Voice Prosthesis Insertion Research Articles

Mediastinal abscess and esophageal stricture following voice prosthesis insertion

The use of a tracheo-esophageal voice prosthesis is a well-established procedure to restore the voice in total laryngectomees. The insertion of the prosthesis is not a risk-free procedure, various complications having been reported especially in irradiated patients. Here described is a case of an esophageal rupture after secondary tracheo-esophageal puncture with mediastinal abscess in a patient previously treated with pharyngo-laryngectomy and subsequent radiotherapy for a left pyriform sinus carcinoma, which required immediate surgical drainage through a left cervical approach. Few weeks after surgical drainage an esophageal stricture at the site of the rupture developed, which was only temporarily resolved after the insertion of biodegradable esophageal stents, followed by re-stenosis once the reabsorption of the stent took place.

Secondary voice prosthesis insertion in patients without direct access to the upper esophagus

After total laryngectomy, voice rehabilitation can be achieved by use of voice prosthesis insertion (e.g. Blom-Singer®, Inhealth Technologies, USA; Provox®, Atos Medical, Sweden; Tracoe®, Tracoe Medical, Germany), esophageal voice or assistive digital speech device (e.g. Servox®, Servox AG, Germany). Various studies have shown that insertion of a voice prosthesis leads to superior rehabilitation results compared to other voice methods 1,2 and has become standard of care in many countries. However, insertion of voice prosthesis requires tracheo-esophageal puncture (TEP) which normally is performed during laryngectomy procedure or secondarily as an elective procedure following adjuvant therapy. Primary TEP allows almost direct visualization of the proposed TEP site and protection of the posterior esophageal wall by a rigid pharyngoscope or by the therefore introduced pharynxprotector (e.g. Provox Pharynx Protector®, Atos Medical, Sweden) In case of secondary puncture, the use of rigid scopes to protect the posterior pharyngeal wall and verify correct position of the prosthesis requires sufficient head reclination and mouth opening to ascertain adequate exposure of the upper esophagus and correct placement of the trocar. However, due to degenerative changes of the cervical spine, trismus, pharyngeal reconstruction (e.g. microvascular free tissue transfer), scar tissue formation in postirradiated patients or most often a combination of these factors, the upper esophagus sometimes cannot directly be accessed by rigid instruments. Alternative techniques for secondary TEP comprehend a special wire-guided TEP using a flexible scope 3, transnasal esophagoscopy with air insufflation 4 and a fiberoptic laryngoscope inserted in the cuffed part of an endotracheal tube for visualizing the puncture site 5. Even though these fiberoptic guided methods allow access to the upper esophagus and the puncture site can be directly visualized, safe TEP is compromised by the lack of a rigid abutment protecting the posterior esophagus wall and in some cases, air insufflation can lead to pneumomediastinum and mediastinitis due to a created “via falsa”. In our experience sufficient protection of the posterior esophagus wall is one of the key factors in preventing from possible TEP-complications, such as mediastinitis and sepsis 6. With regard to these few patients, who don’t qualify for secondary TEP by using rigid optic control, we opted for a simple, cheap and safe method to insert voice prosthesis after laryngectomy.

New Method for in-Office Secondary Voice Prosthesis Insertion under Local Anesthesia by Reverse Puncture from Esophageal Lumen

We clarify and demonstrate the utility of our new method of voice prosthesis insertion using puncture from the esophageal lumen. Our new reverse puncture method using a flexible endoscope can be performed in an outpatient clinic under local anesthesia. We conducted a clinical trial with patients with head and neck cancer between April 2010 and February 2012. Our study focused on the following three points: 1) the percentage of patients for whom the procedure was successful; 2) the duration of the operation; and 3) any adverse effects. The puncture was performed successfully for 21 of 22 patients (95%). The mean duration of the operation, excluding the time for local anesthesia, was only 11.6 minutes. All patients began voice rehabilitation and attained peroral intake immediately after the operation. None of the patients suffered complications from the procedures. Most patients were treated with our new method with ease and at low risk. The high success rate and the absence of complications demonstrate the benefits of our method. We conclude that our method can be recommended for secondary reverse tracheoesophageal puncture.

