Biodeterioration of medical-grade silicone rubber used for voice prostheses: a SEM study

Development of iodine based sustained release antimicrobial coatings for polyurethane voice prostheses

Voice prostheses are known to fail in few weeks to several months of implantation due to the clogging mainly caused by microbial biofilm formation, which is a cause of concern. Iodine is a known broad-spectrum biocide and is reported to easily form complexes with various polymers. For long term device disinfection, strong iodine complexation that offers sustained iodine release for a prolonged period is essential. The present research work deals with the synthesis of a poly(methyl methacrylate-n-butyl acrylate-N-vinyl-2-pyrrolidone) (poly[MMA-BA-NVP]) tercopolymer through free radical polymerization for surface coating thermoplastic polyurethane (TPU) based voice prostheses. The NVP content in the tercopolymer was varied from 20% to 50% to optimise iodine loading and subsequent release. Base TPU coated with the tercopolymer was treated with 4% aqueous iodine solution at room temperature (28 ± 3 °C) for two hours. It was observed that the tercopolymer containing 35% N-vinyl-2-pyrrolidone (NVP), 32.5% methyl methacrylate (MMA) and 32.5% butyl acrylate (nBA) gave a stable coating on TPUs together with sustained iodine release for a prolonged period. Furthermore, the tercopolymer coated and iodine loaded TPUs exhibited excellent antimicrobial activity against Candida albicans, Staphylococcus aureus and Escherichia coli.

Effect of silver sulfadiazine on mature mixed bacterial biofilms on voice prostheses

BACKGROUND

Biofilm formation on voice prostheses disrupts the function and limits the lifespan of voice prostheses. There is still no effective clinical strategy for inhibiting or removing these biofilms. Silver sulfadiazine (SSD), as an exogenous antibacterial agent, has been widely used in the prevention and treatment of infection, however, its effect on voice prosthesis biofilms is unknown. The purpose of this study was to explore the effect of SSD on the mature mixed bacterial biofilms present on voice prostheses.

METHODS

Quantitative and qualitative methods, including the plate counting method, real-time fluorescence quantitative PCR, crystal violet staining, the 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide) (XTT) reduction assay, scanning electron microscopy, and laser confocal microscopy, were used to determine the effect of SSD on the number of bacterial colonies, biofilm formation ability, metabolic activity, and ultrastructure of biofilms in a mature mixed bacterial (Staphylococcus aureus, Streptococcus faecalis and Candida albicans) voice prosthesis biofilm model. The results were verified in vitro on mature mixed bacterial voice prosthesis biofilms from patients, and the possible mechanism of action was explored.

RESULTS

Silver sulfadiazine decreased the number of bacterial colonies on mature mixed bacterial voice prosthesis biofilm, significantly inhibited the biofilm formation ability and metabolic activity of mature voice prosthesis biofilms, inhibited the formation of the complex spatial structure of voice prosthesis biofilms, and inhibited the synthesis of polysaccharides and proteins in the biofilm extracellular matrix. The degree of inhibition and removal effect increased with SSD concentration.

CONCLUSIONS

Silver sulfadiazine can effectively inhibit and remove mature mixed bacterial voice prosthesis biofilms and decrease biofilm formation ability and metabolic activity; SSD may exert these effects by inhibiting the synthesis of polysaccharides and proteins among the extracellular polymeric substances of voice prosthesis biofilms.

Νanomaterial-Loaded Polymer Coating Prevents the In Vitro Growth of Candida albicans Biofilms on Silicone Biomaterials

Early failure of silicone voice prostheses resulting from fungal colonization and biofilm formation poses a major concern in modern ear nose throat surgery. Therefore, developing new infection prevention techniques to prolong those implants' survivorship is crucial. We designed an in vitro laboratory study to include nanomaterial-enhanced polymer coating with a plasma spraying technique against Candida albicans growth to address this issue. The anti-biofilm effects of high- and low-dose Al2O3 nanowire and TiO2 nanoparticle coatings were studied either alone or in conjunction with each other using checkerboard testing. It was demonstrated that both nanomaterials were capable of preventing fungal biofilm formation regardless of the anti-fungal agent concentration (median absorbance for high-dose Al2O3-enhanced polymer coating was 0.176 [IQR = 0.207] versus control absorbance of 0.805 [IQR = 0.381], p = 0.003 [98% biofilm reduction]; median absorbance for high-dose TiO2-enhanced polymer coating was 0.186 [IQR = 0.024] versus control absorbance of 0.766 [IQR = 0.458], p < 0.001 [93% biofilm reduction]). Furthermore, synergy was revealed when the Bliss model was applied. According to the findings of this work, it seems that simultaneous consideration of Al2O3 and TiO2 could further increase the existing antibiofilm potential of these nanomaterials and decrease the likelihood of localized toxicity.

Development of an Innovative Soft Piezoresistive Biomaterial Based on the Interconnection of Elastomeric PDMS Networks and Electrically-Conductive PEDOT:PSS Sponges

A deeply interconnected flexible transducer of polydimethylsiloxane (PDMS) and poly(3,4-ethylenedioxythiophene):polystyrenesulfonate (PEDOT:PSS) was obtained as a material for the application of soft robotics. Firstly, transducers were developed by crosslinking PEDOT:PSS with 3-glycidyloxypropryl-trimethoxysilane (GPTMS) (1, 2 and 3% v/v) and using freeze-drying to obtain porous sponges. The PEDOT:PSS sponges were morphologically characterized, showing porosities mainly between 200 and 600 µm2; such surface area dimensions tend to decrease with increasing degrees of crosslinking. A stability test confirmed a good endurance for up to 28 days for the higher concentrations of the crosslinker tested. Consecutively, the sponges were electromechanically characterized, showing a repeatable and linear resistance variation by the pressure triggers within the limits of their working range (∆RR0 max = 80% for 1-2% v/v of GPTMS). The sponges containing 1% v/v of GPTMS were intertwined with a silicon elastomer to increase their elasticity and water stability. The flexible transducer obtained with this method exhibited moderately lower sensibility and repeatability than the PEDOT:PSS sponges, but the piezoresistive response remained stable under mechanical compression. Furthermore, the transducer displayed a linear behavior when stressed within the limits of its working range. Therefore, it is still valid for pressure sensing and contact detection applications. Lastly, the flexible transducer was submitted to preliminary biological tests that indicate a potential for safe, in vivo sensing applications.

