Phonetic rehabilitation after laryngectomy

Bioarcd & Pharnraco/hcr( 0 Elscvicr. Paris

1993) 47. 53-59

53

Focus

Phonetic

G Acquaviva,

M Mignano, Divisiorle

rehabilitation

Otorinolariugoiatrica. (Received

after laryngectomy

F Martini, Ospedale

20 July

1992:

C Dominici,

S Camille.

accepted

USL

8 October

Summary

RM

R Dellavalle 10. Rome,

Iraly

1991)

- This work deals with the phonetic rehabilitaGon of patients after laryngectomy. describing the various of alaryngeal voice. The rehabilitation was monitored with a computer by means of a specific voice programme permits the registration. visualization and reproduction of each sound emitted in conjunction with the classification principal parameters. thus allowing the patient 10 check his acoustic feedback.

laryngectomy R&urn6

/ loudness / computer

- RChabilitation

phonktique

apres laryngectomie.

tonris6s SOIIS /‘angle des diff@renrs types de voix alatyg@es. an programme spicifiqae vocal pernletranr I ‘enregistrenlent, de la codijicarion des principalts pararr&res. er aurorisanr Ilri-mime.

laringectomie

types which of the

/ intensitf

II est rrairh ici de la rPhabi/itation phonPliqre des IorygecCerre rc;llabilitation a PIP moniror@e par ordinarew grice ri la visaalisarion er la reproduction de chaque son Cnris. en plus ainsi an conrrdle de son feed-back acousrique par Ie nlalade

sonore / ordinateur

Introduction Total laryngectomy is indicated in all malignant tumours of the larynx which do not respond to conservative laryngeal surgery or radiotherapy treatment due to their position or extension. Such an operation consists of the total removal of the larynx after having separated it from the trachea, wiih the resultin! embouchement of the tracheal stump to the adJoIning anterior region of the neck to form the final tracheostomy. The esophagus is stitched in the section adjoining the larynx, thus producing a recanalization of the esophageal lumen. Consequently, there will be complete isolation of the upper air tracts and breathing will come about solely through the tracheostomy. Following total laryngectomy, the patient will lose his normal respiration and phonation, as only the latter two of the four mechanisms necessary for voice production (expiratory bre:lth, cord oscillation, supraglottic resonance, phonemic articula-

tion) remain unimpaired. They are, however, unable to function because the expiratory breath is deviated outwards through the tracheostomy and cannot therefore produce a fundamental tone. Consequently, the patient’s voice is reduced to a whisper. The rehabilitative treatment of the laryngectomy concerns the development of an alaryngeal voice which is adequate for communication and which permits the patient to resume his social life as normally as possible. Two types of alaryngeal voice exist, according to the level of the vocal tract in which vibrations are produced; they vary according to the degree of intelligibility: i) oral voice; ii) pharyngeal voice; iii) esophageal voice. Oral voice This is also referred to as consonantic or stomatic voice, this type of voice is produced through the use of the residual stomatic air which causes the

cheeks and then the tongue or the alveolar arch to vibrate. The resulting speech is virtually unintelligible, but easily acquired by the patient in a natural way. It is typical of a patient who has not yet been re-educated and once learnt, it becomes an obstacle for a more correct vocal development. It is virtually unintelligible because it lacks the air current needed for the production of vowels, for which the patient compensates with the exaggerated articulation of certain consonants. Pharyngeal

voice

This is typical of patients who have learnt the correct esophageal voice techniques but are unable to use the pseudoglottis or, more uncommonly, in cases of constriction of the pharyngeal funnel which prevents air from descending into the esophagus. This voice production is created by the vibrations of the lingual base and the back region of the pharynx. It therefore produces a grating voice, with an unpleasant timbre which is intelligible, but requires a long supply of air for too brief a phonation .time. It is difficult to modify this type in an esophageal voice because it requires muscolar activity which is quite the opposite of that which is necessary for the esophageal voice. A total laryngectomy, as said previously, requires the removal of the phonation organ, therefore the anatomic situation in which the patient finds himself is characterized by the presence of structures which can compensate for the function of the larynx. In such a situation, the esophagus will permit breathing and phonation, functions which were previously carried out by the lungs and the larynx: it will have the role of a vicarious lung, as it will become an air tank. This air will cause the upper part of the esophagus to vibrate, exploiting its elasticity and consenting phonation. The seat of the pseudoglottis is the pharyngoesophageal segment formed by the crycopharingeal muscle by the upper esophageal sphincter. This condition will therefore give way to a new heading: Esophageal voice There are various methods for the development of this type of voice which differ due to different ways an air reserve is obtained: i) Inspiration method; ii) Deglutition method; iii) Injection method a) consonantic b) standard.