Intraoperative Tracheoesophageal Partywall Thickness (PWT) Measurement in Laryngectomy Patients Using Modified PROVOX Guidewire

Post laryngectomy voice rehabilitation using primary tracheoesophageal puncture (TEP) and voice prosthesis insertion is considered the "gold standard" method. No special effort is taken to measure the tracheoesophageal partywall thickness before inserting voice prosthesis. TE puncture related problems (peri-prosthetic leakage) are commonly seen in our population as compared to device failures (central leak). An accurate prosthesis inserted primarily may prevent the development of peri-prosthetic leakage. We surmise that tracheoesophageal party wall thickness (PWT) to be an important factor determining this phenomenon. There is still no consensus on the size of the prosthesis to be inserted during a primary TEP. To cater this, we propose a simple, quick and accurate method of measuring tracheoesophageal PWT intraoperatively. This method will guide us to determine an accurate prosthesis size which can be inserted during primary TEP. We also propose that this method will prevent future TE puncture related problems.

Customization of the voice prosthesis to prevent leakage from the enlarged tracheoesophageal puncture: Results of a prospective trial

Customization of the tracheoesophageal (TE) voice prosthesis (VP) is often preferred over surgical closure to prevent aspiration around the VP in laryngectomized patients with an enlarged tracheoesophageal puncture (TEP), but it has not been thoroughly evaluated. Single-institution prospective trial. A prospective trial was conducted to evaluate the effectiveness of a customized VP with the addition of an enlarged tracheal and/or esophageal collar in patients with leakage around an enlarged TEP. Absence of leakage around the VP after placement defined immediate effectiveness. Long-term success was defined by the prevention of adverse events related to leakage during the study period. Events that defined failure included: permanent gastrostomy dependence, aspiration pneumonia, and/or surgical TEP closure. Twenty-one patients with enlarged TEP were enrolled (2003-2006). Insertion of a customized VP was unsuccessful in one patient; 145 customizations were performed in the remaining 20 patients (median, 3.5 customizations) during the trial period. Of the customizations, 77% (112/145) prevented leakage immediately after VP insertion. The most common adverse event was dislodgement of the prosthesis (11%) or the collar alone (7%) in 18% (26/145) of customized VP placements. Six patients who died of disease were not evaluable for long-term outcomes. Long-term success was achieved in 80% (12/15) of evaluable patients who avoided permanent gastrostomy, aspiration pneumonia, and surgical TEP closure. Prosthetic customization offers an effective method to prevent leakage around the VP in many patients with an enlarged TEP, thereby preserving TE voice while avoiding surgical closure in this high-risk population.

Development and (pre-) clinical assessment of a novel surgical tool for primary and secondary tracheoesophageal puncture with immediate voice prosthesis insertion, the Provox Vega Puncture Set

Development and (pre-) clinical assessment were performed of a novel surgical tool for primary and secondary tracheoesophageal puncture (TEP) with immediate voice prosthesis (VP) insertion in laryngectomized patients, the Provox Vega Puncture Set (PVPS). After preclinical assessment in fresh frozen cadavers, a multicenter prospective clinical feasibility study in two stages was performed. Stage-1 included 20 patients, and stage-2 had 27. Based on observations in stage-1, the PVPS was re-designed (decrease in diameter of the dilator from 23.5 to 18 Fr.) and further used in stage-2. Primary outcome measure was immediate VP insertion without requiring additional instruments. Secondary outcome measures for comparison of the new with the traditional TEP procedure were: appreciation, ease of use, time consumption, estimated surgical risks and overall preference. A mini-max two-stage study design was used to establish the required sample size. In stage-1, dilatation forces were considered too high in patients with a fibrotic TE wall. With the final thinner version of the PVPS, VPs were successfully inserted into the TEP in ‘one-go’ in 24/27 (89%) of TEPs: 20 primary and 7 secondary. Participating surgeons rated appreciation, ease of use, time consumption and estimated surgical risks as better. Related adverse events were few and minor. The new PVPS appeared to be the preferred device by all participating surgeons. This study shows that the novel, disposable PVPS is a useful TEP instrument allowing quick and easy insertion of the VP in the vast majority of cases without requiring additional instruments.

Operativer Verschluss einer persistierenden tracheoösophagealen Provox-Fistel

Voice rehabilitation after laryngectomy by tracheo-esophageal puncture with insertion of voice prosthesis (provox, bloom singer) has proven a valuable tool for many years. However, in some patients major problems arise due to enlarged tracheo-esophageal fistulas causing troublesome aspiration. Many different approaches for closure of these fistulas have been suggested including major surgery like myocutaneous flaps. In the paper we describe our safe and reliable procedure of a three layered closure of tracheao-esophageal fistulas using a sliding trachea as the third layer.