Fungicidal Effect of Lemongrass Essential Oil on Candida albicans Biofilm Pre-established on Maxillofacial Silicone Specimens

Aims:

This in-vitro study aimed to evaluate the efficacy of lemongrass (Cymbopogon citratus) essential oil in eradicating Candida albicans biofilm pre-established on the maxillofacial silicone specimens.

Materials and Methods:

Two maxillofacial silicones, namely, MDX4-4210 and Multisil Epithetik, were used for the fabrication of 6 mm diameter disks (n = 21 for each brand of silicone). A 48-h mature C. albicans ATCC 10231 biofilm was pre-established on sterile silicone specimen. These disks were then exposed to various concentrations of lemongrass essential oil ranging from 0.31% to 5% (v/v), 20% (v/v) nystatin, and RPMI-1640 medium for 18–20 h. After exposure, the remaining viable fungal biofilm was examined by the XTT [2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide]-reduction assay. All data were analyzed by using a regression coefficient and a post hoc Tukey HSD multiple comparisons test (α = 0.05).

Results:

Different brands of silicone used for fabrication did not significantly affect the formation of mature C. albicans biofilm (P =0.302). A 5% (v/v) lemongrass essential oil significantly eliminated fungal biofilm by approximately 95% (P =0.031). However, less than 50% of the fungal biofilm was eliminated by the tested oil at a concentration as low as 0.31% (v/v). Furthermore, the fungicidal efficacy against C. albicans biofilm of lemongrass essential oil at 2.5% (v/v) was as potent as that of 20% (v/v) nystatin suspension (P = 0.99).

Conclusion:

Lemongrass essential oil expressed fungicidal effect on C. albicans biofilm pre-established on the disks fabricated from different brands of silicone. Additionally, the fungicidal effectiveness of the oil against the mature fungal biofilm was dose-dependent.

In vitro Inhibition of Biofilm Formation on Silicon Rubber Voice Prosthesis: Α Systematic Review and Meta-Analysis

INTRODUCTION

Biofilm formation on voice prostheses is the primary reason for their premature implant dysfunction. Multiple strategies have been proposed over the last decades to achieve inhibition of biofilm formation on these devices. The purpose of this study was to assess the results of the available in vitro biofilm inhibition modalities on silicone rubber voice prostheses.

METHODS

We conducted a systematic search in PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases up to February 29, 2020. A total of 33 in vitro laboratory studies investigating the efficacy of different coating methods against Candida, Staphylococcus, Streptococcus, Lactobacilli, and Rothia biofilm growth on silicone rubber medical devices were included. Subgroup analysis linked to the type of prevention modality was carried out, and quality assessment was performed with the use of the modified CONSORT tool.

RESULTS

Data from 33 studies were included in qualitative analysis, of which 12 qualified for quantitative analysis. For yeast biofilm formation assessment, there was a statistically significant difference in favor of the intervention group (standardized mean difference [SMD] = -1.20; 95% confidence interval [CI] [-1.73, -0.66]; p < 0.0001). Subgroup analysis showed that combined methods (active and passive surface modification) are the most effective for biofilm inhibition in yeast (SMD = -2.53; 95% CI [-4.02, -1.03]; p = 0.00001). No statistically significant differences between intervention and control groups were shown for bacterial biofilm inhibition (SMD = -0.09; 95% CI [-0.68, 0.46]; p = 0.65), and the results from the subgroup analysis found no notable differences between the surface modification methods. After analyzing data on polymicrobial biofilms, a statistically significant difference in favor of prevention methods in comparison with the control group was detected (SMD = -2.59; 95% CI [-7.48, 2.31]; p = 0.30).

CONCLUSIONS

The meta-analysis on biofilm inhibition demonstrated significant differences in favor of yeast biofilm inhibition compared to bacteria. A stronger inhibition with the application of passive or combined active and passive surface modification techniques was reported.

Preparation of medical hydrophilic and antibacterial silicone rubber via surface modification

Bacterial adhesion of medical indwelling devices shortens their service life and brings about infections in patients. The combination of hydrophilic and antibacterial modifications can not only kill the bacteria in contact with the surface, but also avoid the adhesion of dead bacteria. From this view, with a self-made quaternary ammonium salt and a zwitterion as the modifiers, a modified silicone rubber, SR-g-(DMAPS-co-QA), was prepared via random co-grafting. The static water angle test and antibacterial assays proved the enhancement of both the hydrophilicity and antibacterial activity. In addition, compared with the unmodified silicone rubber, after 7 days of co-cultivation in E. coli suspension, SR-g-(DMAPS-co-QA) demonstrated good resistance to biofilm formation. Furthermore, to simulate the real situation, its antibacterial effect in dynamic flow condition was measured, confirming that SR-g-(DMAPS-co-QA) still maintained good antibacterial performance after a 48 hour cyclic flow of E. coli bacterial suspension.

Surface modification of silicone rubber to enhance hydrophilicity and antibacterial effect.

Antifungal and biofilm inhibitory effect of Cymbopogon citratus (lemongrass) essential oil on biofilm forming by Candida tropicalis isolates; an in vitro study

ETHNOPHARMACOLOGICAL RELEVANCE

Cymbopogon citratus (lemongrass) essential oil has been widely used as a traditional medicine and is well known for antimicrobial properties. Therefore, it might be a potent anti-infective and biofilm inhibitive against Candida tropicalis infections. Until now, no ideal coating or cleaning method based on an essential oil has been described to prevent biofilm formation of Candida strains on silicone rubber maxillofacial prostheses, voice prostheses and medical devices susceptible to C. tropicalis infections.

AIM OF THE STUDY

To investigate the antifungal and biofilm inhibitory effects of Cymbopogon citratus oil. Clinical isolates of C. tropicalis biofilms on different biomaterials were used to study the inhibitory effect.

MATERIALS AND METHODS

The efficacy of Cymbopogon citratus, Cuminum cyminum, Citrus limon and Cinnamomum verum essential oils were compared on biofilm formation of three C. tropicalis isolates on 24 well polystyrene plates. C. citratus oil coated silicone rubber surfaces were prepared using hypromellose ointment as a vehicle. The antifungal tests to determine minimum inhibitory and minimum fungicidal concentrations were assessed by a microbroth dilution method and biofilm formation was determined by a crystal violet binding assay.

RESULTS

C. tropicalis strains formed more biofilm on hydrophobic materials than on hydrophilic glass. C. citratus oil showed a high antifungal effect against all C. tropicalis strains. For comparison, C. limon oil and C. cyminum oil showed minor to no killing effect against the C. tropicalis strains. C. citratus oil had the lowest minimal inhibitory concentration of all essential oils tested and inhibited biofilm formation of all C. tropicalis strains. C. citratus oil coating on silicone rubber resulted in a 45-76% reduction in biofilm formation of all C. tropicalis strains.

