Tongue strength: Part I: Following total laryngectomy

Surgical repositioning of the genioglossus muscle, as in total laryngectomy, may have an adverse effect on the protrusive strength of the tongue. To test this premise, anterior and lateral tongue strength measures were obtaind from 10 laryngectomized and 15 normal subjects by means of a pressure transducer and recording device. The results indicated no significant difference between laryngectomized and normal subjects on tongue strength measures. Further, all laryngectomized subjects were judged to have good to excellent esophageal speech. It was concluded that laryngectomy does not adversely affect the major musculature concerned with protrusive tongue strength for proficient esophageal speakers.     

Acoustic voice analysis in phonatory fistuloplasty after total laryngectomy

A comparative study was made of the voices of three groups of male patients by acoustic analysis of sustained phonation of the vowel /a/: 1) 20 patients who had undergone total laryngectomy and phonatory fistuloplasty, fitted with a Herrmann voice prosthesis, who had achieved successful prosthetic speech; 2) 20 laryngectomized patients with good quality esophageal speech, and 3) 20 subjects with normal voices. Statistical analysis of fundamental frequency disclosed significant differences between groups, the group with phonatory prostheses having the closest to normal voice of the fistuloplastic groups. There were no statistically significant differences in jitter, shimmer, and the harmonic-to-noise ratio between the esophageal and prosthetic voice groups, which suggests that the disturbances in the vibratory esophageal ring were similar.     

Voice rehabilitation after total laryngectomy using the Provox voice prosthesis

Esophageal speech is the first choice for vocal rehabilitation in laryngectomized patients. However, shunt speech is a needed alternative for patients who cannot succeed at esophageal speech. Many kinds of voice prostheses, with good results, have been reported. Provox was selected for 15 laryngectomized patients who were treated in our department. Voice rehabilitation was successful in 13 patients. However, removal of the prosthesis was required in one patient because of stomal stenosis. Voice rehabilitation was not successful in one patient who exhibited esophageal stenosis. The rate of voice rehabilitation was not influenced by the extent of surgery, the dose of radiation, etc.. The maximum phonation time was more than 10 minutes in the 13 patients who succeeded at shunt speech. Prosthetic rehabilitation was requested by two patients who had been successful at esophageal speech. These results suggest that prosthetic voice rehabilitation may be indicated for a wide range of conditions.     

Esophageal insufflation testing in nonlaryngectomized adults

Esophageal insufflation testing has been advocated for laryngectomized patients considered for tracheoesophageal puncture. The present work was undertaken to document the degree to which nonlaryngectomized individuals were able to produce and sustain esophageal voice in association with esophageal insufflation testing. Fifteen young, healthy adults were tested in a uniform way. Results were interpreted to support the views that (a) normal function of the pharyngoesophageal segment represents an influence detrimental to the ultimate acquisition of functionally serviceable esophageal or tracheoesophageal speech and (b) laryngectomized patients having airtight closure of the pharyngoesophageal segment during insufflation testing exhibit a normal esophageal response. Implications for completing air insufflation testing and selective myotomy are discussed.     

Tongue strength and endurance: relation to highly skilled movements.

Tongue strength and endurance (fatigue) were examined in subjects who have acquired high skill levels with their tongues (supranormal) and in subjects who use the tongue normally. The supranormal groups were trumpet players and high school debaters who were able to speak intelligibly at rates much faster than normal. Hand strength and fatigue were also assessed. Maximal strength was measured by recording how much pressure an individual could exert on an air-filled bulb. Endurance was measured by determining how long subjects could sustain 50% of their maximal pressure. Results showed that maximal strength of the tongue and hand did not differentiate the supranormal subjects from the normal subjects. Hand endurance did not differentiate the subjects either. However, the supranormal groups had significantly longer tongue endurance times than did the normal subjects.     

Analysis of pressure generation and bolus transit during pharyngeal swallowing

Current pharyngeal deglutition theory has stressed the role of the pharyngeal constrictors as producing a peristaltic wave responsible for bolus propulsion through the pharynx. This thesis presents data obtained using manofluorography which supports the significance of tongue and laryngeal motion in swallowing. The usage of the term peristalsis to describe the constrictor contraction is challenged. The results of this quantitative study of swallowing in normal subjects, laryngectomized patients, and patients with restricted tongue motion show that tongue driving pressure and the negative pressure developed in the pharyngeal esophageal segment appear more important than the peristaltic-like pressure of the constrictors. Bolus transit is really dependent upon these two pressures. This model for analysis has clinical significance because it permits quantification of the pharyngeal swallowing mechanism.     

Effects of auditory feedback and phonetic context on stomal noise in laryngectomized speakers

Stomal noise intensity during esophageal speech was measured in 7 laryngectomized subjects during amplified monaural auditory feedback and during control conditions without feedback. A significant (5-10 dB) reduction in stomal noise was observed when auditory feedback was applied. The conditions without feedback were designed to provide additional information regarding the effects of the initial phonetic element in the esophageal speech token on stomal noise. During the control conditions, esophageal speech tokens beginning with voiceless consonants resulted in significantly more stomal noise than was present for the other speech tokens. Clinical implications of the findings are discussed.     

