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Leakage through the prosthesis may occur in association with candida overgrowth, underpressure in the esophagus, or displacement of the radiopaque ring (valve seat, very rare). Endoscopic examination should be performed to determine whether either of these phenomena has occurred. Dislodgment of the radiopaque ring (very rare) is an indication for replacement of the prosthesis and also for thorough examination of the patient to make sure that the dislodged ring not has been aspirated. If so, it should be removed immediately from the tracheobronchial tree with appropriate bronchoscopy equipment. If the radiopaque ring has not been dislodged, and if cleaning of the prosthesis does not resolve the leakage through it, the cause is usually candida overgrowth and replacement of the prosthesis is indicated. In case of early/frequent leakage, underpressure is often the case and the Provox Activalve can fix the problem.