CONCLUSION

Cymbopogon citratus oil has good potential to be used as an antifungal and antibiofilm agent on silicone rubber prostheses and medical devices on which C. tropicalis biofilms pose a serious risk for skin infections and may cause a shorter lifespan of the prosthesis.

Nasolacrimal stent with shape memory as an advanced alternative to silicone products

Epiphora is the overflow of tears typically caused by obstruction or occlusion of the nasolacrimal duct. More attention is required to address this global health issue owing to the increase in air pollution. Implantation of a silicone stent is the preferred treatment for epiphora; however, introducing a silicone stent into a narrow duct with complex geometry is challenging as it requires guidance by a sharp metal needle. Additionally, silicone can cause adverse reactions such as biofilm formation and tear flow resistance due to its extreme hydrophobicity. To overcome these problems, in this study we developed a new type of biocompatible shape memory polymer (SMP) stent with elasticity capacity for self-expansion. First, SMPs in the form of x%poly(ε-caprolactone)-co-y%poly(glycidyl methacrylate) (x%PCL-y%PGMA) were synthesized via ring opening polymerization by varying the molar ratio of PCL (x%) and PGMA (y%). Second, the shape memory and mechanical properties were tuned by controlling the crosslinking degree and concentration of x%PCL-y%PGMA solution to produce a test type of SMP stent. Lastly, this 94%PCL-06%PGMA stent exhibited more standout critical functions in a series of in vitro and in vivo experiments such as a cell growth-supporting level of biocompatibility with nasal epithelial cells without significant inflammatory responses, better resistance to biofilm formation, and more efficient capacity to drain tear than the silicone control. Overall, 94%PCL-06%PGMA can be suggested as a superior alternative to the currently used materials for nasolacrimal stents. STATEMENT OF SIGNIFICANCE: Silicone intubation (stenting) has been widely used to treat nasolacrimal duct obstruction, however, it can cause adverse clinical effects such as bacterial infection; presents procedural challenges because of the curved nasolacrimal duct structure; and shows poor drainage efficiency stemming from the highly hydrophobic nature of silicone. In this work, we describe an innovative shape memory polymer (SMP) as a superior alternative to conventional silicone-based materials for nasolacrimal duct intubation. We demonstrate the clear advantages of the SMP over conventional silicone, including a much higher drainage capacity and superior resistance to bacterial infection.

Fabrication of Food-Safe Water-Resistant Paper Coatings Using a Melamine Primer and Polysiloxane Outer Layer

Paper-based materials are highly desirable as packaging materials due to their numerous advantages that include low cost, renewability, and biodegradability. However, their hydrophilicity has limited their range of applications. Reported herein is a facile and economical approach for the preparation of biodegradable water-resistant paper for food-contact applications. Commercial printing paper and cup papers are coated with melamine, which is FDA approved for food-contact applications. Subsequently, a water-repellent outer layer is applied using poly(dimethylsiloxane) (PDMS)-isocyanate. A relationship between the PDMS concentration and water contact angles (WCAs) of the obtained coating was studied. Typically, the coated cup paper and printing paper had coating loadings of 1.61 ± 1.10 and 0.93 ± 0.74 wt %, respectively. After the coatings had been applied, the WCAs were very high (>125°), and water absorption had decreased by 70% for printing paper and by 35% for cup paper. Considering the facile fabrication method and the low-cost food-safe raw materials, herein, this approach will have great potential for the large-scale production of materials for use in food- and nonfood contact applications.

Biofilm in voice prosthesis: A prospective cohort study and laboratory tests using sonication and SEM analysis

OBJECTIVE

The objective of the study was to compare the biofilm growing pattern and its morphological extent on silicone and a teflon-like material using a sonication process and a Scanning Electron Microscope (SEM).

DESIGN

A prospective cohort study and a laboratory study.

SETTING

Otolaryngology -Head and Neck surgery Department and the Microbiology Institute.

PARTICIPANTS

The participants included fifteen laryngectomised patients with phonatory prostheses, which were removed because of device failure, and two different kinds of phonatory prostheses from the laboratory (Provox 2 and ActiValve) that were artificially colonised by Candida albicans.

MAIN OUTCOME MEASURES

Tracheo-oesophageal puncture (TEP) is currently considered the gold standard for post-laryngectomy voice rehabilitation. "Leakage" represents the most common cause of substitution and is generated by biofilm colonisation of the prosthesis by mixed mycotic and bacterial agents. New biomaterials have been developed that are deemed to be more resistant to the colonisation of micro-organisms and material deformation.

RESULTS

The devices showed colonisation by mixed bacterial flora (Staphylococci 13%, Streptococci 9%, and Haemophilus influenzae 5%) and by yeasts (Candida albicans 12%). Moreover, we observed a different distribution of biofilm layers in Provox ActiValve (22.56%) compared to Provox 2 (56.82%) after experimental colonisation by the previously isolated Candida strain.

CONCLUSION

Resident microbiological species from the upper airways unavoidably colonise the polymer surfaces, and no strategies have been effective except for the manipulation of the chemical-physical properties of the device's polymer. Our study confirms that Provox ActiValve, which is made with a fluoroplastic material (teflon-like), is less subject to in vitro colonisation by Candida, and thus showed a higher clinical resistance to biofilm and a longer lifespan. The sonication seems to significantly improve the knowledge of bacterial and mycotic flora in biofilm colonisation. The design of a device for the daily cleaning capable to reach and brush the oesophageal flange of the prosthesis preserving the valve mechanism could represent a practical and simple help in this still unsolved problem.

Fermentation based carbon nanotube multifunctional bionic composites

The exploitation of the processes used by microorganisms to digest nutrients for their growth can be a viable method for the formation of a wide range of so called biogenic materials that have unique properties that are not produced by abiotic processes. Here we produced living hybrid materials by giving to unicellular organisms the nutrient to grow. Based on bread fermentation, a bionic composite made of carbon nanotubes (CNTs) and a single-cell fungi, the Saccharomyces cerevisiae yeast extract, was prepared by fermentation of such microorganisms at room temperature. Scanning electron microscopy analysis suggests that the CNTs were internalized by the cell after fermentation bridging the cells. Tensile tests on dried composite films have been rationalized in terms of a CNT cell bridging mechanism where the strongly enhanced strength of the composite is governed by the adhesion energy between the bridging carbon nanotubes and the matrix. The addition of CNTs also significantly improved the electrical conductivity along with a higher photoconductive activity. The proposed process could lead to the development of more complex and interactive structures programmed to self-assemble into specific patterns, such as those on strain or light sensors that could sense damage or convert light stimulus in an electrical signal.