Speech outcome of supracricoid partial laryngectomy: Comparison with total laryngectomy and anatomic considerations

Objective We studied speech after a supracricoid partial laryngectomy (SCPL) and compared it to speech after a total laryngectomy and insertion of voice prosthesis (TL-VP). We also determined the anatomical factors related to speech after SCPL. Study Design and Setting Historic cohort study. Patients were recruited for data collection. Subjects and Methods We enrolled 28 patients who had undergone SCPL or TL-VP for laryngeal cancer from 1995 to 2005 (15 with SCPL and 13 with TL-VP). Patients had no recurrence, no respiratory problems, and were followed-up more than one year. Using sustained vowel phonation and standard paragraph reading, maximum phonation time, maximum loudness, total time for reading the paragraph, number of syllables per breath, and speech intelligibility were tested, and the patients' self satisfaction was evaluated using the Voice Handicap Index questionnaire. In addition, we performed stroboscopic examination for the SCPL group to study the configuration of the neoglottis during phonation. Results Maximum phonation time was longer in the TL-VP group than in the SCPL group ( P = 0.048). There was no significant difference in the other parameters between the groups. With stroboscopic examination, we observed widely variable findings with reference to arytenoid mobility, mucosal vibration, and neoglottic occlusion in the SCPL group. Conclusions Speech after SCPL was not better than speech after TL-VP and was widely variable. The configuration of the neoglottis during phonation in the SCPL group was also variable. We believe that some technical refinement during the operation could improve speech outcome after SCPL.

Treatment outcome in patients undergoing surgery for carcinoma larynx and hypopharynx – a follow-up study

Conclusions: Compared with larynx cancers salvage rates are poorer for hypopharyngeal cancers and the role of primary surgery seems to be significantly higher and more decisive in overall survival (OS). Hypopharyngeal cancers therefore warrant a closer follow-up after an organ preservation protocol, to detect recurrence at the earliest stage and plan for an effective salvage surgery. Objective: To evaluate the survival and morbidity of patients treated by surgery for carcinoma of the larynx and hypopharynx according to site. Patients and methods: All patients who had undergone laryngectomy at the Division of Surgical Oncology Regional Cancer Center (RCC) from June 1995 to December 2005 were included in the study, which retrospectively recorded the age and sex distribution, TNM stage, indication, type of laryngectomy and reconstructive option used. The therapeutic outcome, disease-free survival (DFS), OS, voice preservation and postoperative voice rehabilitation were analysed. Results: Of a total of 167 cases, 123 (74%) had salvage surgery for failed chemoradiotherapy/radical radiotherapy and 44 (26%) had primary surgical treatment. Conservation surgery was undertaken in 4 cases, near total laryngectomy or pharyngectomy (NTL/NTLP) was done in 14 and total laryngectomy (TLPE) with gastric pull up was done in 5. Total laryngectomy (TL) or TL with partial or subtotal pharyngectomy was done in 144 cases. Concomitant neck dissection (ND) was done in 46 cases, 14 posterolateral selective, 15 radical neck dissections (RNDs), 2 extended RNDs, 12 bilateral NDs and 3 modified neck dissections (MNDs). Five patients received platinum-based neoadjuvant chemotherapy and nine had postoperative chemotherapy. In 116 patients the pharyngeal remnant was closed primarily, 21 patients had pectoralis major myocutaneous flap patch reconstruction, 18 had tubed pectoralis major myocutaneous (PMMC) flap reconstruction, 4 had folded (bipaddled) PMMC flap reconstruction, 7 had PMMC and 3 patients had deltopectoral (DP) flap for skin cover. Pathological margin positivity was seen in seven cases and perinodal disease was seen in nine. There was a statistically significant survival difference between salvage and primary surgical cases among cancers of the larynx and hypopharynx. Hypopharyngeal salvage rate was significantly lower in the present study. Sixty-two (37%) patients had postoperative leaks. Five leaks persisted to form pharyngocutaneous fistulae. All of these patients had either wound infection with or without flap necrosis or previous radiation. Two were repaired and in two cases speech prosthesis insertion was possible due its anatomical position. One patient refused further surgical closure after a partially failed repair. Fifty-six (34%) patients recurred locoregionally, 4 (2.3%) patients developed a second primary and 5 (2.9%) had distant metastasis. Thirty patients were voice rehabilitated with an electronic larynx. Seventeen patients had voice prosthesis insertion (6 primary and 10 secondary), 3 patients developed good oesophageal speech and voice preservation was possible in 18 patients. Seventy-nine patients were alive at the time of completing the study.