Inspiration method (also referred to as inhalation, exhaltation or gobage This is the only method which considers the separation of breaths because it follows respiration: during a sudden lung inhalation, negative pressure in the esophagus increases due to extension of the rib cage. This negative pressure creates a vacuum at the level of the esophagus, which permits an opening in the esophageal mouth and consequently the passage of air through it to form an air reserve. The air will then be expelled during the exhalation phase of breathing. The advantage of this method consists of the fact that the patient need not change his habitual phonatory scheme. The problem with this method is that a stoma noise which is emitted with the esophageal voice, exists, as this voice is produced through breathing, and this noise may cover the voice itself. Noise is however reduced when the patient is capable of producing more syllables with a sole air supply. Deglutition method With this method, the patient must carry out a normal deglutition in an attempt to force air into the esophagus before speaking. This is advantageous because it is easily learnt by the patient. On the other hand, it presents a serious disadvantage because a small quantity of air ends up in the stomach, making it difficult to achieve an adequate increase in the air pressure in the esophagus, before its expulsion. Apart from these disadvantages, we must also consider the longer latency and the need for frequent air supplies during phonation due to the small quantity of air which actually enters the esophagus. For this reason, this is the oldest and least used method. Injection method This modern and more widely utilized method consists of the active injection of air, under pressure, into the esophagus. The reserve is obtained through the increase of pressure in the pharingooral cavity, an increase which injects air into the esophagus. The injection method can be subdivided into: consonantic injection; standard injection. Consonantic injection This method exploits the articulation of certain unvoiced consonants IPI ITI IKI, which provoke the increase of air pressure in the pharingo-oral cavity and consequently its injection into the esophagus. This method is valid because a reserve is created

by the articulation of these consonants at the beginning of the word, thus eliminating the need to make frequent interruption in the sentence for further supplies. Standard injection The increase in air pressure in the pharyngo-oral cavity occurs by means of standard mechanisms, which can be created through the various movements of the articulatory organs, that is to say the tongue, lips and cheeks. Standard injection can be subdivided into: a) pharingoglossal pump; b) blockage. a) Also referred to as “half-deglutition”; consists of the increase of pressure which is created in the pharyngo-oral cavity with the rise and fall of the corpus linguae as in the initial phase of deglutition. This principle is utilized to increase air pressure in that area without continuing deglutition. b) Air pressure is created by means of movements between lips and cheeks, in this case we could observe a labial blokage; between tongue and alveoli - gloss0 alveolar - and between tongue and palate - glossopalatine. The injection method, as described above, permits the elimination of the synchronism of breathing with the aim of avoiding the noise of the expiratory breath produced at the level of the tracheostomy. Moreover, it permits a more rapid supply in comparison to the other methods and consequently major intelligibility. Therapy Psychological support, which is too often neglected, has a prime role in the re-education of laryngectomy. In fact, a total laryngectomy is a destructive operation which seriously alters the patient’s life, and his social relationships. The patient often sees the stoma as an offence to his body schema. Some research data indicate an increase in the percentages of alcoholism, withdrawal from social activities and depression to the point of suicide as consequences of this disability. These patients suffer the anguish of the loss of their natural voice and the fear o.f not succeeding in acquiring a compensatory one. Moreover, on their return home, doubts arise as to whether or not the cancer has actually been cured, as regards the quality of their life and the possibility of reinsertion into a working and social life.

Apart from emotional lability, some fundamental aspects, above all technical factors, must be considered before a course of therapy can be undertaken; for example: - the type of operation the patient has undergone. In fact, in cases of simple total laryngectomy where the laryngeal muscle has, as far as possible been preserved, the development of an alaryngeal voice will be facilitated; but in cases of total laryngectomy with laterocervical extirpation or with radical removal of the neck lymphnodes, embarrassing situations may arise with regard to muscular mobility, due to nerve lesions or scar retraction. Therefore, muscle stretching and head, neck and shoulder decontraction are essential. It is extremely important to establish to what extent lingual motility has been affected, so as to develop compensatory movements, but without, however, jeopardizing the success of the method proposed. Therefore, speech therapy must, in the first place, begin with motor rehabilitation. Another aspect to be considered is the possibility of auditory deficit in the patient, as this is vital for the choice of the method to be proposed. In fact, as presbyacusia is characterized by a decrease in acute frequencies, it is necessary to choose a method which does not encourage stoma noise, as this would affect the intelligibility of the alaryngeal voice. Moreover, it is important to consider the suitability of the environment in which therapy is to take place. An environment which is insufficiently humidified causes the formation of mucous plugs in the trachea, due to frequent catarrhal secretions, which provoke serious respiratory problems. The glossopharyngeal pump or “half-deglutition” method is what we usually propose to laryngectomy when their postoperative condition is suitable. We have however noticed that the best speakers with an esophageal voice is usually achieved with a combination of the injection and inspiration methods. Our choice of method in fact has not been definite in consideration of this observation. We propose the glossopharyngeal pump at the first visit but we prefer not to impose any particular method, letting the patient himself try to produce a voluntary eructation which must then be modelled in linguistic sound. We introduce this linguistic sound by means of monosyllabic words; /PA/ ITAl KAI. Once they have been developed easily by the patient, it is

