Tracheo-oesophageal puncture (TEP) voice prosthesis
A one-way valve that lets a laryngectomy patient speak. In an emergency it is left alone - pulling it out helps nothing and opens a tract into the oesophagus.
Also called: TEP, TEP valve, voice prosthesis, Provox, Blom-Singer, speaking valve (laryngectomy)
What it is
A TEP is a small one-way valve sitting in a surgically created puncture between the back wall of the trachea and the oesophagus behind it, in a patient who has had a total laryngectomy. On covering the stoma and exhaling, air is driven through the valve into the pharynx to produce voice. The valve stops food and fluid passing the other way into the airway.
Because every TEP patient is a laryngectomy patient, the laryngectomy entry governs any airway emergency - this page is about the valve itself and its two failure modes: aspiration when it leaks, and the understandable but wrong instinct to remove it.
How to recognise it
- A laryngectomy stoma with a small circular valve visible in its posterior (back) wall. Brand names on records include Provox and Blom-Singer.
- The patient speaks by occluding the stoma with a finger or a hands-free valve in a stoma cover, not by moving air through the mouth. Speech does not mean an upper airway.
- A leaking valve classically causes coughing when drinking, often worst with thin fluids, as fluid tracks through or around the valve into the trachea.
What it gets confused with
The valve sits inside a laryngectomy stoma - it is not a separate kind of airway. Any breathing emergency in this patient is managed on the red laryngectomy algorithm: oxygen to the stoma, not the face. Do not let the word 'speaking valve' make you think of a tracheostomy speaking valve, which is a different device on a different patient.
What goes wrong
Leaking valve (aspiration)
Coughing, especially on thin fluids; recurrent chest infections. Leakage may be through a failed valve or around an enlarging puncture.
Red flag
Ongoing aspiration needs the head and neck team or speech and language therapy promptly, but it is not an airway-obstruction emergency and is not fixed by removing the valve.
Dislodged, lost or inhaled valve
The valve has fallen out, leaving an open tract between oesophagus and trachea; fluids and food may enter the airway. The prosthesis itself is small and, once out, may be swallowed or inhaled into the trachea.
Red flag
The tract can narrow or close within hours, so it needs same-day specialist attention to keep it patent - but in the ED the priority is protecting the airway from aspiration, not re-inserting the valve. Account for the prosthesis: if it cannot be found and the patient has a new cough, wheeze or breathlessness, get a chest X-ray, as an inhaled prosthesis may need bronchoscopic retrieval.
Candida or granulation causing valve failure
A valve that no longer seals, biofilm or fungal colonisation, or granulation around the puncture.
Red flag
A chronic problem for the speech and language team, not an emergency - included so it is not mistaken for one.
The first ten minutes
- If there is any breathing difficulty, treat the patient as a laryngectomy and follow that algorithm: oxygen to the stoma, assess stoma patency, call airway help. The valve is not the airway.
- For a leaking valve with aspiration, keep the patient upright, give oxygen as needed by the stoma, consider nil by mouth, and refer to head and neck / SALT.
- For a dislodged valve, do not try to re-insert it. Protect the airway, note the time it came out (the tract can close), and get the head and neck team the same day - a catheter may be placed by a competent specialist to keep the tract open.
- Do not remove the valve in any of these situations.
Do not
should not be removed in an emergency as they should not occlude the airway and removing them will not improve acute respiratory problems. Removing it opens a direct tract into the oesophagus and makes aspiration worse.
Who owns it
ENT / head and neck surgery and speech and language therapy own the valve and the puncture. Tell them whether the valve is leaking, dislodged or absent, and - if it is out - the time it came out, because the tract can close.
Who to call
The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.
- Say the device name first
- Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
- Say what you have already established
- Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
- Ask who owns it out of hours
- Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
- The patient's own team is a resource, not an afterthought
- Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.
When the device is not the problem
A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.
- The NTSP says it out loud
- The project's own manual warns that
patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy.
The same sentence applies to every device in this tool. - Clear the device, then leave it
- Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
- The anchoring runs both ways
- The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.
- NTSP manual — Red flags · read in full
What the patient will be carrying
Many patients carry details of their valve type and size and know their SALT team's contact. The red NTSP laryngectomy bedhead sign, if present, flags the neck-breather status.
Scope of this page
This page covers what the valve is and the two ways it fails in front of you - leaking and dislodged - plus the one instruction that matters: leave it in. Any actual airway emergency is managed on the laryngectomy page, not here. Re-insertion, sizing and routine valve changes belong to ENT and speech and language therapy, not the ED.
Sources
- NTSP manual - Speech after total laryngectomy (TEP valves) · read in full
- NTSP adult red laryngectomy emergency algorithm (review date 1/1/27) · read from the rendered figure