The increasing use of voice prostheses has improved the prospects of vocal rehabilitation after
total laryngectomy considerably. Consistently high success rates have been reported in the last 35
years, after the first description of a useful prosthetic device by Singer and Blom in 1980.1
Compared with esophageal and electrolarynx speech, a higher percentage of patients achieve an
acceptable voice, enabling communication under almost all social circumstances. Success rates
up to 90% are not exceptional any longer, making prosthetic voice rehabilitation the method of
choice for early and reliable restoration of oral communication after total laryngectomy.2
In general, two types of voice prosthesis can be distinguished, i.e. non-indwelling and indwelling
devices. The former devices can be removed and replaced by the patient. The latter stay in place
permanently and have to be removed and replaced by the clinician at the end of the device life,
which is determined by leakage of fluids through the prosthesis or an increased airflow resistance.
Indwelling devices have the definite advantage that the patient’s dexterity plays a less important
role in the daily maintenance of the device, which mainly consists of cleaning with a brush and/or
a flushing device without the need of regularly replacing the prosthesis. Even with increasing age
and/or decreasing health a useful (prosthetic) voice can be preserved.
Based on our experiences with surgical and prosthetic voice rehabilitation (Staffieri’s procedure,
and the Blom-Singer, Panje, and Groningen prostheses), acquired since 1979 in the Department
of Otolaryngology-Head & Neck Surgery of the Netherlands Cancer Institute, we co-developed
since 1988 a novel low-resistance, indwelling silicon voice prosthesis, Provox, in close
collaboration with the medical engineering industry.3,4 It has been successfully used in our Institute
since then in all laryngectomized patients. The long-term clinical results obtained with this voice
prosthesis are favorable.2,5-7
Additional instruments and devices to facilitate its application have been developed as well.3 Their
use, along with the surgical techniques involved and the management of many of the clinical and
technical aspects, are the subject of this manual. The subsequent development of a second
generation (Provox2) voice prosthesis for bidirectional, i.e. anterograde and retrograde,
application is a further improvement of the Provox system.8 The anterograde replacement in the
outpatient office has considerably decreased the discomfort of this procedure for the patient and
the medical professionals involved.8,9 Further improvements since development of Provox2 will be
discussed in the various voice rehabilitation chapters.
The problem of post-laryngectomy pulmonary function disorders has also been addressed
extensively in our clinic.10-12 The relevance of simultaneous pulmonary rehabilitation for optimal
voice restoration and an improved quality of life has become increasingly clear in recent years.13-15
The development of a novel, dedicated ‘valved’ Heat and Moisture Exchanger (HME, Provox
HME) has added a new tool to the armamentarium of the clinicians, in this respect.16-18 Further
improvements since the development of the first generation Provox HMEs will be discussed in the
various pulmonary rehabilitation chapters.
Hands-free speech is the ultimate goal of postlaryngectomy voice rehabilitation, preferably taking
care of pulmonary protection and rehabilitation at the same time. This is now possible with the
newly developed Provox FreeHands HME.19 Further improvements since the development of
FreeHands will be discussed in the chapter on hands free speech.
A further problem resulting from the permanent disconnection of the upper and lower airways is a
deterioration of the sense of smell. The main cause for this disturbing side effect of total
laryngectomy is the lack of a nasal airflow, which normally transports odorous substances to the
olfactory epithelium high up in the nose. There are two types of smelling: ‘passive’ and ‘active’
smelling. Passive smelling continuously takes place during normal nasal breathing, whereas
active smelling (‘sniffing’) is used intentionally. Research in our Institute has given more insight in
the magnitude of the olfaction problem after total laryngectomy.20 Stoma breathing precludes
passive smelling and only some 30% of the patients is still able to actively smell something.
However, it now appears to be possible to restore olfaction in a considerable number of
laryngectomized individuals.21,22 The nasal airflow-inducing maneuver (NAIM, also called ‘polite
yawning’ technique, since that is what the maneuver is mimicking) enables active smelling again,
will be described in detail. Further research underpinning the validity of the NAIM, since it’s
conception early 2000, will be presented as well.