Long‐Term Quality of Life After Total Laryngectomy and Postoperative Radiotherapy Versus Concurrent Chemoradiotherapy for Laryngeal Preservation

To compare the quality of life (QoL) of patients who underwent total laryngectomy with voice prosthesis insertion and postoperative radiotherapy (PORT) with those receiving concurrent chemoradiation for laryngeal preservation. Retrospective, cross-sectional study in a tertiary academic center. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaires were used to assess long-term QoL in 67 patients treated for laryngeal cancer. The scores of functional scales for physical (P < .000), social (P = .001), and role functioning (P = .043) were more favorable in the chemoradiation group. The global QoL score was higher in the nonsurgical group (P = .016). Surgical patients reported on sleep disturbance (P < .000), dyspnea (P = .001), and pain (P = .003), with a higher scores and greater difficulties with the senses (P < .000), social contact (P = .002) and speech (P = .010). The chemoradiation group reported greater problems with dry mouth (P < .000) and sticky saliva (P = .005). We found better long-term QoL scores in patients undergoing concurrent chemoradiation. This appears to be mainly because of better physical functioning, social functioning, and social contact and smaller problems with pain, respiration, speech, the senses, and sleep disturbances.

Voice Quality After Supracricoid Laryngectomy and Total Laryngectomy With Insertion of Voice Prosthesis

Vocal quality was analyzed in 20 subjects who underwent total laryngectomy with insertion of voice prosthesis (TL with VP) and in 10 subjects who underwent supracricoid laryngectomy (SCL). Acoustic analysis was carried out using Lingwaves and Praat, for sustained vowels and conversation to obtain the fundamental frequency (F(0)) and jitter parameters. Perceptual evaluations and self-assessment of voice impact on the quality of life were also performed. Results showed statistically significant differences between TL+VP and SCL individuals for the mean F(0) during conversation, for Roughness, Grade of voice quality, and self-assessment of speech, with worst results in the SCL group.

Long-term Results with Tracheoesophageal Voice Prosthesis: Primary versus secondary TEP

The aim of this study was to evaluate the influence of timing of tracheoesophageal puncture (TEP)with indwelling voice prosthesis insertion regarding long-term success rate and postoperative complication. We conducted a Retrospective clinical study at tertiary academic center. There were 75 patients with primary TEP (80.6%) and 18 with secondary TEP (19.3%). Long-term success rate was 81.7%, with 80.0% in primary TEP and 88.9% in secondary TEP. No significant difference in Harrison-Robillard-Schultz Rating Scale success assessment were observed between patients with primary and secondary TEP (P = .596). The use of postoperative radiotherapy did not significantly influence the success rate. The age of patients who were older or younger than 60 years significantly influence the success rate in primary TEP (P = .012). The higher rate of complications in primary TEP was not statistically significant. These findings suggest that primary and secondary TEP are equally safe and effective procedures. Primary TEP should be preferred because of avoiding a second surgical intervention and allowing early voice restoration with a considerable psychological impact.

Voice prosthesis insertion after endoscopic balloon-catheter dilatation in case of a stenotic hypopharyngo-oesophageal junction

Stenosis of the hypopharyngo-oesophageal junction can be a rare complication of laryngectomy and/or partial pharyngectomy and makes the insertion of voice prosthesis extremely difficult. This study describes the authors' experiences gained by endoscopic balloon-catheter dilatation of hypopharyngo-oesophageal stenoses prior to implantation of voice prostheses in four cases. In two patients a single balloon-catheter dilatation resulted in wide enough pharyngo-oesophageal lumen on the long run. The average prosthesis wearing-times were 6.8 months in case 1 and 4.6 months in case 2, corresponding to the published literature data. In case 3, repeated dilatation of the pharyngo-oesophageal transition had proved to be unsuccessful despite taking every effort with the endoscopic balloon-catheter method. Having excised the stenotic segment, reconstruction with pectoralis major myocutaneous flap (PMMF) was indicated. Eighteen months later, a repeated restenosis was observed and a free jejunal flap needed to be performed as a final solution. In case 4, the insertion was carried out into a previously dilated jejunal free flap, which became gradually ischemic and stenotic since the major head-and neck procedure was carried out that resulted in prosthesis rejection after just 1 week. The authors emphasize that correct indication of pedicled and free flaps in head and neck reconstruction is a prerequisite from the aspect of prevention of pharyngo-oesophageal strictures. Endoscopic balloon-catheter dilatation is a safe and established method for dilatating hypopharyngo-oesophageal stenoses of different origin. The procedure provides maximum patient benefit with minimal trauma and morbidity; moreover, facilitates insertion of voice prostheses. However, a single balloon-catheter dilatation cannot always result in wide enough oesophageal lumen on the long run (case 3). Insertion of a voice prosthesis into a previously dilated ischemic jejunal segment is challenging and avoidable due to risks of complications.

