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

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.

Cost-Effectiveness Study of Double-Flange Voice Prostheses in the Treatment of Periprosthetic Leakage in Laryngectomized Patients

BACKGROUND

Tracheoesophageal speech with a voice prosthesis is considered the rehabilitation treatment of choice in laryngectomized patients. The main reasons for prosthesis failure are endoprosthetic leakage and periprosthetic leakage. The Provox XtraSeal^® stent incorporates an additional double flange on the esophageal side to prevent periprosthetic leakage. The objective of this study is to compare the duration and costs of the Provox Vega^® and Provox XtraSeal^® prostheses used in these patients in a tertiary university hospital.

MATERIALS AND METHODS

A prospective crossover case study of laryngectomees with Provox Vega^® who underwent Provox XtraSeal^® placement due to recurrent periprosthetic leaks and decreased theoretical prosthesis life. The duration and possible factors affecting voice prostheses were studied using Kaplan-Meier curves and Cox regression. A cost-effectiveness analysis was carried out from the perspective of the Spanish National Health System with an incremental cost-effectiveness calculation.

RESULTS

A total of 38 patients were recruited, 35 men and 3 women, with a mean age of 66.26 ± 9.36 years old. Information was collected from 551 voice prostheses, 484 Provox Vega^® and 68 Provox XtraSeal^®. The mean duration of Provox Vega^® was 119.75 ± 148.8 days and that of Provox XtraSeal^® was 181.99 ± 166.07 days (p = 0.002). The most frequent reason for replacement was endoprosthetic leakage in both groups: 283 (60.86%) in the case of Provox Vega^® and 29 (48.33%) in that of XtraSeal^® (p < 0.000). To obtain no cost differences (ICE ~ 0) between Provox Vega and Provox XtraSeal, the latter should cost EUR 551.63.

CONCLUSIONS

The Provox XtraSeal^® is a cost-effective option in patients with increased prosthesis replacements due to periprosthetic leakage, reducing the number of replacements, increasing the duration of the prosthesis, and providing savings compared to Provox Vega^®.

Post-Laryngectomy Voice Prosthesis Changes by Speech-Language Pathologists: Preliminary Results

Background: In the present study, we assess the feasibility and success outcomes of voice prosthesis (VP) changes when performed by a speech-language pathologist (SLP). Methods: Patients treated with total laryngectomy (TL) from January 2020 to December 2020 were prospectively recruited from our medical center. Patients benefited from tracheoesophageal puncture. The VP changes were performed by the senior SLP and the following data were collected for each VP change: date of placement; change or removal; VP type and size; reason for change or removal; and use of a washer for periprosthetic leakage. A patient-reported outcome questionnaire including six items was proposed to patients at each VP change. Items were assessed with a 10-point Likert-scale. Results: Fifty-two VP changes were performed by the senior SLP during the study period. The mean duration of the SLP consultation, including patient history, examination and VP change procedure, was 20 min (range: 15–30). The median prosthesis lifetime was 88 days. The main reasons for VP changes were transprosthetic (n = 34; 79%) and periprosthetic (n = 7; 21%) leakages. SLP successfully performed all VP changes. He did not change one VP, but used a periprosthetic silastic to stop the periprosthetic leakages. In two cases, SLP needed the surgeon’s examination to discuss the following indication: implant mucosa inclusion and autologous fat injection. The patient satisfaction was high according to the speed and the quality of care by the SLP. Conclusions: The delegation of VP change from the otolaryngologist–head and neck surgeon to the speech-language pathologist (SLP) may be achieved without significant complications. The delegation of VP change procedure to SLP may be interesting in some rural regions with otolaryngologist shortages.

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^®.

Improving heat and moisture exchanger therapy with a hydrogel base adhesive in laryngectomised patients: an open, randomised, crossover trial

OBJECTIVE

This study aimed to assess individual preference, symptoms and compliance between habitual use of Provox XtraFlow and the combination of Provox XtraFlow during the day and Provox Luna during the night for heat and moisture exchanger therapy in laryngectomised patients.

METHOD

This was an open, randomised, crossover trial for 25 days. After this first study period and a 5-day wash-out period, treatments were switched for another 25 days.

RESULTS

A total of 28 patients were enrolled. Differences were found (p = 0.009) in the incidence of dermatological problems with XtraFlow (46.4 per cent) versus Provox Luna (14.3 per cent), as well as in the need to abandon the use of adhesives (46.4 per cent vs 10.7 per cent; p = 0.003). A total of 60.7 per cent of the patients preferred the Provox Luna system as their preference for heat and moisture exchanger therapy.

CONCLUSION

The Provox Luna system is a viable additive to heat and moisture exchanger therapy, especially in the setting of compliance concerns and in patients who desire dermatological relief overnight.