HOW I DO IT ARTICLE Open Access

Tracheoesophageal voice prosthesismanagement in laryngectomy patientsduring the COVID-19 pandemicDavid P. Goldstein1*, Gilbert Ralph1, John R. de Almeida1, Ashok R. Jethwa1, Jonathan Irish1, Douglas B. Chepeha1,Dale Brown1, Patrick Gullane1, John Waldron2, Elana Aziza3 and Lisa Durkin3

Abstract

With the COVID-19 pandemic, there has been significant changes and challenges in the management of oncologypatients. One of the major strategies to reduce transmission of the virus between patients and healthcare workers isdeferral of follow-up visits. However, deferral may not be possible in total laryngectomy patients. Urgent proceduresmay be necessary to prevent complications related to ill-fitting tracheoesophageal puncture (TEP) voice prostheses,such as aspiration or loss of voicing. In this paper, we describe the Princess Margaret Cancer Center’s approach tomanaging this unique patient population.

Keywords: Laryngectomy, Tracheoesophageal puncture, Voice prosthesis, COVID-19, Complications

IntroductionWith the outbreak of the Coronavirus (COVID-19) pan-demic a state of emergency was declared in Ontario onMarch 17, 2020 with directives from the Ministry ofHealth and Long-term Care to restrict all but essentialambulatory care services [1]. Since then, health care sys-tems and teams have had to significantly adjust how theycare for oncology patients in order to reduce the risk ofvirus transmission [2]. Changes include virtual consults,screening for COVID-19 prior to care, wearing personalprotective equipment (PPE) and deferral of visits andtreatments [3].Since coronavirus is transmitted through respiratory

droplets or aerosolization of virus from the upper aerodi-gestive tract (UADT), aerosol generating procedures(AGPs), such as those frequently performed inOtolaryngology-Head and Neck Surgery, can put health

care workers at significant risk of transmission of the viruswhen performed in COVID-19 positive patients [4–6].Laryngectomy patients with tracheoesophageal

puncture (TEP) who use a voice prosthesis for vocalrestoration require frequent specialized on-going carein addition to their oncology follow-up. Voice pros-theses will eventually fail, resulting in complications,and need for replacement. The most common com-plication is leakage, through or around, the voiceprosthesis resulting in aspiration of liquids whiledrinking. The life span of the device is variable be-tween patients (median device life of 61 days) andcan vary within the same patient over time [7].Many patients using TEP voice prostheses may beable to tolerate small amounts of aspiration on atemporary basis without developing pneumonia,while a minority can experience serious negativehealth consequences from aspiration such ashospitalization for pneumonia or respiratory com-promise [8]. Another complication of TEP voiceprosthesis use is dislodgement which can result inaspiration of the voice prosthesis, aspiration of solids

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* Correspondence: david.goldstein@uhn.ca1Department of Otolaryngology-Head and Neck Surgery, University HealthNetwork, University of Toronto, Toronto, ON, CanadaFull list of author information is available at the end of the article

Goldstein et al. Journal of Otolaryngology - Head and Neck Surgery (2020) 49:59 https://doi.org/10.1186/s40463-020-00456-z

and/or liquids, or closure of the TEP tract requiringa future secondary procedure to recreate the fistula.Any or all of the above complications may result inpatients requiring emergency department servicesand/or hospital admission for treatment.In the context of the current pandemic, it is important

to develop clear processes to support patients at risk forcomplications associated with TEP voice prosthesis use inorder to guard their safety and reduce potential additionalhealth system burden. Given the manipulation of theUADT with TEP voice prosthesis change, there is the pos-sibility for aerosolization of virus particles [5]. In this con-text, TEP voice prosthesis change should be carefullyconsidered and undertaken after all other reasonable strat-egies for temporary management have been employed [9,10]. There have been several recommendations publishedby institutions and societies on the management of totallaryngectomy patients during the COVID-19 pandemic [9,10]. Described below is the process for inter-professionalcare and management of laryngectomy patients with TEPcomplications at the Princess Margaret Cancer Centreduring the COVID-19 pandemic.