It should be stressed that vocal, pulmonary and olfactory rehabilitation after total laryngectomy is a
multi-disciplinary team effort and that the motivation of the Otolaryngologist, the (Head Neck)
oncology nurse, the speech therapist and last, but not least, of the patient is mandatory to obtain
optimal results.
Amsterdam 2003/2016
References
1. Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol
Laryngol 1980; 89:529-533.
2. Op de Coul BM, Hilgers FJ, Balm AJ, Tan IB, van den Hoogen FJ, van TH. 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 2000; 126:1320-1328.
3. Hilgers FJM, Schouwenburg PF. A new low-resistance, self-retaining prosthesis (Provoxr) for voice
rehabilitation after total laryngectomy. Laryngoscope 1990; 100:1202-1207.
4. Hilgers FJ, Cornelissen MW, Balm AJ. Aerodynamic characteristics of the Provox low-resistance indwelling
voice prosthesis. EurArchOtorhinolaryngol 1993; 250:375-378.
5. Hilgers FJM, Balm AJM. Long-term results of vocal rehabilitation after total laryngectomy with the lowresistance,
indwelling Provoxr voice prosthesis system. ClinOtolaryngol 1993; 18:517-523.
6. Ackerstaff AH, Hilgers FJ, Aaronson NK, Balm AJ. Communication, functional disorders and lifestyle changes
after total laryngectomy. Clin Otolaryngol Allied Sci 1994; 19:295-300.
7. Hilgers FJM, Balm, A.J.M., Gregor, R.T., Ackerstaff, A.H., Scholtens, B.E.G.M. Voice results using the indwelling
Provoxvoice prosthesis. . In: Clemente MP, ed. Voice Update; Proceedings 1st World Voice Congress,
Oporto, April 9-13, 1995: Excerpta Medica ICS, 1996:173-182.
8. Hilgers FJ, Ackerstaff AH, Balm AJ, Tan IB, Aaronson NK, Persson JO. Development and clinical evaluation of
a second-generation voice prosthesis (Provox 2), designed for anterograde and retrograde insertion. Acta
Otolaryngol 1997; 117:889-896.
9. Ackerstaff AH, Hilgers FJ, Meeuwis CAet al. Multi-institutional assessment of the Provox 2 voice prosthesis.
Arch Otolaryngol Head Neck Surg 1999; 125:167-173.
10. Hilgers FJ, Ackerstaff AH, Aaronson NK, Schouwenburg PF, Van Zandwijk N. Physical and psychosocial
consequences of total laryngectomy. Clin Otolaryngol Allied Sci 1990; 15:421-425.
11. Ackerstaff AH, Hilgers FJ, Balm AJ, Van Zandwijk N. Long-term pulmonary function after total laryngectomy.
Clin Otolaryngol Allied Sci 1995; 20:547-551.
12. Ackerstaff AH, Hilgers FJ, Meeuwis CA, Knegt PP, Weenink C. Pulmonary function pre- and post-total
laryngectomy. ClinOtolaryngolAllied Sci 1999; 24:491-494.
13. Hilgers FJ, Aaronson NK, Ackerstaff AH, Schouwenburg PF, van Zandwikj N. The influence of a heat and
moisture exchanger (HME) on the respiratory symptoms after total laryngectomy. Clin Otolaryngol Allied Sci
1991; 16:152-156.
14. Ackerstaff AH, Hilgers FJ, Aaronson NK, Balm AJ, Van Zandwijk N. Improvements in respiratory and
psychosocial functioning following total laryngectomy by the use of a heat and moisture exchanger. Ann Otol
Rhinol Laryngol 1993; 102:878-883.
15. Ackerstaff AH, Hilgers FJ, Aaronson NKet al. Heat and moisture exchangers as a treatment option in the postoperative
rehabilitation of laryngectomized patients. Clin Otolaryngol Allied Sci 1995; 20:504-509.
