Leaking
Leakage is the most frequent issue regarding the use of a voice prosthesis. The more comfortable you become with these simple troubleshooting techniques, you will be able to more independently manage your voice prosthesis, as well as be able to determine when to contact the SLP staff for assistance.
Before you can attempt to resolve the leakage, you must first determine if the leakage is coming through the prosthesis (through the center hole) or if it is leaking around the prosthesis (around the outside of the prosthesis, seeping between the device and the tissue). Observe in a mirror (or have someone else look) while you drink water. If it is not clear where the leakage is coming from, sometimes it’s helpful to use blue or green food coloring in the water. This can sometimes help to see when/where the leakage is occurring.
If for any reason, you are not able to resolve the leakage yourself, contact the SLP office and inform them you are experiencing leakage. These patients have a priority for scheduling and will be seen the same day or as soon as you are able to come to the office. Until your appointment, however, it is important you control the leakage to prevent material from entering your lungs. See the Preventing Aspiration section below.
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Leakage through the voice prosthesis
If you have found the leakage is coming through the center of the prosthesis, you should first be sure the prosthesis is properly aligned in the tract. Although it is normal for the voice prosthesis to spin in place an no typical concern should be given to the alignment of the prosthesis. If however, your are experiencing leakage through the device, be sure it is properly aligned. This means the bottom of the tracheal flange (the part you can see) should be at the 6 0’clock position. There will either be a number imprinted or a small silicone “stump” at the bottom of the flange. With this at the 6 o’clock position, you ensure proper alignment. Check for leakage by taking a sip of water. If the prosthesis continues to leak, proceed to the next step.
Thoroughly clean your prosthesis using the brush/flush. Following this, take a sip of water and determine if the leakage continues. If it does, and you are sure the device has been thoroughly cleaned, contact the SLP office for further assistance.
Thoroughly clean your prosthesis using the brush/flush. Following this, take a sip of water and determine if the leakage continues. If it does, and you are sure the device has been thoroughly cleaned, contact the SLP office for further assistance.
Leakage around the voice prosthesis
The causes of leakage around the prosthesis can be varied. How to best resolve this issue will be determined by the SLP staff. If you are experiencing leakage around the prosthesis, you should contact the SLP office immediately. If you believe you are leaking both through and around the prosthesis, still contact the office, but attempt resolve the leakage through the prosthesis using the above instructions.
Preventing Aspiration
When the voice prosthesis is leaking
Having swallowed material enter your trachea/lungs is never a safe event. Although you may not become ill from this, it is important you try to prevent aspiration as much as possible. Once you have determined you are unable to resolve the leakage yourself, follow the following guidelines when drinking until you are seen by the SLP staff. Be sure to contact the office for an immediate appointment.
Thickening liquids
Agents can be added to liquids to make them thicker. In doing so, they thicker liquids are not so easily able to seep through the valve/around the prosthesis. Thickened liquids are helpful in preventing aspiration regardless of the source of the leakage. Thicken the liquids until they achieve a consistency that no longer leaks when you are drinking. For most patients, a thick-honey texture is sufficient.
Provox Plug and provox vega plug
These are commercially available devices meant to act like “corks” when drinking. These can be inserted into the center of the prosthesis to prevent leakage. It is important to have this on hand before you experience leakage as these need to be ordered and delivered. If you decide you would like to have a plug for your prosthesis, the SLP staff will identify which plug is appropriate and instruct you on how to properly use this.
If the Plug is removed during use, you can disinfect the Provox Plug with either hydrogen peroxide 3% for 60 minutes, ethanol 70% for 10 minutes or isopropyl alcohol 70 % for 10 minutes at least once a day, according to the manufacturer.
NOTE: The Provox Plug or Provox Vega Plug will only assist in preventing leakage/aspiration when it occurs through the prosthesis. The plugs are NOT effective in preventing leakage that is occurring around the prosthesis.
