Facemasks, N95 respirator and face covers for neck breathers

It is recommended that neck breathers including laryngectomees cover their stoma (even when using an HME) and nose and mouth with two surgical masks or respirator (stoma only), and if these are not available with a soft (cloth) cover.

If worn properly, a surgical mask can help block large-particle droplets, splashes, sprays or splatter that may contain germs (viruses and bacteria). Facemasks may also help reduce exposure of the wearer’s respiratory secretions to others.

While a surgical mask may be effective in blocking splashes and large-particle droplets, it does not filter or block very small particles in the air that may be transmitted by coughs, and sneezes. It is important to note that the use of an N95 respirator and face shield may not be 100% effective at preventing COVID-19 transmission. Two recent meta-analyses; by Smith et al., and Long et al, failed to demonstrate the superiority of N95 respirators over standard surgical masks in preventing influenza.

An N95 respirator (the "N" means Not effective against oily materials, the "95" means 95% of non-oily airborne particles are filtered out, and the "respirator" means a device that protects against inhalation of hazardous particles) works by providing both a physical and an electrostatic barrier to incoming droplets carrying SARS-CoV-2 virus particles. They are 95% effective at filtering out particles larger than 0.3 microns. Although the virus particles themselves are smaller than 0.2 microns, they are carried by much larger droplets of water, mucus, and saliva. Because the pores in the respirators are about 1 micron in size, the electrostatic component of filtration is very important in providing protection.

The outer layer of the N95 mask is made of fluid-resistant material to keep moisture from coming in, and the inner layer is made of synthetic fabric. When washed with soap and water, an it loses much of its efficiency. UV light and H₂O₂ fumes as well as warm, moist heat destroy the viruses without damaging the synthetic fabric and may permit reuse without diminishing efficiency.

If a respirator is reused, great care should be taken in removing the mask without touching its surfaces and thus contaminating it. Careful fitting is required. Mask testing is done by spraying saccharine on its surface; if you can inhale and taste the saccharine, the mask doesn't meet standards. If one can smell the onions, garlic, or alcohol on someone's breath, he/she are too close, 6 feet or not.

     Current evidence suggests that it is harder to transmit the COVID-19 via a soft surface such as fabric masks or cloth (survives up to 24 hours) than on hard surfaces such as doorknobs, elevator buttons, table tops, silverware, drinking glasses, etc  were it can survive for 3-4 days. However, fabric masks and cloth can be laundered in hot water from someone with COVID-19 along with that of the rest of the family, as the temperature is high enough to destroy the virus.

Watch a video explaining the way N95 mask works  

https://www.youtube.com/watch?v=eAdanPfQdCA

     

N95 respirator

Beard or facial hair interfere with face mask's efficacy against COVID-19

The CDC recommends wearing face covering (e.g., face mask, respirator) in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission. Although neck breathers (laryngectomee and those with tracheostomy) breathe through their stoma, it is recommended that they wear a facemask in addition to covering their stoma with a modified mask or HME.

Ensuring the face mask seal is a vital part of respiratory protection practices. Facial hair that lies along the sealing area of a respirator, such as beards, sideburns, or some mustaches, will interfere with respirators that rely on a tight face piece seal to achieve maximum protection. Gases, vapors, and virus particles in the air will take the path of least resistance and bypass the part of the respirator that captures or filters hazards out. This can allow the COVID-19 virus access to the respiratory tract.

It is therefore recommended that all individuals including neck breathers remove their facial hair prior to wearing a mask.  Shaving may be challenging for those who had radical neck dissection because of their facial numbness. Using an electrical shavers allows safe removal of the hair without injuring the skin. 

Guidelines for head and neck cancer care during COVID-19 pandemic

Neck breathers (including laryngectomees) infected with COVID-19 carry a high risk of transmitting the virus to other individuals by aerosolizing tracheal secretions to their environment.  Infection control strategies specific to patients with laryngectomy should be adhered whenever they are cared for.

Personal protective equipment (PPE) should be adequately utilized, and only necessary medical providers should be in the treatment or patient’s room.  Patients should always be presumed positive with COVID-19, until proven otherwise. It is recommended that whenever they care for a laryngectomee medical providers wear a N95 respirator and face shield or a powered air‐purifying respirator (PAPR), a disposable surgical cap, gown, gloves, and shoe covers when evaluating a laryngectomee with unknown, suspected, or positive COVID‐19 status.  Standard PPE, as defined by the OccupationalHealth and Safety Administration (OSHA), can be used for COVID‐19‐negative patients. 

