"My Voice"

Order a paperback or Kindle Edition or e-book of "My Voice: A Physician's Personal Experience with Throat Cancer," the complete 282 page story of Dr. Brook's diagnosis, treatment, and recovery from throat cancer.

Order a paperback or Kindle Edition or e-book of "The Laryngectomee Guide," the 170 page practical guide for laryngectomees. To obtain a free paperback copy fill this form and mail it to J. Harrison 11390 W. Theo W. Allis, WI 53214, or fax it to 414 227 9033. The Guide can also be requested by emailing to customersupport.us@atosmedical.com

Obtain and/or view a video presentation, a slide presentation and an instructive manual how to ventilate laryngectomees and neck breathers (free). A self examination guide for detection of primary and recurrent head and neck cancer is available.

Methods of speaking after laryngectomy


Although total laryngectomy ( also called laryngectomie, laryngektomie, laringectomia, laryngektomii, laringektomija, laringektomiya, and larenjektomi) removes the entire larynx (vocal cords/voice box). However, most laryngectomees can acquire a new way of speaking. About 85-90% learn to speak using one of the three main methods of speaking described below. About 10% do not communicate by speaking but can use computer-based or other methods to communicate.

Individuals normally speak by exhaling air from their lung to vibrate their vocal cords. These vibration sounds are modified in the mouth by the tongue, lips, and teeth to generate the sounds that create speech.  Although the vocal cords that are the source of the vibrating sounds are removed during total laryngectomy, other forms of speech can be created by using a new pathway for air and a different airway part to vibrate. Another method is to generate vibration by an artificial source placed on the outside of the throat or mouth and then using the mouth parts to form speech.


The method(s) used to speak again depend on the type of surgery. Some people may be limited to a single method, while others may have several choices. Each method has unique characteristics, advantages and disadvantages. The goal of attaining a new way to speak is to meet the communication needs of each laryngectomee

Patient education about the available speech choice after laryngectomy is essential both before and after surgery. Speech and language pathologists (SLPs) can assist and guide laryngectomees in the proper use of the methods and/or devices they use to obtain the most understandable speech. Speech improves considerably between six months and one year after total laryngectomy Active voice rehabilitation is associated with attaining better functional speech.


A SLP who specialize in caring for laryngectomees can be found through this link.



  
Methods of speaking after laryngectomy

The three main methods of speaking after laryngectomy are:

1. Tracheoesophageal speech

This method provides the most natural sounding voice, is loud, requires a puncture connecting the trachea and esophagus and a prosthesis that is inserted into it.

Tracheoesophageal speech requires placing the silicone voice prosthesis that is inserted into a puncture (called tracheoesophageal puncture or TEP) created by the surgeon. The hole is made at the back of the trachea (the windpipe) and goes into the esophagus (food tube). The hole between the trachea and esophagus can be done at the same time as the laryngectomy surgery (a primary puncture), or after healing from the surgery has occurred (a secondary puncture). A small tube called a voice prosthesis, is inserted in this hole and prevents the puncture from closing. It has a one-way valve at the end on the esophagus side which allows air to go into the esophagus but prevents swallowed liquids from coming through the prosthesis and reaching the trachea and lungs.


Speaking is possible by diverting the exhaled air through the prosthesis into the esophagus by temporarily occluding the stoma. This can be done by sealing it with a finger or by pressing on a special Heat and Moisture Exchange (HME) filter that is worn over the stoma. An HME partially restores the lost nasal functions. Some use a" hands free" HME (automatic speaking valve) that is activated by speaking. 


After occlusion of the stoma exhaled lung air moves through the prosthesis into the esophagus causing the walls and top of the esophagus to vibrate. These vibrations are used by the mouth (tongue, lips, teeth, etc.) to create the sounds of speech.

There are two different basic types of voice prosthesis: the patient-changed type, designed to be changed by the laryngectomee or by another person, and the indwelling type, designed to be changed by a medical professional (an otolaryngologist or speech/language pathologist)

The HME or automatic speaking valve can be attached in front of the tracheostoma in different ways: by means of an adhesive housing that is taped or glued to the skin, or by means of a laryngectomy tube or stoma button that is placed inside the stoma. 


The voice prosthesis need to be periodically replaced (covered by some medical insurances). This method requires obtaining supplies, daily up keeping and cleaning, dealing with failure of the prosthesis mostly due to leakage ( see “Tracheo-esophageal voice prosthesis use and care” section) , and the prosthesis may need adjustments and individual fitting.

