Tracheoesophageal Voice Prosthesis Use and Maintenance in Laryngectomees

THIEME Letter to the Editor Tracheoesophageal Voice Prosthesis Use and Maintenance in Laryngectomees Itzhak Brook1 Joseph F Goodman2 1 Department of Pediatrics/Medicine, Georgetown University, Washington, District of Columbia, United States 2 Department of Otolaryngology, George Washington University School of Medicine, Washington, District of Columbia, United States Address for correspondence Itzhak Brook, MD, MSc, 4431 Albemarle St NW, Washington, DC, 20016, United States (e-mail: ). Int Arch Otorhinolaryngol 2020;24(4):e535–e538. Abstract Keywords ► tracheoesophageal voice prosthesis ► tracheoesophageal prosthesis maintenance ► laryngectomees ► sputum ► speech outcomes Tracheoesophageal speech is the most common voicing method used by laryngectomees. This method requires the installation of tracheoesophageal prosthesis (TEP), which requires continuous maintenance to achieve optimal speaking abilities and prevent fluid leakage from the esophagus to the trachea. The present manuscript describes the available types of TEPs, the procedures used to maintain them, the causes for their failure due to fluid leakage, and the methods used for their prevention. Knowledge and understanding of these issues can assist the otolaryngologist in caring for laryngectomees who use tracheoesophageal speech. Background Restoring speech communication using a voice prosthesis was a significant medical advancement for laryngectomees. It enables the laryngectomee to create sound again immediately after its insertion.1 A one-way valve (tracheoesophageal prosthesis, TEP) is inserted through a previously-created tracheoesophageal puncture connecting the trachea and esophagus in those wishing to speak through tracheoesophageal speech. When the patient occludes the stoma, the exhaled air is shunted through the TEP into the esophagus, where it induces vibration of the upper esophageal sphincter. The main advantage of TEP is that it generates the most intelligible, fluent, natural sounding voice in contrast to other alaryngeal speech methods.2 Even though esophageal speech also uses the upper esophageal sphincter as the sound source, laryngectomees using a TEP rely on pulmonary air for speech production, rather than the limited air supply available in esophageal speech. This leads to increased fluency and longer utterance lengths.3 A disadvantage of tracheoesophageal speech is that it requires continuous care and maintenance. The patient has to clean and care for the TEP received June 27, 2019 accepted November 21, 2019 DOI https://doi.org/ 10.1055/s-0039-3402497. ISSN 1809-9777. daily, and the prosthesis needs to be replaced at regular intervals.4 Those who rely on the speech and language pathologist (SLP) for TEP changes may have to be seen in the clinic on average every two to three months.5 Furthermore, patients with stricture or narrowing of the upper esophageal sphincter region may not be able to achieve good voice. Tracheoesophageal puncture can be performed at the time of the laryngectomy (primary puncture) or at a later date (secondary puncture). The advantages of placing primary TEP are that individuals are not subjected to an additional surgical procedure, and they can start speech rehabilitation shortly after laryngectomy. However, primary TEP is associated with an increased risk of fistula formation, leakage at the puncture site, stomal stenosis, and local infection.6 Additionally, In those who undergo secondary puncture, the SLP has the advantage of determining the tracheoesophageal voice quality before the procedure.6–8 This can assist in determining if the tracheoesophageal voice will be acceptable/functional. Not every laryngectomee is able to use voice prosthesis.4 The relative contraindications for voice prosthesis include: Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil 535 536 Tracheoesophageal Voice Prosthesis in Laryngectomees Brook and Goodman poor dexterity, eye sight, and 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 the speech pathologist or otolaryngologist; the lack of support system; and the potential cost and lack of reimbursement. The assessments needed before the insertion of the TEP include consideration of the patient’s surgical history and exposure to radio-chemotherapy, the condition of the upper esophageal sphincter (the presence of pain or dysphagia), and examination of the stoma (size, regularity and signs of infection) and the TEP (location, free rotation, patency and fluid leak).9 Tracheoesophageal prostheses last only a limited period of time, and require repeated replacements. They require continuous maintenance by the laryngectomee to achieve optimal speaking abilities and prevent fluid leakage from the esophagus to the trachea because of buildup of biofilm by yeast and bacteria.10 Extending the lifespan of the TEP can reduce the medical expenses associated with its replacement. The present manuscript describes the available types of TEPs, the procedures used to maintain them, the causes for their failure due to fluid leakage from the trachea to the esophagus, and the methods used for their prevention. Knowledge and understanding of these issues can assist the otolaryngologist in caring for laryngectomees who use tracheoesophageal speech. generated by swallowing.10 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.12 It has been linked to shorter prosthesis life span. 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.10 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 it.12 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 period, a comprehens (...truncated)