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326 The Voice and Voice Therapy
The Artificial Larynx
We frequently encourage the use of an AL during the first few days, weeks, or months following
surgery. When healing is still incomplete, and swelling may be significant, we may introduce the
patient to a Cooper-Rand intraoral AL, commonly used in years past and still available. This
device is shown in Figure 9–9 with other ALs. Any intraoral AL such as the Cooper-Rand or orally
adaptable neck instrument does not require pressure to the neck and thus works when fistulae or
swelling are problems. Older models such as the Western Electric and Aurex (also presented in
Figure 9–9) have been superseded by technologically more advanced options such as the Servox
Digital, Servox Inton, Romet, NuVois, SolaTone, and TruTone. Their operational concept remains
unchanged, and familiarity with both older models and current versions is beneficial for any practicing clinician. Currently available ALs and a review of features are easy to find online through the
IAL website, WebWhispers, or specific manufacturer sites. SLPs should know that many of these
websites offer new laryngectomees loaner ALs. Also, a number of states offer free ALs through
their telecommunications equipment distribution program association.
FIGURE 99. Seven artificial devices. Top left: Cooper-Rand electrolarynx. Top center: Memacon
artificial larynx DSP8 pneumatic. Top right: Western Electric neck device. Bottom left: Park
Jed-Com electrolarynx. Bottom center: Tokyo reed-type pneumatic artificial larynx. Center right:
Servox neck device. Bottom right: Aurex neck-held electrolarynx NeoVox.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 327
When introducing the AL to new laryngectomies, it is critical that the SLP understand the
basics of AL speech and AL devices. A number of strategies that the SLP is already familiar with
can help increase comprehensibility by reintroducing the patient to the articulatory functions
of the tongue, teeth, lips, and palate for precise sound production. By teaching overarticulation,
the VFA of open-mouth, and effective timing of the on/off AL vibration button to coincide with
phrasing, the SLP can help the patient increase comprehensibility. Stoma blast can be reduced by
encouraging the patient to continue the normal rest breathing patterns of inhalation and exhalation while simply mouthing the words (Blanchet, 2014).
In looking at alternative types of ALs, one should not overlook the various pneumatic types of
artificial devices. (Two examples of pneumatic types may be seen in Figure 9–9.) These devices are
simple and easy to use and remain quite affordable. One end of the device is placed over the stoma,
and the other end has a mouthpiece that contains a diaphragm sound generator that is activated
when the user exhales through the stoma. They produce a satisfactory form of alaryngeal speech.
Indeed, we have had professional voice users such as a preacher and athletic coach who used the
pneumatic type of AL quite successfully. In our experience, this category of device has seen a
dramatic decline in use over the years in the United States. The pneumatic type is typically not
even presented as a postoperative option. Even though cost effectiveness and good intelligibility
are afforded by these instruments, their visual appearance seems prohibitive. Obviously, patient
choices appear to be driven by socioeconomic factors (Stanisce et al., 2023).
In the course of rehabilitation and beyond, a patient often chooses more than one communication method. Typically, an AL is the initial option and by choice may be used exclusively.
Conversely, the AL may be abandoned altogether or relegated as a backup to another method such
as esophageal speech or tracheoesophageal puncture (TEP) speech.
Esophageal Speech
While the development of TEP speech has made the use of esophageal speech less frequent, the
SLP should know something about this form of speech and how to teach it if the need arises.
At the very least, one needs to know where to find information on the teaching of esophageal
speech. We provide this information in this chapter based on our experiences with hundreds of
laryngectomees. Also, many of the techniques for development of esophageal speech are good
principles to follow in the development of other types of alaryngeal speech.
Following a conventional laryngectomy, two methods of teaching esophageal speech may be
employed: injection and inhalation. Both methods employ the same basic principle of compressing
air within the oropharynx and injecting this denser air into the more rarefied (less dense) space of
the upper esophagus. Denser air within a body moves in the direction of the less dense body of air
whenever the two bodies are coupled. Some of the compressed air within the oral cavity undoubtedly escapes through the lips, some through the velopharyngeal port, and some (particularly if the
esophagus is open) into the esophagus. Once the air is in the esophagus, external forces compress
the air within it and expel it. Not much air is needed for vibration — just about 80 to 100 cc. It is
hoped that the esophageal expulsion sets up a vibration of the PE segment, and the patient experiences an eructation or “voice.” We consider separately the procedures for teaching the injection
method and the inhalation method (sometimes combined with injection).