Vibratory stimulus reduces in vitro biofilm formation on tracheoesophageal voice prostheses

OBJECTIVES/HYPOTHESIS

Demonstrate that biofilm formation will be reduced on tracheoesophageal prostheses when vibratory stimulus is applied, compared to controls receiving no vibratory stimulus, in a dynamic in vitro model of biofilm accumulation simulating the interface across the tracheoesophageal puncture site.

STUDY DESIGN

Prospective, randomized, controlled, crossover in university laboratory.

METHODS

Ex vivo tracheoesophageal prostheses were obtained from university-affiliated speech language pathologists at Indiana University School of Medicine, Indianapolis. Prostheses demonstrating physical integrity and an absence of gross biofilm accumulation were utilized. Sixteen prostheses were cleansed and sterilized prior to random placement by length in two modified Robbins devices arranged in parallel. Each device was seeded with a polymicrobial oral flora on day 1 and received basal artificial salivary flow continuously with three growth medium meals daily. One device was randomly selected for vibratory stimulus, and 2 minutes of vibration was applied to each prosthesis before and after meals for 5 days. The prostheses were explanted and sonicated, and the biofilm cultured for enumeration. This process was repeated after study arm crossover.

RESULTS

Tracheoesophageal prostheses in the dynamic model receiving vibratory stimulus demonstrated reduced gross biofilm accumulation and a significant biofilm colony forming unit per milliliter reduction of 5.56-fold compared to nonvibratory controls (P < 0.001). Significant reductions were observed within length subgroups.

CONCLUSION

Application of vibratory stimulus around meal times significantly reduces biofilm accumulation on tracheoesophageal prostheses in a dynamic in vitro model. Further research using this vibratory stimulus method in vivo will be required to determine if reduced biofilm accumulation correlates with longer device lifespan.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:2752-2757, 2016.

Production and Biomedical Applications of Probiotic Biosurfactants

Biosurfactants have been widely used for environmental and industrial applications. However, their use in medical field is still limited. Probiotic biosurfactants possess an immense antimicrobial, anti-adhesive, antitumor, and antibiofilm potential. Moreover, they have an additional advantage over conventional microbial surfactants because probiotics are an integral part of normal human microflora and their biosurfactants are innocuous to human. So, they can be effectively exploited for medicinal use. Present review is aimed to discourse the production and biomedical applications of probiotic biosurfactants.

Robust and biodegradable elastomers based on corn starch and polydimethylsiloxane (PDMS)

Designing starch-based biopolymers and biodegradable composites with durable mechanical properties and good resistance to water is still a challenging task. Although thermoplastic (destructured) starch has emerged as an alternative to petroleum-based polymers, its poor dimensional stability under humid and dry conditions extensively hinders its use as the biopolymer of choice in many applications. Unmodified starch granules, on the other hand, suffer from incompatibility, poor dispersion, and phase separation issues when compounded into other thermoplastics above a concentration level of 5%. Herein, we present a facile biodegradable elastomer preparation method by incorporating large amounts of unmodified corn starch, exceeding 80% by volume, in acetoxy-polyorganosiloxane thermosets to produce mechanically robust, hydrophobic bioelastomers. The naturally adsorbed moisture on the surface of starch enables autocatalytic rapid hydrolysis of polyorganosiloxane to form Si-O-Si networks. Depending on the amount of starch granules, the mechanical properties of the bioelastomers can be easily tuned with high elastic recovery rates. Moreover, starch granules considerably lowered the surface friction coefficient of the polyorganosiloxane network. Stress relaxation measurements indicated that the bioelastomers have strain energy dissipation factors that are lower than those of conventional rubbers, rendering them as promising green substitutes for plastic mechanical energy dampeners. Corn starch granules also have excellent compatibility with addition-cured polysiloxane chemistry that is used extensively in microfabrication. Regardless of the starch concentration, all of the developed bioelastomers have hydrophobic surfaces with lower friction coefficients and much less water uptake capacity than those of thermoplastic starch. The bioelastomers are biocompatible and are estimated to biodegrade in Mediterranean seawater within three to six years.

Voice prosthetic biofilm formation and Candida morphogenic conversions in absence and presence of different bacterial strains and species on silicone-rubber

Morphogenic conversion of Candida from a yeast to hyphal morphology plays a pivotal role in the pathogenicity of Candida species. Both Candida albicans and Candida tropicalis, in combination with a variety of different bacterial strains and species, appear in biofilms on silicone-rubber voice prostheses used in laryngectomized patients. Here we study biofilm formation on silicone-rubber by C. albicans or C. tropicalis in combination with different commensal bacterial strains and lactobacillus strains. In addition, hyphal formation in C. albicans and C. tropicalis, as stimulated by Rothia dentocariosa and lactobacilli was evaluated, as clinical studies outlined that these bacterial strains have opposite results on the clinical life-time of silicone-rubber voice prostheses. Biofilms were grown during eight days in a silicone-rubber tube, while passing the biofilms through episodes of nutritional feast and famine. Biofilms consisting of combinations of C. albicans and a bacterial strain comprised significantly less viable organisms than combinations comprising C. tropicalis. High percentages of Candida were found in biofilms grown in combination with lactobacilli. Interestingly, L. casei, with demonstrated favorable effects on the clinical life-time of voice prostheses, reduced the percentage hyphal formation in Candida biofilms as compared with Candida biofilms grown in absence of bacteria or grown in combination with R. dentocariosa, a bacterial strain whose presence is associated with short clinical life-times of voice prostheses.

Candida biofilm formation on voice prostheses

Laryngopharyngeal malignancy is treated with radiotherapy and/or surgery. When total laryngectomy is required, major laryngeal functions (phonation, airway control, swallowing and coughing) are affected. The insertion of a silicone rubber voice prosthesis in a surgically created tracheoesophageal puncture is the most effective method for voice rehabilitation. Silicone, as is the case with other synthetic materials such as polymethylmethacrylate, polyurethane, polyvinyl chloride, polypropylene and polystyrene, has the propensity to become rapidly colonized by micro-organisms (mainly Candida albicans) forming a biofilm, which leads to the failure of the devices. Silicone is used within voice prosthetic devices because of its flexible properties, which are essential for valve function. Valve failure, as well as compromising speech, may result in aspiration pneumonia, and repeated valve replacement may lead to either tract stenosis or insufficiency. Prevention and control of biofilm formation are therefore crucial for the lifespan of the prosthesis and promotion of tracheoesophageal tissue and lung health. To date, the mechanisms of biofilm formation on voice prostheses are not fully understood. Further studies are therefore required to identify factors influencing Candida biofilm formation. This review describes the factors known to influence biofilm formation on voice prostheses and current strategies employed to prolong their life by interfering with microbial colonization.