Acoustical analysis of Spanish vowels produced by laryngectomized subjects.

The purpose of this study was to describe the acoustic characteristics of Spanish vowels in subjects who had undergone a total laryngectomy and to compare the results with those obtained in a control group of subjects who spoke normally. Our results are discussed in relation to those obtained in previous studies with English-speaking laryngectomized patients. The comparison between English and Spanish, which diFfer widely in the size of their vowel inventories, will help us to determine specific or universal vowel production characteristics in these patients. Our second objective was to relate the acoustic properties of these vowels to the perceptual data obtained in our previous work (J. L. Miralles & T. Cervera, 1995). In that study, results indicated that vowels produced by alaryngeal speakers were well perceived in word context. Vowels were produced in CVCV word context by two groups of patients who had undergone laryngectomy: tracheoesophageal speakers (TES) and esophageal speakers. In addition a control group of normal talkers was included. Audio recordings of 24 Spanish words produced by each speaker were analyzed using CSL (Kay Elemetrics). Results showed that F1, F2, and vowel duration of alaryngeal speakers differ significantly from normal values. In general, laryngectomized patients produce vowels with higher formant frequencies and longer durations than the group of laryngeal subjects. Thus, the data indicate modifications either in the frequency or temporal domain, following the same tendency found in previous studies with English-speaking laryngectomized speakers.     

Possible factors influencing rehabilitation of the total laryngectomy patient using esophageal speech

One of the handicaps of patients that have had a total laryngectomy is the loss of oral speech. There are three possibilities to rehabilitate these patients; surgery, voice prosthesis or esophageal speech. This last one appears as an inexpensive, non-invasive rehabilitation method; it does not need a complex learning and in spite of new technics, it continues to be an effective method in the social rehabilitation of laryngectomized patients. We have made a retrospective study of patients who underwent TL between 1992-1998 and that were rehabilitated by esophageal voice learning. Three factors have been evaluated: first, those related to the patient (gender, age, study level...); second, those related to the treatment itself [TL, pharyngolaryngectomy (PTL), TL plus radiotherapy...] and third, those related to the rehabilitation (technics, delayed on starting, number of sessions...). Data were compared with rehabilitation outcome: good (usually using esophageal voice), medium (speaking sometimes) and bad (not speaking). 74.1% had an acceptable outcome and they use esophageal voice with more or less difficulty to communicate, and this outcome increases to 95.8% when we do not take into account 7 patients who gave-up rehabilitation before finishing the first five sessions.     

Tongue strength and alternate motion rates in normal and dysarthric subjects

Tongue strength and alternate motion rates were measured in 50 normal subjects and in 18 subjects who had different neuropathologic types of dysarthria. The dysarthric subjects did not differ significantly from one another on any of the test measures. However, as a group they differed significantly from their normal counterparts in that they demonstrated weaker tongue strength, reduced and unsustained levels of maximum tongue strength effort, and slower alternate motion rates. Clinical implications are discussed.     

A comparative acoustic study of normal, esophageal, and tracheoesophageal speech production

Acoustic characteristics of two types of alaryngeal speech were quantified and compared to normal speech production. High-quality audio recordings were obtained from 15 subjects who had undergone the tracheoesophageal puncture method of postlaryngectomy vocal rehabilitation (Singer & Blom, 1980), 15 esophageal speakers, and 15 laryngeal talkers as they sustained the vowel /alpha/ and read a standard paragraph. Ten frequency, 7 intensity, and 13 duration variables were quantified. Central tendency and variability measures of frequency and duration for the three speaker groups indicated that tracheoesophageal speech is more similar to normal speech than is esophageal speech. Intensity measures indicated that tracheoesophageal speech is more intense than normal and esophageal speech.     

Relationships between esophageal speech proficiency and surgical, biographical, and social factors

The relationship between judged esophageal speech proficiency and detailed medical/surgical, biographical, and social factors was investigated among a large sample of alaryngeal speakers. The data suggested that more extensive surgery such as radical neck dissection did not lessen the subjects' ability to learn esophageal speech. Surprisingly, subjects who had undergone radical neck surgery had better voices in many cases than those who had undergone only a simple laryngectomy. Educational level, socioeconomic status, length of time spent in speech therapy, and the number of years since surgery did not statistically influence speech results. However, those subjects still gainfully employed did achieve esophageal speech more often than those who were unemployed, particularly with reference to female subjects.     

Neoglottic reconstruction following total laryngectomy

Aspiration of saliva and food and postoperative stenosis of the shunt are not infrequent among laryngectomized patients who have undergone surgery for voice rehabilitation. A new technique for neoglottic reconstruction has been developed to overcome these complications. A neoglottis was created from the upper-tracheal rings to prevent postoperative stenosis and was also made to protrude into the esophagus, in order to prevent aspiration. This procedure has been performed on eight patients, seven of whom are speaking well and have no aspiration. Their speech is superior to esophageal speech when judged on the basis of duration and intelligibility. In one case, however, the neoglottis had to be closed because of aspiration.     

