TROUBLESHOOTING TRACHEOESOPHAGEAL VOICE

TROUBLESHOOTINGTRACHEOESOPHAGEAL VOICEPROSTHESIS ISSUESTeresa H. Lyden And Marc J. HaxerDepartments of Speech-Language Pathologyand Otolaryngology/Head and Neck SurgeryUniversity of Michigan Health System

Tracheoesophageal Speech Air expelled from the lungs into trachea anddiverted via silastic prosthesis into esophagus whenthe stoma is occluded. Results in vibration of the PE segmentTEP can occur at time of surgery or as a secondaryprocedureProsthesis can be placed at the time of the punctureor at a later time

TE Speech: Patient Selection Patient motivation vs being pressured by family, SLP,surgeonStable mental and cognitive statusGood manual dexterityGood visual acuityAdequate pulmonary supportPatent stomaFunctional PE segment ?

Contraindications to TE Voice: Who Notto Puncture Reduced patient motivationAltered mental status/ compromised cognition of patientInadequate patient understanding of post-surgical changes inanatomy and mechanics of voice prosthesis.Insufficient manual dexterity and/or visual acuity to care forstoma and prosthesisSignificant stenosis of the hypopharynx.Increased pressures within pharyngoesophageal segment Inability to produce TE voice following esophagealinsufflation via properly positioned esophageal catheter (theTaub test)

Contraindications to TE Voice: WhoNot to Puncture Inadequate pulmonary reserve Hx of COPD, emphysema, pulmonary fibrosis, interstitiallung disease, etc.Inadequate depth and diameter of stoma to accept prosthesiswithout airway compromiseRecurrent DiseaseUnresolved fistula“Bad” TissuesReduced IncomePoor or No InsuranceTransportation Issues

TE Speech: Primary vs Secondary TEPPrimary TEP Secondary TEPMay allow for feeding through the TEPsite (no need for DHT) Patient does not have to undergosecondary procedure/return to OR Migration of the TEP as healingprogresses Dilation of the TEP due to movement ofcatheterMay be able to place prosthesis at timeof procedure (location specific) Allows time for healingMay promote morestability of TEPCan be done in the clinic(Surgeon specific)May be able to placevoice prosthesis at thetime of the procedure

TE Speech: Prosthesis InfoBrands/Types/Sizes/Method ofInsertion InHealth Technologies (BlomSinger) and Atos Medical(Provox)Indwelling and patientchangeable/non-IndwellingDiameters: 16, 17, 18, 20,22.5FrLengths: 4-20mm, 22mm,25mm, 28mmGel Cap, “forced” entry, anduse of a tubed loading systemStyles Duckbill (increasedresistance)Low pressure (lessresistance)Options Large tracheal and/oresophageal flange,increased resistance,custom lengths, alteredstrap length, yeast resistant

Prosthesis Selection 16Fr. at 1st fittingTissue integrityPatient ability tomanage VisualAcuity Manual Dexterity Gastric fillingTEP locationTransportationStock AvailabilityCost/Insurancecoverage

Prosthesis Insertion Placement generally coincides with clearance for oralintake for primary TEP, 5-7 days for secondary TEP**depending on integrity of tissue Prefer initial placement to be a 16Fr. Prosthesis (14Fr.catheter placement at time of surgery is our preference)Dilate to 16 or 18Fr. Depending on tissue integrityMeasure TEPAssess for TE sound productionInsert voice prosthesis

Prosthesis Replacement Leaking throughLeaking aroundPoor fit (too long or too short)Reduced or no soundRoutine replacement after 6 months

Care and Maintenance of the VoiceProsthesis Indwelling Clean In-SituPatient changeable Canremove to clean if/as needed Can clean In-Situ (brand dependent) “Brush and Flush” 2 to 3 times daily as neededRemove mucous away from face of prosthesis

Trouble Shooting

Leaking Through the Voice ProsthesisCAUSE Valve contact with posterioresophageal wallProsthesis length too short forpuncture “pinching valve”Valve deteriorationFungal (yeast) colonization of thevalve **most commonBack PressureMucous or Food LodgementSOLUTION Replace prosthesis to a differenttype or lengthRemeasure TEP and fit withappropriate lengthReplace voice prosthesisNystatin/other antifungal agentand/or use of “yeast resistant”or dual-valve voice prosthesisIncreased resistance prosthesisCleaning prosthesis in-situ

Yeast Colonization

Care and Maintenance of the VoiceProsthesis: Leaking Through Brushand flush Plug shaft of prosthesis with Q-tip Consume 8 ounces of hot/carbonated beverage Produce loud “aah” Check for leak; if still leaking, repeat steps If still leaking, can place a plug (if Indwelling) duringoral intake

Leaking Around the Voice ProsthesisCAUSE TEP locationUnnecessary dilation of thepuncture during initial or routineplacementSOLUTION Thin party wall (6mm or less) Incorrect prosthesis length (toolong) Poor tissue integrity secondary toradiation, chemoradiation,diabetes, nutritional imbalance,thyroid issues, recurrenceAllow TEP to close/repunctureDefer dilation or dilate only tosize of voice prosthesisProsthesis selection/custom fitRemeasure TEP/place correctsizeProsthesis selection/custom fit,check thyroid levels, managemedical issues, diet changes