328 The Voice and Voice Therapy
The Injection Method
Certain consonants appear to have a facilitating effect in producing good esophageal speech. Individuals may have their own favorite facilitating sounds, but more often than not, these are plosive
consonants (/p/, /b/, /t/, /d/, /k/, and /g/) or affricatives containing plosives (/t/ or /d/). Hudgins
and Stetson (1937) reported many years ago that /p/, /t/, and /k/ were the easiest sounds for the
new laryngectomee to use; Moolenaar-Bijl (1953) reported that the same phonemes produced
esophageal speech faster in most patients than the traditional swallow method of teaching. Specific
steps for teaching injection might include the following:
1. Discuss with the patient the dynamics of airflow, explaining that compressed, dense air
always flows in the direction of less dense, rarefied air. Explain how the movements of the
tongue in the injection method increase the density of the air within the mouth, enabling
the air to move into the esophagus. Then demonstrate how the whispered articulation of a
phoneme, such as a /t/ or a /k/, is the kind of tongue movement that produces the injection
of air into the esophagus. After producing the whispered /t/, demonstrate for the patient an
esophageal voice for words such as tot or talk.
2. Now ask the patient to produce the phoneme /p/ by intraoral whisper. Care must be taken
that the sound is made by good firm compression of the lips, with no need for stoma noise.
Make sure that the patient avoids pushing out the pulmonary exhalation or using tongue
and palatal-pharyngeal contact as the noise source. The intraoral whisper can be taught
effectively by having the patient hold their breath and then attempt to “bite off” a /p/ by
compressing the air caught between their abruptly closed lips. The patient should continue
practicing this until true intraoral articulation is clearly demonstrated by consistent
production of a precise /p/. Once the patient can do this, the patient should move to the
next voiceless plosive, /t/. Here, the tongue tip against the upper central alveolar process
is the site of contact, and practice should be continued until the patient can produce a
precise, clear /t/. The same procedure should be repeated for /k/, again first demonstrating
for the patient the different site of contact.
3. When good intraoral voiceless plosives have been produced, the patient is ready to add
the vowel /a/ to each plosive. With /p/, for instance, the patient makes the plosive and
then immediately attempts to produce an esophageal phonation of /a/, producing in effect
the word pa. If this is successful, the patient may combine the /p/ with a few other vowel
combinations before going on to the /t/ and /k/. If the patient fails to produce the esophageal
voice at this point, the patient should go back and work for even crisper articulation of the
plosive sounds. If the patient is still unsuccessful after increased practice in articulation,
the patient should attempt the inhalation method as the primary means of air intake.
4. Introduce the words pat, pip, pack, pot, and pop. The task is now to say each word, one
at a time, renewing the esophageal air supply as the patient speaks, which is an obvious
advantage of using the injection method. It is through the mere process of articulation that
the patient takes in air. After the patient has demonstrated success with these phonemes,
introduce their voiced cognates, /b/, /d/, and /g/. The fricatives and affricates may be
introduced after that. As the patient gains phonatory skill with each new consonant, the
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 329
patient must spend extra time learning to improve both the quickness and the quality of
production. Too many patients err in trying to develop functional conversation too early.
Considerable time should be spent at the monosyllabic word level practicing one word at a
time and making constant efforts to produce sharp articulation and a good-sounding voice.
5. Practice with basic control techniques is essential for developing successful and fluent
esophageal speech. Therefore, we have the patient practice several skills directly in each
speech session:
a. Rapid production (one-half second or less) of esophageal phonation can improve
response. If we call for 10 productions of the /a/ vowel, the patient must respond with
20 productions.
b. Ability to sustain a tone for 2.5 to 3 s or longer
c. Ability to interrupt the tone into three or four segments
d. Ability to stress the first or second syllable on command, such as in the word chipper
(for first-syllable stress) and above (for second-syllable stress)
e. Ability to make a soft or loud tone on command
6. At this point, if the patient has been successful, the inhalation method can be introduced
to improve air intake and esophageal phonation. The patient should produce a normal
inhalation and, at the initial moment of exhalation, produce the consonant and say the
word. Beyond the single words alone, we often couple the words together in phrases,
such as bake a cake, stop at church, park the black cart, and so on. Once plosive-laden
phrases are mastered, we then use the oral reading materials from voice and diction books,
including, when possible, the facilitative consonants we have been using.
