Determining the efficacy and cost-effectiveness of the activalve: Results of a long-term prospective trial

Prevention of periprosthetic leakage with double flange voice prosthesis: a systematic review and management protocol proposal

OBJECTIVE

To conduct a systematic review of the use and results of the Provox®VegaTMXtraSealTM in the prevention of periprosthetic leakage and to propose a management protocol for this voice prosthesis.

METHODS

Systematic search based on the PRISMA Statement during February 2020. Keywords were double flange, periprosthetic leakage, voice prosthesis, and laryngectomy.

RESULTS

Four articles with 315 voice prosthesis (94 XtraSeal and 221 controls) in 55 patients were found. The XtraSeal mean duration was 114.28 ± 73.2 (CI 95%, 98.29-130.26) days compared to 102.98 ± 17.74 (CI 95%, 100.62-105.35) days of the control group. Out of 266 replacements, endoprosthetic leakage was the most frequent cause in both groups (62.41%). Periprosthetic leaks were less frequent in the XtraSeal (9.62%) than in the control group (22.43%).

CONCLUSIONS

The XtraSeal could be effective in preventing periprosthetic leakage and lengthening the time between replacements. Studies with a robust methodology are necessary to confirm these results. Managing voice prosthesis is complex and requires a multidisciplinary and systematic approach by experienced professionals to reduce replacements and complications. Incorrect placement of the XtraSeal could cause a foreign body reaction and consequently inflammation, extrusion, or pressure lesions. The Tower of Hercules protocol: (1) Measurement of the tracheoesophageal fistula using the Provox® Measure, (2) Minimization of XtraSeal slack by avoiding the complete visualization of the prosthesis' blue ring, (3) Nasofibroscopic examination of the oesophageal wall confirming both flanges are in correct position; could prevent or minimize complications derived from the use of the XtraSeal.

[Troubleshooting with difficult replacement of voice prostheses and a novel retrograde procedure]

The implantation of a voice prosthesis has become a standard procedure during a laryngectomy. A voice prostheses enables patients to develop speech shortly after surgery, which strongly improves rehabilitation and quality of life.The lifetime of a voice prosthesis is limited and highly variable due to different causes. A replacement is usually necessary several times a year and can easily been done in an outpatient setting with surface anesthesia. In some cases, replacing the prosthesis becomes difficult. This article will take a closer look at different reasons that can lead to difficulties in prostheses replacement and discuss possible solutions, thereby focusing especially on a retrograde technique. The aim of this article is to help colleagues that already have experience with voice prostheses and want to expand their therapeutic armamentarium.

Long-term outcomes and cost-effectiveness of a magnet-based valve voice prosthesis for endoprosthesis leakage treatment

PURPOSE

Tracheoesophageal speech is considered the gold standard for rehabilitation following total laryngectomy. The main reason of voice prosthesis failure is the endoprosthesis leakage. Provox ActiValve^® incorporates a magnet-based valve system to achieve active closure of the valve to treat these leakages, with the drawback of being significantly more expensive. The aim of the study was to compare the Provox Vega^® and Provox ActiValve^® duration and costs in patients with replacements increase due to endoprosthetic leakage.

METHODS

Prospective case-crossover study in laryngectomized patients with Provox Vega^® and endoprosthesis leakage to whom a Provox ActiValve^® was placed. Survival and possible factors that affect voice prosthesis were studied using Kaplan-Meier curves and Cox Proportional Hazards Regression. Cost-effectiveness analysis from the perspective of the Spanish Public National Health System with incremental cost-effectiveness calculation was performed.

RESULTS

A total of 159 prostheses were evaluated. The most frequent reason for replacement was the endoprosthesis leakage (N = 129; 83.77%) in both models. The mean duration-time of Provox Vega^® was 44.77 ± 2.82 days (CI 95%, 39.18-50.35; median 36 days), and 317.34 ± 116.8 days (CI 95% 86.66-548; median 286 days) for the Provox ActiValve^® (p < 0.000). For every replacement not made thanks to the Provox ActiValve^® there was saving of 133.97€ CONCLUSIONS: The Provox ActiValve^® is a cost-effective solution in patients with increased prosthesis replacements due to endoprosthetic leakage, reducing the number of changes and cost compared to Provox Vega^®.

