics such as Lactobacillus acidophilus to prevent yeast overgrowth


A probiotic that is often used to prevent yeast overgrowth is a preparation containing the viable bacteria Lactobacillus acidophilus. There is no FDA approved indication to use Lactobacillus acidophilus to prevent yeast growth. This means that there were no controlled studies to ensure its safety and efficacy. L. acidophilus preparations are sold as a nutritional supplement and not as a medication. The recommended dosage of L. acidophilus is between 1 and 10 billion bacteria. Typically, acidophilus tablets contain somewhere within this recommended amount of bacteria. Dosage suggestions vary by tablet, but generally it is advised to take between one and three L. acidophilus tablets daily.

Although generally believed to be safe with few side effects, oral preparations of L. acidophilus should be avoided in people with intestinal damage, a weakened immune system, or with overgrowth of intestinal bacteria. In these individuals this bacterium can cause serious and sometimes life threatening complications. This is why individuals should consult their physician whenever this live bacteria is ingested. It is especially important in those with the above conditions.




Lactobacillus as seen under the microscope