It is recommended to defer nasopharyngoscopy and tracheoscopy if possible as these are high risk aerosol generating procedures.  When performing flexible tracheoscopy, attempts should be made to minimize mucosal stimulation and resultant coughing.

A special article just published by DrGivi and colleagues in JAMA Otolaryngology-Head & Neck Surgery, presented guidelines 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 guidelines state 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.
• Maintaining 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 ( e.g. postoperative visits, tracheoesophageal prosthesis complications, symptoms concerning for cancer recurrence, etc.).
  Detailed guidelines are provided for physical examinations and associated procedures.

It is expected that following carefully planned routines and procedures, will enable providing adequate care and help protect the safety and health of health providers and patients.

It is helpful to have a plan in place in case one becomes sick. Identifying a caregiver and staying in touch with family, friends, neighbors, and healthcare professionals during the pandemic through email or phone, especially if some lives alone is important. If one is aware of an exposure or are experiencing symptoms such as a sore throat, dry cough, fever, and/or shortness of breath, seek medical help as soon as possible. Trying to contact one’s care team over the phone before coming into a medical center can facilitate their care.

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


Hennessy et al. present their special considerations and best practice recommendations in the management of total laryngectomy patients. They also presented their recommendations for laryngectomy patients and how to minimizing community exposures. 

Endoscopic examination by an otolaryngologist

Coping with COVID-19 pandemic as head and neck cancer patient

Navigating the COVID-19 crisis: Resources for Patients, Survivors and Caregivers

By The Head and Neck Cancer Alliance (modified)

The global COVID-19 pandemic is particularly stressful for those undergoing treatment for head and neck cancer, their caretakers, and cancer survivors. Because of the increasing numbers of patients with COVID-19 infections, many health systems adopted strategies to provide sound care for non COVID-19 patients while reducing the risk of infection transmission to patients and medical personal. Additional considerations include the limited availability of operating rooms and inpatient beds, and the scarcity of personal protective equipment needed to provide safe and hygienic conditions.

Below is a brief outline of some of the changes in near future.

People undergoing active treatment (especially chemotherapy) are at increased risk of getting an infection. it is very important that they and those in close contact withe them,  follow the CDC and local government instruction:

• Washing hands with soap and water frequently, for 20 seconds, including wrists.
• If unable to wash hands, using hand sanitizer and rubbing them for 20 seconds.
• Disinfecting commonly used surfaces such as tabletops, doorknobs, and phones.
• Avoiding direct contact with others such as hugging or shaking hands, and staying at least 6 feet away from other people.
• Avoiding being in large groups of 6 or more people, especially when in an enclosed space.
• Avoiding sharing cups or utensils with others.
• Covering the mouth or stoma during a cough or sneeze.
• Wearing a face mask and protective glasses when at risk of exposure to the virus
• Avoiding contact with anyone with a known COVID-19 infection or individuals with a cough and/or fever.
• Avoiding air travel or other public transportation.
• Notifying their doctor immediately when feeling sick (develop a cough, fever, muscle aches, or other symptoms) or if after having contact with anyone with a known or suspected COVID-19 infection. It may be necessary to be evaluated and potentially tested for the virus.

Patients who have finished therapy are seen regularly to monitor for cancer recurrence and also to address any of their treatments side effects. In the current crisis, these visits are typically not urgent and may increase the risk of exposure to COVID-19 to both survivors and physicians. As a result, many hospitals are postponing non-urgent surgeries, routine follow-up visits and imaging tests (such as CT and PET/CT scans) to minimize the risk of transmission and to conserve health care resources that may be in limited supply. However, if a patient experiences concerning new signs or symptoms for cancer ( e.g., worsening mouth or throat pain, changes in one’s voice or swallowing, a spot in the mouth that has not healed in 2 weeks, unexplained ear pain, new lump in your neck) he/she should inform their doctor as they may still need to be seen.

