There are two forms of tracheoesophageal voice prosthesis leak- THROUGH and AROUND.  The problem of through voice prosthesis leaking is a common occurrence.  Most often prosthesis leaking is the result of Candida Albicans colonization invading the polymer surface of the prosthesis, resulting in eventual valve seat failure.  Candida is most often treated prophylactically using some form of antifungal agent such as Nystatin with the patient and by submerging and soaking patient changeable prostheses in hydrogen peroxide.  Inevitably, all prostheses will fail by leaking through,  whether from Candida colonization or simple mechanical failure.  Prosthesis failure results in leaking through the prosthesis and necessitates the need to change the prosthesis.  Obviously, the objective of good prosthesis management is to keep Candida at bay for as long as possible, thus reducing the need for replacement and the costs associated with the replacement.

    Passage of liquid around the shaft of the (leak around) voice prosthesis is a much less common form of tracheoesophageal voice prosthesis leaking.  This form of voice prosthesis leak in which the leaking occurs around the shaft of the prosthesis may be associated with existing or reoccurring disease, improper puncture placement, incorrectly fitted prosthesis, TEP tract trauma, radiation necrosis and is a signal of inappropriate tracheoesophageal puncture tract dilation.

    Working in a larger university cancer center where it is common to see patients with advanced cancers and multiple medical problems, I am occasionally asked to modify prostheses to stop leak-around problems.  When I first encountered a 2-centimeter diameter tract failure I immediately turned to my friend and colleague, Eric Blom, who taught me his technique of how to modify both the tracheal and esophageal flange of a voice prosthesis to stop the leak-around problem.  Over the years, I have modified prostheses for a number of patients with leak-around problems to simply stop aspiration and improve the quality of life or preserve use of tracheoesophageal voice.

    At the recent 43^rd Annual IAL Meeting and Voice Institute held in Atlanta, Murray Allan related to me the difficulties he was having with leaking around his voice prosthesis.  Assuring me that he had worked with both his physician and SLP on this problem, he related the following information:  "Although I was having no problems with the type of prosthesis I was using, I agreed to become part of a test group to try a different brand prosthesis."  The speech valve was placed on a long blue plastic insertion device and inserted by the surgeon.  It was traumatic and very painful, with bleeding from the puncture tract.  I developed an infection two days later, which required treatment with antibiotics.  Since that time I continue to have leak around my prosthesis any time I drink liquids.  I was fortunate to speak with Dan Kelly at the convention as my surgeon and SLP had never heard that a flange could be added to a regular TEP valve."

    To make the modification, the esophageal flange of 20Fr voice prosthesis was modified as seen in Figure 1.  The modification requires access to both medical grade silicone (Pharmelast) and medical grade silicone adhesive (NuSil).  In the case of Murray Allan's prosthesis, a 20.320mm disc of 0.020mil Pharmelast was fabricated to slide over the shaft of the prosthesis and was secured to the existing esophageal side flange using medical grade silicone.  The adhesive was then cured for 72 hours at ambient temperature and humidity.  After curing, the prosthesis was then hand loaded into a 20Fr prosthesis gel-cap ready for insertion.  Murray reported that his leak-around problem has completely resolved with this simple modification.

Figure 1.

    Prosthesis modification should only be done by a properly trained professional who utilizes medical grade materials.  Those interested in learning more about the techniques of prosthesis modification should watch for a forthcoming article on this topic by Dr. Eric Blom.

Dan H. Kelly, Ph.D.
Associate Professor
University of Cincinnati Medical School
Department of Otolaryngology-Head & Neck Surgery
Barrett Cancer Center
Cincinnati, OH 45219

Murray Allan
President, WebWhispers
Richmond, BC, Canada

PREVENTION AND TREATMENT OF RADIATION-INDUCED DRY MOUTH

    Recently I had to undergo radiation treatment for a cancer discovered in my naso-pharynx (the area where the nasal passages join the throat).  Even though I was to receive IMRT, a highly focused type of radiation designed to minimize radiation exposure to all areas except the tumor itself; I was still due to get a pretty heavy dose to my salivary glands.  It was explained to me that this could kill all or most of the saliva-producing cells and result in a permanent dry mouth.  In order to prevent this in so far as possible, my physician elected to irradiate one side of my face less intensely in order to try and retain some salivary function there.  To provide additional protection to the glands, she administered amifostine (am-i- fos'-teen) prior to each radiation treatment.

    Amifostine is in a class of drugs known as chemoprotectants; it protects the kidneys against the harmful effects of the cancer-fighting drug cisplatin in patients with ovarian cancer or lung cancer, and reduces the severe dry mouth caused by radiation treatment after surgery for head and neck cancer. In my case it was injected 30 minutes before each treatment.

    The most common side effect of amifostine is a decrease in blood pressure, which may start while the drug is being given and lasts about 6 minutes.  It can also cause nausea and an allergic type rash at the site of the injection, as well as other side effects.  In order to minimize these, I was put into a recliner during the injection and for the 30 minute wait afterwards.  My blood pressure was also checked.  In addition, I took an antihistimine and an anti-nausea medication about 45 minutes before going for my injection.  I was very fortunate in that my blood pressure did not drop as a result of the amifostine.  The preventive meds I took in advance kept me from having any side effects other than being drowsy for most of the day.  I am very sensitive to sedative effects, and both the antihistamine and anti-nausea drugs had sedating properties.

    I am now three months post radiation, and still have very minimal saliva production.  My physician says that there is still a good possibility of it getting better and has also put me on a medication called pilocarpine (pye-loe-kar'-peen), brand name Salagen.  This is a drug that stimulates the cells of the salivary glands, causing them to grow larger.  In this way, they can help increase saliva flow.  This drug is also used to treat dry eyes in certain cases.  Salagen is slow acting and the drug information sheet cautions that it may take 3 months to work.   I have been on it about 6 weeks so far. 