Alternate Methods
For leakage through the prosthesis, if you do not have access to a plug, some patients are able to control aspiration by using a cotton swab. It is very important you do not drop the swab into the stoma! By placing the end of the swab so that it blocks the inner lumen of the prosthesis as much as possible, you may be able to prevent aspiration until you see the SLP staff for replacement. It is very important to see the SLP staff once you have persistent leakage!
Voice prosthesis dislodges
Although the indwelling type voice prostheses used in this practice rarely dislodge, or come out accidentally, this may occur. Should this happen, it is very important you act immediately.
First: Insert the "emergency catheter" given to you during one of your first few visits after your TEP placement. This is a red rubber tube. Insert the rounded end at least 6 inches into the tract (the "hole" left by the dislodged prosthesis). Ensure there is a knot at the other end to prevent leakage of stomach contents onto your clothes. Tape the catheter to your neck to ensure it does not fall out.
Next: Contact the office right away. If after hours, you may contact the SLP staff via this website. If needed, seek attention from the Baylor All Saints Emergency Department.
Finally: Attempt to locate the prosthesis. It is important this prosthesis not fall into the lungs. A chest x-ray will usually be ordered to ensure the prosthesis is not in the lungs if you are unable to locate this.
Since the emergency catheter is smaller in diameter than the dislodged prosthesis (so it can be easily placed by you in an emergency), it may be necessary for you to avoid drinking thin liquids for a period of time: either until a new prosthesis is placed or until the TE tract shrinks sufficiently around the catheter. Remember, the voice prosthesis acts to prevent swallowed material from entering the airway. Without this in place, you will aspirate everything you try to swallow. Placing the catheter helps to reduce this aspiration amount as much as possible while also serving to ensure the TE tract stays open and doesn't close (requiring another surgery to replace this).
Difficulty with Voicing
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The air you talk with uses the same pathway through the throat that you swallow through. For this reason, food, liquid, saliva and mucous can sometimes pool in the throat. When you speak, the air flows through this pooling and gives you the “under water” quality some patients experience. In this case, swallow, drink some water, swallow again. This typically clears the pathway to allow for clear speech.
The air you talk with uses the same pathway through the throat that you swallow through. For this reason, food, liquid, saliva and mucous can sometimes pool in the throat. When you speak, the air flows through this pooling and gives you the “under water” quality some patients experience. In this case, swallow, drink some water, swallow again. This typically clears the pathway to allow for clear speech.
CHeck for Air Leaks
Without sufficient airflow through the prosthesis and into the pharynx, you will not be able to produce your best voice possible.
Regardless of the method you use to seal your tracheostoma, you should be sure no air is leaking from the stoma when you are trying to speak. The following are the most common ways to seal your tracheostoma during voicing. Find the method you use to best troubleshoot:
HELPFUL HINT: When pressing against the throat to seal the stoma, regardless of the method used, it is very important that while you use enough pressure to effectively seal off the stoma, be sure NOT to use so much pressure that the airflow through the throat is restricted. Pressing too hard against the throat can prevent the air from moving through the throat and into the mouth for speech.
Regardless of the method you use to seal your tracheostoma, you should be sure no air is leaking from the stoma when you are trying to speak. The following are the most common ways to seal your tracheostoma during voicing. Find the method you use to best troubleshoot:
- Finger Occlusion: If you are using your finger to seal against your stoma, be sure you are fully covering the stoma with the finger. It is also important to not block the opening to the prosthesis, preventing air from entering the prosthesis when you cover the stoma. The SLP staff can assist you with this technique if necessary.
- Adhesive Housing with HME Cassette: Be sure the adhesive has no leaks in the seal. A poor adhesive seal is a very common problem when air leaking occurs. If the seal is good, ensure the center of the HME cassette is being fully compressed. The SLP staff can assist you in improving the seal of the adhesive and/or properly compressing the HME cassette.
- Larytube with HME Cassette: Leakage from around the Larytube can be a common issue, although the SLP staff can help improve the seal in many cases. If no leakage around the tube is noted, ensure the center of the HME cassette is being fully compressed.