While social distancing, isolation, and quarantine at home are effective in reducing the incidence of COVID-19, they do increase health risks from other causes. Social isolation among older adults is associated with heightened risk of cardiovascular, autoimmune, neurocognitive, and mental health problems. It is therefore important that individuals do not neglect their medical problems during the pandemic.

Some institutions are offering virtual clinic visits (Telemedicine) interactions with medical providers by way of a video conference call) in an effort to reduce exposure of both patients and health care staff. While virtual visits and telemedicine will never completely replace in-person interactions, in times of crisis, they can provide an effective means to maintain a patient-doctor relationship, allowing them to engage in a directed conversation about disease-specific symptoms and concerns, and to discuss future plans of care. Virtual visits can be very important for head and neck cancer survivors, as they reduce individual patient exposure in clinics and hospitals, and minimize the risk to other cancer patients with compromised immune systems, as well as health care providers and staff. Survivors and caregivers should be reassured that these encounters are a sound approach to cancer surveillance and can allow providers to identify patients who may require an in-person visit.

Other general considerations:

• Maintaining close communication with family/loved ones and health care team
• Having a sufficient supply (at least a 2-week supply) of easy to preserve food items, prescriptions and cleaning supplies and other essentials. 
• Contacting one’s physician to ensure one has adequate access to prescription medications, and necessary supplies (e.g., tube feedings, tracheostomy supplies and personal protective equipment)

Neck breathers ( Laryngectomees and those with tracheostomy) are likely at higher risk of becoming infected with COVID-19 due to the increased exposure of their airway. These individuals should observe special precautions (Click for precautions).

Making home Corona virus proof.

How to coronavirus-proof your home

modified from an article by Scottie Andrew,  CNN 

It that Life under coronavirus means staying at home as much as possible is recommended during the COVID-19 pandemic. However, making trips  to the grocery store or pharmacy are necessary at some point.

Because recommendations for Covid-19 may change monitoring one’s local health department and the Centers for Disease Control and Prevention for updates is important.

General plan:

• Designate one person to be the household errand-runner to limit outside exposures
• Set up a disinfecting station in an area outside the home or in a room with low foot traffic where one can disinfect packaged food

While being outside the home:

• Avoiding coming within less than six feet of others
• Wiping handles on carts or baskets while shopping
• Wearing mask at all times especially near other individuals
• It is not necessary to wear gloves. However, washing hands frequently while being out and avoiding touching one’s face are important

When get back home

• Washing hands with soap and water for 20 seconds
• Disinfect takeout boxes and packaged foods at your disinfecting station
• Thoroughly wash produce before putting it in your kitchen

Disinfecting

• Disinfect everything touched — doorknobs, light switches, keys, phone, keyboards, remotes, etc.
• Using EPA-approved disinfectants (these include Clorox Disinfecting Wipes and certain Lysol sprays) and leaving surfaces wet for 3-5 minutes

Delivery

• Asking workers to drop deliveries off on the doorstep or an at a designated area
• If they need you to come to the door, keeping six feet of distance
• Paying and tipping online when possible
• After picking up mail from the mailbox, wash your hands
• Keep the mail and boxes for 1-2 days before opening. If this is not possible wash your hands after handling them

Laundry 

• Washing clothes, towels and linens regularly on the warmest setting
• Disinfecting laundry hamper, too, or placing a removable liner inside it
• Not shaking dirty laundry to avoid dispersing the virus in the air

Guests

• Not allow guests over when social distancing is required
• When housing a family member or friend, avoiding shared living spaces as much as possible
• When they need to enter shared living spaces, keeping six feet of distance

If someone in the home gets sick

• First, consulting your doctor
• Isolating them in another room and asking them to use a separate restroom
• Disinfecting frequently touched surfaces every day
• Avoiding sharing items with them
• Wearing gloves when washing their laundry
• Continuing to wash hands frequently
• Asking them to wear a face mask if they have one

Supplies need 

• EPA-approved disinfectants
• If one does not have disinfectants, making a bleach solution by mix four teaspoons bleach per quart of water; or using a 70% alcohol solution
• Laundry detergent
• Trash bags
• Prescription medicines (these can mail order)
• Canned foods — fruits, veggies, beans
• Dry goods — breads, pastas, nut butters
• Frozen foods — meats, veggies, fruits

Pets

• Supervising pet in the backyard
• Keeping distance from other humans when playing or walking with pets
• Asking someone in the household to take care of them while being sick
• If one must care for the pets while being sick, washing one’s hands frequently