Patients who used TEP had the best results in speech intelligibility 6 months and 1 year after total laryngectomy. The larger the inner diameter of  the TEP, the stronger is the voice and the easier it is to speak. 


Speech can be made clearer and easier by:

  • Speaking slowly
  • Speaking only 4-5 words between each air exhalation
  • Using diaphragmatic breathing (see below)
  • Over articulating the words
  • Speaking by using low air pressure


Laryngectomees often try to compensate for their low volume by increasing the exhalation air pressure. This is tiring and can lead to air leak around the HME’s base plate.


Individuals who suffer from chronic obstructive pulmonary disease (COPD) may have difficulties using tracheoesophageal speech and may find it impossible to use hands free HME. 


Speech can also  be improved by enhancing air flow. This can be achieved by relaxing the throat muscles, breathing deep breathes (preferably using diaphragmatic breathing) (see below), and lubricating the airway by drinking. Drinking water also relaxes the throat muscles. Making sure that the adhesive housing is sealed and not leaking air. (see HME filter care section) 






2. Esophageal speech

In esophageal speech the vibrations are generated by air that is injected (“belched”) out from the upper esophagus and used to vibrate the phartyngeal-esophageal segment.. This method does not require any instrumentation. 

Of the three major types of speech following laryngectomy, esophageal speech usually takes longest to learn. However, it has several advantages, not the least of which includes freedom from dependency on devices and instrumentation, it does not require purchasing any equipment and is hands free. Disadvantages include the need for training, slow speaking rate, often lower volume and dependency on the function of the cricoparyngeal muscle and pharyngeal segment. Some speech/language pathologists are familiar with esophageal speech and can and assist laryngectomees in learning this method. Self-help books and tapes can also help in learning this method of speech.
Read about the value and how to learn esophageal speech at this link.




3. Electrolarynx or artificial larynx speech

This method of speaking is quickly and easily learned, produces a strong sound, is powerful, requires a device with batteries, and the use of one hand. It requires, however, manually dexterity, and ability to turn the device on before and off after speaking.

The vibrations in this speech method are generated pneumatically by an external battery operated vibrator (called electrolarynx or artificial - larynx) which is usually placed on the cheek or under the chin.  

It makes a buzzing vibration that reaches the throat and mouth of the user. The person then modifies the sound using his/her mouth to articulate the speech sounds.

There are three methods to deliver the vibration sounds created by an artificial larynx into the throat and mouth (intra orally). One is directly into the mouth by a straw-like tube ( i.e., the Cooper Rands electrolarynx) and the other through the skin of the neck or face. In the last method, which produces the best results the electrolarynx (EL) is held against the face or neck. A denture type artificial larynx is also available. However, is rarely used and has limited success in phonation. 

ELs are often used by laryngectomees shortly after their laryngectomy while they are still hospitalized. Because of the neck swelling and post-surgical stitches the intra oral route of delivery of vibration is preferred at that time. The best placement of the intra oral straw (adaptor) need to be individually explored. It generally works best to place the straw far enough in the mouth to allow the sound to resonate. If it is placed too far forward, the sound may not be audible. The straw should not be placed in the side of mouth and its head should not be placed under the tongue or check.  Many laryngectomees can learn other methods of speaking later. However, they can still use an EL on as their main speaking methods or as a back-up in case they encounter problems with their other speaking methods (i.e,. a blown baseplate seal, excess mucous, a plugged or blocked TEP).





Cooper-Rands electrolarynx 




An electrolarynx with an oral adaptor 



Tips for Electrolarynx Use

Even though using an EL is not hard, practice and acquiring the correct technique can improve communication and ensure one is understood. It is also important the device be in adequate working order. There are several adjustments that can be made to the device to assist in achieving the best quality speech possible. The SLP can adjust and teach the laryngectomee how to troubleshoot this device as needed to ensure production of understandable speech.

Although it may be frustrating to use at first, with proper training and practice, most people can become very effective EL speakers in a very short period of time. If possible, it is a good idea to hold and operate the EL in one's non-dominant hand since it frees up the other hand to write.