Patients using antifungals following laryngectomy: a qualitative study of community pharmacists in the North of England

OBJECTIVE

To explore community pharmacists' understanding and opinions in relation to the prevention of fungal colonisation of voice prostheses amongst laryngectomy patients.

METHOD

Semi-structured interviews were conducted on a purposive sample of 12 community pharmacists from the North of England. Interviews were undertaken until data saturation was reached and responses were transcribed verbatim and analysed using a thematic approach.

KEY FINDINGS

Six themes emerged from the data analysis. These were: terminology confusion about laryngectomy, stoma and voice prostheses; smoking as a risk factor for the development of laryngeal cancer; using nystatin to prevent biofilm formation; counselling information related to nystatin; prescription intervention and additional education in relation to laryngectomy. The theme of counselling information related to nystatin use and additional education was a key finding: our data show that when dispensing nystatin to patients with a voice prosthesis, community pharmacists would either give no advice related to medication use or would give incorrect advice that may lead to premature prosthesis failure amongst this patient group.

CONCLUSION

This study highlights that community pharmacists lack understanding in relation to laryngectomy and are unaware of the off-label doses and administration methods of the drugs (specifically nystatin) used to prevent fungal colonisation on voice prostheses. Additional information sources in the form of an educational leaflet, possibly obtained through the local department of speech and language therapy, would be perceived as a valuable resource to support community pharmacists who are required to manage these patients in the community.

Is Montgomery tracheal Safe-T-Tube clinical failure induced by biofilm?

OBJECTIVES

Montgomery Safe-T-Tube deterioration and early biofilm colonization may explain the discomfort claimed by many patients and clinical failures. The aim of the study was to analyze the deterioration of Montgomery Safe-T-Tube morphological and mechanical properties in vivo in 16 patients by using microbiological methods, optical and electron microscopy, and engineering tests.

STUDY DESIGN

Prospective controlled study at a single medical center.

SETTING

University hospital.

SUBJECTS AND METHODS

The study, conducted from April 2007 to February 2012 at the "Sapienza" University of Rome, was designed to collect 2 Montgomery Safe-T-Tubes from each patient. The first was removed 3 to 15 days after insertion (group A) and the second at least 90 days after (group B). Specimens underwent microbiologic assays, electron microscopic analysis, immunocytologic analysis, and mechanical tests.

RESULTS

Microorganisms were not isolated in 2 group A cases (12%), whereas they were in all group B cases. Biofilm was identified in 11 of 16 (69%) group A samples and in 16 of 16 (100%) group B samples (P = .0149) using scanning electron microscopy. Immunohistochemistry showed monocyte-granulocyte line cells producing interleukin-1β on the external surfaces of Montgomery Safe-T-Tubes. The tensile test showed that the wear related to the longer period of use makes Montgomery Safe-T-Tubes more rigid than newer ones.

CONCLUSION

Early biofilm colonization takes place in Montgomery Safe-T-Tubes in most cases. The mechanical decay could be justified in part by the destructive biofilm activity and by the release of inflammatory effectors and enzymes.

Complications of long-term ventilation tubes

OBJECTIVE

To demonstrate that ventilation tubes can remain in situ much longer than expected, and that the materials used in the manufacturing of these tubes can degrade and cause complications. Long-term follow up and replacement of the tube is recommended.

METHOD

Case report and review of the literature concerning the use of long-term ventilation tubes.

RESULTS

In the case reported, the ventilation tube was in place for 19 years, which resulted in chronic ear discharge. When it was removed, it was noted that the tube itself had degraded and had caused a chronic inflammatory reaction.

CONCLUSION

We recommend that the long-term use of ventilation tubes is followed up and that the tube is replaced before material degradation takes place.

Microbial colonization of Blom-Singer indwelling voice prostheses in laryngectomized patients: a perspective from India

We analyzed a series of adults with an implanted voice prosthesis that had malfunctioned and required removal as a result of the attachment and growth of microorganisms. Our goal was to determine the characteristics of these colonizing microbes. We swabbed the esophageal side of each prosthesis to obtain microbial flora for analysis with standard culture media. In all, we studied 22 prostheses in 18 patients (3 patients had received multiple prostheses). We found mixed contamination (both yeast and bacteria) in 19 of the 22 cultures (86.4%); the other 3 cultures yielded bacteria only, and there was no instance of yeast only. The most common yeast isolated was Candida albicans (68.2% of cultures), and the most common bacterium was Pseudomonas aeruginosa (63.6%). The average lifetime of the prostheses was 201 days (∼6 mo, 3 wk). This study, which was the first of its kind in India, revealed that the microbial picture here was different from that found in previously reported studies of European populations. We presume the differences are attributable to different lifestyles and dietary habits.

Removal of Biofilms from Tracheoesophageal Speech Valves Using a Novel Marine Microbial Deoxyribonuclease

Objective

The growth of biofilms on tracheoesophageal speech valves shortens their life span and produces a reservoir of pathogens that may infect the respiratory tract. The authors have discovered a novel nontoxic deoxyribonuclease, NucB, from a marine isolate of Bacillus licheniformis that is effective at dispersing a variety of mono and mixed-species bacterial biofilms. The aim of this preliminary study was to determine whether NucB could also disrupt and remove mixed-species biofilms from tracheoesophageal speech valves.

Study Design

Laboratory-based treatment and analysis of discarded tracheoesophageal speech valves.

Setting

University human biology laboratory and the Department of Speech and Language Therapy at a tertiary referral hospital.

Subjects and Methods

Seventeen ex vivo tracheoesophageal speech valves fouled with natural human biofilms were collected and divided into 2 equal parts. One half was treated with NucB and the other half with a control buffer solution. Biofilm removal was measured by microscopy and by culture of dispersed biofilm organisms on agar plates.

Results

Significantly more organisms were released from biofilms using NucB than with buffer solution alone. On nonselective medium, more organisms were cultured in 11 samples (65%, n = 17, P < .05). Using growth media favoring fungi, more organisms were cultured in 14 samples (82%, n = 17, P < .05).

