Voice prosthesis leakage, medical, hospital care during COVID-19 pandemic

Coping with voice prosthesis leakage or dislogement during the corona (COVID- 19) pandemic

The corona (COVID-19) pandemic presents many challenges for laryngectomees and their medical providers. Because of the reduction or decrease in outpatient services and voice prosthesis availability, those using tracheoesophageal speech may have trouble in having their clinician-changed (indwelling) prosthesis replaced because of leakage through or around the prosthesis. A patient with a leak around or through the voice prosthesis is at an increased risk of aspiration with potential sequelae including pneumonia, which could lead to devastating outcomes if patients contract COVID-19.

Enclosed are suggestions how to cope with these challenges:

• If possible, switching to using patient-changed voice prosthesis (non indwelling)
• Extending the life span of the current voice prosthesis by keeping it clean using a cleaning brush and flushing bulb and preventing buildup of candida biofilm (see below).

If voice prosthesis leakage occurs:

• Attempting to stop the leak by cleaning and brushing it as suggested in The Laryngectomee Guide (pages 75-19 ) or at http://dribrook.blogspot.com/p/tracheo-esophageal-voice-prosthesis-tep.html 
• Stopping the leak by inserting an adequate plug (see picture below) into the prosthesis whenever consuming fluids or leaving it permanently and switching to alternate speaking method (e.g., esophageal speech, electrolarynx)
• Consuming viscous fluids that generally do not leak (i.e., yogurt, jelly, soup, oatmeal, etc) through or around the prosthesis 
• Drink small amount of fluid without strong effort or swallowing the liquid as if it is a food item 

If the prosthesis has been accidentally removed or dislodged (not aspirated), a 12 Fr/ 16’’red rubber catheter (see picture below) or puncture dilator can be inserted into the trachea-esophageal puncture to prevent its closure until the voice prosthesis is replaced. An advantage to using a rubber catheter is that the red rubber catheter can serve as alternate means of nutrition until prosthesis replacement is possible.

The laryngectomee should seek immediate medical care if aspiration of the dislodged voice prosthesis has occurred as this may requires urgent intervention to remove it.

One’s speech and language pathologist and/or physician should be contacted for guidance when leakage occurs. The prosthesis should be replaced when consuming liquids becomes difficult, or recurrent aspiration occurs. The speech and language pathologist and other medical providers may wear personal protective equipment (PPE) when they change the voice prosthesis and may perform the procedure in a negatively pressurized room. .

More information how to prevent and deal with voice prosthesis leakage can be found in the Laryngectomee Guide http://goo.gl/z8RxEt and My Voice website at  http://dribrook.blogspot.com/p/tracheo-esophageal-voice-prosthesis-tep.html

Click to watch a video that explains what to do if the voice prosthesis leaks.

                                                           Voice prosthesis plugs

                                                                            Red Catheter

Ensuring adequate care during hospitalization for neck breathers including laryngectomees during the COVID-19 pandemic

Neck breathers are at a high risk of receiving inadequate care when hospitalized. The medical staff is often not aware of their condition, do not know how to care for their airways, and may not know how to communicate with them.

 The COVID-19 pandemic created greater workload for hospital staff and may make it difficult to pay attention to laryngectomee’s special needs. Because most hospital limit or prohibit the presence of patients’ companions, making it more difficult for laryngectomees to communicate with the staff. It is therefore important to take certain steps to ensure that the care is adequate:

1. Inform the ward’s head nurse and attending physician about the laryngectomee’s general and specific needs. In case of elective admission, this can be done prior to the admission to allow the staff time to get ready and to get adequate supplies and equipment.

2. Inform the ward’s head nurse, attending physician and anesthetist (when undergoing a procedure with sedation or surgery) about the proper way of administrating anesthesia, suctioning, ventilating and intubation.   Show them the video in YouTube:  https://goo.gl/Unstch (See video below). The video is available in DVD from Atos Medical. 

