Tongue strength: Part II: In artificial alaryngeal speech

Tongue strength does not appear to be reduced in proficient esophageal speakers. However, no data exist on tongue strength for laryngectomized subjects who have not developed esophageal speech. Anterior and lateral tongue strength measures were obtained from 13 laryngectomized subjects who used an artificial larynx and 15 normal subjects by means of a pressure transducer and recording device. The results indicated that laryngectomized subjects had significantly weaker tongues in two of three directions measured. It was concluded that laryngectomy may affect tongue strength, but that the method of alaryngeal speech utilized postoperatively influences the return to normal.     

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.     

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.     

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.     

食管发音患者的语音学分析

目的 观察喉全切除食管发音患者的语音声学特征。方法对16例喉全切除食管发音患者进行语音声学分析及最大发声时程的测定，并以健康男性作对照。同时比较食管发音者和健康人的声波周期性。结果同健康男性比较，食管发音患者的语音声学参数除振幅外，基频、基频微扰、振幅微扰、谐噪比、标准化噪声能量均有统计学差异，且声波周期性差。结论食管发音的声学特性与正常男性相比有显著差别，声音稳定性差、声时短、音调低钝，但食管发音仍是喉全切除术后患者获得发音的一种重要途径。     

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.     

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.     

Ventilatory function in laryngectomized patients

It is established that maximum expiratory flow-volume curve coupled with closing volume curve may give important information on obstructive impairment in the laryngectomized patients. In the patients after laryngectomy, the pattern of the flow-volume curve was similar to that found in patients with chronic bronchitis. These abnormalities of the flow-volume curve which became convexity to the volume axis can be reversed at least partially by bronchodilator drug inhalation. It is concluded that the patients after laryngectomy have abnormalities of ventilation distribution despite relatively normal results of routine pulmonary function tests and respiratory resistance.     

喉全切除发声重建术后发声功能评估

目的 :对喉全切除气管断端膜样部食管吻合分流发声重建术后气管食管 (TE)音患者的发声功能进行客观评估。方法 :对TE音组、食管音组及健康组进行发声声学分析及最大发声时间比较。测定了 2 0例TE音患者舒适发声时的气管内压。在电子喉镜下观察TE音和食管音患者发声时咽食管段黏膜的振动情况及“新声门”的形态。结果 :TE音与食管音相比各发声声学参数差异均无统计学意义 ,而与健康组相比 ,除基频、振幅外 ,基频微扰、振幅微扰、谐噪比和标准化噪声能量等参数均有统计学意义。TE音患者舒适发声时的气管内压为(2 .86± 0 .6 9)kPa。两组无喉音发声时的咽食管段黏膜大多振动规律 ,新声门形状多为环状。结论 :TE音组的发声声学特征同食管音组相近 ,与健康组相比均有显著差异 ,但TE音的音调更接近健康组。本发声重建术后患者发声省力。     

喉近全切除术的扩大适应证

目的进一步总结喉近全切除术的经验。方法选择Ｔ３、Ｔ４喉鳞状细胞癌５７例行喉近全切除术。结果术后发音成功率９３％，３年生存率为６７．５％，下咽癌为５０％，局部复发率仅３．５％。其适应征为不适宜常规部分喉切除的喉癌；还可应用于舌根口咽癌、梨状窝癌、颈段食管癌等。结论只要适应证选择得当，喉近全切除术是一种手术方法不过繁、安全、减少无喉残废的方法。     

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.     

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.     

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.     

Video-roentgen cinematographic evaluation of pharyngeal phase disorders during swallowing in patients after partial laryngectomy due to localized supraglottic cancer

Videorentgenocinematographic examinations of swallowing were conducted on 81 patients after partial laryngectomy and on 35 subjects being a control group. Resection of piriform recess, a part of base of the tongue, the hyoid bone or its part is the factor that causes intensified difficulty during swallowing and increase in the frequency of the occurrence of aspiration. The results of videorentgenocinematographic examinations indicate that the shape and mobility of the tongue and the mobility of remaining after the surgery parts of the larynx have the greatest influence on the efficient swallowing in patients who have undergone partial laryngectomy due to cancer initially located in the supraglottic area. The larynx mobility is closely related to the remaining of the hyoid bone. The importance of remaining the possibly non-deformed structure and mobility of the tongue during partial laryngectomy involves the issue of reconstruction of defects occurred during the surgery. Videorentgenocinematographic examinations confirm the effectiveness of the method involving reconstruction of defects in a part of the base of the tongue with a vascular pedicle flap of the submandibular gland.     

Manometric evaluation of disorders in oral and pharyngeal phases of swallowing in patients after partial laryngectomy for localized supraglottic cancer

Manometric examinations of swallowing were conducted on 81 patients after partial laryngectomy and on 35 subjects being a control group. Resection of piriform recess, a part of the base of the tongue, the hyoid bone or its part is the factor that causes intensified difficulty during swallowing and increase in the frequency of the occurrence of aspiration. The results of manometric examinations indicate that the shape and mobility of the tongue and the mobility of remaining after the surgery parts of the larynx have the greatest influence on the efficient swallowing in patients who have undergone partial laryngectomy due to cancer initially located in the supraglottic area. The larynx mobility is closely related to the remaining of the hyoid bone. The importance of remaining the possibly non-deformed structure and mobility of the tongue during partial laryngectomy involves the issue of reconstruction of defects occurred during the surgery. Manometric examinations confirm the effectiveness of the method involving reconstruction of defects in a part of the base of the tongue with a vascular pedicle flap of the submandibular gland.     