Conclusion

The nontoxic deoxyribonuclease NucB was effective in releasing more microorganisms from biofilms on tracheoesophageal speech valves. This reflects its potential ability to break up and disperse these biofilms. Future studies will aim to develop NucB as a novel agent to prolong the life span of tracheoesophageal speech valves, thus reducing health care costs.

Yeast Colonization of Voice Prostheses: Pilot Study Investigating Effect of a Bovine Milk Product Containing Anti—Candida Albicans Immunoglobulin A Antibodies on Yeast Colonization and Valve Leakage

Objectives:

Our goals were to determine whether a bovine milk product containing anti– Candida albicans immunoglobulin A antibodies (“immune milk”) could reduce the adherence of C albicans to voice prosthesis silicone in vitro, and whether administration of the milk could reduce C albicans colonization and voice prosthesis damage in vivo.

Methods:

An in vitro assay of C albicans attachment to silicone was developed with radiolabeled C albicans. A pilot crossover in vivo trial, over 3 periods of 3 months, was also undertaken for 4 patients with voice prostheses, comparing daily administrations of immune milk and a control milk product. The prosthesis valves were replaced at each change-over and were assessed for wet weight of removable biofilm, yeast numbers in removable biofilm, valve leakage, and valve damage.

Results:

Immune milk inhibited C albicans adherence to silicone in vitro. However, in a small clinical pilot study, this effect was not replicated.

Conclusions:

There is scope to further investigate the topical use of immune milk for management of voice prosthesis biofilms.

Microbial biofilms on facial prostheses

The composition of microbial biofilms on silicone rubber facial prostheses was investigated and compared with the microbial flora on healthy and prosthesis-covered skin. Scanning electron microscopy showed the presence of mixed bacterial and yeast biofilms on and deterioration of the surface of the prostheses. Microbial culturing confirmed the presence of yeasts and bacteria. Microbial colonization was significantly increased on prosthesis-covered skin compared to healthy skin. Candida spp. were exclusively isolated from prosthesis-covered skin and from prostheses. Biofilms from prostheses showed the least diverse band-profile in denaturing gradient gel electrophoresis (DGGE) whereas prosthesis-covered skin showed the most diverse band-profile. Bacterial diversity exceeded yeast diversity in all samples. It is concluded that occlusion of the skin by prostheses creates a favorable niche for opportunistic pathogens such as Candida spp. and Staphylococcus aureus. Biofilms on healthy skin, skin underneath the prosthesis and on the prosthesis had a comparable composition, but the numbers present differed according to the microorganism.

Comparison of biofilm formation on new Phonax and Provox 2 voice prostheses - a pilot study

BACKGROUND

In voice rehabilitation for laryngectomized patients, voice prosthetic biofilm formation is still an unsolved problem. Design and materials of voice prostheses have been altered by manufacturers to improve function and extend the lifetime of devices. The goal of the study was to investigate biofilm formation on Provox 2 and Phonax, recently introduced voice prostheses made of thermoplastic polyurethane.

METHODS

Five laryngectomized patients were equipped with both Phonax and Provox 2 voice prostheses. Microbial colonization was analyzed using standard microbiological methods. Biofilm formation and material infiltration were illustrated using scanning electron microscopy, fluorescence microscopy, and thin-section light microscopy.

RESULTS

Although no differences in quality or quantity of microbial colonization were assessed, microscopic imaging revealed differences in material surfaces, biofilm composition, and infiltration morphologies; the polyurethane material seems to destabilize biofilm architecture by inhibition of hypheal Candida growth forms.

CONCLUSIONS

Polyurethane material for voice prostheses seems to reduce biofilm stability and infiltrative processes.

Biofilms on tracheoesophageal voice prostheses: a confocal laser scanning microscopy demonstration of mixed bacterial and yeast biofilms

The aim of this study was to demonstrate the presence of yeast and bacterial biofilms on the surface of tracheoesophageal voice prostheses (TVPs) by a double-staining technique with confocal laser scanning microscopy (CLSM). Biofilms of 12 removed TVPs were visualized by scanning electron microscopy, then stained with ConA-FITC and propidium iodide for CLSM. Microbial identification was by partial 16S rRNA gene analysis and ITS-2 sequence analysis. Microbial biofilms on the TVPs consisted of bacteria and filamentous cells. Bacterial cells were attached to the filamentous and unicellular yeast cells, thus forming a network. Sequence analyses of six voice prostheses identified the presence of a variety of bacterial and yeast species. In vivo studies showed that Klebsiella oxytoca and Micrococcus luteus efficiently attached to Candida albicans. CLSM with double fluorescence staining can be used to demonstrate biofilm formations composed of a mixture of yeast and bacterial cells on the surface of TVPs.

In vitro colonization of an experimental silicone by Candida albicans

Denture soft-lining materials are exposed to the oral cavity for long periods and are in continuous contact with saliva, subject to inhibition of liquid molecules, and susceptible to colonization by microorganisms. The opportunist yeast Candida albicans is of particular concern in this context, being associated with denture plaque and denture-related stomatitis. In this study, penetration of C. albicans into an experimental silicone elastomer soft-lining material was investigated under batch and continuous culture conditions. A model "denture plaque" microcosm was also used. Increasing the filler concentration within the elastomer decreased penetration under both batch and continuous culture conditions. In continuous culture, C. albicans penetration was significantly greater in pure culture than in the presence of bacteria after 72-h incubation (p < 0.05).

Wettability, water sorption and water solubility of seven silicone elastomers used for maxillofacial prostheses

The wettability, water sorption and solubility of silicone elastomers used for maxillofacial prostheses were studied. The hypothesis was, that a material that has absorbed water would show an increase in the wettability and thus also the surface free energy of the material. Seven silicone elastomers, both addition- and condensation type polymers, were included. Five specimens of each material were subjected to treatment according to ISO standards 1567:1999 and 10477: 2004 for water sorption and solubility. The volumes of the specimens were measured according to Archimedes principle. The contact angle was measured with a contact angle goniometer at various stages of the sorption/solubility test. Wettability changed over the test period, but not according to theory. The addition type silicones showed little or no sorption and solubility, but two of the condensation type polymers tested had a significant sorption and solubility. This study showed that condensation type polymers may show too large volumetric changes when exposed to fluids, and therefore should no longer be used in prosthetic devices. The results of this study also suggests that it might be of interest to test sorption and solubility of materials that are to be implanted, since most of the materials had some solubility.