The National Patient Safety Project has developed an algorithm for emergency management of patients with laryngectomy.

Rescue breathing for laryngctomees

DVD of Rescue breathing for laryngctomees

3. Inform the dietitian about the food requirements of the laryngectomee.

4. Inform and, when possible, meet with the hospital’s speech and language pathologist to ensure adequate care and availability of adequate supplies.

5. Laryngectomees who experience swallowing difficulties should request that the orally administered medications be given in liquid or easy to swallow form.

6. Request specific supplies and equipment to ensure adequate respiratory care, such as saline bullets, humidifier, and suction machine.

7. Keep reminding every staff member caring for the laryngectomee about his or her condition. This can be done by the patient and/or advocate.

8. Inform the head nurse; attending physician, and/or patient’s hospital advocate if medical care is not adequate or if errors are made.

9. Request that signs informing the staff about the laryngectomee are placed in the patient’s room.

10. Wear the hospital patient ID wristband on the same hand that identifies them as neck breathers. (see below) Because staff is required to continuously check the patient ID wristband, they will be reminded of the condition.

11. Make sure that the laryngectomee is able to communicate with staff. Those using tracheoesophageal speech may need to use alternative speech methods such as an electrolarynx and/or communicate through writing and speech generating devices, i.e., laptop, smartphone, etc.

12. Preparing a kit with essential information and material when going to the hospital.  

The kit should contain the following:

• An updated and current summary of the medical and surgical history, allergies and diagnoses
• An updated list of the medications taken and the results of all procedures, radiological examinations, scans and laboratory tests. These may be placed on a disc or USB flash drive
• Contact information and proof of medical insurance
• Information (phone, email, address) of the laryngectomee’s physician(s), speech and language pathologist, family members and friend(s)
• A figure or drawing of a side view of the neck that explains the anatomy of the laryngectomee's upper airways and if relevant where the voice prosthesis is located
• A paper pad and pen
• An electrolarynx with extra batteries (even for those using a voice prosthesis)
• A box of paper tissues
• A supply of saline bullets, HME filters, HME housing, and supplies needed to apply and remove them (e.g., alcohol, Remove, Skin Tag, glue) and to clean the voice prosthesis (brush, flushing bulb)
• Tweezers, mirror, flash light (with extra batteries)

Head and neck cancer care during COVID-19 pandemic

A special article just published by DrGivi and colleagues in JAMA Otolaryngology-Head & Neck Surgery, guidelines are presented for head and neck physical examination and surgical and non-surgical procedures during the coronavirus (COVID-19) pandemic.

Because head and neck examinations are considered high risk in patients with suspected or confirmed COVID-19, the authors developed recommendations for health care workers based on review of the literature and communication with physicians with firsthand knowledge of safety procedures during the COVID-19 pandemic.

The authors note that:

• Non urgent appointments should be postponed to limit infection of patients or health care workers. This may include postponing appointments for patients with benign disease and for those undergoing routine surveillance after treatment for head and neck cancer.
• Patients should be queried by telephone about new or concerning signs or symptoms that may indicate recurrence and/or pending issues, as well as symptoms suggestive of COVID-19.
• In-person clinic visits should be offered to those at risk for significant negative outcomes without evaluation.
• To maintain relationships with patients and support assessments that can be made without in-person examinations, the use of telephone, video, or telemedicine visits should be considered.
• In-person examinations should be limited to patients who need a thorough head and neck examination. Detailed guidelines are provided for physical examinations and associated procedures.

The authors are hopeful that following carefully planned routines and procedures, it will be possible to provide excellent care and help protect the safety and health of health providers and patients.

To read the Guidelines click this link. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2764032

A review summarizing some of the more readily available clinical protocols for head and neck specialists caring for patients in an environment of a SARS CoV-2 mediated COVID-19 pandemic was published by Kowalski et al. https://onlinelibrary.wiley.com/doi/pdf/10.1002/hed.26164

An international consensus published their recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30334-X/fulltext