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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), most laryngectomees can acquire a new way of speaking. About 85-90% of laryngectomees 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, fluent and intelligible sounding voice.

Tracheoesophageal speech requires a puncture created by the surgeon that connects the trachea (the windpipe) and esophagus (food tube) and a silicone voice prosthesis that is inserted into the puncture (called tracheoesophageal puncture or TEP). The puncture is made at the back of the trachea and goes into the esophagus . 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). 

The advantages of placing primary TEP are that individuals are not subjected to an additional surgerical procedure, can start speech rehabilitation shortly after laryngectomy. However, primary TEP is associated with an increased risk of s fistula formation, leakage at the puncture site, stomal stenosis, and local infection.

In patients who will undergo secondary puncture, the SLP has the advantage of determining trachea esophageal voice quality prior to the procedure. This allows the patient and the clinicians to determine whether their voice will be acceptable/functional.  The technique used to ascertain voice prior to the puncture is known as insufflation testing. If the patient is not fluent or the voice quality is poor, the clinician can work with the surgeon to determine appropriate interventions prior to puncture to optimize outcomes.

Following the 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. The voice prosthesis is inserted using a special imsertion device that may be guide by a gel cap.

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 or connected to a Lary Tube that is inserted into 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 converted into sounds of speech in the mouth (by the tongue, lips, teeth, etc.).

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 SLP)

The HME or automatic speaking valve can be attached in front of the tracheostoma in 3 different ways: by means of an adhesive base plate housing that is taped or glued to the skin, or by means of a laryngectomy tube or stomal button that is placed inside the stoma. 

The voice prosthesis need to be periodically replaced (this is 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 use TEP have 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:

  • Swallow your saliva before speaking 
  • Speak slowly
  • Speaking only 4-5 words between each air exhalation
  • Using diaphragmatic breathing (see below) 
  • Speak while standing is easier (using the diaphragm to inhale)
  • Over articulating the words
  • Speaking by using low air pressure
  • Placing low pressure on the HME when speaking (excessive pressure can prevent speech)

Laryngectomees often try to compensate for their low voice volume by increasing the exhalation air pressure. This is tiring and can lead to air leak around the HME’s base plate. Placing too much pressure on the HME can block air movement and prevent speech.

For patients relying on the SLP for prosthesis changes, this may require clinic visits as frequently as once per month and on average every two to three months.  Because this speaking method relies on the upper esophageal sphincter as the sound source, patients with issues like stricture or narrowing of this region may not be able to achieve good voiceIndividuals 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. 

It is important to make sure that the adhesive housing is sealed and not leaking air. (see HME filter care section) 

Voice production through tracheoesophageal or esophageal speech (see below), may become more difficult during and immediately after radiation therapy because of the swelling of the tissues behind the valve or to thick secretions blocking the valve. 

The puncture site can be reversed by removing the voice prosthesis. It generally closse within a few hours, but may take longer time to heal in those who had received radiation therapy where surgical closure may be required.  

 Karen Vanderpool Haerle and Atos Medical granted  permission to use this illustration 

2. Esophageal speech

Esophageal speech is produced by insufflating the esophagus with air and then allowing this air to be released through the upper esophageal sphincter where vibration creates soundThis method does not require any instrumentation. 

In contrast to tracheoesophageal speech, which occurs when pulmonary air is shunted through a prosthesis, esophageal speech relies on active air insufflation from the mouth.  Air can enter the esophagus only when there is higher pressure above the upper esophageal sphincter than below.  Thus, air insufflation occurs either when patients produce high intra-oral pressure or when they create low pressure at the level of the upper esophageal sphincter by relaxing the cricopharyngeus muscle.

Esophageal speech training includes training in strategies to accomplish air insufflation as well as treatment of distracting secondary behaviors.  Positive pressure injection methods rely on using the articulators to force high-pressure air through the cricopharyngeus while the inhalation method relies on chest expansion and dropping of UES pressures to pull air into the esophagus.

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. Individuals with esophageal narrowing may require dilation to be able to use esophageal speech. Lack of tonicity of the pharyngo-esophageal segment  segment may present a problem for esophageal speakers. Limited number of individuals know how to teach it. Some speech and language pathologists are familiar with esophageal speech and can 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.

 Karen Vanderpool Haerle and Atos Medical granted  permission to use this illustration

3. Electrolarynx or artificial larynx speech

The use of electrolarynx requires manual dexterity, visual acuity, and motivation.  It cannot be used in those whose tongue had been removed. This method of speaking is usually covered by medical insurance, is quickly and easily learned enabling early communication, does not require breath support and additional surgery, it requires less maintenance compared to tracheoesophageal speech, produces a strong sound. It also requires manually dexterity, and the ability to turn the device on before and off after speaking. It’s disadvantages are that it produced monotonic or robotic speech quality, and uses batteries that require charging, and the use of one hand.  