Die Kollageninjektion zur Augmentation des insuffizienten Stimmprothesenlagers

After laryngectomy the majority of patients receive a vocal rehabilitation by tracheo-esophageal puncture and insertion of voice prosthesis. Periprosthetic leakage causing aspiration represents a well known complication and is frequently treated by temporary removal of the prosthesis with shrinkage of the shunt. Here we describe 10 patients with such a leakage treated by collagen injection for periprosthetic tissue augmentation. A mean of 1,6 injections were necessary for complete control of the leakage. The injection was well tolerated and was found effective for median period of 9,3 months. In our hands the periprosthetic collagen injection represents an effective and well tolerated procedure for temporary augmentation of tracheo-esophageal leakage in post-laryngectomy patients. However, alternative fillers without pre-testing necessity and longer augmentation intervals should be considered.

Managing problems with tracheoesophageal puncture for alaryngeal voice rehabilitation

The tracheoesophageal puncture (TEP) technique and the insertion of its associated voice prostheses may give rise to adverse events. We present our experience with this technique, paying special attention to the incidence and management of these adverse events. A retrospective clinical analysis was undertaken. Seventy-five laryngectomized patients underwent TEP for voice restoration. They were divided into two groups: group one, 43 patients with secondary TEP; and group two, 32 patients with primary TEP. Patient medical records were reviewed for data on the incidence, management and outcome of adverse events encountered during patients' follow up. Problems that arose in the patients were itemized as either early or late. The same patient could develop one or more problems in either group. The management of these problems, concerning the creation and maintenance of the TEP and associated prostheses, was noted. In group one, results were initially favourable in 91 per cent of patients and still positive in 81.4 per cent after three years. In group two, early results were favourable in all patients, and only two patients asked for late elective closure of the TEP (with a success rate of 93.7 per cent). Via an intensive and multidisciplinary approach to problems, most of the inevitable adverse events could be solved adequately, minimizing the discomfort of patients who had undergone laryngectomy and indwelling voice prosthesis insertion.

Die Custom-fit-Stimmprothese

Leakage around an indwelling voice prosthesis is detected during 13% up to 27% of all replacement procedures of voice prosthesis and causes serious complications in further voice restoration of the laryngectomee. Lots of therapeutic options to stop periprothetic leakage have been described (Injection of Bioplastique, autologous fat or collagen, suture techniques, spacer therapy) without convincing success rates. Custom-fit voice prostheses are ordinary indwelling voice prostheses (Blom-Singer low pressure Indwelling 20 fr) with enlarged flanges and reduced shaft length that are individually sized for the shunt of the laryngectomee. Especially enlarging the esophageal flange provides a tight sealing of leakage around the prosthesis. In a one year lasting clinical trial 692 voice prostheses were changed. In 77 cases periprothetic leakage was detected and fistulas were fitted with individually sized voice prostheses. In 76 cases total control of leakage was achieved without any specific complications taking place. Moreover two types of leaking tracheoesophageal fistulas were distinguished, a dilated-atrophic and an infected-necrotic type. 57% of the fistulas were dilated-atrophic type and 43% of the fistulas were classified infected-necrotic type. Infected-necrotic fistulas needed enlarged flanges tracheal an esophageal for tight sealing in 91% of the cases whereas dilated-atrophic fistulas needed double flanges only in 45%. 70% of infected-necrotic type fistulas needed only one singular history of a custom-fit prosthesis and could be changed back to ordinary indwelling prostheses after healing had taken place. As the insertion of a modified prosthesis is only slightly more effort than an ordinary voice prosthesis insertion, the success rate is high und complications are rare we recommend the custom-fit voice prosthesis for treatment of periprothetic leakage.