Voice Rehabilitation by Voice Prostheses After Total Laryngectomy: A Systematic Review and Network Meta-Analysis for 11,918 Patients

Purpose Our aim was to assess the different voice prostheses (VPs) to identify the most efficient, safest, patient-tailored, longest lifetime, and inexpensive VPs and assess the different factors affecting their quality. Method In September 2017, 15 databases were searched to include all randomized controlled trials. A new search was done in May 2019 to include all other study design articles, which include all the new-era VPs subtypes. Network meta-analysis (NMA) was applied to all 27 outcomes, besides NMA overall and partial order setting was done by using Hasse scatter plots. p values were used in NMA, where the best VPs are approaching one and the least approaches zero. Meta-analysis was done for the rest of the outcomes. Results Two hundred one articles were eligible for inclusion in our study (N = 11,918). Provox-2 was significantly the most efficient and safest device concerning the most patient preference (odds ratio [OR] = 33.88 [0.65, 1762.24]; p = .92), the least dislodgement (risk ratio [RR] = 0.27 [0.13, 0.57]; p = .79), the least airflow resistance (RR = 0.42 [0.08, 2.11]; p = .84), the least granulation formation (RR = 0.73 [0.02, 26.32]; p = .60), and the least VPs' inaccurate size (RR = 0.77 (0.23, 2.61); p = .66). Heat and moisture exchanger addition showed a significant increase in maximum phonation time and breathing experience, with p values (1 and .59), respectively. While heat and moisture exchanger addition showed a significant decline in stoma cleaning frequency, coughing frequency, forced expectoration, sputum production, sleeping problems, and loosening of adhesive, with p values (.99, .72, .69, .96, 1, and 0.96), respectively, Groningen low resistance and Nijdam were considered the worst devices with both overall mean p value of .44. Conclusions Provox-2 is considered the best choice as being the most preferable for patients, with the least airflow resistance, dislodgment, granulation formation, and prosthesis inaccurate size. Groningen low resistance and Nijdam were considered the worst devices according to our analysis. Supplemental Material https://doi.org/10.23641/asha.14802903.

Use of double flange voice prosthesis for periprosthetic leakage in laryngectomised patients: A prospective case-crossover study

INTRODUCTION

Tracheoesophageal speech is considered the gold standard for rehabilitation following total laryngectomy. One of the main problems of voice prosthesis is the periprosthesis leakage. Provox Vega XtraSeal incorporates a double flange on the pharyngeal side of the prosthesis in order to avoid these failures. The aim of the study is to compare the device lifetime between the Provox Vega and Provox Vega XtraSeal and to examine possible related factors that influence their duration.

METHODS

Prospective case-crossover study in 20 laryngectomised patients with Provox Vega and periprothesis leakage to whom a Provox Vega XtraSeal was placed. Survival and possible factors that affect voice prosthesis were studied using Kaplan-Meier curves and Cox Proportional Hazards Regression with Schoenfeld residuals to test the possible assumptions.

RESULTS

A total of 230 prostheses were evaluated. The most frequent reason for replacement was due to an endoprosthesis leakage (n = 146, 67%) in both models. Mean lifetime of Provox Vega was 104.474 ± 7.29 days (CI 95% 90.19-118.76) and of Provox XtraSeal was 176.76 ± 26.46 days (CI 95% 124.9-228.61) (P = .012). Complementary treatment with radiotherapy demonstrated a higher device survival (P = .007).

DISCUSSION

Provox XtraSeal seems to be effective reducing the number of changes due to periprosthetic leakage, thus increasing the survival of voice prosthesis.

