Communication After Total Laryngectomy

Several communication methods are available to people who have had total laryngectomies. These include writing, gesture, low- and high-tech augmentative and alternative communication (AAC) devices, and alaryngeal speech. This resource focuses on alaryngeal speech and voice restoration techniques used following total laryngectomy. For more information on AAC, see ASHA’s Practice Portal page on Augmentative and Alternative Communication.

Individuals may use various communication methods after total laryngectomy based upon postoperative time frame and healing, chemoradiation side effects, conversational context, extensivity of resection, and temporary versus long-term needs (Messing, 2016). Speech-language pathologists (SLPs) evaluate candidacy and preferences for voice restoration on a case-by-case basis when counseling individuals about the methods that best suit their needs and lifestyle. This helps to maximize successful rehabilitation and communication outcomes. SLPs consider

visual, cognitive, and fine motor skills/manual dexterity;
medical history (e.g., pulmonary or gastroesophageal function);
surgical recommendations, procedures, and outcomes;
individual anatomy and physiology (e.g., fibrosis, stricture, stoma patency);
the communication environment;
family/care partner support; and
access to equipment and follow-up care (e.g., geography, cost, transportation).

Electrolarynx

An electrolarynx (sometimes called an artificial larynx) is a handheld, battery-operated or pneumatic device that creates an external vibratory source for voicing (Kaye et al., 2017). Most people who use this method have a battery-operated neck-placement electrolarynx that is placed flush to the skin on the side of the neck, under the chin, or on the cheek. When the user presses a button, sound is conducted into the oropharynx and shaped by the articulators for speech.

Electrolarynxes may also be used with intraoral devices, which introduce sound into the posterior oral cavity, typically via a small tube inserted into the corner of the mouth (or, less commonly, via a dental appliance). The sound is then shaped into words with the articulators. Intraoral devices may be used when people cannot achieve adequate sound conduction via external placement on the skin or in the immediate postoperative period when the neck is healing. An electrolarynx with an intraoral tube can be trialed within 1–3 days of surgery.

The tone produced for voicing with an electrolarynx has an electronic quality. Typical electrolarynxes allow the frequency and volume of the tone produced to be adjusted. Some electrolarynxes offer pitch modulation and loudness control during active speech to mimic natural voice modulations during conversation.

Candidacy

Most individuals are candidates for the use of electrolarynxes after laryngectomy. Some people use these devices as their only method of communication, whereas others use them as a backup to other methods. Electrolarynx use requires good manual dexterity and intact initiation and sequencing to time the device vibration to articulation. In addition, trismus may impact articulation and the ability to place the intraoral adapter into the oral cavity.

SLP Role

SLPs work with individuals to maximize speech intelligibility using an electrolarynx. They evaluate candidacy for the best device type and often arrange for a loaner in the early stages of treatment. SLPs may focus on training in

device placement and contact;
device maintenance (e.g., cleaning and changing batteries);
increasing oropharyngeal air pressure for consonants that are not easily perceived (e.g., plosives, fricatives, affricates);
on/off timing to minimize background noise from the device;
overarticulation;
phrasing and pacing;
rate of speech; and
using volume modulation and/or pitch variation to achieve intonation.

Esophageal Speech

In esophageal speech, air is taken into the mouth, brought down into the esophagus, and returned back from the esophagus to generate sound for speech. As the air returns, the pharyngoesophageal (PE) segment vibrates for sound production in place of the vocal cords. Air is released in a controlled way through the oral cavity. The sound is then shaped into words by the articulators (Doyle & Finchem, 2019).

Esophageal speech allows hands-free communication independent of additional devices. There are different methods for getting air into the esophagus to produce speech. The two most common methods are injection and inhalation.

Injection involves using the articulators to create high oropharyngeal air pressure to override the sphincter pressure of the PE segment and insufflate the esophagus.
Inhalation involves rapidly expanding the chest to create low pressure at the level of the PE segment by relaxing the cricopharyngeus muscle so that air insufflates the esophagus.

Esophageal speech has a sound quality that is harsh, low in intensity/volume and pitch, and sometimes wet. It tends to result in short utterance length, which can limit speech duration and fluency.

Candidacy

There is no surgery required to use esophageal speech, and there are no expenses for equipment. However, anatomical factors—such as a tight cricopharyngeus muscle, a flaccid or strictured PE segment, esophageal stenosis, or radiation fibrosis—may impact a person’s ability to use esophageal speech. Esophageal speech requires an extended learning period, and many people have trouble acquiring use at a functional conversational level.

SLP Role

SLPs can begin training in esophageal speech once the medical team has given postoperative clearance. Treatment includes instruction in

air injection or inhalation techniques,
articulatory precision,
increasing utterance length,
improving prosody, and
reducing behaviors that inhibit speech output (e.g., burps on air intake or loud, effortful expulsions of air from the stoma).

Tracheoesophageal Speech

In tracheoesophageal speech, a surgical puncture (known as a tracheoesophageal puncture [TEP]) forms a fistula tract between the trachea and the esophagus that is fitted with a voice prosthesis. When an individual occludes the stoma, exhaled tracheal air passes through the prosthesis via a one-way valve into the esophagus. The air vibrates the PE segment, creating sound that the articulators can shape into speech. The one-way valve allows air exchange for speech production while preventing aspiration of food and liquid.

Surgeons may perform the TEP as a primary procedure during laryngectomy surgery or later as a secondary procedure. Similarly, voice prosthesis placement can occur at the time of the TEP or sometime after the primary or secondary procedure. In the case of delayed fitting, a catheter is placed in the TEP site to keep it open and prevent aspiration until the voice prosthesis is inserted.