Princess Margaret Cancer Centre approach tomanaging patients with TEP complicationsThe processes described below are represented in Fig. 1.Laryngectomy patients who are booked for routine am-bulatory care follow-up or patients who call to requestan appointment are screened by the speech languagepathologist (SLP) via an initial telephone call. The SLPdetermines the nature of request for service (i.e. educa-tion, assistance in ordering supplies, requests for speechtherapy to improve communication function or requeststo change a voice prosthesis which is leaking). Once theissue is identified, the SLP works with the patient andtheir family by phone to temporarily resolve the issue.For patients with a leaking voice prosthesis a variety ofstrategies for self-management are discussed with thepatient and family. Strategies that have the highest likeli-hood to successfully eliminate or ameliorate aspirationwith the least complexity and effort on the patient’s partare coached first. Such strategies might include cleaningthe prosthesis to ensure the valve is fully closed;intentionally consuming a bite of solid food before tak-ing a sip of liquid; use of commercially available plugs;

Fig. 1 Algorithm for managing TEP complications where COVID swab screening is available

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adaptation of voice prosthesis insertion stick to serve asa plug; holding a cotton tip applicator at the lumen ofthe prosthesis to help absorb drops of liquid or use ofthickening powders to thicken liquids that are con-sumed. Recommendations provided are customized tosuit each patient’s unique situation. Coaching and sup-port for implementation of the recommendations areprovided by the SLP.If the initial phone follow-up does not result in reso-

lution of the issue, the SLP will arrange a secure video-based Ontario Telehealth Network visit, if possible. Thisvisit has the added advantage to allow for the voice pros-thesis to be viewed and for face-to-face problem solving.All requests for out-patient SLP service during the pan-demic, particularly those not resolved by virtual appoint-ments, are reviewed weekly by SLP and an assigned headand neck surgeon. In addition to the problem or concernwith the TEP, other factors such as patient’s age, pastmedical history (e.g. comorbidities including other re-spiratory conditions, immunosuppression, previous his-tory of aspiration pneumonia and severity), currenthealth condition with particular attention to patient re-port of stable or deteriorating condition and signs of as-piration pneumonia (fever or discoloration of trachealsecretions) are taken into account to determine whetheran in-person appointment is required. These factors notonly help determine the risk of a major complicationfrom aspiration but also the risk of morbidity or mortal-ity should the patient be exposed to COVID-19.If the recommendation either from the phone call or

the video-based visit is to defer an in-person visit, thepatient’s name is added to a deferred appointment list tobe arranged when ambulatory care restrictions are less-ened. Where needed, deferred patients will also be con-tacted 2 weeks later to continue to receive support andre-evaluation.Patients who are negative by COVID-19 clinical

screening who require an in-person visit will undergo aCOVID-19 screening swab 24 to 48 h prior to their pros-thesis change. Given that tracheal swabs are not rou-tinely performed, screening of laryngectomy patients isusually performed in clinic by the surgeon or theirtrained delegate. Laryngectomy patients will undergoswabs of the trachea in addition to the oropharynx andnasal cavity/nasopharynx [9]. This can be done using ei-ther separate swabs or a single swab (start with the tra-chea, followed by oropharynx and lastly thenasopharynx). Patients will then be sent home to self-isolate until their return appointment within 48 h onceCOVID-19 negative status is confirmed. At this visit thepatient’s voice prosthesis will be changed by SLP usingfull PPE (level 2 gown, gloves, N95 Mask and a faceshield). Even if patients are negative on their screeningtest, full PPE precautions are undertaken when

performing voice prosthesis change as sensitivity of nasalswab and/or tracheal screening tests in asymptomaticpatients may vary depending upon where patients are intheir infection course should they be infected and thefact that an AGP is being performed [11]. Whiletopicalization with local anesthetic spray is frequentlyused in the non-COVID setting, currently we havemoved away from using lidocaine spray and if needed ei-ther topicalize the airway with a lidocaine soaked pledgetor inject lidocaine around the TEP site. Fortunately,most patients are well-known to the head and neck SLPteam who will thus know the extent to which they re-quire topicalization and how easy the TEP change willbe. After completion of the visit, the examination/pro-cedure room will be cleaned based on the hospitals in-fection, prevention and control (IPAC) guidelines.Patients who screen positive for COVID-19 will be ad-