Tips that can assist in improving speech include:
  • “Head” Placement: The head of the EL has to be placed in full contact with the skin surface of the neck. Even beard whiskers can interfere with proper contact and voice production.
  • Contact pressure: For best vocalization results the contact pressure of the "head" should be adequate. This is achieved by trial and error. Too little pressure enhances external vibration noises, while too pressure decreases the sound.
  • Proper Positioning: For every laryngectomee, there will be areas of more/less resonance in the throat. This is determined mostly by the density or thickness of the neck tissues at that location. The most ideal placement is generally in a location where the neck tissues are thinner and softer, at a level where there is space in the throat to resonate. In general, the more dense or “tough” the neck tissues are, the harder it will be to produce a good tone.
  • The “Sweet Spot": There is generally an individual “sweet spot” (perfect position) where the EL produces the best resonant tone. This can be found by placing the EL at various positions around the neck, under the chin and even on the cheek. The sweet spot can change over time as healing progresses.
  • Improving articulation: The typical EL user need to change their speech pattern somewhat in order to be well understood. It is helpful to articulate more precisely and over articulate, speaking only 4-5 words in each air exhalation, speak slowly, clearly and concisely, and remembering to do that with open mouth. Taking time to articulate each sound is important. 
  • Turning the device on and off at appropriate times can significantly impact how well others understand you. The device should be turned on at the same time as you start speaking and turned off at the end of a short phrase or at a natural pause to reduce the unnecessary mechanical buzz. Avoid turning the device on for each individual word or keeping it on for an entire conversation without a break. Short phrases are the easiest for conversational partners to understand.








Types of electrolarynx




Other methods of speech and communication


A pneumatic artificial larynx (also called Tokyo Artificial Larynx ) is also available to generate speech. This method uses lung air to vibrate a reed or rubber material that produces a sound. The device's cup is placed over the stoma and its tube is inserted in the mouth.The sound generated is injected into the mouth through the tube. It does not use any batteries and is relatively inexpensive.





Pneumatic artificial larynx



Those who are unable to use any of the above methods  can use speech generated devices such as computer generated speech using either a standard laptop computer, or a single purpose speech aid. (see below) The user types what he/she wants to say onto a keyboard, and the computer speaks out loud what has been typed. Some cell phones can also operate in this manner.

Sending written messages and texting through mobile phones (smart phones, or cell phones) and computers can help laryngectommees communicate in noisy places or when they have other communication difficulties.

Other methods of communication can use  a travel companion, writing messages on a pencil or an erasing board, gestures, facial expressions, and predetermined clicks .










Using speech generating devices


Speech-generating devices produce a pre-recorded or electronic message in response to pressing a button or icon. There are many devices available and include smartphones, laptops, androids and iPhones. There are programs that convert a written language into speech.

Many individuals with communication impairments including laryngectomees are using their personal electronic devices ( i.e., laptop, smartphone, etc.) generate speech. Any computer can be used as speech generating device (SGD) by enabling its user to input a message that the computer then speak aloud.

Laryngectomees can use SGDs for communication in one or more of the following ways:

1.         For communication after surgery until they regain speech through use of a voice prosthesis, electrolarynx or esophageal speech.
2.         As the main communication method for those who are unable to regain speech because of extensive surgery or other reasons.
3.         As a secondary communication method to clarify their spoken messages when they are not easily understood or where they anticipate difficulty being understood ( i.e,. noisy environment, using the telephone, etc.)
4.         As a back-up method for occasional use when there is difficulty with their speech method (e.g., the EL is broken).

Many devices can be used as an SGD after installing appropriate programs or applications.

There are two types of SGDs:

•           Integrated Devices: Devices such as laptop computers, desktop computers, smartphones or tablets can function as an SGD after installation of a program or application.
•           Dedicated Devices: These SGDs are designed for communication. They are regarded as medical equipment and requires a physician’s prescription. Their design typically includes an adequate speaker, various voice options and multi-functional communication software.

Evaluation by a speech-language pathologist (SLP) is advisable when considering obtaining an SGD. The SLP can assist in the selection and evaluation process and arrange for trials of different devices.

Selection of the most appropriate SGD requires considering how they are to be used:
•           Is it to be used in or outside home, at work, on the telephone, or all of these?
•           Will it be the main method used in conjunction with one’s speech?
•           Determining the size and weight of an SGD is based on one’s vision and ability to carry it.
•           Selecting the number of available features in an SGD depends on one’s comfort using this technology.

Some available features make the use of an SGD easier through auto prediction and auto correction.

SGD can assist in communication over the phone: A speakerphone is placed near the SGD and the message can be typed into the SGD which that speak it aloud. The speakerphone picks up the computerized voice and sends it out. It is helpful to begin conversations by telling the other person that one is using a computer to talk, so that the listener will know it is a person on the other end and not an automated call.

