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RESTORATION OF SPEECH AFTER LARYNGECTOMY
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against the soft tissues just under the lower jaw, part of the sound is conducted into the mouth and pharynx. Normal articulation converts this into monotonous speech of reasonable intelligibility. The voice is produced against a background of fairly loud unmodulated noise from the vibrator. Experiments with variable frequency patterns have so far failed to produce a reliable aid. The instruments require rather large batteries to vibrate the diaphragm, they are rather cumbersome to use, and their cost is high. Mr. MacGregor’s suggestion (in a letter on RESTORATION OF SPEECH AFTER LARYNGECTOMY p. 38) is to construct a collar pattern to hold the instruTHE development of speech is peculiar to man, but the ment against the neck so that the patient’s hands are primary function of the larynx in all stages of its evo- free. In spite of some of their drawbacks, external vibralution is to protect the entrance to the pulmonary airway tors have been of great service in promoting rehabilitaby means of its valvular sphincter, so it is incorrect and tion after laryngectomy and allowing patients to resume misleading to speak of the larynx as the organ of voice. work more quickly, while still learning oesophageal The larynx is a highly complex structure capable of Dr. Armitage Whitman, a New York surgeon, speech. producing an almost infinite variety of sounds with dif- has used one for five veritable years and found it a ferent pitch, loudness, and colour. It has been justly miracle in him to continue in practice.2 helping observed that only talented singers and trained actors To overcome some of its defects the vibrator principle make use of more than a fraction of the available range, has recently been adapted by carrying the source of and the vast majority of people use their voice almost in sound directly into the mouth. The advantage of the oral a monotone.1 Everyday speech depends more on the vibrator is that all the sound is generated where it can intact articulating mechanism of the mouth, nose, and be used for voice production, resulting in highly intellipharynx, with its central connections, than on the func- gible speech. The device is relatively inconspicuous and tion of the larynx. requires no special cleaning or maintance. The frequency The loss of the larynx is nearly always the result of of the sound may be varied so that vocal inflexions and radical surgery for malignant disease. With suitable prea better modulated speech are possible. Mr. Tait has paration before operation and tuition afterwards most devised an electromagnet diaphragm unit (to which he patients acquire an alternative method of speaking by refers on p. 38) enclosing an air space and attached to " cesophageal voice. There are several techniques for the upper denture or artificial palate.3 This diaphragm producing this voice and most patients finally develop an is connected by a fine flex cable to a small transistorised individual way of speaking. Air is taken into the oesooscillator housed in a small box with its batteries. This phagus during inspiration, with the cricopharyngeal electric circuit may conveniently be worn in the pocket sphincter relaxed, and then released from the oesophageal and supplies current to the electromagnet in the mouth, reservoir against the contracting sphincter. The column whereby the diaphragm is vibrated to produce sound. A of air is thus set vibrating and the note so produced is similar approach has been used by Cooper and Millard,’ articulated into speech in much the same way as when who analysed the resulting speech with a special cinerathe basic note is produced in the larynx. A high degree of diographic unit incorporating image intensification and a fluency and clarity may be achieved by this method, and sound spectrograph. The speech was at least as satisfacoesophageal speech is the ideal to strive for after every tory as that produced by good oesophageal speakers. total laryngectomy. Because of the character of the Conley et al.5 have devised a new surgical treatment. A operation or of the patient, or an associated disease, small mucosal or skin tunnel, or a free vein graft, is however, a hard core of patients are unable to acquire used to connect the upper oesophagus with the tracheothis speech; and such patients would have to remain perstome. This tunnel curves steeply upwards and forwards manently mute were it not for help from various artificial from the oesophageal opening and collapses on swallowsources of sound, from which they may fashion a voice. ing, so that spill-over of oesophageal contents into the The artificial larynx is the simplest aid and has been trachea is prevented. A specially adapted tracheostomy available for many years. One end of an angulated tube tube is used with a connecting outlet fitting into the containing a reed is placed in the tracheostomy, the other tunnel. Intermittent obstrucion of the external opening in the mouth; the current