16. Hilgers FJ, Ackerstaff AH, Balm AJ, Gregor RT. A new heat and moisture exchanger with speech valve (Provox
stomafilter). Clin Otolaryngol Allied Sci 1996; 21:414-418.
17. Ackerstaff AH, Hilgers FJ, Balm AJ, Tan IB. Long-term compliance of laryngectomized patients with a
specialized pulmonary rehabilitation device: Provox Stomafilter. Laryngoscope 1998; 108:257-260.
18. Van As CJ, Hilgers FJ, Koopmans-van Beinum FJ, Ackerstaff AH. The influence of stoma occlusion on aspects
of tracheoesophageal voice. Acta Otolaryngol 1998; 118:732-738.
19. Hilgers FJ, Ackerstaff AH, van As CJ, Balm AJ, Van den Brekel MW, Tan IB. Development and clinical
assessment of a heat and moisture exchanger with a multi-magnet automatic tracheostoma valve (Provox
FreeHands HME) for vocal and pulmonary rehabilitation after total laryngectomy. Acta Otolaryngol 2003;
123:91-99.
20. van Dam FS, Hilgers FJ, Emsbroek G, Touw FI, Van As CJ, de JN. Deterioration of olfaction and gustation as a
consequence of total laryngectomy. Laryngoscope 1999; 109:1150-1155.
21. Hilgers FJ, van Dam FS, Keyzers S, Koster MN, Van As CJ, Muller MJ. Rehabilitation of olfaction after
laryngectomy by means of a nasal airflow-inducing maneuver: the "polite yawning" technique. Arch Otolaryngol
Head Neck Surg 2000; 126:726-732.
22. Hilgers FJ, Jansen HA, Van As CJ, Polak MF, Muller MJ, van Dam FS. Long-term results of olfaction
rehabilitation using the nasal airflow-inducing ("polite yawning") maneuver after total laryngectomy. Arch
Otolaryngol Head Neck Surg 2002; 128:648-654.
total laryngectomy considerably. Consistently high success rates have been reported in the last 35
years, after the first description of a useful prosthetic device by Singer and Blom in 1980.1
Compared with esophageal and electrolarynx speech, a higher percentage of patients achieve an
acceptable voice, enabling communication under almost all social circumstances. Success rates
up to 90% are not exceptional any longer, making prosthetic voice rehabilitation the method of
choice for early and reliable restoration of oral communication after total laryngectomy.2
In general, two types of voice prosthesis can be distinguished, i.e. non-indwelling and indwelling
devices. The former devices can be removed and replaced by the patient. The latter stay in place
permanently and have to be removed and replaced by the clinician at the end of the device life,
which is determined by leakage of fluids through the prosthesis or an increased airflow resistance.
Indwelling devices have the definite advantage that the patient’s dexterity plays a less important
role in the daily maintenance of the device, which mainly consists of cleaning with a brush and/or
a flushing device without the need of regularly replacing the prosthesis. Even with increasing age
and/or decreasing health a useful (prosthetic) voice can be preserved.
Based on our experiences with surgical and prosthetic voice rehabilitation (Staffieri’s procedure,
and the Blom-Singer, Panje, and Groningen prostheses), acquired since 1979 in the Department
of Otolaryngology-Head & Neck Surgery of the Netherlands Cancer Institute, we co-developed
since 1988 a novel low-resistance, indwelling silicon voice prosthesis, Provox, in close
collaboration with the medical engineering industry.3,4 It has been successfully used in our Institute
since then in all laryngectomized patients. The long-term clinical results obtained with this voice
prosthesis are favorable.2,5-7
Additional instruments and devices to facilitate its application have been developed as well.3 Their
use, along with the surgical techniques involved and the management of many of the clinical and
technical aspects, are the subject of this manual. The subsequent development of a second
generation (Provox2) voice prosthesis for bidirectional, i.e. anterograde and retrograde,
application is a further improvement of the Provox system.8 The anterograde replacement in the
outpatient office has considerably decreased the discomfort of this procedure for the patient and
the medical professionals involved.8,9 Further improvements since development of Provox2 will be
discussed in the various voice rehabilitation chapters.