    I am optimistic that all the steps taken to keep my salivary glands working, at least at a partial level, will eventually pay off.  In the meantime, I keep a bottle of water handy at all times and sleep with a room humidifier going.

Rick Rivenbark

Hopefully Handy Hints (1)  Much of the difficulty about stoma size could avoided if the lary keeps the stoma tube given to them in the hospital and they were discharged with.  Insert it periodically into the stoma for a period of time and the stoma  won't shrink. Putting it in at night usually does the trick and avoids having to undergo any "procedures". If one does undergo a procedure, insist that a tube be given you for future care. (Shared by SLP Frances Stark, Laryngectomee since '55) (2)  Don't forget the two upcoming "laryngectomee conferences" taking place in September -  (a)  Comprehensive Interdisciplinary Conference: "From Initial Voice Evaluation to Laryngectomy Rehabilitation"; Thursday-Friday, September 18-19, 2003; Hotel Royal Plaza, Lake Buena Vista, Florida and (b) New Jersey 2003 Laryngectomee Conference, Saturday, September 20, 2003; New Jersey Hospital Association, 760 Alexander, Princeton, New Jersey; Hotel - Radisson Hotel, 4355 Route 1 at Ridge Road, Princeton, New Jersey. (3) POLICE WHISTLE WITH ADAPTER:  For someone who spends a good bit of time out of doors in relatively desolate areas, or someone who is concerned about nighttime safety, a police whistle which has been modified by the attachment of a nipple from a baby's bottle which has been cut off at the small end and placed over the mouth part of the whistle. The larger part of the nipple can then be placed over the stoma and blown for a loud, piercing signal, without concern about a dead battery or other power source. (4) WANT TO BE ABLE TO SMELL AND BLOW YOUR NOSE?:  "Rube" Goldberg did not think of everything!  Here is one device you should have at hand.  You can make it yourself in less than five minutes, and it will help you do several things you probably thought you would never do again....." This is an excellent article describing a device that enables you to do just that:  "A Simple Device for Smelling and Nose Blowing after Laryngectomy" by Zilpha T. Bosone, Ph.D. Speech-Language Pathologist, Veterans Administration Medical Center, Washington, D.C. (5)  A FREE TEXT TO VOICE COMPUTER PROGRAM:  The first version of "SpeakEasy" was made available on the Internet in early 1995.  It is now called "E-triloquist?" and they are now on Version 5.0, having incorporated many changes suggested by users.  Version 5.0 includes a US English Speech Engine (Male or Female voice) as part of the package, so you don't have to purchase one separately.   You can check out this innovative program at: http://www.etriloquist.com/. Many other ideas can be found through our web site Hints Index of separate 25 topics at:    http://www.webwhispers.org/pages/hints/hintsindex.htm

    Generally, veterans who have received an honorable or general discharge may qualify for Veteran?s Administration (VA) benefits, but in greater or lesser degree, depending on individual circumstances.  I will discuss here only the medical benefits available.

    To receive medical benefits from the VA, veterans must either be enrolled with the VA, have a service connected disability of 50% or more or want care only for a lesser, service connected, disability.  However, all veterans are urged to enroll right away as previous enrollment makes it easier to get an appointment and will ensure the proper priority of care.

    To enroll, a veteran must present his or her discharge papers, DD Form 214, to the VA.  Priorities for care are set by Congress in eight levels ranging from:

1. Veterans with a service connected disability of 50% or more,

2. Those with 30% to 40% service connected,

3. Purple Heart recipients and former POW's who were captives for at least 30 days,

4. Other veterans receiving aid and assistance from the VA,

5. Veterans unable to defray expenses of need care,

6. Certain other veterans NOT required to make co payments for treatment,

7. Non service connected and zero percent non compensable service connected disability with incomes
above the VA threshold and whose net worth exceeds $80,000 and who agree to pay co payments..

8. This category is not of interest as the VA will no longer enroll veterans in category 8.

    Co-payments for medication are currently set by Congress at $7 for a 30 day supply of each medication.  If a drug is prescribed for a lesser period of time, the $7 still applies.  For example an antibiotic prescribed for ten days would cost $7.  Note that not only prescription drugs but over the counter items, such as aspirin and cough medicine, are also covered.  Since these items are usually less than $7 for a 30 day supply, unless one is on non co-pay status, they should be obtained elsewhere.  For veterans that have a lot of medications, the co-payment is capped at $840 for calendar year 2003.  The cap amount may change from year to year.  In addition, there is ?no? co-pay for injections during the course of treatment, for medical supplies such as wipes or syringes, or for medicines prescribed for inpatient treatment.  Note also that prescription medication may be obtained from the VA pharmacy for medications prescribed by non VA physicians by having the need for the prescription reviewed by a VA physician.  In this way, nearly all veterans can get prescriptions filled for $7 for a 30 day supply.  Refills are filled by mail.  There is no co-payment for prosthetic devices prescribed by the VA, such as wheel chairs, electric scooters, adaptive driving equipment, or TEP valves, wipes and housings for laryngectomy patients.

    There are certain limits on frequency of refills of some items, such as one pair of glasses per year.  In addition to the above benefits, Vietnam era veterans who were "in country" for 30 days or more during certain dates, (not on a ship off shore or flying over, but on the ground), and who subsequently develop certain types of cancers, including cancer of the larynx, may be eligible for 100% service connected disability pension.  This is currently $2193 per month, tax free.  An additional $125 per month is payable for a spouse and $64 each for eligible children.