Strategies for the prevention of microbial biofilm formation on silicone rubber voice prostheses

Total laryngectomy, a surgical treatment for extensive cancer of larynx, which alters swallowing and respiration in patients, is followed up with a surgical voice restoration procedure comprising tracheoesophageal puncture techniques with insertion of a "voice prosthesis" to improve successful voice rehabilitation. However, microbial colonization is a major drawback of these devices. Antimicrobials are usually used to prevent the colonization of silicone rubber voice prostheses by microorganisms. However, long-term medication induces the development of resistant strains with all associated risks and the development of alternative prophylactic and therapeutic agents, including probiotics and biosurfactants, have been suggested. The inhibition of microbial growth on surfaces can also be achieved by several other techniques involving the modification of physicochemical properties of the biomaterial surface or the covalently binding of antimicrobial agents to the biomaterial surface. An overview of the different approaches investigated to date and future perspectives to reduce the frequent replacements of voice prostheses in laryngectomized patients through microbial biofilm retardation is presented and discussed.

Isolation and partial characterization of a biosurfactant produced by Streptococcus thermophilus A

Isolation and characterization of the surface active components from the crude biosurfactant produced by Streptococcus thermophilus A was studied. A fraction rich in glycolipids was obtained by the fractionation of crude biosurfactant using hydrophobic interaction chromatography. Molecular (by Fourier transform infrared spectroscopy) and elemental compositions (by X-ray photoelectron spectroscopy) were determined. Critical micelle concentration achieved was 20 g/l, allowing for a surface tension value of 36 mJ/m(2). Moreover, this glycolipid rich fraction was found to be an anti-adhesive and antimicrobial agent against several bacterial and yeast strains isolated from explanted voice prostheses. Further purification steps should be carefully analyzed as each purification step will increase the costs and decreases the amounts of biosurfactants recovered.

Interference in adhesion of bacteria and yeasts isolated from explanted voice prostheses to silicone rubber by rhamnolipid biosurfactants

AIMS

The effects and extent of adhesion of four different bacterial and two yeast strains isolated from explanted voice prostheses to silicone rubber with and without an adsorbed rhamnolipid biosurfactant layer obtained from Pseudomonasaeruginosa DS10-129 was studied.

METHODS AND RESULTS

The ability of rhamnolipid biosurfactant to inhibit adhesion of micro-organisms to silicone rubber was investigated in a parallel-plate flow chamber. The anti-adhesive activity of the biosurfactant at different concentrations was significant against all the strains and depended on the micro-organism tested. The results showed an effective reduction in the initial deposition rates, and the number of bacterial cells adhering after 4 h, for all micro-organisms tested at the 4 g l(-1) undiluted rhamnolipid solution. Maximum initial reduction of adhesion rate (an average of 66%) occurred for Streptococcus salivarius GB 24/9 and Candida tropicalis GB 9/9. The number of cells adhering after 4 h on silicone rubber conditioned with biosurfactant was reduced to 48% for Staphylococcus epidermidis GB 9/6, Strep. salivarius GB 24/9, Staphylococcus aureus GB 2/1 and C. tropicalis GB 9/9 in comparison to controls. Perfusing the flow chamber with biosurfactant containing solution followed by the passage of a liquid-air interface, to investigate detachment of micro-organisms adhering to silicone rubber, produced high detachment (96%) of adhered cells for all micro-organisms studied, except for Staph. aureus GB 2/1 (67%).

SIGNIFICANCE AND IMPACT OF THE STUDY

It is concluded that biosurfactant represent suitable compounds that should be considered in developing future strategies to prevent the microbial colonization of silicone rubber voice prostheses.

Microbial adhesion in flow displacement systems

Flow displacement systems are superior to many other (static) systems for studying microbial adhesion to surfaces because mass transport and prevailing shear conditions can be adequately controlled and notoriously ill-defined slight rinsing steps to remove so-called "loosely adhering organisms" can be avoided. In this review, we present the basic background required to calculate mass transport and shear rates in flow displacement systems, focusing on the parallel plate flow chamber as an example. Critical features in the design of flow displacement systems are discussed, as well as different strategies for data analysis. Finally, selected examples of working with flow displacement systems are given for diverse biomedical applications.

Inhibition of microbial adhesion to silicone rubber treated with biosurfactant fromStreptococcus thermophilusA

Microbial adhesion of four bacterial and two yeast strains isolated from explanted voice prostheses to silicone rubber before and after conditioning with a biosurfactant obtained from the probiotic bacterium Streptococcus thermophilus A was investigated in a parallel plate flow chamber. The silicone rubber with and without an adsorbed biosurfactant layer was characterized using contact angle measurements. Water contact angles indicated that the silicone rubber surface with adsorbed biosurfactant was more hydrophilic (58 degrees) than bare silicone rubber (109 degrees). The results obtained showed that the biosurfactant was effective in decreasing the initial deposition rates, and the number of bacterial cells adhering after 4 h, for all microorganisms tested. A decrease in the initial deposition rate was observed for Rothia dentocariosa GBJ 52/2B and Staphylococcus aureus GB 2/1 from 1937+/-194 to 179+/-21 microorganisms cm(-2) s(-1) and from 1255+/-54 to 233+/-26 microorganisms cm(-2) s(-1), respectively, accounting for an 86% reduction of the initial deposition rate for both strains. The number of bacterial cells adhering to the silicone rubber with preadsorbed biosurfactant after 4 h was further reduced by 89% and 97% by the two strains, respectively. The two yeast strains tested showed less reduction in adhesion after 4 h, to values between 67% and 70%. Such a pretreatment with surface-active compounds may constitute a promising strategy to reduce the microbial colonization rate of silicone rubber voice prostheses.

Differences in aerodynamic characteristics of new and dysfunctional Provox 2 voice prostheses in vivo

Tracheoesophageal voice prostheses need to be replaced due to increased airflow resistance or retrograde leakage of fluid into the trachea as a consequence of biofilm formation. Previous in vitro studies show a change of aerodynamic features of biofilm covered voice prostheses after removal of the prostheses out of the patient. To assess these changes in an in situ situation, aerodynamic characteristics were measured within 45 patients at the beginning and at the end of the wearing process of the Provox 2 voice prosthesis. As a consequence, the influence of biofilm formation on aerodynamic characteristics can be evaluated. In the majority of cases, leakage through the prosthesis was the reason for replacement. No differences were found in the total flow, volume range and intratracheal pressure (ITP) of the voice prostheses measured. The airflow resistance of biofilm covered prostheses was significantly reduced compared to new clean prostheses. However, no correlation was found between the extent of biofilm and the different aerodynamic features measured. Biofilm formation on the Provox 2 is responsible for both reduction in airflow resistance and leakage through the prosthesis by deterioration of the silicone rubber material.

