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In the past 30 years, the use of a voice prosthesis has become the treatment of choice for the restoration of speech following laryngectomy. Not only is the placement of a voice prosthesis a simple surgical procedure, but it is also associated with a low rate of complications and an excellent success rate. Approximately, 20-30 % of all patients with voice prostheses, however, develop periprosthetic leakage with aspiration over time. Periprosthetic leakage is usually caused by an enlargement of the tracheo-oesophageal fistula and substantially affects the quality of life of the patients concerned. In a retrospective analysis of our patients, the incidence of periprosthetic leakage was 35.7 % in a total of 232 patients who underwent laryngectomy during a period of 20 years. Substantial enlargement of the tracheo-oesophageal fistula which required multiple treatments occurred in 12.5 % of the patients. In this review, the various causes of fistula enlargement are discussed on the basis of the literature and the experience that we have accumulated during the past 20 years in the management of patients with voice prostheses.

In the past 30 years, the use of voice prostheses has become the gold standard for voice rehabilitation after total laryngectomy. The placement of a voice prosthesis is a simple procedure that is associated with only a minor increase in operating time and a low rate of complications. Most problems with voice prostheses are minor and can be easily managed. Enlargement of the tracheo-oesophageal fistula, however, can be a severe complication. Approximately 25 % of all patients with voice prostheses develop periprosthetic leakage with aspiration within 1-4 years after the placement of a voice prosthesis. Depending on the severity of fistula enlargement, treatment ranges from conservative approaches to maximally invasive procedures. In some cases, however, these measures prove unsuccessful. The causes of treatment failure and fistula enlargement are not yet fully understood. Apart from a discussion of treatment options, an algorithm for the management of this complication is presented on the basis of the literature and the experience that we have accumulated at our institution during the past 20 years in the treatment of 232 laryngectomised patients.