Provox 2® and Provox Vega® device life-time: a case-crossover study with multivariate analysis of possible influential factors and duration

INTRODUCTION

Tracheoesophageal speech is considered the gold standard for rehabilitation following total laryngectomy. Current literature is limited and contradictory about the possible causes of device failure. The aim of the study is to compare the device life-time between the Provox 2 and Provox Vega and to examine possible related factors that influence their duration.

METHODS

Retrospective case-crossover study in 34 laryngectomized patients who had undergone tracheoesophageal voice rehabilitation using indwelling Provox 2 and Provox Vega voice prostheses between 2010 and 2016 in a tertiary care centre.

RESULTS

A total of 440 prostheses were evaluated. The most frequent reason for replacement was due to an endoprosthesis leakage (n = 221, 64.2%) in both models. Radiotherapy increases the risk of prosthesis replacement (IRR = 1.88, p = 0.007) as well as bilateral neck dissection (IRR = 1.56, p = 0.017) in Provox 2. Age and unilateral neck dissection do not seem to influence the duration of the prosthesis. Mean life-time of Provox 2 was 106.64 days and 124.19 days for Provox Vega (p = 0.261). Complementary treatment with radiotherapy demonstrated a lower device survival (p < 0.001).

DISCUSSION

Results confirmed the non-significant differences on device life between Provox Vega and Provox 2, as well as the relevant role of radiotherapy treatment in the increase of replacements and diminution of the device duration.

Device Life of the Tracheoesophageal Voice Prosthesis Revisited

Importance

Voice prosthesis (VP) device life is a limiting factor of tracheoesophageal (TE) voice restoration that drives patient satisfaction, health care costs, and overall burden. Historic data suggest that TE VPs have an average device life of generally 3 to 6 months, but these data are typically derived from small samples using only 1 or 2 devices.

Objective

To reexamine current device life in a large, contemporary cancer hospital in the United States that uses a wide assortment of VPs.

Design, Setting, and Participants

This retrospective observational study included 390 laryngectomized patients with a tracheoesophageal puncture (TEP) who had VP management at MD Anderson Cancer Center between July 1, 2003, and December 31, 2013.

Main Outcomes and Measures

Tracheoesophageal voice-related outcomes were: (1) device life duration to VP removal, and (2) treatment-related and prosthetic-related factors influencing device failure. Primary independent variables included treatment history (extent of surgery and radiation history), VP type (indwelling vs nonindwelling, size, specialty features), and reason for removal (leakage, complication, other). Duration was examined using Kaplan-Meier analysis. Disease, treatment, and patient-specific factors were analyzed as predictors of duration.

Results

Overall, 3648 VPs were placed in the 390 patients (median [range] age, 62 [34-92] years). Indwelling prostheses accounted for more than half (56%) of the devices placed (55%, 20-Fr diameter; 33%, 8-mm length). More than two-thirds (69%) of prostheses were removed because of leakage, while the rest were removed for other reasons. Median device life was 61 days for all prostheses. Indwelling and nonindwelling VPs had median device lives of 70 and 38 days, respectively. There was no significant difference between specialty prostheses compared with standard devices (median duration, 61 vs 70 days, respectively). The Provox ActiValve (Atos Medical) had the longest life. Neither radiation therapy nor extent of surgery had a meaningful impact on device life.

Conclusions and Relevance

Our data suggest that VP duration demonstrates a lower durability than historically reported. This may reflect the intensification of treatment regimens that complicate TEP management in an era of organ preservation; however, further investigation is needed.

Systematic Review of the Quality of Economic Evaluations in the Otolaryngology Literature

Objective

To evaluate the quality of economic evaluations published in the otolaryngology—head and neck surgery literature, which will identify methodologic weaknesses that can be improved on in future studies. A secondary objective is to identify factors that may be associated with higher quality economic evaluations.

Data Sources

Ovid Medline (including PubMed), Embase, and the National Health Services Economic Evaluation databases.