Difficulties in the fixation of prostheses for voice rehabilitation after laryngectomy

In most patients with advanced or recurrent laryngeal or hypopharyngeal cancer, total laryngectomy is indicated. This means the loss of three main functions: phonation; respiration; and the prevention of aspiration during deglutition. Laryngectomy patients have various options to restore phonation: an oesophageal voice; an electrolaryngeal voice; or a tracheo-oesophageal voice. In the last case a silicone rubber shunt valve is placed in the tracheo-oesophageal wall and phonation is generated when exhaled air is forced through the oesophagus and neopharynx. This method is widely applied in Western Europe. In this paper we review the literature on fixation problems with shunt valves, tracheostoma valves and heat and moisture exchange (HME) filters. Tracheo-oesophageal speech without a valve is not considered. Despite 22 years of experience with the implantation of tracheo-esophageal shunt valves and many improvements in the design, problems still remain, such as biofilm formation with subsequent leakage through the valve, the need for frequent and inconvenient replacements, fistula enlargement leading to leakage around the device and reduced fixation, and infections. The high cost of shunt valves is a drawback to their use worldwide. To enable hands-free speech, different types of tracheostoma valve have been developed. These valves are fixed to the skin or to the tracheostoma by means of an intra-tracheal device. An HME filter is used to protect the airway and maintain physiological balance. Such devices are only suitable for a selected group of patients as fixation to the skin or trachea can be a major problem. Speaking and coughing cause pressure increases, which often result in mucous leakage and disconnection of the valve and/or HME filter. Recommendations are made for future improvements in fixation techniques.

Biosurfactant from Lactococcus lactis 53 inhibits microbial adhesion on silicone rubber

The ability of biosurfactant obtained from the probiotic bacterium Lactococcus lactis 53 to inhibit adhesion of four bacterial and two yeast strains isolated from explanted voice prostheses to silicone rubber with and without an adsorbed biosurfactant layer was investigated in a parallel-plate flow chamber. The microbial cell surfaces and the silicone rubber with and without an adsorbed biosurfactant layer were characterized using contact-angle measurements. Water contact angles indicated that the silicone-rubber surface with adsorbed biosurfactant was more hydrophilic (48 degrees) than bare silicone rubber (109 degrees). The results showed that the biosurfactant was effective in decreasing the initial deposition rates of Staphylococcus epidermidis GB 9/6 from 2,100 to 220 microorganisms cm(-2) s(-1), Streptococcus salivarius GB 24/9 from 1560 to 137 microorganisms cm(-2) s(-1), and Staphylococcus aureus GB 2/1 from 1255 to 135 microorganisms cm(-2) s(-1), allowing for a 90% reduction of the deposition rates. The deposition rates of Rothia dentocariosa GBJ 52/2B, Candida albicans GBJ 13/4A, and Candida tropicalis GB 9/9 were far less reduced in the presence of the biosurfactant as compared with the other strains. This study constitutes a step ahead in developing strategies to prevent microbial colonization of silicone-rubber voice prostheses.

The effect of formation of the liquid crystalline phase on the blood compatibility of a cholesterol modified silicone

Cholesterol modified silicones were synthesized by grafting copolymerization of 10-Cholesteryloxydecanol onto polymethylhydrosiloxane (PMHS). Fourier transform infrared (FT-IR) spectroscopy, proton nuclear magnetic resonance ((1)H-NMR) spectroscopy and gel permeation chromatography (GPC) confirmed the chemical structures of polymers. Differential scanning calorimetry (DSC) and polarized optical microscopy (POM) results indicated the mesogenic properties of those polymers. The modified silicone with 45% 10-Cholesteryloxydecanyl (SC45) indicated obvious thermotropic liquid crystalline transform at about 122-124.9 degrees C. The thermotropic liquid crystalline phase could be retained at room temperature via a special annealing/quenching process. The anneal-quenched film (SC45C) formed continuous liquid crystalline phase, whereas the unannealed films presented amorphous structure. The blood compatibility of the coatings was assessed from SEM observation of the platelet's adhesion to coating surface and plasma recalcification time (PRT). The results revealed that the formation of the liquid crystalline phase could greatly improve the in vitro blood compatibility of the materials. The positive results of liquid crystalline onto haemocompatibility allow broad potential in biomaterials.

In vitro leakage susceptibility of tracheoesophageal shunt prostheses in the absence and presence of a biofilm

Although leakage through a tracheoesophageal shunt prosthesis is the main cause of prosthesis failure in a laryngectomy patient, this has never been the subject of in vitro evaluation. The aim of this study was to compare three commercially available voice prostheses by comparison of their in vitro leakage patterns, in absence or presence of a biofilm. To compare in vitro leakage patterns, a model comprised of an artificial throat equipped with a single prosthesis coupled to a water reservoir was developed. By varying the height of the water reservoir, different pressures on the voice prosthesis can be obtained. Both in absence and presence of a biofilm, the Blom Singer voice prosthesis demonstrated the lowest leakage, followed by Groningen Low Resistance. The Provox2 showed significantly the most leakage, however, in presence of a biofilm the leakage of the Provox2 significantly decreased. Regular airflow during biofilm formation significantly increased leakage through the Provox2. Out of 746 clinical replacements, Provox2 showed 76% and Groningen Low Resistance 57% replacements due to leakage. The model used in this study showed significant differences in leakage of the three types of voice prostheses used. Leakage occurred more readily through Provox2 than through Groningen Low Resistance and Blom Singer prostheses, which is in line with clinical observations and enforces the model.

Effect of dairy products on the lifetime of Provox2 voice prostheses in vitro and in vivo

BACKGROUND

Reduction of biofilm formation on tracheoesophageal voice prostheses by certain dairy products might extend their clinical lifetime. The purpose of this study was to determine the influence of certain dairy products on voice prosthetic biofilms and lifetimes in vitro and in vivo.

METHODS

The in vitro results were accomplished using an artificial throat. The lifetimes of Provox2 prostheses were evaluated in a patient group that daily consumed the evaluated products.

RESULTS

Buttermilk and Yakult Light fermented milk decreased the amount of bacteria on voice prostheses but stimulated yeast prevalence in vitro. Concurrently, lifetimes of voice prostheses in patients consuming buttermilk were not significantly different, whereas patients consuming Yakult Light fermented milk drink had a significantly (p < .01) increased prosthesis lifetime by a factor of 3.76.

CONCLUSION

Yakult Light fermented milk drink reduced biofilm formation on Provox2 prostheses in vitro and in vivo and significantly increased prosthesis lifetime. In vivo, no significant effects were observed for patients consuming buttermilk.