Sources of the information in the article were:

• Dr. Leana Wen, former Baltimore City Health Commissioner and an emergency physician and public health professor at George Washington University in Washington. 
• Dr. Koushik Kasanagottu, an internal medicine resident physician at John Hopkins Bayview Medical Center in Baltimore, Maryland, and who is among the thousands of health care professionals treating patients with coronavirus.
• Dr. Richard Kuhn, a virologist, director of the Purdue Institute of Inflammation, Immunology and Infectious Disease and editor-in-chief of the journal “Virology.”
• Centers for Disease Control and Prevention.

Protection from COVID-19

Protecting immunocompromised patients from COVID-19

Older adults, people who have severe underlying medical conditions like heart or lung disease or diabetes, and immunocompromised individuals seem to be at higher risk for developing serious complications from COVID-19 illness. The greater number of risk factors the higher the risk.

Examples of persons with weakened immune systems include those with HIV/AIDS; cancer and transplant patients who are taking certain immunosuppressive drugs; and those with inherited diseases that affect the immune system. 

Individuals with cancer including those with head and neck are at higher risk of suffering from a serious and life threatening COVID -19 infection when they also have the following conditions:

:

• Age > 55 years
• Pre-existing pulmonary disease
• Chronic kidney and or kidney disease
• Hypertension and/or cardiovascular disease
• Diabetes
• Immunosuppression to include: chronic prednisone treatment (>20 mg/day), biologics, transplant, chemotherapy, and HIV. The risk of developing severe disease may depend on the degree of immune suppression.

These persons as well as those who are in close contact with them, should be extra vigilant in following the CDC and local government instructions. It is recommended that they isolating themselves by staying home and avoiding any contact.   

It is advisable to contact one’s physicians for guidance and when becoming ill.
Click this link to get information how to make your home corona proof.

Message from the Japanese Head and Neck Support Society. (in Japanese and English)

Message from the Singapore Cancer Society

Message from Atos in Spanish: Laringectomía y Total y el nuevo virus corona: Sugerencias para la protección.

Message from Nu Voice ( University of Southern California)  Los Angeles. 

How laryngectomees can cope with the COVID -19 quarantine

The forced quarantine imposed by COVID -19 can be difficult for laryngectomees. Their communication difficulties may increase their social isolation, leading to medical and psychological problems.

In addition to taking steps to improve psychological vulnerability, e.g., developing a routine, reading, watching movies, taking walks, exercising, and learning a new skill, laryngectomees may want to consider the following:

• Communicating with family, friends and support groups by speaking over the phone; and e-mailing and texting using computer, tablet and smartphone. There are several applications that allow video communication (e.g., Skype, FaceTime, Zoom) to keep in touch. The volume and quality of the voice when using telecommunication methods  can be improved by using a hand held microphone  and placing it near the laptop, iPad or iPhone. It would be helpful for support groups to continue meeting using some of these methods.
• Those using tracheo-esophageal speech can learn how to communicate through other methods of speaking (e.g., esophageal speech, electrolarynx, sign language) in case they need to plug their leaking voice prosthesis.
• Not ignoring medical, dental and psychological issues. Continuing to receive care from physicians, dentists, mental health providers, and speech and language pathologists. If physical access to them is limited, contacting them using telemedicine.
• Having adequate supplies needed to speak and care for the airways (e.g., baseplate, HME, saline bullets).
• As home confinement and other restrictions are being slowly lifted, it would be prudent for laryngectomees to continue to observe these other precautionary measures. As more clinical experience in managing COVID-19 infection is gained and new medications and  vaccines are available the consequences of becoming infected may become less dangerous.

As home confinement and other restrictions are being slowly lifted, it would be prudent for laryngectomees to continue to observe precautionary measures. As more clinical experience in managing COVID-19 infection is gained and new medications and vaccines are available the consequences of becoming infected may become less dangerous.

Placing the voice amplifier near the iPad increases voice volume 

Hopefully, following these suggestion may help laryngectomees cope with their quarantine.