The Inhalation Method
This method capitalizes on the expansion of the thoracic cavity to pull air into the inflated upper
esophagus. When the thorax enlarges because of muscle movement (see Chapter 2), the air reservoir
within the lung increases in size, rarefying (decreasing) the air pressure within the lung. Because the
outside atmospheric air pressure is now greater, the air rushes in until the pressure within equals
the outside pressure. The flow of air is always from the more dense to the less dense air body, and
the flow continues until the two bodies are equal in pressure. By this same airflow mechanism,
the esophagus inflates in the inhalation method of air intake. The patient experiences a thoracic
enlargement during pulmonary inhalation, which reduces the compression on all thoracic structures, including the esophagus. If the cricopharyngeus opening into the esophagus is slightly open
at the time of the slight increase in the size of the esophagus, air from the hypopharynx flows into
the esophagus. During the exhalation phase of pulmonary respiration, when there is a general
compression of thoracic structures, the esophagus also experiences some compression, which aids
in the expulsion of the entrapped air. As this air passes through the approximated structures of
the PE segment, a vibration is set up, producing esophageal phonation. The advantage of the
inhalation method of esophageal air intake is that it follows the patient’s natural inclination of
pulmonary inhalation followed by exhalation phonation. Simply to take a breath and then talk
is the most natural way of speaking, and for this reason, the inhalation method offers the patient
learning esophageal speech some early advantages.
330 The Voice and Voice Therapy
The following steps for teaching the inhalation method are best used in combination with
the injection method:
1. Explain and demonstrate to the patient some aspects of normal respiration. Explain to the
patient that when the chest is enlarged by muscle action, the air flows into the lungs; in the
laryngectomee’s case, the air comes through the stoma opening in the trachea and down
into the lungs. Point out that the chest enlarges by muscle action, not by air inflation;
thus, the air comes in as the chest enlarges. When the laryngectomee’s chest enlarges, a
concomitant enlargement of the esophagus usually takes place. When the esophagus is
enlarged, there is a greater chance for air to flow in. When the chest becomes smaller, the
pulmonary air is forced out, and the air within the esophagus is also more likely to be
expelled. The clinician should demonstrate esophageal voice using this method.
2. Before attempting to produce voice, the patient should practice conscious relaxation and
correct breathing methods. The patient should become aware of thoracic expansion and
abdominal distention on inhalation and of thoracic contraction on exhalation. Respiration
practice should only be long enough to permit the patient to develop this kind of breathing
awareness because patients do not seem to benefit much from extended breathing exercises,
per se.
3. Now the patient should attempt to add air into the esophagus during their pulmonary
inhalation. Diedrich (1968) recommended that “the patient be told to close his mouth
and imagine that he is sniffing through his nose, and to do so in a fairly rapid manner”
(p. 112). Even though the sniff is basically a constricted inhalation, it is frequently
accompanied by esophageal dilation (the normal person often swallows what they sniff). As
an extension of the sniff, the patient should be asked to take a fairly large breath (through
the stoma). When the patient’s lungs appear to be about half inflated, the patient should
say “up” on exhalation. This procedure can be repeated until the patient experiences some
phonatory success.
4. For the patient who does not experience success in Step 3, the following variation of the
inhalation method sometimes produces good esophageal air. Ask the patient to take a deep
breath, and, as the patient begins the inhalation, to cover the stoma. While the muscular
enlargement of the thorax continues (despite the patient’s lack of continuing inhalation),
there will be a corresponding enlargement of the esophagus, perhaps permitting air to flow
into the esophagus. For the patient who can get air into the esophagus but cannot produce
the air escape necessary for phonation, the same mechanism applies in reverse. Here, the
patient takes a deep inhalation and, as the patient begins to exhale, occludes the stoma. As
the thorax begins to decrease in size, pressure increases on the esophagus, which might well
result in expulsion of esophageal air (and phonation).
5. If esophageal phonation is achieved by either of the last two steps, the patient should
proceed from their “up” response to single monosyllabic words beginning and ending
with voiceless plosives. Time should be spent practicing at this single-word level until the
technique is mastered in terms of loudness, quality of sound, and articulation. The patient
who masters the basic techniques of air intake and phonation at the single-word level may
become the most competent esophageal speaker.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 331
Because esophageal speech does not require any external device, surgical procedures, or prostheses, it is a preferred technique for a number of postlaryngectomy speakers. However, a number
of complicating factors may preclude many laryngectomees from developing esophageal speech,
including postsurgical radiation complications, other medical complaints, the patient’s age, selfconfidence, emotional state, active personality, and family support (Bozan et al., 2015). For the
past three decades, TEP voice restoration has been used increasingly in postlaryngectomy voice
rehabilitation (Eadie et al., 2015). We visit this option next.