- Larybutton: Because the Larybutton is self-retaining, it is important it fit properly, especially when making a voice. Although the SLP staff should properly size/fit the Larybutton, changes to your stoma shape/size over time are possible. If you notice the Larybutton is leaking air when trying to speak, the SLP staff can be helpful in determining if you need a change in this regard.
- FreeHands Device: Be sure the adhesive has no leaks in the seal. A poor adhesive seal is a very common problem when air leaking occurs. Also be sure the valve is positioned in the “talk” position. In order to achieve voicing with this device, it is very important this be properly fitted. If this has all been done and you are noticing persistent air leakage, contact the SLP staff for further assistance.
HELPFUL HINT: When pressing against the throat to seal the stoma, regardless of the method used, it is very important that while you use enough pressure to effectively seal off the stoma, be sure NOT to use so much pressure that the airflow through the throat is restricted. Pressing too hard against the throat can prevent the air from moving through the throat and into the mouth for speech.
Valve Sticking
Occasionally, mucous or other debris may cause the valve to partially stick or not open as easily as it is designed to. If you notice this, clean your prosthesis thoroughly using the brush and flush. Drink some water. If sticking continues, contact the SLP office for further assistance.
Short Utterance length
Although some laryngectomees may have difficulty producing long strings of speech, this may be noticed on an inconsistent basis, especially when first learning to speak with a voice prosthesis. In other cases, some patients, normally able to produce full sentences without a problem, may experience from time to time, some limited speech, noticing it becomes difficult (or impossible) to produce more than a word or two before their speech stops. If air leakage is clearly not the problem, the following tips may help.
Water is also very effective in lubricating the tissues used to produce speech. With a constant flow of air through those tissues, it is easy for them to become relatively dry which may impact their ability to vibrate well and produce your best voice. Drinking water can help restore moisture to this region and may effectively improve your voice.
- Relax: Many times, the anxiety over not being able to speak can cause you to be tense. Tension in the muscles of the throat can make it difficult for the air to escape through your mouth. This will cause you to produce less and less speech.
- Drink Water: This can be especially helpful when first learning to speak with the voice prosthesis. It’s normal to tense your throat when first learning to speak. Although this is the opposite of what you should do (Think: relax), sometimes it’s hard to control. When you swallow water, the water must pass through those same muscles in your throat that are tensing up. As swallowing is something done without conscious thought or effort, the body takes over, relaxing the muscles necessary to swallow well. Once these muscles are relaxed, you may notice your speech returns as well. Follow this with a “Reset” described below.
Water is also very effective in lubricating the tissues used to produce speech. With a constant flow of air through those tissues, it is easy for them to become relatively dry which may impact their ability to vibrate well and produce your best voice. Drinking water can help restore moisture to this region and may effectively improve your voice.
Reset
Articulation, or moving your mouth and throat muscles to pronounce words can often create some excess tension in the throat muscles used for producing a voice. In this case, STOP TALKING! Relax…take a deep breath and say “ahhhhhhh.” Hold the “ah” for as long as you can, focusing on keeping your throat muscles relaxed and paying attention to how your throat feels when making a voice. In our office, we refer to this as a “reset.” Using this method can be helpful whenever you notice feeling extra tense in your throat.
In some cases, more aggressive medical intervention may be required to help achieve the best voice possible. The SLP staff will determine if further treatment is appropriate and can thoroughly discuss these options with you. If you feel you are having more difficulty speaking that you should, or notice speaking is becoming more and more difficult, be sure to mention this to the SLP staff so this can be further evaluated.
In some cases, more aggressive medical intervention may be required to help achieve the best voice possible. The SLP staff will determine if further treatment is appropriate and can thoroughly discuss these options with you. If you feel you are having more difficulty speaking that you should, or notice speaking is becoming more and more difficult, be sure to mention this to the SLP staff so this can be further evaluated.
