Talking is a basic form of communication. Therefore, losing the ability to talk can be frustrating for a patient who has had a total laryngectomy, i.e. the removal of the larynx. This procedure is done for patients who have cancer of the larynx or voice box. In doing so, the patient loses his or her ability to produce voice as the vocal cords are also removed in the process. The trachea or airway is then diverted to a permanent breathing hole in the neck called a stoma.

After surgery, the patient communicates through alternative ways such as writing, using picture boards, gesturing or mouthing words. These methods are limited in vocabulary and are time consuming, as thoughts are not expressed immediately. Relatives and friends also take some time to get used to these modalities of communication. There are, however, three alternative ways of restoring ‘voice’ after a total laryngectomy. These methods are:

• Oesophageal Speech
• Artificial Larynx
• Tracheo-Esophageal Speech

Oesophageal Speech

This type of speech requires the speaker to learn how to “swallow” air into the oesophagus and create a sound by releasing the air and articulating words at the same time. This method is quite like burping. Sound is created when the air vibrates in the oesophagus and words are produced when this sound is shaped by the articulators, for example, lips, tongue and cheeks, into meaningful words and sentences. This method requires the speaker to learn to sustain the air that is released and involves a substantial amount of coordination and practice.



Artificial Larynx

This method involves the use of a hand-held electronic device that translates vibrations into sounds. This device is held on the neck and under the chin. The vibrations produced by this device are converted into speech through slow and deliberate articulation. The voice produced using this method is robotic but the pitch can be altered to suit the speaker. The speaker and the listener will need some time to get used to this type of voice and speech produced.



Tracheo-oesophageal Speech

This mode of speech requires a surgical procedure to create a connection between the trachea and the oesophagus. A voice prosthesis, which has a one-way valve, is then fitted through this fistula. Voice is produced when the speaker occludes his or her stoma to divert all the air from the lungs through the prosthesis and up the pharyngo-oesophageal segment to the mouth. The segment vibrates to produce a sound and this sound is then shaped by the articulators to produce meaningful speech.

As the voice prosthesis is made of silicone, it may be damaged by candida. If the candida grows at the valve and damages it, leakage of fluids will occur resulting in coughing and possible aspiration of fluids. Voice quality may also be affected. When this happens, the patient will need to visit his or her speech therapist to get the voice prosthesis replaced. One way of reducing the growth of candida is to take Nystatin regularly. This helps to prevent the growth of candida and increases the lifespan of the prosthesis.

The Rehabilitation Process

Speech therapists work very closely with post-laryngectomy patients right from the beginning. They meet the patient before the surgery to tell them more about it and the follow-up plan after the surgery. The three modes of voice restoration are discussed at this point.

When the patient is ready to start voice rehabilitation, the speech therapist explores with the patient the three modes of voice restoration and the mode most suited to the patient.

Regular sessions are needed as the speech therapist works with the patient on the technique for the particular modality. The speech therapist also works closely with the patient on the other aspects that improves communication, for example, articulation and rhythm of speech.

Post-laryngectomy patients may often find communication frustrating at the beginning. However, with proper guidance and support from the medical team (consisting of doctors, nurses and speech therapists), communication becomes natural again.

 

Melissa Chua
Head of Department
Speech Therapy Department
Singapore General hospital