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, it 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 in the intra oral route of delivery of vibration is preferred at that time. The best placement of the intra oral straw (adapter) need to be individually explored. It generally works best to place the straw far enough in the mouth to allow the sound to resonate. The optimal position for most patients is approximately half way back in the mouth, midway between the check and the center of the mouth. If it is placed too far forward, the sound may not be audible. The straw should be placed in a position that prevents check, teeth, or gums from covering the tip. It should not 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 

Even though using an EL is not hard, practicing and acquiring the correct technique can improve communication and ensure one is understood. It is also important the device be in adequate working order. Adjustments of the volume and pitch can be made to assist in achieving the best quality speech possible. The SLP can adjust and teach the laryngectomee how to troubleshoot the 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.

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 much little pressure enhances external vibration noises, while too pressure decreases the sound.
  • Proper Positioning: For every laryngectomee there will be areas of higher or lower 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 or the cheek. The sweet spot can change over time as healing progresses.
  • Adjusting the pitch appropriately for age and gender, and loudness to 50%-60% for in person conversations.
  • Improving articulation: The typical EL user needs to change their speech pattern somewhat in order to be well understood. It is helpful to articulate more precisely and over articulate; speaking only 5-7 words in each air exhalation; avoiding one words answers;speaking slowly, clearly and concisely; and remembering to do that with an open mouth. Taking time to articulate each sound and phrasing to allow breaks for listeners are important.  It is helpful to face one’s listener and reduce distractions.

  • Turning the device on and off at appropriate times can significantly impact how well others understand the speech. The button of the device should be pressed when starting to speak and released at the end of a short phrase, or at a natural pause to reduce the unnecessary mechanical buzz. It is important to avoid pressing the button  for each individual word or keep it on pressed for an entire conversation without a break. Short phrases are the easiest for conversational partners to understand. Pressing the button should be coordinated the breathing pattern speaking during air exhalation.
  • Avoiding forced air exhalation while speaking to reduce audible rushes of air ("stoma blast") 

Troubleshooting the presence of too loud buzzing  

  • Make sure the head is fully contacting the neck or check.
  • Try a different placement on the neck or check.
  • Reduce the volume
  • Inspect the cap – is the foam ring damaged?
  • With Provox TrueTone, one can switch to the grey sound head if one has fibrosis ( hard neck, scarring)

 Karen Vanderpool Haerle and Atos Medical granted  permission to use this illustration 

Types of electrolarynx

Video: Speaking with an 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 generating devices. (see below) The user types what he/she wants to say onto a keyboard, and the computer speaks out loud what has been typed. Smartphones and some cell phones and 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. See the link https://www.tmobileaccess.com/iprelay 

Other methods of communication can use the assistance of a companion who knows and understands the laryngectomee; writing messages with a pencil or pen, or on an erase board; using sign language, gestures or facial expressions; and by predetermined clicks .

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 backup method for occasional use when there is difficulty with their speech method (e.g., their 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 require a physician’s prescription. Their design typically includes an adequate speaker, various voice options, and multi-functional communication software.

Evaluation by a 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 speaks 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 as 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.

Other methods of generating speech are under development. Tank and his colleagues from the University of Texas at Austin, have developed a non-invasive language decoder that can reconstruct speech from functional MRI data. This technology can one day help people who have lost their ability to speak called a semantic decoder. 

The Australian start-up Laronix is developing a bionic device that uses AI-based voice-cloning technology to restore the voices of laryngectomy patients. 

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 read their 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's 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. The volume and quality of the voice when speaking over the phone can be improved by speaking using a hand held microphone and pace it’s voice amplifier near the phones mouthpiece or iPhone.

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.

Google Duplex is an artificial intelligence (AI) technology that mimics a human voice and makes phone calls on a person's behalf. It enables users to perform a variety of tasks -- including make reservations, schedule appointments and perform other functions -- without having to speak to someone.

Whispp’s language independent AI technology and calling app converts whispered speech and vocal cord impaired speech into a clear and natural voice of one’s choice, without any delay. By providing recordings, one’s Whispp voice can sound like the person’s own healthy voice. 

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. It is easier to use diaphragmatic breathing when standing.

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 a 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.

The volume and quality of the voice when using telecommunication methods (e.g., Zoom, Webinar) can be improved by speaking using a hand held microphone and pace it's voice  amplifier near the laptop, iPad or iPhone.

 A voice amplifier 

Placing the voice amplifier near the iPad increases voice volume 

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