European Archives of Oto-Rhino-Laryngology

, Volume 267, Issue 10, pp 1579–1586 | Cite as

Microbial colonization of tracheoesophageal voice prostheses (Provox2) following total laryngectomy

  • Brigita TićacEmail author
  • Robert Tićac
  • Tomislav Rukavina
  • Palmira Gregorović Kesovija
  • Dijana Pedisić
  • Boris Maljevac
  • Radan Starčević


The purpose of this study was to determine the presence of individual microorganisms and the most frequent microbial combinations in the biofilm of the indwelling Provox2 voice prosthesis in situ. Furthermore, we wanted to evaluate the possible influence of biofilm composition on the mean and median lifetime of these voice prostheses. Over a 5-year period, implantation of a Provox2 voice prosthesis was performed in 85 patients, or 90% of the overall number of patients who underwent total laryngectomy. In total 100 implanted voice prostheses, at least one of every patient, were microbiologically processed immediately after being replaced. Out of the total of 292 isolates, 67% were bacteria and the remaining 33% were yeasts. The most frequently found yeast species on voice prostheses biofilms was C. albicans, followed by C. krusei and C. tropicalis. The most frequently isolated bacteria included Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Proteus mirabilis, and Streptococcus agalactiae. Simultaneous presence of bacteria and fungi was established in 83% of the processed voice prostheses; in 16% of samples the biofilm contained only one or more bacterial species. The mean time of implantation was 238 days and the median lifetime of the device was 180 days. Dividing the prostheses in four groups according to the composition of biofilm revealed that the device lifetimes varied significantly between groups. The longest lifetime of voice prostheses was associated with the presence of single fungal isolate in combination with bacteria. There is a significant correlation between biofilm composition and the device life time.


Microbial colonization Voice prostheses Provox Laryngectomy 



The authors thank Prof. Frans JM Hilgers MD, PhD, for practical and theoretical training, and his critical review of manuscripts. This paper is partially financially supported by research grants 062-0621273-0952 and 062-0621273-0951 of the Ministry of Science, Education and Sport of the Republic of Croatia.

Conflict of interest statement

The authors declare that they have no conflict of interest.