of expired air vibrates the reed of the tracheostomy tube then directs a stream of expired and the resulting sound is formed into words in the air into the cervical oesophagus and pharynx where it mouth. As all the articulation has to take place in the may be used for voice production. Preliminary assessanterior part of the oropharynx, intelligibility is usually ment showed that the technique of oesophageal speech poor. Moreover, the instrument is cumbersome, unsightly, was acquired early and effortlessly, and a number of and unhygienic, requiring frequent dismantling to clear patients were later able to speak without using the it of mucus. It has never been widely used because of tunnel. Its continued presence in the neck seems to have these disadvantages, and it is now being displaced altobeen no handicap. Extension of this method may well gether by recent developments in electronic appliances. provide satisfactory unaided speech for many who would One of its modern counterparts incorporates a transisotherwise fail to acquire a new voice after laryngectomy. torised oscillator in a pocket-sized pack. Sound is directed At this stage, however, the electronic aids are the only into the mouth from a small microphone fused to a plastic reliable alternative for those patients who cannot acquire tube, and both volume and pitch are variable. This device intelligible oesophageal speech. These devices are overcomes most of the snags of the old artificial larynx, when an extensive operation is to be especially helpful but it costs$200. followed by a long programme of reconstruction or The second group of appliances are the vibrators, when early return to work is imperative. where the sound is produced by an electrically operated 2 Prizer Spectrum, 1957, 5, 439 vibrating diaphragm, and external vibrators have been in 3 Tait, R V Brit. dent. J. 1959, 106, 336 use for some years. When the 4 Cooper, H K , Millard, R. T diaphragm is pressed Dent. Digest , March, 1959. 5 Conley, J J , de Amesti, F , Pierce, M. K Ann Otol , &c., St. Louis, 1958, 67, 655 1. Negus, V. E. The Mechanism of the Larynx. London, 1929.
Department of Health for Scotland have taken a leading part in this project. The General Medical Services Subcommittee (Scotland) and the Edinburgh Local Medical Committee, representing the general practitioners of Edinburgh, have given their support, as have the Consultants and Specialists Committee, Scotland. The other principal partners in the venture are the SouthEastern Regional Hospital Board and the University of Edinburgh. The
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against the soft tissues just under the lower jaw, part of the sound is conducted into the mouth and pharynx. Normal articulation converts this into monotonous speech of reasonable intelligibility. The voice is produced against a background of fairly loud unmodulated noise from the vibrator. Experiments with variable frequency patterns have so far failed to produce a reliable aid. The instruments require rather large batteries to vibrate the diaphragm, they are rather cumbersome to use, and their cost is high. Mr. MacGregor’s suggestion (in a letter on RESTORATION OF SPEECH AFTER LARYNGECTOMY p. 38) is to construct a collar pattern to hold the instruTHE development of speech is peculiar to man, but the ment against the neck so that the patient’s hands are primary function of the larynx in all stages of its evo- free. In spite of some of their drawbacks, external vibralution is to protect the entrance to the pulmonary airway tors have been of great service in promoting rehabilitaby means of its valvular sphincter, so it is incorrect and tion after laryngectomy and allowing patients to resume misleading to speak of the larynx as the organ of voice. work more quickly, while still learning oesophageal The larynx is a highly complex structure capable of Dr. Armitage Whitman, a New York surgeon, speech. producing an almost infinite variety of sounds with dif- has used one for five veritable years and found it a ferent pitch, loudness, and colour. It has been justly miracle in him to continue in practice.2 helping observed that only talented singers and trained actors To overcome some of its defects the vibrator principle make use of more than a fraction of the available range, has recently been adapted by carrying the source of and the vast majority of people use their voice almost in sound directly into the mouth. The advantage of the oral a monotone.1 Everyday speech depends more on the vibrator is that all the sound is generated where it can intact articulating mechanism of the mouth, nose, and be used for voice production, resulting in highly intellipharynx, with its central connections, than on the func- gible speech. The device is relatively inconspicuous and tion of the larynx. requires no special cleaning or maintance. The frequency The loss of the larynx is nearly always the result of of the sound may be varied so that vocal inflexions and radical surgery for malignant disease. With suitable prea better modulated speech are