possible to go on to the disyllabic words and gradually to lonser ones, trying however to avoid the insertion of unvoiced consonants in this phase. 3s they are more difficult to pronounce, even resorting to the use of lofotomes. To stimulate ;I patient to a more careful articulation. we utilize screened reading, which we also find useful for checking the level of intelligibility achieved. Gradually. we proceed from single words to the reconstruction of sentences, starting from: article + noun: and little by little adding other elements for the completion of the sentence. Initially. attention will be drawn to the intelligibility of the eructation of single elements of the xentence while further on we will be more concerned with the patient’s ability to extend his phonation time by liviting his latency. To reach this goal. we use. above all. spontaneous conversation. Once intelligibility has improved through constant exercise, attention will be directed to improving the pitch and loudness of the alaryngeal voice obtained and then e intonation, giving the patient questions and exclamations to read. The meetings,

treatment once

will be the patient

reduced to has achieved

occasional sufficient

autonomy exchange

and with

self-confidence others.

to permit

3 spoken

The computerized programme. speech-viewer IBM. is of great help in this treatment. It is connected to a personal computer PS? IBM which is fitted with an adaptor, a microphone and a loudspeaker which enables the computer to accept as input. verbal emission and to digitulize, analyze, reproduce and visualize it. It also permits us to work with double screenings. comparing patients to therapist. This programme contains I3 modules, each with a different goat. from which we the loudness and pitch module most require. which belongs to the model-creation modules. These permit the visual representation of the following attributes: loudness, pitch, sound emission, shapes of synchronization models. Figure I shows the loudness of the a. e. i, o, u, emission. Screenings relative to ;\ sample-rehubilitee x-e provided. The sound part is dark grey. the aphonic part light grey. A good level of loudness will be about 20 dB on averqe. Figure repeated

2 shows twice.

the

sound

emission

of

aiuole,

57

Fig

Fig

2.

3.

Loudness

of the emission

“mi

piace

il dolce”

(Iralian)

58

Fig

4. Sound

Fig

5.

Spectrum

emission

of “mi

piace

of a sustained

“0”.

il dolce”.

pitched

IO the

frequency

vibrations

of the cricoesophagus.

59 Variations are visible because the second emission is more highly pitched and louder than the first, this shows how useful this type of visualization can be to the patient. Figure 3 shows the loudness of the emission “mi piace il dolce” (Italian) and shows how this programme also helps us to carry out work on prosody. Figure 4 shows the same sound emission, but this time it is pitched to the frequency vibration of cricoesophagus. In figure 5, a spectrum of sustained “0” is visible. We can see that the values of the formants are very similar to normal ones (vn: 600-1000). In the course of this experience, we have ascertained that group therapy has proved more efficient, as the patient who has more models with which to confront himself is also stimulated to be competitive, in addition to receiving psychological support from the group. As the procedure requires, there must be a leader in the group, and in our group the leader is the patient who is in the final stages of therapy. The leader, apart from stimulating the patient who takes the course of therapy, is also able to

provide information regarding the proprioseptive sensation which can help the development of the alaryngeal voice more easily than a person who has not experienced a laryngectomy. Once the patient feels satisfied with the results obtained, the therapy is terminated. He is however advised to have occasional meetings so that his progress may be checked.

References 1 Arnold Aronson E (1985) 1 distrubi della vote. Masson Editori, Milan0 2 Croatto L (1985) Trattato di foniatria e logopedia. La Garangola Padova 3 De Filippis Cippone A (1985) Manuale di logopedia. Italia Editori, Milan0 4 IBM Personal system/2 speech viewer (1988) Copyright International Business Machine Corporation 5 Schindler 0 (I 984) Breviario di patologia della comunicazione. Edizioni Omega, Torino 6 Segre R (1980) La comunicazione orale norrnale e patologica. CG Edizioni Medico Scientifiche srl, Torino