The SGD’s volume can be increased when needed with the addition of a small speaker that plugs into the device.

Some speech generating software and applications are available at no cost and others are sold at different prices. Expensive ones offer better voice quality and more features (e.g., the ability to store frequently used messages, word prediction, ability to vary the speech settings, etc.). Many of the more expensive programs offer either a free trial period or the ability to download a rudimentary version of the application at no cost. This allows one to try the basic features of the software and see if it fits one’s needs before making the purchase.

Medicare and private insurances generally cover a portion of the cost of dedicated devices (e.g., 80% - 90% of the cost), and may cover the purchase of speech generating software programs. However, they do not provide funding to purchase a computer to be used as an SGD. Purchasing an SGD through Medicare or insurance, requires an evaluated by an SLP who will document one’s need for the device. The state of Oregon provides an SGD through their telephone assistance program.




Speech generating device



Speaking on the phone

Speaking over the phone is often difficult for laryngectomees. Their voice is sometimes hard to understand and some individuals may even hang up the phone when they hear them.  

It is best to inform the other party about the speaking difficulties of the laryngectomee by first asking them "can you hear me?". This may enable the larynngectomee to inform and explain to their party about their speaking difficulties.


It is important to articulate clearly when speaking over the phone. One should speak slowly and even "over articulate" words.  Those who converse with a laryngectomee can his/her lips during face-to-face conversation. This is of course not possible over the phone. However, speaking through a video call (such as with Skype) allows for lip reading. One can practice phone conversation (without lip reading) by speaking to someone in person while not facing them


Tips that can help electrolarynx (EL) users include:

1. Place the phone microphone  right at the lips, or slightly above
them. Placing the microphone close to the EL introduces some of the buzzing sounds 
which would make it more difficult to be understood.

2. Articulate your words very carefully.

3. Turn the EL volume down. With the phone’s microphone close to the mouth, the EL sounds can be very low. Louder EL sounds might masks one’s articulation and make it difficult to be understood. 


There are phones available that can amplify the outgoing voice, making it easier for the laryngectomee to be heard and understood. 

There is a nationwide phone service that allows a person whose speech may be difficult to understand to communicate over the telephone with the help of a specially trained Communications Assistant.  No special telephone is needed for this calling option. The three digit number 711 can be used as a shortcut to access Telecommunications Relay Services (TRS) anywhere in the U.S. TRS facilitates telephone conversations by one or more people who have speech and hearing disabilities. All telecommunications carriers in the U.S., including wire-line, wireless and pay phone providers must provide 711 service.

Sending written messages (texting) through mobile phones (smart phones, or cell phones) can help laryngectommees communicate in noisy places or when they have other communication difficulties.




Other communication methods include teletypewriter devices (TTY), telecommunication device for the deaf (TDD), and using a telephone modem and display between devices, and using relay operators.

  
Telecommunication device for the deaf (TDD)



Diaphragmatic breathing and speech


Diaphragmatic breathing ( also called abdominal breathing ) is the act of breathing  slowly and deeply by using the diaphragm muscle rather than by using one's rib cage muscles. When breathing using the diaphragm, the abdomen, rather than the chest expands. This method of breathing allows for greater utilization of the lung capacity to obtain oxygen, dispose of bicarbonate gasses and increases air flow. 

Neck breathers are often shallow breathers who use a relatively smaller portion of their lung capacity. Becoming accustomed to inhaling by using the diaphragm can increase one’s stamina and also improve esophageal and tracheoesophageal speech by enhancing the ability to speak and increasing the voice volume. 

Diaphragmatic breathing is also relaxing and can be used to decrease general anxiety, tension and perception of pain.

This breathing method can be taught by speech and language pathologist.




Diaphragmatic breathing



Increasing the voice volume using a voice amplifier


One of the problems encountered when using tracheoesophageal or esophageal speech is the weakness of the volume. Using a waistband voice amplifier enables one to speak with less effort and can allow one to be heard even in noisy places. It also prevents breakage of the stoma's housing seal because the laryngectomee who uses tracheoesophageal speech does not need to generate a strong expiratory air pressure to exhale air though the voice prosthesis.

Using a microphone with a foam windscreen cover makes the voice clearer and reduces unwanted background noises created by the lips. Holding the microphone close to the lips, having the windscreen touching  the lower lip is best. Ideally it should never be more than 1/4 inch away.



 A voice amplifier