Tracheoesophageal Voice Restoration: Problems & Solutions

 This text-based course is a transcript of the live seminar, “Tracheoesophageal Voice Restoration: Problems & Solutions”, presented by Julie Bishop-Leone, M.A., CCC-SLP. This is my disclosure statement:  “I am employed by ATOS and receive remuneration for sales of ATOS within my district.”  I am going to discuss troubleshooting in the tracheoesophageal puncture patient, and I think this is one of the things that encompasses what we primarily do with this patient population. Facts and FiguresBased on data by St. Louis University, about two-thirds of the patients only require replacement of the voice prosthesis  - mostly for mild leakage - after their voice prosthesis has failed after about 3 to 4 months.  But there are about a third of patients that do experience some sort of adverse event. However, I think that is on the rise lately.  I think the idea of having an average patient who comes in, their prosthesis is leaking and you change the voice prosthesis, is few and far between anymore.  A great deal of troubleshooting is actually required with these patients.  I think the key is really focusing, not necessarily on the symptom that it is leaking, but why is it leaking.  After today’s course, you should have some good tools for assessing that.  Leakage through the ProsthesisFirst and foremost, the most frequent thing that people encounter is leakage through the prosthesis.  Typically the cause for that is blockage of the valve by mucus, or crusting of food, or biofilm formation on the back of the valve.  Many of us refer to that as Candida, but we will talk later about what that may really be.  Another cause could be an increase in pressure when they go to swallow, so it sucks the valve open, causing it to leak; or it may be a superior tract migration.  We are going to show a video demonstrating that leakage through, and this is what I typically tell patients to look for.  They should take a sip of something that is colored so they can see it, and you are looking to see if it is coming through it, or if it is coming around it.  Obviously you can see that green fluid is coming through it in this video.  Insert Video 1 here That is always a good thing to teach them, because when they come back to you and say, “I am leaking,” there are different ways that you would troubleshoot that.  If they are leaking through it, you would troubleshoot in these manners.  Later we are going to talk about leakage around it as well.  Valve Blockage by Mucus/FoodOne of the solutions, if it is an inconsistent leak, may be that the patient has not cleaned the voice prosthesis. I always recommend that they clean it with a brush and the flush, then go back and check to see if it continues to leak.   If it continues to leak, then there may be an issue with the prosthesis itself.  I always recommend that patients who are using an indwelling style voice prosthesis have a temporary plug.  I am sure when all of you started in the field, you never thought there were speech pathology emergencies, but this is probably the one.  It always ends up at 2 AM on Saturday night when their voice prosthesis starts to leak or they are on a cruise, and those kinds of things.  That is when these plugs really come in handy, so that they can plug the prosthesis, and do not endanger themselves of aspirating until they can get to see you.  Prosthesis Too ShortIt could also be that leakage through the voice prosthesis is due to the prosthesis being too short.  Certainly in that case, resize and refit it, and educate the patient about signs that it is too short.  Is it retracting back into the puncture?  Does it look like there is any sort of swelling or edema around the puncture itself?  That could also be a reason.  Illustration courtesy of: Elizabeth C. Ward and Corina J. van As-Brooks, Head and Neck Cancer, Treatment, Rehabilitation, and Outcomes  Biofilm FormationThe other is biofilm formation.  This is your new word of the day: Biofilm.  I think many of us take out that voice prosthesis and the first thing we say is, “There is yeast or Candida, depending on where you are from.”  Really what has been found is there are several different microorganisms on the back of those voice prostheses.  It is not just yeast, and so one term that would be all-encompassing certainly is biofilm.  It could be on the valve of the prosthesis, and that is typically what makes it leak through.  It certainly could be on the shaft of it as well as the retention collar.  These are things to look through.  Biofilms on voice prostheses consist of a large variety of oral of micro organisms, including streptococci, staphylococci, and yeasts (Mahieu et al., 1986) I do an extensive talk just on this topic alone, and one thing that I found quite interesting is how biofilm really works.  I am not going to give you a microbiology lecture today, but I had an “A-ha” moment when looking into this.  If you think about it, we all have this sort of free-floating opportunistic bacteria and fungi that are within our system.  They do not cause any trouble unless there is some sort of change in the pH.  You have heard of women getting yeast infections after being on antibiotics or people getting diarrhea because of being on antibiotics. That is because antibiotics kill all that natural flora within the organ.  That is when they become opportunistic, and form fungal or bacterial infections.   The interesting thing about biofilm is it likes very inert and rough surfaces.  It likes necrotic tissue and ischemic normal tissue.  The biofilm senses a surface.  It actually sends a chemical signal to that surface and the surface allows it to infiltrate into the surface.  Then at that point it creates its own ecosystem, and the interesting thing about it is it creates this “extracellular polysaccharide matrix.”  I imagine it...