Leaking Around: ManagementMyths/What not to do Electro-cautery to “shrink” TEPNever insert larger prosthesis or largertube/catheter to “plug” the TEPPlacement of smaller catheter to allow for TEPstenosis (Temporary Solution-NOT a long termSolution)

Poor or NO TE SoundCAUSE Prosthesis pluggedPartial extrusion ofprosthesis with closure ofTEPPE spasm/hypertonicityExcessive digitalpressure duringphonationProsthesis too longSOLUTION Clean prosthesisRemove prosthesis,establish TEP if able,replace prosthesis,secondary TEP ifneededBotox injectionPatient training on “lighttouch”Remeasure TEP-downsize prosthesis

Prosthesis Extrusion: Partial orCompleteCAUSE Poor Tissue IntegritySOLUTION Prosthesis fit (Tight A/P)Accidental Prosthesis with LargeEsophageal and orTracheal FlangeR/O diabetes,malnutrition, low TSH,DiseaseRemeasure TEP andadjust prosthesis lengthTrain Patient

Poor Visualization of Voice ProsthesisCAUSE Stenosis (small tracheostoma)SOLUTION Silicone laryngectomy tubeSilicone stoma button such as aBarton Mayo Button or LaryButton Migration of TEP Location of TEP Shelf of tissueSurgical revision of stoma Allow TEP to close/repuncture Prosthesis selection Allow TEP to close/repuncture

Length of cotton tip 15mm; widthof stoma is approximately 8mm

Gastric FillingCAUSE Increased negative pressurein esophagus duringinhalation resulting ininadvertent (prosthesis) valveopeningHypertonicity of PE segmentStrictureExcessive respiratory forceduring phonationSOLUTION Prosthesis with increasedresistanceBotox injectionDilationTeach “easy onset” voicing

Granulation TissueCAUSE Irritation associated withpresence of foreign body(prosthesis) Circumferential (“donut”of tissue) Unilateral BilateralProsthesis fit too tightSOLUTION Surgical removal(“donutectomy”)Reassess fit of prosthesis

Hypertonic VoiceCAUSE PE spasm/hypertonicityExcessive digital pressurePartial closure of TEP(related to partialprosthesis dislodgement)Prosthesis failure (wornout)SOLUTION Botox injectionPatient training on “lighttouch”Remove prosthesis,establish TEP, measureand fit with newprosthesisReplace prosthesis

Objective Insufflation Introduction of air into PE segment prior to or subsequent to formation of TE puncture Determines capability for TE voice Measures pressures within PE segment Aids in assessment of TE voice capability Can be completed transnasally or transtracheally Transnasal method catheter placed 23, 25, or 28 cm along floor of nasopharynx to level of PE segment Continuous airflow from wall source/patient’s pulmonary air flow introduced throughcatheter into PE segment Pressures measured Transtracheal method Length of patient’s current voice prosthesis marked on tip end of catheter Catheter inserted into TEP to current prosthesis length Air then introduced into PE segment as in transnasal procedure Pressures measured Above procedures advocated by Taub, Blom, and Lewin over last 40 years

Botox InjectionMarkingInjection

Botox InjectionVoicing to MarkInjection

Botox InjectionMarkingInjection

Manometry Training aid for clinicians to teach patients how toself-regulate intra tracheal air pressure.Proper airflow control results in better voice quality,less fatigue, and longer duration of thetracheostoma adhesive housing sealUse to check pressure ranges pre and post BotoxPressure Ranges (cm of H2O) 10-25cm of H2O Excellent/green 26-40 cm of H2O Good/blue 41-120 cm of H2O High

Hypotonic VoiceCAUSE Hypotonic PE segment Extended myotomyduring TL Repeated dilatationsover prolongedperiod of time Botox InjectionSOLUTION Digital pressurePressure bandAdjust diameter ofprosthesisAllow time for Botox towear off

TE Speech: ED IssuesProsthesis extrusion/intrusion If you know where prosthesis is Insert 14Fr. Red Robinson catheter intoTEPIf unable to insert 14, try insertion ofnext smallest sizeContinue until TEP stented with acatheter (#12, 10, or 8)Insert all but 1-3 inches of the catheterTie a tight knot in the endTape end of catheter to peristomal skinclose to stomaIf you do not know where prosthesis is Chest X-ray to locate prosthesisFollow items listed aboveProsthesis aspirated Visualize or confirmvia X-RayReview options forremoval with attendingInsert 14Fr. RedRobinson rubbercatheter (repeat stepslisted to the left)

Voice Restoration After Free-FlapReconstruction Voice/quality of voice dependent on type/extent offlap utilizedMay require increased vocal effortIntensity/quality of voice may be reduced

Final Thoughts NEVER use a larger diameter prosthesis to “plug” aTEP that is dilating/getting biggerBecome familiar with the available productsGet Training BothAtos and InHealth offer training courses for theirproducts Seek advice from Local Experts Remember: There is skill required to place andmange a voice prosthesis. Know your limitations

QuestionsContact Information:(734)763-4003Teresa H. Lyden: lyden@med.umich.eduMarc J. Haxer: haxer@med.umich.edu

Singer) and Atos Medical (Provox) Indwelling and patient changeable/non-Indwelling Diameters: 16, 17, 18, 20, 22.5Fr Lengths: 4-20mm, 22mm, 25mm, 28mm Gel Cap, “forced” entry, and use of a tubed loading system Duckbill (increased resistance) Low pressure (less res