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 . Active voice rehabilitation is associated with attaining better functional speech.
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 (
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).
Patients who used TEP had the best results in speech intelligibility 6 months and 1 year after . The larger the inner diameter of the TEP, the stronger is the voice and the easier it is to speak.
- 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
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
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.
3. Electrolarynx or artificial larynx speech
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).
- “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.
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.
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.
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 .
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.
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
Diaphragmatic breathing and speech
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.