My Prosthesis Leaks - What can I do?
Carla DeLassus Gress, ScD,CCC-SLP, UCSF Voice Center
Box 1703, San Francisco, CA 94143-1703

As others have said, the first thing to decide is whether the leak is coming from AROUND the prosthesis or THROUGH it. These are very different problems and have different solutions, though the end result is the same - aspiration of liquids, coughing, and in the worst case, pneumonia.

Let's assume the leak is AROUND the prosthesis. If that is not the case, then ignore the following discussion.

With respect to leaving the prosthesis out over night - I have never known this to be a good idea, and I'm curious as to what the rationale was for someone recommending it. I assume it was because the leak was AROUND the prosthesis, and the clinician thought that the puncture had dilated and this would help the puncture shrink down to a smaller size. But you risk the puncture closing up entirely, which would then require further surgery to re-establish the puncture tract, and in the meantime, you would be aspirating saliva and possibly gastric acid into the lungs if you have tendencies toward reflux. Granted that at night the frequency of spontaneous swallowing decreases so that it may not be a lot of aspiration, but a person would still be aspirating. That is not good for the health of the lungs.

If the leak is AROUND the device because the puncture has dilated, then the clinician needs to determine WHAT CAUSED THE PUNCTURE TO DILATE? There can be many reasons. The most common is that the prosthesis is too long and is pistoning in the tract, causing it to dilate. But you should be able to see the prosthesis pistoning as you swallow. One shouldn't just assume that this is the problem and go to a shorter size. Doing that could get you into trouble with the puncture closing because the prosthesis was too short. If it is just a slight bit too long, not a full size difference, a retention collar can help to tighten the fit.

If the prosthesis is the correct size, the next thing to consider is your swallowing mechanism in relation to the puncture location. Sometimes we see leakage around (as well as through) the device when there is a puncture that is angled straight up and there is (what I call) a "high-pressure swallow" (you hear a "gulp" or "klunk" with the swallow instead of silence. This is usually the result of a narrowed area of the pharynx or esophagus, and a person needs to do an extra push to get the food or liquid bolus through. That means that the bolus is traveling with extra force, and that can cause some leakage. The narrowing should be visible on a fluoroscopy (a type of motion picture xray). The solution here is to try to swallow "gently" (don't laugh!) or to have the ENT dilate the throat to ease the swallowing process.

The other possibility is that there is some compromise to the health of the tissue around the puncture. This can be due to heavy radiation, especially if it was directed to the stoma region. There is not much to be done for repairing the tissue due to radiation, except in severe cases, hyperbaric oxygen is recommended. It is helpful however, to use a retention collar to act like a washer and help seal the prosthesis against the tissue.

Other causes of weakened tissue around the puncture include: thyroid dysfunction (check with a blood test), diabetes (blood test), or other immune system problems. It can also be due to chronic malnutrition, as seen commonly in individuals who are heavy alcohol consumers. Another reason can be recurrent or persistent disease, not just in the throat, but we see leakage around the puncture in the late stages of liver, lung, prostate
cancers, etc.

It is my opinion that when the tissue is weakened for whatever reason, it is helpful to use a very soft prosthesis, rather than the stiffer extended wear types. And we usually like to stick with the 16 French smaller diameter if possible. Sometimes the tissue is so weak that it simply can't support the weight of a heavier prosthesis. It does not make sense to use a larger diameter prosthesis to solve the problem of a dilating puncture as though you are plugging a bigger hole with a bigger cork (contrary to some all-too-common misconceptions), as this will just irritate the puncture tissue further and result in more dilation.

So my recommendation to you is to have your clinicians put their heads together and find out WHY you are having the leakage. Then you'll have a shot at fixing the problem.