possible. Mr. Tait has paration before operation and tuition afterwards most devised an electromagnet diaphragm unit (to which he patients acquire an alternative method of speaking by refers on p. 38) enclosing an air space and attached to " cesophageal voice. There are several techniques for the upper denture or artificial palate.3 This diaphragm producing this voice and most patients finally develop an is connected by a fine flex cable to a small transistorised individual way of speaking. Air is taken into the oesooscillator housed in a small box with its batteries. This phagus during inspiration, with the cricopharyngeal electric circuit may conveniently be worn in the pocket sphincter relaxed, and then released from the oesophageal and supplies current to the electromagnet in the mouth, reservoir against the contracting sphincter. The column whereby the diaphragm is vibrated to produce sound. A of air is thus set vibrating and the note so produced is similar approach has been used by Cooper and Millard,’ articulated into speech in much the same way as when who analysed the resulting speech with a special cinerathe basic note is produced in the larynx. A high degree of diographic unit incorporating image intensification and a fluency and clarity may be achieved by this method, and sound spectrograph. The speech was at least as satisfacoesophageal speech is the ideal to strive for after every tory as that produced by good oesophageal speakers. total laryngectomy. Because of the character of the Conley et al.5 have devised a new surgical treatment. A operation or of the patient, or an associated disease, small mucosal or skin tunnel, or a free vein graft, is however, a hard core of patients are unable to acquire used to connect the upper oesophagus with the tracheothis speech; and such patients would have to remain perstome. This tunnel curves steeply upwards and forwards manently mute were it not for help from various artificial from the oesophageal opening and collapses on swallowsources of sound, from which they may fashion a voice. ing, so that spill-over of oesophageal contents into the The artificial larynx is the simplest aid and has been trachea is prevented. A specially adapted tracheostomy available for many years. One end of an angulated tube tube is used with a connecting outlet fitting into the containing a reed is placed in the tracheostomy, the other tunnel. Intermittent obstrucion of the external opening in the mouth; the current of expired air vibrates the reed of the tracheostomy tube then directs a stream of expired and the resulting sound is formed into words in the air into the cervical oesophagus and pharynx where it mouth. As all the articulation has to take place in the may be used for voice production. Preliminary assessanterior part of the oropharynx, intelligibility is usually ment showed that the technique of oesophageal speech poor. Moreover, the instrument is cumbersome, unsightly, was acquired early and effortlessly, and a number of and unhygienic, requiring frequent dismantling to clear patients were later able to speak without using the it of mucus. It has never been widely used because of tunnel. Its continued presence in the neck seems to have these disadvantages, and it is now being displaced altobeen no handicap. Extension of this method may well gether by recent developments in electronic appliances. provide satisfactory unaided speech for many who would One of its modern counterparts incorporates a transisotherwise fail to acquire a new voice after laryngectomy. torised oscillator in a pocket-sized pack. Sound is directed At this stage, however, the electronic aids are the only into the mouth from a small microphone fused to a plastic reliable alternative for those patients who cannot acquire tube, and both volume and pitch are variable. This device intelligible oesophageal speech. These devices are overcomes most of the snags of the old artificial larynx, when an extensive operation is to be especially helpful but it costs$200. followed by a long programme of reconstruction or The second group of appliances are the vibrators, when early return to work is imperative. where the sound is produced by an electrically operated 2 Prizer Spectrum, 1957, 5, 439 vibrating diaphragm, and external vibrators have been in 3 Tait, R V Brit. dent. J. 1959, 106, 336 use for some years. When the 4 Cooper, H K , Millard, R. T diaphragm is pressed Dent. Digest , March, 1959. 5 Conley, J J , de Amesti, F , Pierce, M. K Ann Otol , &c., St. Louis, 1958, 67, 655 1. Negus, V. E. The Mechanism of the Larynx. London, 1929.
Department of Health for Scotland have taken a leading part in this project. The General Medical Services Subcommittee (Scotland) and the Edinburgh Local Medical Committee, representing the general practitioners of Edinburgh, have given their support, as have the Consultants and Specialists Committee, Scotland. The other principal partners in the venture are the SouthEastern Regional Hospital Board and the University of Edinburgh. The
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