  1. 1.
    Manni JJ, van den Broek P, de Groot MA, Berends E (1984) Voice rehabilitation after laryngectomy with the Groningen prosthesis. J Otolaryngol 13:333–336PubMedGoogle Scholar
  2. 2.
    Panje WR (1987) Experience with Panje voice prosthesis. Rev Laryngol Otol Rhinol 108:129–137Google Scholar
  3. 3.
    Singer MI, Hamaker RC, Blom ED, Yoshida GY (1989) Applications of the voice prosthesis during laryngectomy. Ann Otol Rhinol Laryngol 98:921–925PubMedGoogle Scholar
  4. 4.
    Singer MI, Blom ED (1990) Medical techniques for voice restoration after total laryngectomy. CA Cancer J Clin 40:166–173CrossRefPubMedGoogle Scholar
  5. 5.
    Hilgers FJM, Schouwenburg PF (1990) A new low-resistance, self-retaining prosthesis (Provox) for voice rehabilitation after total laryngectomy. Laryngoscope 100:1202–1207CrossRefPubMedGoogle Scholar
  6. 6.
    Hilgers FJM, Ackerstaff AH, van As CJ (1999) Tracheoesophageal puncture: prosthetic voice management. Curr Opin Otolaryngol Head Neck Surg 7:112–118CrossRefGoogle Scholar
  7. 7.
    Ackerstaff AH, Hilgers FJM, Meeuwis CA, van den Hoogen FJA, Marres HA et al (1999) Multi-institutional assessment of the Provox 2 voice prosthesis. Arch Otolaryngol Head Neck Surg 125:167–173PubMedGoogle Scholar
  8. 8.
    Op de Coul BMR, Hilgers FJM, Balm AJ, Tan IB, van den Hoogen FJA, van Tinteren H (2000) A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single institution’s experience with consistent application of Provox indwelling voice prostheses. Arch Otolaryngol Head Neck Surg 126:1320–1328PubMedGoogle Scholar
  9. 9.
    Soolsma J, van den Brekel MW, Ackerstaff AH, Balm AJ, Tan B, Hilgers FJM (2008) Long-term results of Provox ActiValve, solving the problem of frequent Candida-and “underpressure”-related voice prosthesis replacements. Laryngoscope 118:252–257CrossRefPubMedGoogle Scholar
  10. 10.
    Elving GJ, van der Mei HC, van Weissenbruch R, Busscher HJ, Albers FWJ (2002) A comparison of the microbial composition of voice prosthetic biofilms from patients requiring frequent versus infrequent replacements. Ann Otol Rhinol Laryngol 111:200–203PubMedGoogle Scholar
  11. 11.
    Millsap KW, Bos R, van der Mei HC, Busscher HJ (2001) Adhesive interactions between voice prosthetic yeast and bacteria on silicone rubber in the absence and presence of saliva. Antonie Van Leeuwenhoek 79:337–343CrossRefPubMedGoogle Scholar
  12. 12.
    Everaet EPJM, van der Mei HC, Busscher HJ (1998) Adhesion of yeasts and bacteria to fluoro-alkyl-siloxane layers chemisorbed on silicone rubber. Colloids Surf B Biointerfaces 10:179–190CrossRefGoogle Scholar
  13. 13.
    de Carpentier JP, Ryder WD, Saeed SR, Woolford TJ (1996) Survival times of Provox valves. J Laryngol Otol 110:37–42PubMedGoogle Scholar
  14. 14.
    Donlan RM, Costerton JW (2002) Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 15(2):167–193CrossRefPubMedGoogle Scholar
  15. 15.
    Aniansson G, Alm B, Andersson B, Larsson P, Nylén O, Peterson H, Rignér P, Svanborg M, Svanborg C (1992) Nasopharyngeal colonization during the first year of life. J Infect Dis 165(Suppl 1):38–42Google Scholar
  16. 16.
    Mahieu HF, van Saene HKF, Rosingh HJ, Schutte HK (1986) Candida vegetations on silicone voice prostheses. Arch Otolaryngol Head Neck Surg 112:321–325PubMedGoogle Scholar
  17. 17.
    van den Hoogen FJA, Mj Oudes, Hombergen G, Nijdam HF, Manni JJ (1996) The Groningen, Nijdam and Provox voice prostheses: prospective clinical comparison based on 845 replacements. Acta Otolaryngol 116:119–124CrossRefGoogle Scholar
  18. 18.
    Elving GJ, van der Mei HC, Busscher HJ, van Nieuw Amerongen A, Veerman EC, van Weissenbruch R, Albers FW (2000) Antimicrobial activity of synthetic salivary peptides against voice prosthetic microorganisms. Laryngoscope 110:321–324CrossRefPubMedGoogle Scholar
  19. 19.
    Hilgers FJM, Ackerstaff AH, Balm AJM, Tan IB, Aaronson NK, Persson JO (1997) Development and clinical evaluation of a second-generation voice prosthesis (Provox 2), designed for anterograde and retrograde insertion. Acta Otolaryngol 117:889–896CrossRefPubMedGoogle Scholar