The problem of post-laryngectomy pulmonary function disorders has also been addressed
extensively in our clinic.10-12 The relevance of simultaneous pulmonary rehabilitation for optimal
voice restoration and an improved quality of life has become increasingly clear in recent years.13-15
The development of a novel, dedicated ‘valved’ Heat and Moisture Exchanger (HME, Provox
HME) has added a new tool to the armamentarium of the clinicians, in this respect.16-18 Further
improvements since the development of the first generation Provox HMEs will be discussed in the
various pulmonary rehabilitation chapters.
Hands-free speech is the ultimate goal of postlaryngectomy voice rehabilitation, preferably taking
care of pulmonary protection and rehabilitation at the same time. This is now possible with the
newly developed Provox FreeHands HME.19 Further improvements since the development of
FreeHands will be discussed in the chapter on hands free speech.
A further problem resulting from the permanent disconnection of the upper and lower airways is a
deterioration of the sense of smell. The main cause for this disturbing side effect of total
laryngectomy is the lack of a nasal airflow, which normally transports odorous substances to the
olfactory epithelium high up in the nose. There are two types of smelling: ‘passive’ and ‘active’
smelling. Passive smelling continuously takes place during normal nasal breathing, whereas
active smelling (‘sniffing’) is used intentionally. Research in our Institute has given more insight in
the magnitude of the olfaction problem after total laryngectomy.20 Stoma breathing precludes
passive smelling and only some 30% of the patients is still able to actively smell something.
However, it now appears to be possible to restore olfaction in a considerable number of
laryngectomized individuals.21,22 The nasal airflow-inducing maneuver (NAIM, also called ‘polite
yawning’ technique, since that is what the maneuver is mimicking) enables active smelling again,
will be described in detail. Further research underpinning the validity of the NAIM, since it’s
conception early 2000, will be presented as well.
It should be stressed that vocal, pulmonary and olfactory rehabilitation after total laryngectomy is a
multi-disciplinary team effort and that the motivation of the Otolaryngologist, the (Head Neck)
oncology nurse, the speech therapist and last, but not least, of the patient is mandatory to obtain
optimal results.
Amsterdam 2003/2016
References
1. Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol
Laryngol 1980; 89:529-533.
2. Op de Coul BM, Hilgers FJ, Balm AJ, Tan IB, van den Hoogen FJ, van TH. 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 2000; 126:1320-1328.
3. Hilgers FJM, Schouwenburg PF. A new low-resistance, self-retaining prosthesis (Provoxr) for voice
rehabilitation after total laryngectomy. Laryngoscope 1990; 100:1202-1207.
4. Hilgers FJ, Cornelissen MW, Balm AJ. Aerodynamic characteristics of the Provox low-resistance indwelling
voice prosthesis. EurArchOtorhinolaryngol 1993; 250:375-378.
5. Hilgers FJM, Balm AJM. Long-term results of vocal rehabilitation after total laryngectomy with the lowresistance,
indwelling Provoxr voice prosthesis system. ClinOtolaryngol 1993; 18:517-523.
6. Ackerstaff AH, Hilgers FJ, Aaronson NK, Balm AJ. Communication, functional disorders and lifestyle changes
after total laryngectomy. Clin Otolaryngol Allied Sci 1994; 19:295-300.
7. Hilgers FJM, Balm, A.J.M., Gregor, R.T., Ackerstaff, A.H., Scholtens, B.E.G.M. Voice results using the indwelling
Provoxvoice prosthesis. . In: Clemente MP, ed. Voice Update; Proceedings 1st World Voice Congress,
Oporto, April 9-13, 1995: Excerpta Medica ICS, 1996:173-182.