Tracheoesophageal Puncture
Most laryngectomees are candidates for the TEP and the prosthetic approach to alaryngeal
speech rehabilitation (Lorenz, 2015; Mayo-Yáñez et al., 2024). In many patients, the TEP will be
performed at the same time as the total laryngectomy, which is called a primary TEP. For others,
the TEP will be performed at a later date. Cricopharyngeal myotomy (weakening the PE segment
by surgically cutting selected muscle fibers) can be performed at the time of laryngectomy or later.
This is done to create a PE segment that does not present excessive resistance to the outward flow
of air during phonation and allows for adequate vibration of the PE segment during alaryngeal
voice production.
There are a number of candidacy requirements for successful tracheoesophageal speech,
regardless of the timing of the procedure. First, the patient must have adequate pulmonary support
to shunt air from the lungs and trachea to the esophagus. Therefore, individuals with lung cancer,
asthma, or other severe lung disease may not be appropriate candidates for this mode. Second,
the patient must possess the necessary cognitive and sensorimotor skills to occlude the stoma
for speech (or manipulate a tracheostoma valve) and to remove and clean the prosthesis. These
two criteria have been superseded in importance, however, secondary to the introduction of lowpressure prostheses options requiring reduced pulmonary support, and the advent of indwelling
prostheses that are placed by either an ENT physician or an SLP. The patient must have a PE
segment that vibrates adequately to generate a sound source for speech. This is performed via
insufflation testing, a diagnostic procedure that transfers air from the stoma site to below the PE
segment through a transnasally placed catheter. If the PE segment does not adequately vibrate
via insufflation testing, alternative intervention techniques may be applied. Techniques currently
include Botox injections, myotomy, and pharyngeal plexus neurectomy. For details of these techniques, see American Speech-Language-Hearing Association (2004b).
Consensus appears to support no substantial outcome differences between primary versus
secondary TEP placement (Luu et al., 2018). Khaled and colleagues (2021) conducted a randomized-controlled clinical study that included 24 patients, with 12 having had a primary TEP and
12 having had a secondary TEP. All patients were evaluated for successful voice restoration and
complications rates. The short-term success rate was 92% in the primary group and 83% in the
secondary group. The long-term success rate was 83% in the primary group and 75% in the
secondary group. Success rates were higher in the primary group but without statistically significant difference. The complications rate in the primary group was 58% and in the secondary group
67%. The complications rate was higher in the secondary group but without statistically significant
332 The Voice and Voice Therapy
difference. The obvious advantages of the primary procedure are more rapid communication
rehabilitation and the elimination of a second surgical procedure. If the TE prosthesis has not been
inserted at the time of the primary or secondary puncture, the patient will be ready for prosthesis
insertion 5 to 7 days after fistula creation. It is important to understand that there are two major
types of prostheses: those that the patient can insert and manipulate (traditional) and those that are
inserted and removed by the physician or the SLP (indwelling). Although a variety of prostheses
are available, they have in common a silicone tube, a one-way valve, and a tracheal flange. Some
prostheses feature a dual valve to help prevent fluid leakage through the valve. The fistula is dilated,
and the prosthesis is inserted. The fitting of the correct length of the prosthesis is critical for the
best TE voice result. A prosthesis that is too short may be expelled during forceful coughing, and
there is a substantial risk for distal tract closing even if the prosthesis remains in place. One that is
too long makes contact with the posterior esophageal wall, thus interfering with voice production
and causing a leak due to malfunction of the one-way valve or fistula enlargement. The correct
length is determined by placing the measuring device (Figure 9–10) into the stoma and through
the punctured fistula. This procedure allows one to gauge the distance from the posterior wall of
the trachea to the posterior wall of the esophagus. When the correct prosthesis is selected, the TE
puncture fistula must be dilated with the dilator (Figure 9–11). With an inserting device and a gel
cap for an indwelling prosthesis in this case, constant firm pressure is applied until the prosthesis
slips into place (Figure 9–12). The gel cap eases the insertion of the prosthesis by reducing friction
and providing lubrication for the surrounding skin. The stoma is then occluded by the thumb
or the finger, and voice production is tested. If the prosthesis is in place and the back wall of the
FIGUR E 910. Measurement of tracheoesophageal puncture tract length
using the Blom-Singer measurement device.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 333
F IGU R E 911. A Blom-Singer tracheoesophageal dilator is inserted through
the stoma into the esophageal puncture.
FI GUR E 9 12. Insertion of a Blom-Singer low-pressure voice prosthesis on a
safety lock.
334 The Voice and Voice Therapy
esophagus is not in contact with the prosthesis, then the air is shunted into the esophagus, and
the PE segment is set into vibration.