  20. 20.
    Hilgers FJM, Balm AJM (1993) Long-term results of vocal rehabilitation after total laryngectomy with the low-resistance, indwelling Provox™ voice prosthesis system. Clin Otolaryngol 18:517–523CrossRefPubMedGoogle Scholar
  21. 21.
    Hilgers FJM, Ackerstaff AH, Balm AJM, van den Brekel MWM, Tan IB, Persson JO (2003) A new problem-solving indwelling voice prosthesis, eliminating the need for frequent Candida-and “underpressure”-related replacements: Provox ActiValve. Acta Otolaryngol 123:972–979CrossRefPubMedGoogle Scholar
  22. 22.
    Laccourreye O, Menard M, Crevier-Buchman L, Couloigner V, Brasnu D (1997) In situ lifetime, causes for replacement, and complications of the Provox voice prosthesis. Laryngoscope 107:527–530CrossRefPubMedGoogle Scholar
  23. 23.
    Elving GJ, van der Mei HC, Busscher H, van Weissenbruch R, Albers F (2003) Influence of different combinations of bacteria and yeasts in voice prosthesis biofilms on air flow resistance. Antonie Van Leeuwenhoek 83:45–55CrossRefPubMedGoogle Scholar
  24. 24.
    Free RH, van der Mei HC, Elving GJ, van Weissenbruch R, Albers FWJ, Busscher HJ (2003) Influence of the Provox flush®, blowing and imitated coughing on voice prosthetic biofilms in vitro. Acta Otolaryngol 123:547–551CrossRefPubMedGoogle Scholar
  25. 25.
    Palmer MD, Johnson AP, Elliott TSJ (1993) Microbial colonization of Blom-Singer prostheses in postlaryngectomy patients. Laryngoscope 103:910–914CrossRefPubMedGoogle Scholar
  26. 26.
    Leunisse C, van Weissenbruch R, Busscher HJ, van der Mei HC, Albers FWJ (1999) The artificial throat: a new method for standardization of in vitro experiments with tracheo-oesophageal voice prostheses. Acta Otolaryngol 119:604–608PubMedGoogle Scholar
  27. 27.
    Elving GJ, van Weissenbruch R, Busscher HJ, van der Mei HC, Albers FWJ (2002) The influence of radiotherapy on the lifetime of silicone rubber voice prostheses in laryngectomized patients. Laryngoscope 112:1680–1683CrossRefPubMedGoogle Scholar
  28. 28.
    Schwandt LQ, van Weissenbruch R, van der Mei HC, Busscher HJ, Albers FW (2005) Effect of dairy products on the lifetime of Provox2 voice prostheses in vitro and in vivo. Head Neck 27(6):471–477CrossRefPubMedGoogle Scholar
  29. 29.
    Jelinić JD, Cvetković JP, Nola IA, Senta A, Milošević M, Kern J (2009) Regional differences in dietary habits of adult Croatian population. Coll Antropol 33(Suppl 1):31–34PubMedGoogle Scholar
  30. 30.
    Neu TR, Verkerke GJ, Herrmann IF, Schutte HK, van der Mei HC, Busscher HJ (1994) Microflora on explanted silicone rubber voice prostheses: taxonomy, hydrophobicity and electrophoretic mobility. J Appl Bacteriol 76:521–528PubMedGoogle Scholar
  31. 31.
    Neu TR, De Boer CE, Verkerke GJ, Schutte HK, Rakhorst G, van der Mei HC, Busscher HJ (1999) Biofilm formation in vivo on perfluoro-alkylsiloxane-modified voice prostheses. Arch Otolaryngol Head Neck Surg 125:1329–1332Google Scholar
  32. 32.
    Hilgers FJM, Cornelissen MW, Balm AJM (1993) Aerodynamic characteristics of the low-resistance, indwelling Provox™ voice-prosthesis. Eur Arch Otorhinolaryngol 250:375–378CrossRefPubMedGoogle Scholar
  33. 33.
    Hilgers FJM, Jansen HA, van As CJ, Polak MF, Muller MJ, van Dam FSAM (2002) Long-term results of olfaction rehabilitation in laryngectomized individuals using the nasal airflow-inducing ‘Polite Yawn-ing’ maneuver. Arch Otolaryngol Head Neck Surg 128:648–654PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Brigita Tićac
    • 2
    • 3
    Email author
  • Robert Tićac
    • 1
  • Tomislav Rukavina
    • 2
    • 4
  • Palmira Gregorović Kesovija
    • 2
  • Dijana Pedisić
    • 1
  • Boris Maljevac
    • 1
  • Radan Starčević
    • 1
  1. 1.Clinic of OtorhynolaryngologyClinical Hospital Center RijekaRijekaCroatia
  2. 2.Department of MicrobiologyTeaching Institute of Public HealthRijekaCroatia
  3. 3.Department of Microbiology and Parasitology, Medical FacultyUniversity of RijekaRijekaCroatia
  4. 4.Department of Social Medicine and Epidemiology, Medical FacultyUniversity of RijekaRijekaCroatia

Personalised recommendations