vised of their status and instructed to continue to self-isolate. The IPAC team will be informed of the resultand hospital protocols related to the COVID-19 positivepatient should be followed. The SLP and surgical teamwill review the case in further detail to determine ifprosthesis change can be deferred without significantmedical compromise. Decisions regarding re-evaluationand re-swabbing will be made in conjunction with IPACfollowing hospital guidelines. Patients who are deemedto critically require immediate prosthesis change will bediscussed with IPAC and undergo prosthesis change bya member of the surgical team in full PPE, with prefer-ence to use a negative pressure room and a powered airpurifying respirator (PAPR) where available. A terminalclean of the room will be required.

DiscussionThe protocol that was developed at the Princess Marga-ret Cancer Centre has undergone a number of iterationsbased on availability of PPE as well as accessibility toCOVID-19 testing. The algorithm outlined in Fig. 1 isthe most up to date and is similar to that described byHennessey et al. For centers without the availability ofCOVID-19 screening tests, Fig. 2 presents our initial al-gorithm prior to the implementation of screening tests.As noted by Hennessey et al, and others, deferral

where possible is the best management option for redu-cing the risk of transmission of COVID-19 [9, 10, 12].However, deferral may not always be feasible for patientsat risk for potential serious complications of prosthesisfailure, such as frail, elderly patients or patients withmultiple co-morbidities. These patients require face-to-face evaluation and management. Prior to being broughtto clinic, patients undergo a verbal screening forCOVID-19 symptoms. Difficulty arises from the fact thatthe symptoms of aspiration (dyspnea, cough and fever)can be similar to those of COVID-19. For these patients,

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laboratory screening tests are critical. As screening testsbecome more readily available, pre-screening should bepossible. However, in the event a patient requires inter-vention before results from a laboratory screening testare available; the patient should be managed via theCOVID-19 positive arm of Fig. 1.While the above screening algorithm works well for

patients that live within close proximity to the center,some head and neck patients reside at a distance andthus having two visits in a short time period is not oftenfeasible. This highlights the importance of virtual con-sults, particularly using telehealth platforms that allowperson to person consultation to troubleshoot problemswithout having to come to hospital. For those that do re-quire an in-person visit, testing at a local screening cen-ter may be a possibility prior to the appointmentdepending on availability. If the latter is not available,patients may require two visits or less favorably the pa-tient may be seen without screening but precautionstaken assuming the patient is COVID-19 positive.Screening for COVID-19 in the laryngectomy patient

population also represents a unique situation given that

the UADT is discontinuous. While there is no data tosuggest that tracheal and nasopharyngeal swabs will bediscordant in laryngectomy patients, there are reports inthe general population of COVID-19 positive patientsdemonstrating that nasopharyngeal swabs and trachealaspirates can be discordant [13]. Given this uncertainty,we recommend swabbing both sites similar to the tech-nique by Hennessey et al. [9]One way to potentially reduce transmission to health

care workers and reduce community spread in the laryn-gectomy patient is to cover the tracheostoma with a heatmoisture exchanger (HME), and as noted by Hennesseyet al, preferably with an integrated viral/bacterial hydro-scopic filter, and a physical barrier over the stoma priorto their arrival to the clinic. Further discussion of avail-able devices as they relate to COVID-19 is presented byHennessey et al [9] and Parrinello et al. [12] In addition,HME devices reduce crusting and potential trips to hos-pitals to address obstruction related to such.For the dislodged prosthesis when there is concern for

aspiration of the prosthesis, patients can be seen at theirlocal emergency department to undergo chest imaging

Fig. 2 Algorithm for managing TEP complications where COVIS swab screening is NOT available