8. Hilgers FJ, Ackerstaff AH, Balm AJ, Tan IB, Aaronson NK, Persson JO. Development and clinical evaluation of
a second-generation voice prosthesis (Provox 2), designed for anterograde and retrograde insertion. Acta
Otolaryngol 1997; 117:889-896.
9. Ackerstaff AH, Hilgers FJ, Meeuwis CAet al. Multi-institutional assessment of the Provox 2 voice prosthesis.
Arch Otolaryngol Head Neck Surg 1999; 125:167-173.
10. Hilgers FJ, Ackerstaff AH, Aaronson NK, Schouwenburg PF, Van Zandwijk N. Physical and psychosocial
consequences of total laryngectomy. Clin Otolaryngol Allied Sci 1990; 15:421-425.
11. Ackerstaff AH, Hilgers FJ, Balm AJ, Van Zandwijk N. Long-term pulmonary function after total laryngectomy.
Clin Otolaryngol Allied Sci 1995; 20:547-551.
12. Ackerstaff AH, Hilgers FJ, Meeuwis CA, Knegt PP, Weenink C. Pulmonary function pre- and post-total
laryngectomy. ClinOtolaryngolAllied Sci 1999; 24:491-494.
13. Hilgers FJ, Aaronson NK, Ackerstaff AH, Schouwenburg PF, van Zandwikj N. The influence of a heat and
moisture exchanger (HME) on the respiratory symptoms after total laryngectomy. Clin Otolaryngol Allied Sci
1991; 16:152-156.
14. Ackerstaff AH, Hilgers FJ, Aaronson NK, Balm AJ, Van Zandwijk N. Improvements in respiratory and
psychosocial functioning following total laryngectomy by the use of a heat and moisture exchanger. Ann Otol
Rhinol Laryngol 1993; 102:878-883.
15. Ackerstaff AH, Hilgers FJ, Aaronson NKet al. Heat and moisture exchangers as a treatment option in the postoperative
rehabilitation of laryngectomized patients. Clin Otolaryngol Allied Sci 1995; 20:504-509.
16. Hilgers FJ, Ackerstaff AH, Balm AJ, Gregor RT. A new heat and moisture exchanger with speech valve (Provox
stomafilter). Clin Otolaryngol Allied Sci 1996; 21:414-418.
17. Ackerstaff AH, Hilgers FJ, Balm AJ, Tan IB. Long-term compliance of laryngectomized patients with a
specialized pulmonary rehabilitation device: Provox Stomafilter. Laryngoscope 1998; 108:257-260.
18. Van As CJ, Hilgers FJ, Koopmans-van Beinum FJ, Ackerstaff AH. The influence of stoma occlusion on aspects
of tracheoesophageal voice. Acta Otolaryngol 1998; 118:732-738.
19. Hilgers FJ, Ackerstaff AH, van As CJ, Balm AJ, Van den Brekel MW, Tan IB. Development and clinical
assessment of a heat and moisture exchanger with a multi-magnet automatic tracheostoma valve (Provox
FreeHands HME) for vocal and pulmonary rehabilitation after total laryngectomy. Acta Otolaryngol 2003;
123:91-99.
20. van Dam FS, Hilgers FJ, Emsbroek G, Touw FI, Van As CJ, de JN. Deterioration of olfaction and gustation as a
consequence of total laryngectomy. Laryngoscope 1999; 109:1150-1155.
21. Hilgers FJ, van Dam FS, Keyzers S, Koster MN, Van As CJ, Muller MJ. Rehabilitation of olfaction after
laryngectomy by means of a nasal airflow-inducing maneuver: the "polite yawning" technique. Arch Otolaryngol
Head Neck Surg 2000; 126:726-732.
22. Hilgers FJ, Jansen HA, Van As CJ, Polak MF, Muller MJ, van Dam FS. Long-term results of olfaction
rehabilitation using the nasal airflow-inducing ("polite yawning") maneuver after total laryngectomy. Arch
Otolaryngol Head Neck Surg 2002; 128:648-654.