Mental health issues in head and neck patients during COVID-19 pandemic

The current COVID-19 outbreak is spurring depression, fear, anxiety, and stress on a societal level. On an individual level, it may exacerbate anxiety and psychosis-like symptoms as well as lead to non-specific mental issues (e.g., mood problems, sleep issues, phobia-like behaviors, panic-like symptoms). Head and neck cancer patients (HNCP) (including laryngectomees) are more vulnerable to these psychological issues as well the viral infection. Laryngectomees may experience increased social isolation and loneliness.

Contributing to these are the difficulties in get medical and diagnostic care, prescription drugs, and medical supplies, and the economic situation.

HNCP with mental health issues such as obsessive compulsive disorders (OCD), post-traumatic stress disorder (PTSD), anxiety and depressive disorders, and paranoia may experience exacerbation of their symptoms.

HNCP can be proactive and alleviate some of their psychological vulnerability by:

• Reaching out and seeking support from mental health professionals (i.e., psychiatrists, psychologists, social workers)
• Getting medical and other supplies delivered to one’s residence 
• Engaging in healthy distractions such as reading, watching movies, taking walks, exercising, and learning a new skill
• Developing a routine
• Obtaining information from reliable sources
• Curbing media exposure to certain times in the day
• Being aware of what is anxiety and what is reality in one’s thoughts and conversations
• Following guidelines (i.e., using prescribed handwashing methods, avoiding touching the face, avoiding hugging and shaking hands, staying at home and contacting one’s medical provider when experiencing medical problems)
• Connecting with family and friends through the internet, social media, video calls and phone 

Following these guidelines can assist HNCP navigate through the corona virus pandemic.

Coping with voice prosthesis leakage during 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 
• Drinking small amount of fluid without strong effort while lying down, swallowing the liquid as if it is a food item, speaking a few words each time fluids are swallowed, can reduce or  prevent the liquids from leaking into the trachea  

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.

It is helpful to contact one’s speech and language pathologist and/or physician for guidance and when voice prosthesis leakage occurs.

More information how to prevent and deal with voice prosthesis leakage can be found in the sections below.
Information is also available 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

Cleaning the voice prosthesis and preventing leaking

It is very important to keep the voice prosthesis clean to insure its proper function and durability. When not cleaned properly the prosthesis can leak, and the ability to speak can be compromised or weakened. It is recommended that the inner space (lumen) of the voice prosthesis be cleaned at least twice a day (morning and evening), and preferably after eating because this is the time when food and mucus can become trapped. Sometimes mucus blocks the prosthesis (when getting up in the morning or after eating) which interfere with the ability to speak. Cleaning is especially helpful after eating sticky foods or whenever one’s voice is weak.

The valve of a newly installed voice prosthesis may initially be stuck. The SLP can lubricate the valve with a small amount of olive oil, using the cleaning brush. This is done with great caution to prevent aspiration of the oil.

A prosthesis cleaning brush and flushing bulb are used in cleaning the prosthesis. 

                                               



Maintenance and prevention of leakage guidelines are:

1. Before using the brush provided by the manufacturer, dip it in a cup of hot water and leave it there for a few seconds. 
2. Insert the brush into the prosthesis (not too deep) and twist it around a few times to clean the inside of the device. 
3. Take the brush out and rinse it with hot water and repeat the process 2-3 times until no material is brought out by the brush. Because the brush is dipped in hot water one should be careful not to insert it beyond the voice prosthesis inner valve to avoid traumatizing the esophagus with excessive heat.
4. Flush the voice prosthesis twice using the bulb provided by the manufacturer using warm (not hot!) potable water. To avoid damage to the esophagus sip the water first to make sure that the water temperature is not too high.
5. Prevent formation of biofilm by yeast and bacteria (see below)

Warm water works better than room temperature water in cleansing the prosthesis probably because it dissolves the dry secretions and mucus and perhaps even flushes away (or even kills) some of the yeast colonies that had formed on the prosthesis.

Initially the mucus around the prosthesis should be cleaned using tweezers preferably with rounded tips. Following that the manufacturer-provided brush should be inserted into the prosthesis and twisted back and forth. The brush should be thoroughly washed with warm water after each cleaning. The prosthesis is then flushed twice with warm (not hot) water using the manufacturer’s provided bulb.