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(Chest x-ray or Chest Computed Tomography) and canundergo COVID-19 testing there, if available. Unless pa-tients are seen at a specialized head and neck cancercenter, it is unlikely that SLP services will be available tomanage a dislodged prosthesis. In such cases, patientscan be managed by a physician with insertion of a cath-eter (Foley or red rubber catheter) through the TEP.Hennessey et al suggest that patients with a dislodged(non-aspirated) voice prosthesis may also be conserva-tively managed at home by self-insertion of a red rubbercatheter or dilator into the TEP tract, for patients famil-iar with this procedure until TEP replacement becomesa viable option [9]. Whether the catheter is placed by alocal physician or by the patient, the patient should con-tact their primary SLP for phone evaluation and furthermanagement as indicated.Catheter placement can also be considered to tempor-

arily manage leakage through or around the voice pros-thesis. This approach involves removal of the prosthesisfollowed by insertion of the catheter. While the catheterplacement might temporarily manage leakage, it doesnot eliminate the need for airway manipulation as theleaking voice prosthesis needs to be removed and thecatheter needs to be inserted through the TEP. Insertionof the catheter may eliminate leakage for many patients,however, some patients may continue to leak around acatheter, thereby not addressing the underlying problem.In addition, if the catheter becomes dislodged and thepatient is not able to reinsert it themselves, they will re-quire a face-to-face visit for the catheter to be reinserted,resulting in additional health care burden and potentialexposure for the patient. Additionally, for patients whouse a device such as a laryngectomy tube or stoma but-ton, the presence of the catheter may make stoma careand use of an HME more difficult, which in turn couldincrease the risk for mucous plugging and need for fur-ther health care intervention. For these reasons, we donot routinely recommend removal of a leaking voiceprosthesis and placement of a catheter as first line man-agement; direct replacement of a voice prosthesis mayhave a greater likelihood to completely resolve the issuewithout significantly more airway manipulation.One particular challenge is the COVID-19 positive pa-

tient that is having significant aspiration and is at riskfor pneumonia from both aspiration as well as the cor-onavirus. Careful consideration by the SLP and surgicalteam is needed with regard to bringing these patients inand changing their prosthesis. We have made theprovision that if there is significant concern that theTEP complication is life threatening in a COVID-19positive patient, the patient will be brought in for man-agement under full protective guidelines. If a voice pros-thesis change is required, it is to be performed by thestaff head and neck surgeon and/or the most

experienced SLP with as few people as possible to be in-volved in the change. COVID-19 positive patientsdeemed necessary to undergo immediate prosthesischange may be medically unstable and require medicalassessment in addition to voice prosthesis change. Byhaving the surgeon perform both the medical assessmentas well as the prosthesis change, the number of peopleinvolved in face-to-face contact is minimized. Further-more, should the patient become unstable during thechange, the surgeon is attending for medical manage-ment. Where possible, the change should happen in anegative pressure room using a PAPR if available. Theroom should subsequently undergo a terminal cleanbased on the hospital’s IPAC guidelines.

ConclusionsModifications to the care of the laryngectomy patientare needed during the COVID-19 pandemic. With thecurrent technology available, most issues can be resolvedtemporarily without an in-person visit. Clear communi-cation with SLP and surgeons is an important aspect ofthe triage process. When a face-to-face visit and changeof the voice prosthesis is deemed necessary, specific pro-tocols are required to reduce the potential transmissionof the virus. Fig. 1 describes a process that can be usedto begin resumption of ambulatory care service for thisspecialized population.

AcknowledgementsNot applicable.

Authors’ contributionsDPG- conception/design of the work, manuscript drafting, RG, JDA, DBC, JI,PG, EA-all contributed equally with editing manuscript and refining algorithmand LD- conception/design of the work, manuscript drafting. All authors readand approved the final manuscript.

FundingNo Funding.

Availability of data and materialsManuscript does not contain any data, and thus Not Applicable.

Ethics approval and consent to participateEthics board approval was not obtained as this report does not report on orinvolve the use of any animal or human data or tissue and thus NotApplicable.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Author details1Department of Otolaryngology-Head and Neck Surgery, University HealthNetwork, University of Toronto, Toronto, ON, Canada. 2Department ofRadiation Oncology, Princess Margaret Cancer Centre, University of Toronto,Toronto, Canada. 3Speech pathology, University Helth Network, University ofToronto, Toronto, ON, Canada.

Goldstein et al. Journal of Otolaryngology - Head and Neck Surgery (2020) 49:59 Page 5 of 6

Received: 24 May 2020 Accepted: 30 July 2020

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