Voice evaluation of myomucosal shunt after total laryngectomy: comparison with esophageal speech

The vocal quality attained with a tracheoesophageal myomucosal shunt (MMS) as described by Strome was evaluated in four patients and compared with three esophageal speakers and two normal subjects. The patients with MMSs acquired speech sooner. Fundamental frequency, pitch, timbre, and melody were analyzed with computerized electroglottography and sonography. Intelligibility was deemed better after the MMS primarily because phonation time approximated that of normal speech, and this study suggests that, following total laryngectomy, the vocal quality achieved using the MMS is preferrable to that of esophageal speech.     

Swallowing and tongue function following treatment for oral and oropharyngeal cancer.

This study examined tongue function and its relation to swallowing in 13 subjects with oral or oropharyngeal cancer treated with primary radiotherapy +/- chemotherapy and 13 age- and sex-matched control subjects. Measures of swallowing and tongue function were obtained using videofluoroscopy, pretreatment and 2 months posttreatment. Maximum isometric strength and endurance at 50% of maximum strength were obtained with the Iowa Oral Performance Instrument (IOPI). Control subjects were tested once. All subjects with head and neck cancer were evaluated pretreatment and 2 months posttreatment. No significant differences were found for the tongue function measures pre- and 2 months posttreatment in the group with head and neck cancer. Significantly higher tongue strength was observed in the control than in the group with head and neck cancer both pre- and posttreatment. No significant differences were found for the 2 groups for tongue endurance measures. Significant correlations of tongue strength and endurance and some swallow measures were found pre- and posttreatment for the group with head and neck cancer and for the control group. These correlations included oral and pharyngeal temporal swallow measures and oropharyngeal swallow efficiency. Pretreatment differences between the 2 groups in tongue strength were likely related to tumor bulk, pain, and soreness. Two-month posttreatment differences were likely related to radiation +/- chemotherapy changes to the oral and pharyngeal mucosa. This study provides support for the hypothesis that tongue strength plays a role in oropharyngeal swallowing, particularly related to the oral phase of the swallow.     

Does lack of glottic closure affect quality of life as a cause of constipation in laryngectomized patients?

The permanent disappearance of glottic closure eventually causes inadequate defecatory propulsion resulting in functional constipation. The aim of this study is to reveal functional constipation probably induced by lack of glottic closure in laryngectomized patients. The study was conducted in a prospective, tertiary care center. Forty patients who had undergone total laryngectomy (study group) and 30 who had undergone microlaryngoscopic surgery (control group) were evaluated. Based on the European Organisation for Research and Treatment of Cancer, Quality of Life Questionnaires C30, the presence of functional constipation was investigated using the Rome II diagnostic criteria and was confirmed by measurement of colonic transit time using a radiopaque marker test. Functional constipation and colonic transit time were found to be increased and statistically significant in laryngectomized patients (70 %) compared with the control group (26 %) (p < 0.01). Functional constipation is more prevalent among laryngectomized patients. When evaluating quality of life of patients undergoing laryngectomy, colorectal functions must be taken into consideration.     

喉近全切除术的扩大适应证

进一步总结这全切除术的经验。方法 选择Ｔ３，Ｔ４喉鳞状细胞部５７例行喉近全切除术。结果 术后发音成功率９３％，３年生存率为６７．５％，下咽癌为５０％，局部复发经仅３．５％。其适应征为适宜常规部分喉切除的喉癌；还可应用于舌根口咽癌，梨状窝癌，颈食食管癌等。     

Relevance of psychosocial factors in speech rehabilitation after laryngectomy

BACKGROUND: Often it is assumed that psychosocial and sociodemographic factors cause the success of voice rehabilitation after laryngectomy. Aim of this study was to analyze the association between these parameters. METHODS: Based on tumor registries of six ENT-clinics all patients were surveyed, who were laryngectomized in the years before (N = 190). Success of voice rehabilitation has been assessed as speech intelligibility measured with the postlaryngectomy-telephone-intelligibility-test. For the assessment of the psychosocial parameters validated and standardized instruments were used if possible. Statistical analysis was done by multiple logistic regression analysis. RESULTS: Low speech intelligibility is associated with reduced conversations (OR 0.970) and social activity (OR 1.049). Patients are more likely to talk with esophageal voice when their motivation for learning the new voice was high (OR 7.835) and when they assessed their speech therapist as important for their motivation (OR 4.794). The risk to communicate merely by whispering is higher when patients live together with a partner (OR 5.293), when they talk seldomly (OR 1.017) and when they are not very active in social contexts (OR 0.966). CONCLUSIONS: Psychosocial factors can only partly explain how voice rehabilitation after laryngectomy becomes a success. Speech intelligibility is associated with active communication behaviour, whereas the use of an esophageal voice is correlated with motivation. It seems that the gaining of tracheoesophageal puncture voice is independent of psychosocial factors.