Voice restoration by primary insertion of indwelling voice prosthesis following circumferential pharyngolaryngectomy with free jejunal graft

Background: Voice restoration after circumferential pharyngolaryngectomy (CPL) with free jejunal graft remains a difficult problem to solve. Few reports have analyzed the success rate and complications following primary insertion of indwelling voice prostheses during CPL with free jejunal graft. Patients and methods: Eight patients who underwent CPL with free jejunal graft had a Groningen voice prosthesis inserted as a tracheoesophageal (TE) shunt at the time of oncological surgery. A 10-point scale was used to assess each patient's speech intelligibility. Complications following the voice prosthesis insertion were also analyzed. Results: Six of the eight patients (75%) achieved excellent speech intelligibility and the remaining two patients (25%) were judged as moderate. Six of the eight patients (75%) used the TE shunt as their major means of daily communication. Leakage through or around the prosthesis, which occurred in six (75%) patients, was the most frequent prosthesis-related complication. Conclusions: This safe and reliable technique can be effective in improving the quality of life in selected patients undergoing CPL.

Secondary tracheoesophageal puncture under local anaesthesia

Introduction. In the Netherlands, primary tracheoesophageal puncture and voice prosthesis insertion is the current method of choice in prosthetic voice rehabilitation after laryngectomy. Secondary, or delayed, puncture is only performed if contraindications for primary puncture apply. Also, in patients with recurrent fistula-related problems, temporary closure of the fistula and consequent secondary puncture may be indicated. Secondary puncture, a minor and quick procedure, is performed under general anaesthesia. To decrease unnecessary patient burdens such as hospital admission or general anaesthesia, we developed a secondary procedure to be performed under local anaesthesia in the outpatient department. The patients were laryngectomized and in whom primary puncture was contraindicated owing to the extent of surgery, and those with persistent fistula-related problems needing a fresh tracheoesophageal puncture. Methods. After application of local anaesthetic, an insufflated balloon (to prevent oesophageal damage) was placed in the oesophagus at the desired fistula site. The tracheoesophageal puncture, in which the balloon was punctured, was performed under endoscopic imaging and the prosthesis was consequently inserted with the aid of a guide wire. Results. Patients do not experience the procedure as cumbersome. The procedure is easily performed and forms a quick and painless insertion technique with good results. Conclusion. This is a quick, easy and painless method for secondary puncture to be used in the outpatient clinic under local anaesthesia.

Effect of antifungal agents on indwelling voice prosthetic biofilms

Rehabilitating the lost voice of laryngectomy patients by insertion of a silicone rubber voice prosthesis is now generally considered to be superior to any other form of substitute voice production. However, a drawback of these implants is the rapid colonization by a mixed biofilm of bacteria and yeasts, mainly Candida species, leading to failure and frequent exchange of the implant. A strategy frequently applied by otolaryngologists is oropharyngeal yeast decontamination by using antifungal agents, despite the fact that there is no compelling evidence that prescription of antifungal agents will prolong the lifetime of voice prostheses. Moreover, the prophylactic use of antifungal agents contributes to the development of resistant strains. Alternative approaches to prolonging the lifetime of silicone rubber voice prostheses may be found in modification of the silicone rubber surface of the implant, diet supplementation with active, probiotic bacteria, or salivary substitutes with synthetic antimicrobial peptides. Curr Opin

Primary Speech Restoration at Laryngectomy by Insertion of Voice Prosthesis - 10 Years' Experience

A total of 88 patients underwent laryngectomy at the ENT Department, Gentofte University Hospital, Hellerup, Denmark, from May 1989 to May 1999. Of these, 85 patients underwent salvage operations for squamous cell laryngeal carcinoma after previous full course radiotherapy. A total of 76 patients had primary tracheo-oesophageal puncture performed at the time of laryngectomy, 11 had a secondary procedure performed, 7 of these had been laryngectomized elsewhere. Eight patients were not eligible for tracheo-oesophageal puncture due to age, social reasons or extensive surgery. In all, 79 patients were able to use the prosthesis for communicative purposes weeks after the operation and developed fluent speech. During the observation time, 14 patients had their voice prosthesis removed or disconnected for various reasons. The average life duration for Provox voice prosthesis generation I vs Provox generation II was 3.1 and 2.3 months, respectively.