Review Methods

A systematic search was performed of the aforementioned databases according to PRISMA guidelines. The search was performed using otolaryngology key terms combined with the term cost. A manual search of 36 otolaryngology journals was also performed. Included studies were graded using the Quality of Health Economics Studies instrument, a 16-item checklist providing a total quality score of 100.

Results

Fifty studies were identified, and the mean quality rating was 54.7/100 (SD = 30.9). The most commonly omitted methodology components were a lack of discussion of limitations and biases, failure to address the negative outcomes of examined interventions, and a lack of a robust sensitivity analysis. Higher quality economic evaluations were associated with a higher journal impact factor (correlation coefficient r = 0.62, P = .0001), having an author with a PhD in health economics ( r = 0.56, P = .0001), and having authors who have published prior economic evaluations ( r = 0.46, P = .001).

Conclusion

Results from this study have demonstrated that there are several methodological domains that can be improved on when publishing economic evaluations in the otolaryngology literature. Authors should follow recommended methodological and reporting guidelines to optimize the transparency and accuracy of the overall conclusions.

Are modern voice prostheses better? A lifetime comparison of 749 voice prostheses

The aim of the study was to compare device life of more recent indwelling voice prostheses Provox Vega and Blom-Singer Dual Valve to device life of well-known standard devices (Provox 2, Blom-Singer Classic). In a prospective, non-randomised study, device life of Blom-Singer Classic, Blom-Singer Dual Valve, Provox2, Provox Vega and Provox ActiValve voice prostheses was recorded in a group of 102 laryngectomised patients. In total 749 voice prosthesis were included. Average overall life time was 108 days, median 74 days. The prosthesis with the longest dwell time was the Provox ActiValve (median 291 days). Provox Vega had longer device life compared with Provox2 (median 92 days vs 66 days; p = 0.006) and compared with Blom-Singer Classic (median 92 days vs 69 days; p = 0.004). In conclusion, device lifetimes of Provox Vega and ActiValve were better than those of Provox2 and the Blom-Singer Classic. New voice prostheses, with a defined valve opening pressure (Provox Vega, Provox ActiValve, Blom-Singer Dual Valve) had longer lifetimes than prostheses without a defined opening pressure (Blom-Singer Classic and Provox 2).

Practice of laryngectomy rehabilitation interventions: a perspective from Europe/the Netherlands

PURPOSE OF REVIEW

Total laryngectomy rehabilitation (TLR) in Europe is not uniform, with quite some differences in approach and infrastructure between various countries. In, for example, the Netherlands, Switzerland, Scandinavia, and more recently also in the UK, head and neck cancer (HNC) treatment and rehabilitation shows a high level of centralization in dedicated HNC centres. In other European countries, the level of centralization is lower, with more patients treated in low-volume hospitals. This article focusses on the situation in the Netherlands and, where applicable, will discuss the regional variations in Europe.

RECENT FINDINGS

Prosthetic surgical voice restoration (PSVR) presently is the method of choice in Europe, and use of oesophageal and electrolarynx voice has moved to the background. In most European countries (except the UK and Ireland), PSVR is physician driven, with an indispensable role for speech-language pathologists and increasingly for oncology nurses. Indwelling voice prostheses are mostly preferred, also because these devices can be implanted at the time of trachea-oesophageal puncture. Pulmonary rehabilitation is achieved with heat and moisture exchangers, which, based on extensive clinical and basic physiology research, are considered an obligatory therapy measure. In addition to PSVR, also issues such as smoking cessation, dysphagia/swallowing rehabilitation, and olfaction/taste rehabilitation are discussed. Especially, the latter has shown great progress over the last decade and is another example of increasing implementation of evidence-based practice in TLR.

SUMMARY

TLR has shown considerable progress over the last decades, and through the intensified collaboration between all clinicians involved, significantly has improved vocal, pulmonary, and olfactory rehabilitation after total laryngectomy.