The flushing bulb should be introduced into the prosthesis opening while applying slight pressure to completely seal off the opening. The angle that one should place the tip of the bulb varies between individuals. (The SLP can provide instructions how to choose the best angle.) Flushing the prosthesis should be done gently because using too much pressure can lead to splashing of water into the trachea. If flushing with water is problematic, the flush can also be used with air.

The manufacturers of each voice prosthesis brush and flushing bulb provide directions of how to clean them and when they should be discarded. The brush should be replaced when its threads become bent or worn out.

The prosthesis brush and flushing bulb should be cleaned with hot water, when possible, and soap and dried with a towel after every use. One way to keep them clean is to place them on a clean towel and expose them to sunlight for a few hours, on a daily basis. This takes advantage of the antibacterial power of the sun’s ultraviolet light to reduce the number of bacteria and fungi.

Placing 2-3 cc of sterile saline in the trachea at least twice a day (and more if the air is dry), wearing an HME 24/7 and using a humidifier can keep the mucus moist and reduce the clogging of the voice prosthesis.

A voice prosthesis cleaning brush (Atos Medical )

A voice prosthesis flushing bulb (Atos Medical)

A sterile saline vial for respiratory tract use ("Saline bullet")

Preventing biofilm of yeast and bacteria from growing on the voice prosthesis

Overgrowth of yeast and bacteria in the form of a biofilm ( a thin, slimy film of microorganisms that adheres to a surface) on the voice prosthesis is one cause of the prosthesis leaking and thus failing. Nevertheless, it takes some time for yeast and bacteria to grow in a newly installed voice prosthesis and form the biofilm  that prevent its valve’s from closing completely. Accordingly, failures immediately after voice prosthesis installation are unlikely due to yeast growth. Formulation of biofilm on the valve may also lead to increased air flow resistance making it harder to speak.

The presence of yeast should be established by the person who changes the failing voice prosthesis  This can be done by observing the typical yeast (Candida) colonies that prevent the valve from closing and, if possible, by sending a specimen from the voice prosthesis for fungal culture.

The antifungal agents Mycostatin and Clotrimazole (Mycelex) troches, can be used to prevent voice prosthesis failure due to yeast. They are available with a prescription in the form of a suspension or tablets ( Mycostain) and troches (Mycelex.) Mycostatin tablets can be crushed and dissolved in water. There is anecdotal information that apple cider vinegar that is known to inhibit candida growth can be used to gargle and be swallowed to prevent yeast growth on the TEP.

Automatically administering anti-fungal therapy (i.e., mycostatin) just because one assumes that yeast is the cause of voice prosthesis failure may be inappropriate without proof. It is expensive, may lead to the yeast developing resistance to the agent, and may cause unnecessary side effects. 

There are, however, exceptions to this rule. These include the administration of preventive anti-fungal agents to diabetics; those receiving antibiotics; chemotherapy or steroid; and those where colonization with yeast is evident (coated tongue etc.).

Some advocate the insertion of small amount of antibiotics inside the voice prosthesis in addition to mycostatin to eliminate the bacterial component of the biofilm. (see below)

There are several methods that help prevent yeast from growing on the voice prosthesis:

• Reduce the consumption of sugars in food and drinks, brush your teeth well after consuming sugary food and/or drinks.
• Brush your teeth well after every meal and especially before going to sleep.
• Clean your dentures daily.
• Diabetic should maintain adequate blood sugar levels.
• Take antibiotics and corticosteroids only if they are needed.
• After using an oral suspension of an antifungal agent, wait for 30 minutes to let it work and then brush your teeth. This is because some of these suspensions contain sugar.
• Dip the voice prosthesis brush in a small amount of mycostatin suspension or vinegar and brush the inner voice prosthesis before going to sleep. (A homemade suspension can be made by dissolving a quarter of a mycostatin tablet in 3-5 cc water). This would leave some of the suspension inside the voice prosthesis  The unused  suspension should be discarded. Do not place too much mycostatin or vinegar in the prosthesis to prevent dripping into the trachea. Speaking a few words after placing the suspension will push it towards the inner part of the voice prosthesis.  
• Consume probiotics by eating active-culture yogurt and/or a probiotic preparation.
• Gently brush the tongue if it is coated with yeast (white plaques) 
• Replace the toothbrush after overcoming a yeast problem to prevent re colonizing  with yeasts
• Keep the prosthesis brush clean

Candida albicans as seen under the microscope