Alaryngeal Speech | Larynx | Human Anatomy
Wigginton is a speech language pathologist in the UK Voice and Swallow Clinic and is also a member of the Dysphagia Research Society, an International Association of Laryngectomee Alaryngeal Speech Instructor and a Board Certified Specialist in Swallowing Disorders.
Voice - Alaryngeal Speech Flashcards | Quizlet
Larynx is the second commonest site for cancer in the whole of aerodigestive tract. Commonest malignancy affecting larynx is squamous cell carcinoma. Surgery carries a good prognosis. Conservative laryngeal surgeries are getting common by the day. After total laryngectomy there is a profound alteration in the life style of a patient. The patient is unable to swallow normally, associated with profound changes in the pattern of respiration. Olfaction is also affected.
There are three methods of alaryngeal speech. They are:
1. Oesophageal speech
3. Tracheo oesophageal puncture
Oesophageal speech: Patients after total laryngectomy acquire a certain degree of oesophageal speech. In fact all the other alaryngeal speech modalities are compared with that of oesophageal speech. It is the gold standard for post laryngectomy speech rehabiltation methods.
In this method air is swallowed into the cervical oesophagus. This swallowed air is immediately expelled out causing vibrations of pharyngeal mucosa. These mucosal vibrations along with tongue in the oral cavity cause articulations. This method is very difficult to learn and only 20 % of patients succeed in this endeavour. Patient's with oesophageal speech speak in short bursts, as the bellow effect of the lungs are not utilised in speech generation. The vibrations of muscles and mucosa of cervical oesophagus and hypopharynx are responsible for speech production. Oral cavity plays an important role in generation of oesophageal speech. Air from the oral cavity is swallowed into the cervical oesophagus before speech is generated.
There are two methods by which air can be pumped into the cervical oesophagus. They are:
Injection method: In this method the person builds up enough positive pressure in the oral cavity forcing air into the cervical oesophagus. This is achieved by elevating the tongue against the palate. Air can also be injected into the cervial oesophagus by voluntary swallowing. Lip closure along with elevation of tongue against the palate generates enough positive pressure within the oral cavity to force air into the cervical oesophagus. This method is also known as tongue pumping, glossopharyngeal press and glossopharyngeal closure. This method is effective before speaking Obstruent phonemes like plosives, fricatives and africatives.
Inhalational method: This method uses the negative pressure used in normal breathing to allow air to enter the cervical oesophagus. The air pressure in the cervical oesophagus below the cricopharyngeal sphincter has the same negative pressure as air in the thoracic cavity. Hence during inspiration, this pressure falls below atmorpheric pressure. Laryngectomees often learn to relax the cricopharyngeal sphincter during inspiration thereby allowing air to get into the cervical oesophagus as it enters the lung. This trapped cervical column of air is responsible for speech generation. Patients are encouraged to consume carbonated drinks during the initial phases of rehabilitation. Gases released can be expelled into the cervical oesophagus causing speech generation.
The major advantage of oesophageal speech is that the patients hands are free. The patient does not have to incur cost of a surgical procedure or a speaking device. Nearly 40% of patients fail to acquire oesophageal speech even after prolonged training. This could be due to cricopharyngeal spasm / reflux oesophagitis. Reflux must be aggressively treated. Cricopharyngeal myotomy must be performed in patients with cricopharyngeal spasm. Botulinum toxin injection into the cricopharyngeus muscle can also be attempted.
Electrolarynx: These are vibrating devices. A vibrating electrical larynx is held in the submandibular region. Muscular contraction and facial tension can be modified to generate rudiments of speech. The initial training phase to use this machine must begin even before the surgical removal of larynx. This helps the patient in easy acclamitiation after surgery. There are three types of electro larynges available. They are:
1. Pneumatic - Dutch speech aid, Tokyo artificial speech aid etc.
3. Intra oral type
Among these three types neck type is commonly used. It should be optimally placed over the neck for speech generation. Hypesthesia of neck during early phases of post op period may cause some difficulties in proper placement of this type of artificial larynx. If this device cannot be used intra oral devices can be made use of.
Fig showing electrolarynx
Intra oral type of artificial larynx.
Diagramatic representation of TEP
Tracheo oesophageal puncture could be of two types:
1. Primary TEP
2. Secondary TEP
Primary TEP: This procedure is performed along with total laryngectomy. After creation of tracheostome, a small opening is created through the posterior wall of trachea to reach the oesophagus. 19 gauge Ryles tube is introduced through this opening to reach the oesophagus. This tube is utilised for feeding the patient during the immediate post operative field. After 6 weeks this Ryles tube is removed and a valve based prosthesis (Blom Singer prosthesis) is introduced through this opening. The main advantage of this procedure is that a second sitting surgery is avoided and the patient will be able to speak within 6 weeks after total laryngectomy.