Experiences with the tracheoesophageal shunt method for vocal rehabilitation after total laryngectomy

The tracheoesophageal (T-E) shunt technique reported by Komorn et al. (1973) was used for vocal rehabilitation in 8 laryngectomized patients including one case of hypopharyngeal cancer. It was proved that this technique was a simple one-stage procedure with a low incidence of complication. Four out of 7 patients, excluding one patient who died of another disease, acquired excellent speech without symptomatic aspiration. Two patients developed fairly good speech. One shunt was closed by aspiration. The shunt constructed by a flap measuring 2 x 4 cm, opened 1 cm below the distal end of the trachea, showed good results. The T-E shunt speech exceeds esophageal speech in duration and intelligibility.     

Esophageal speakers' perceptions of the belch and esophageal voice

Twenty-three male laryngectomized persons were surveyed to determine whether they perceived differences, in their own productions, between the belch and esophageal voice from an auditory and tactile-kinesthetic standpoint. Twenty-one of the subjects did not perceive the belch and esophageal voice as being auditorily similar. All of the subjects perceived tectile-kinesthetic differences.     

The use of a prosthetic speech aid for a laryngectomized esophageal speaker with right hemiparesis of the tongue: a case report.

A dental-palatal prosthetic device, which had been demonstrated to aid laryngectomees who use the glossal press method of esophageal speech, was used on a patient whose primary method of air charging was bilabial plosive injection and who had a right hemiparesis of the tongue. Cointervention of a prosthodontist and a speech pathologist is described.     

Experiences with the tracheoesophageal shunt method for vocal rehabilitation after total laryngectomy

Summary The tracheoesophageal (T-E) shunt technique reported by Komorn et al. (1973) was used for vocal rehabilitation in 8 laryngectomized patients including one case of hypopharyngeal cancer. It was proved that this technique was a simple one-stage procedure with a low incidence of complication. Four out of 7 patients, excluding one patient who died of another disease, acquired excellent speech without symptomatic aspiration. Two patients developed fairly good speech. One shunt was closed by aspiration. The shunt constructed by a flap measuring 2×4 cm, opened 1 cm below the distal end of the trachea, showed good results. The T-E shunt speech exceeds esophageal speech in duration and intelligibility.     

An objective method for prediction of tracheoesophageal speech production

Current methods of esophageal air insufflation testing to predict postoperative tracheoesophageal speech success lack procedural objectivity and rely on subjective interpretation of the voice production results. A range of intraesophageal pressure measurements was obtained prior to tracheoesophageal (TE) puncture in each of 27 laryngectomized patients in an attempt to predict TE speech outcome. Postoperatively, three levels of speech production were identified. Fluent speakers, nonfluent speakers, and nonspeakers demonstrated low, intermediate, and high intraesophageal pressures, respectively. Patients with intermediate and high preoperative pressures did not achieve fluent speech without myotomy. This technique offers a reliable, objective preoperative indication of expected TE speech fluency.     

Low-frequency energy deficit in electrolaryngeal speech.

The present exploratory project was undertaken (a) to determine the relative strength of low-frequency energy in the output of one widely used electronic artificial larynx (Servox) and (b) to assess the relative strength of low-frequency energy in vowels produced by users of this type of artificial larynx. We hypothesized that the outputs of electronic artificial larynges and the vowels produced by laryngectomized users of these devices would be characterized by significant deficits in low-frequency energy level. Five users of electronic larynges and 10 normal speakers (5 female and 5 male) provided the speech samples. Results of spectral analyses indicated that there was a significant deficit in low-frequency energy both in the acoustic signals generated by a Servox electronic larynx and in vowels produced by laryngectomized users of this type of electronic larynx. Based on these findings, a second order filter was designed and implemented digitally to compensate for the observed deficit in low-frequency energy. A perceptual experiment was completed to evaluate the effect of low-frequency enhancement on perceived speech quality. Ninety-eight percent (+/- 2%) of the responses of listeners indicated that low-frequency enhanced speech samples had better vocal quality or were more pleasant to listen to than the original speech samples. We conclude that consideration for enhancing low-frequency characteristics is warranted in the design of improved prosthetic devices for alaryngeal speakers.     

Biophysical requirements for new and projected procedures and devices for voice rehabilitation after total laryngectomy.

This paper reviews the state of the art knowledge of laryngeal physiology and evaluates the parameters necessary for voice production following laryngeal surgery for cancer. Data from normal voice production as well as esophageal speech production are used to generate some relationships that must exist in order to produce sound. Included are the relationships between esophageal pressure, subglottal pressure and intraoral pressure, the mechanical constraints of a pseudolarynx, muscle activity during normal and esophageal speech and the role of the tongue, lips, and palate in esophageal speech. Consideration is given to early and current reed-fistula and air bypass surgical procedures. Alternatives to current experimental and commonly used rehabilitation procedures will also be considered. The limiting factors for use of such devices and some requirements for their operation will be considered. Consideration will also be given to the manner in which various kinds of speech can be compared for acceptability and intelligibility.