The patient who is a TEP speaker is generally able to develop good esophageal voice more
quickly than the patient with a conventional laryngectomy. On expiration, by shutting off the
open stoma with a finger or by using a one-way stoma valve, the patient can divert tracheal air
directly into the esophagus. Being able to do this negates the need for teaching the patient to
trap air in the esophagus by either the injection or the inhalation method. In addition, the TEP
speaker has a much larger air reservoir with which to speak (up to 3,000 cc of pulmonary air versus
approximately 80 to 100 cc of air trapped in the top of the esophagus).
Two types of TE prostheses are shown in Figure 9–13. It appears that research favors the
low-pressure prosthesis (see Figure 9–13) over the duckbill prosthesis for developing the best
speaking voice (Pauloski et al., 1989). See Sapienza and Ruddy (2016) for pictures of a variety of
low-pressure prostheses. The following teaching steps are designed for the patient with a tracheoesophageal prosthesis and who uses finger occlusion of the stoma to speak:
1. The SLP should review the procedures the patient has had. See ASHA.
2. A review of how normal voice is produced is helpful for the patient who may never have
realized, for example, that all speech in English is produced on pulmonary expiration.
3. Practice should be given to producing precise articulation. The patient should be
encouraged to practice intraoral whispers so that the words are distinct and clearly
understandable to listeners.
FI GUR E 9 13. Two Blom-Singer prostheses. The top
larger prosthesis is a modification of the original duckbill
prosthesis inserted via a shunt through the trachea into
the esophagus. The lower slightly smaller prosthesis is
the low-pressure voice prosthesis.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 335
4. The patient is asked to take in a normal breath, occlude their stoma with a thumb or
finger, and say a monosyllabic word on expiration. It is important that the patient be
counseled to use the thumb or finger only as a diverting body to the airstream. Sending
the air through the shunt (or the appliance in the shunt) does not require heavy finger
pressure. Only a very light touch is required to divert the air from the stoma on expiration.
If voice is achieved on the single word, the patient can proceed to the next step. If not,
the patient should practice the timing of inspiration (open stoma) and expiration (closed
stoma) in synchrony with saying one word. Trial-and-error repetitions may be needed
here. Most patients can produce an effortless esophageal voice with very little difficulty.
It has been our observation that patients who cannot successfully divert tracheal air
through the shunt are pushing too hard with their fingers. Only light touch on the stoma
opening is needed. Because many patients undergo a cricopharyngeal myotomy to weaken
the muscle of the PE segment, only modest air pressure is required to set the segment
into vibration. Many patients will opt to wear a one-way valve fastened over the stoma for
hands-free speech production. This valve, also called an automatic speaking valve, permits
air to come in from the outside on inspiration but shuts off on expiration, allowing air
to travel through the TE prosthesis into the esophagus. Lansaat and colleagues (2017)
describe an automatic speaking valve that features an integrated HME system, described
earlier in this chapter. One should note that the HMEs and automatic speaking valves
require peristomal baseplates, unless one wishes to wear an intraluminal device (Foreman
et al., 2016).
5. Move from single words to phrases as soon as the patient is able. It is important to keep
the inspiratory breath a normal one. The patient needs no more breathing effort than they
ever did. It takes some practice to time the inspiratory–expiratory phonation to match the
words or phrases one is attempting to say.
6. Once the patient can say phrases, it has been our observation that, by using natural
articulation, the patient begins injecting air into the esophagus from above and using the
pulmonary air passing out through the esophagus. Therefore, some patients can speak some
words and phrases without occluding their stomas, obviously renewing the air reservoir
within the esophagus by injection. Extended daily practice of several hours for a week or
two is required before a patient with a TE shunt is able to use their new esophageal voice
conversationally.
7. Review with the patient that the best voice seems to be produced with the least amount of
effort, that is, a normal speaking breath, light finger touch, and so on.
8. The patient should be instructed in how to change, clean, maintain, and care for their own
prosthesis. See Brook (2020) for a tutorial covering prostheses and troubleshooting.
PluralPlus
Self-Check
9–4
Anyone who is attempting to assist a patient to develop TEP speech and to manage the
TE prosthesis should become thoroughly familiar with the devices, procedures, and materials
involved. ASHA (2004a) published a comprehensive position statement of practice policy on
the roles and responsibilities of SLPs with respect to the evaluation and treatment for TE puncture and prostheses. A systematic review by Lorenz (2015) and Parrilla and colleagues (2021)
provide insight into periprosthetic leakage, a common occurrence in patients with voice prostheses
over time.