Nonsurgical voice restoration following total laryngectomy

What are the issues after total laryngectomy?

• Swallowing

• Respiration

• Olfaction

• Communication

• Psychosocial Issues 

What Activities of Daily Living can be affected?

• Hygiene/Showering

• Lifting strength

• Defecation

• Swimming

Hygiene:

• Shower Shields

Lifting & Defecation:

• Difficulty w/ both d/t pressure loss throughout the system

  • May need Physical Therapy

• Difficulty straining to have bowel movement

  • Managed w/ dietary changes or medication

Swimming:

• The “Larkel”

What are the non-speech communication options?

• Alternative/augmentative communication

  • Low-tech: Picture Board, etc.

  • High-tech: Speech generating device

• Writing

  • “Old school” w/ pen & paper

  • Technology aided – email, texting

What are the speech communication options?

• Artificial Larynx 

• Esophageal Speech 

  • Without a Tracheo-Esophageal Prosthesis (TEP)

  • With a TEP

  • “Other”

Speech with artificial larynges (AL):

• How is it produced?

  • Electronic Device

  • Pneumatic Device

AL: Placement is Key!

• External

  • Neck

  • Cheek

• Intraoral

AL - Placement Continued:

• “Sweet Spot” 

  • don’t use the phrase “sweet spot” in your reports!

• Use “wow-wow-wow” then “how are you” to find best placement

• NOTE – some devices may use a “holder”

(AL Therapy Goals) Timing - “On” & “Off”:

• Maximize linguistic content

• Watch for co-articulation/overlapping phoneme scenarios

  • “I am Mabel” vs. “I’m able”

• Minimize distracting “buzz”

(AL Therapy Goals) Articulation:

• Nasals/glides are OK

• Voiced/voiceless phoneme confusion

• Difficulty w/ fricatives

• Weak/omitted consonants in medial & final position

• Focus on increasing intra-oral air pressure

(AL Therapy Goals) Pitch & Loudness:

• Controlled by the device

(AL Therapy Goals) Rate of speech:

• slower rate best

• needs to be taught!

(AL Therapy Goals) Emphasis/Stress:

• Difficult to achieve variability

• Lots of practice required

(AL Therapy Goals) Other:

• Singing – helps improve all aspects of speech

(AL Therapy Goals) Distractors:

• Constant buzz

• Stoma blast

• Non-verbal behaviors

  • Grimacing

  • Awkward arm position

Other Considerations: 

• Non-dominant hand 

• Do you think a pt can turn off or dampen EL vibration for voiceless sounds?

Traditional esophageal speech:

• “burping your ABCs”

Traditional esophageal speech - How is it produced?

• The PE segment becomes the vibratory source

  • Looser PES is better when reconstructed

• Esophagus becomes “air reservoir”

• PES vibrates when esophageal pressure is great enough to overcome PES resistance, the PE tissue vibrates

  • different application of Bernoulli’s principle

Esophagus as Air Reservoir: 

• Insufflation

  • Inhalation Method

  • Injection Method

• Exhalation

What does the Inhalation Technique rely on?

• Relies on negative pressure in esophagus 

How is the Inhalation Technique done?

• Inhale quickly through stoma

• Inhalation causes thorax to expand, drop in intra-thoracic pressure

• Pressure drops in esophagus

  • Creates a vacuum-effect, air from mouth/pharynx enters esophagus

What does the Injection Technique rely on?

• Rely on high/increased intraoral air pressure

• Increased pressure above PES, forces air through PES & into esophagus

• Need to maintain good/tight Velopharyngeal closure

How is the Injection Technique done?

• Consonant injection

  • Stops, fricatives, affricates are used to compress the volume of air in oral cavity

  • Tongue rocking to teach air injection - difficult

• Glossopharyngeal Press

  • Articulators reduce oral cavity volume

  • Smaller space → increased pressure

Is it “talking on burp?”

• How is it similar?

• How is it different?

(Traditional esophageal speech) How long to learn? Variable:

• Therapy Goals:

  • First – produce a sound, any sound

  • Next – improve speed of sound production

  • Next – shape the sound

    • Vowels

    • CV syllables w/ stops

    • CV syllables w/ fricatives

(Traditional esophageal speech) What should be done once the pt is consistently producing CV syllables?

• Articulation:

  • Distinguishing between voiced & voiceless sounds

  • Linguistic content helps

• Rate:

  • Longer bursts of speech per insufflation 

• Volume

  • Increased utterance length → Decreased volume 

What are the therapy approaches?

• Indirect 

  • SLP observes pt and guides success

• Semi-direct

  • Clinician models correct behavior

    • Visual & Auditory model

• Direct

  • Clinician actually produced esophageal speech

(Traditional esophageal speech) What about pitch?

• Lower F0 typically, but not always 

• “Glottal Fry - like” 

• Monotone 

(Traditional esophageal speech) Pitch & loudness variability?

• Some can learn to vary pitch 

  • Increased effort

  • Head posture changes

(Traditional esophageal speech) Distractors?

• Unwanted noise

  • Clunking

  • Stoma Blast

  • Intrusive consonants

• Visual Distractions

  • Extra mouth/head movements

  • Jaw thrust

  • Double pumping

  • Facial grimacing

  • Poor eye contact

What are the advantages of traditional esophageal speech?

• No device needed

• Hands-free

• Visual-acuity is non-issue

• Free

What are the disadvantages of traditional esophageal speech?

• Difficult for some people 

• Physical pre-reqs 

• Voice acoustics are “off” 

  • F0

  • Pitch variability

  • Intensity/volume

• Possible distractors

Are good ES speakers good TEP users?

Yes!

Are good TEP users good ES users?

Not necessarily!

What are the other communication options?

• Buccal speech, “Donald Duck talk”

What is pharyngeal speech?

• Uses pharyngeal wall, palate, or tongue as vibratory source 

• Unique → uses tongue as vibratory source and articulatory organ 

Other education:

• Neck breather

• Medical ID

• Telephone use

• Emergency communication if cannot voice

• Amplifiers?

• How to tell listeners to be patient