Only contraindication for this procedure is the patient's inability to maintain the valve due to advancing age.
Blom singer valve
Secondary TEP: Is performed 6 weeks after total laryngectomy. These patients must be given adequate time for acquiring oesophageal voice. Electronic larynx option must also be exhausted before proceeding with secondary tracheo oesophageal puncture. The size of the stoma created is also important. The diameter of the stoma should atleast be 2cm. Anything less than this would be considered to be suboptimal.
For tracheo oesophageal puncture to be successful the following factors should be considered:
1. The patient should be motivated
2. The patient should have good manual
3. Patient should not have cricopharyngeal spasm
4. A trans nasal oesophageal insufflation test must be performed before the procedure. This test will identify those patients who are likely to fail this procedure.
Trans nasal oesophageal insufflation test:
The transnasal esophageal insufflation test is a subjective test that is used to assess the pharyngeal constrictor muscle response to esophageal distention in the laryngectomy patient.
Each form of alaryngeal speech IS the "best" depending on factors such as:
(1) what kind of alaryngeal speech is this individual capable of using? For many, there are no choices because of the nature of their surgery and what will be possible for them. Thus, whatever form of communication they can acquire is "best" for that individual.
(2) how close to laryngeal speech does the individual want or need to come? Will the person be returning to work? If so, what are the speech needs of the job? Also, at this point, there are no electronic or pneumatic artificial larynges which anyone would mistake for a regular laryngeal voice.
(3) how much money is the person willing to spend, and/or who is paying the bill? The ultimate in no-tech, hands-free, zero cost (unless you pay for speech lessons) method of alaryngeal speaking is esophageal speech, although a significant percentage of laryngectomees (with the percentage being VERY arguable) cannot learn esophageal speech, or learn it well. Next in terms of cost is a pneumatic AL (up to $150). Futher up in cost are the electronic ALs which can cost from $450 to $800. The TEP involves the cost of the operation, and then the ongoing costs of the prostheses (from $35-$125). In the long run, the TEP is the most expensive initially, and to maintain over time. However, insurance and Medicare can soften the blow.
(4) how much of a hassle is the person willing to put up with? Again, the ultimate in no-tech, zero maintenance is esophageal speech. Next is the pneumatic AL. You just have to remember to bring it with you, and if you use the type with a diaphragm, bring a spare in case yours tears. After that would come the electronic AL which needs a fresh battery and which may become non functional if you drop it or dunk it in water.
TEP users typically have the biggest hassles even if they do not use the glued-on hands-free valve and/or HME (Heat/Moisture Exchange) filter. They have to change the prostheses themselves (every month or so), or go to an SLP or ENT to change it if they use the "indwelling" type (which is changed twice a year). They also have to deal with leaks through the prosthesis or around it, and the need to keep it clean by squirting water and using a little brush. A negative with the TEP is the potential for aspiration pneumonia caused by leaks from the esophagus into the trachea. It is also possible to drop a TEP prosthesis down the trachea. At this point, we have not heard of anyone losing a Servox down theirs (but then, we have not heard from our friend Paul in awhile). The TEP also carries the risk always associated with even a minor surgical procedure under general anesthetic. For a small percentage of individual who fail to obtain TEP speech, they may need to have Botox shots or another operation (the myotomy) to obtain it, although this is usually discovered before the TEP operation.
(5) how intelligible is the method the individual can use? Max Fried, the first editor of the IAL News said in the June 1961 issue, "Good speech is speech that can be easily understood without drawing on the imagination of, or interpretation by, the listener."
To me the best speech would be that which the highest percentage of people can understand. And understandability is related to how close the speech is to larygeal speech in clarity, tone, range, and volume.
Another factor for some is conspicuousness. It is possible for esophageal speakers and TEP speakers to be completely inconspicuous. It is not unusual for someone to ask an ES or TEP speaker if they have laryngitis. It is hard to imagine anyone making that mistake with a user of any of the ALs.
Still another factor is how long it takes to become proficient with each method. Esophageal speech almost certainly takes longer than either the AL or most TEP users. some TEP users obtain speech instantly. Waiting for the swelling (edema) to go down can cause you to wait awhile to find your AL "sweetspot".
Another benefit of using the TEP is that it gives your lungs a workout since you must move lung air through the prosthesis. This should help maintain some lung capacity. Neither the AL nor ES provides this function.
For most people who can use it, the TEP produces the form of speech which is closest to laryngeal speech because of the capacity of the lungs to sustain it longer than esophageal speech. It is also, on average, louder than ES. However, the ultimate in volume is a good sweet spot and and fresh battery in an AL.
Another fact is that very few people who obtain TEP speech abandon and return to an AL, for example, if their TEP speech is functional.
Perhaps others will have some additional factors I have left out.
David Blevins, ()