There are two main categories of prostheses—namely, indwelling prostheses, which are inserted and changed by a physician or an SLP, and non-indwelling prostheses, which are designed for an individual to insert and remove on their own. Indwelling prostheses last longer and need less maintenance than non-indwelling prostheses, but the non-indwelling types offer greater independence and are less expensive (Brook & Goodman, 2020). Both types require occlusion of the stoma to create sound, with either a finger or a hands-free tracheostoma valve. Utterance length, phrasing, volume, and intelligibility are generally closer to laryngeal speech than other forms of alaryngeal communication due to the pulmonary air supply powering TEP speech.

Candidacy

SLPs collaborate with head and neck cancer team members prior to surgery to identify appropriate candidates and timing for the TEP to avoid unnecessary complications and poor communication outcomes.

When determining TEP candidacy, SLPs consider

access to required TEP care and rehabilitation (e.g., transportation, financial);
cognition, manual dexterity, and visual deficits that may impact the ability to understand anatomy/physiology, occlude stoma, and self-manage TEP use and care;
comorbidities that may impact wound healing and/or successful voicing (e.g., uncontrolled diabetes, hypothyroidism, pulmonary or neurological diseases, reflux, substance use, poor skin integrity on the neck);
evidence of PE segment spasm, fistula, stricture, or stenosis that could impact voicing;
the extent of surgery, the type of reconstruction, radiation, and/or current disease;
the motivation to communicate and participate in the daily maintenance of the TEP;
the patency of the stoma (e.g., diameter, depth, healing) to support TEP use without airway compromise;
psychosocial and emotional factors;
results of esophageal air insufflation testing and pulmonary function tests; and
risk factors for TEP enlargement, prosthesis leakage, and the need for more frequent voice prosthesis replacement (Hutcheson et al., 2012; Jira et al., 2020).

The decision between primary and secondary TEP placement is made on a case-by-case basis. For example, secondary puncture may be preferred to allow more healing time for an individual undergoing extensive salvage total laryngectomy after chemoradiation treatment. Secondary puncture also allows for insufflation testing and/or videofluoroscopic studies to occur prior to the TEP to determine if functional voicing can be achieved (Graville et al., 2019).

SLP Role

Following TEP surgery, the SLP or the physician fits the voice prosthesis for length, diameter, and airflow resistance. In addition to determining candidacy and fitting/changing prostheses, SLPs collaborate with physicians to troubleshoot and manage complications such as poor voicing, valve failure, leakage through and/or around the prosthesis, and loss or aspiration of the prosthesis. They also provide rehabilitation to teach

stoma/prosthesis care, including assisting in the selection of heat and moisture exchanger systems, which may include hands-free voicing options, and education regarding their use;
TEP emergency preparedness;
digital occlusion and/or hands-free valve fitting/use; and
coordination and timing of breath with stoma occlusion and voicing to maximize voice clarity, volume, tone, rate, phrasing, and fluency in various contexts (e.g., phone).

Also see ASHA’s video resource Alaryngeal Speech Options After Total Laryngectomy (Messing, 2016).

Buccal Speech

Buccal speech is rarely used clinically but may be used by some individuals receiving speech-language pathology services, particularly outside the United States. It often develops spontaneously rather than being taught. Buccal speech is produced by compressing air high in the cheek and using an area between the cheek and the upper jaw to function as a glottis (Khaila et al., 2007). Speech intelligibility is often reduced with this method (Khaila et al., 2007; Weinberg & Westerhouse, 1971).

Pharyngeal Speech

Pharyngeal speech, like buccal speech, is a rarely used method of communication and is not often taught clinically. Pharyngeal speech is generated by phonation between the tongue and the upper alveolus, the palate, or the pharyngeal wall using an air source from the pharynx. Similar to what often happens in buccal speech, intelligibility in pharyngeal speech often appears to be decreased when using this communication method—compared with more commonly used alaryngeal speech methods (Weinberg & Westerhouse, 1973).

References

Brook, I., & Goodman, J. F. (2020). Tracheoesophageal voice prosthesis use and maintenance in laryngectomees. International Archives of Otorhinolaryngology, 24(04), 535–538. https://www.scielo.br/j/iao/a/X6VSZFNCS4VSHwDYBH4WXqp/?lang=en

Doyle, P. C., & Finchem, E. A. (2019). Teaching esophageal speech: A process of collaborative instruction. In P. C. Doyle (Ed.), Clinical care and rehabilitation in head and neck cancer (pp. 145–161). Springer. https://doi.org/10.1007/978-3-030-04702-3_10

Graville, D. J., Palmer, A. D., & Bolognone, R. K. (2019). Voice restoration with the tracheoesophageal voice prosthesis: The current state of the art. In P. C. Doyle (Ed.), Clinical care and rehabilitation in head and neck cancer (pp. 163–187). Springer. https://doi.org/10.1007/978-3-030-04702-3_11

Hutcheson, K. A., Sturgis, E. M., & Lewin, J. S. (2012). Early risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy: Nodal metastasis and extent of surgery. Archives of Otolaryngology—Head & Neck Surgery, 138(9), 833–839. https://doi.org/10.1001/archoto.2012.1753

Jira, D., Pickhard, A., Mair, L., Zhu, Z., Wollenberg, B., & Buchberger, A. M. S. (2020). GERD and adjuvant radio-chemotherapy predispose to recurrent voice prosthesis leakage. Laryngo-Rhino-Otologie, 99(11), 788–794. https://doi.org/10.1055/a-1226-6927

Kaye, R., Tang, C. G., & Sinclair, C. F. (2017). The electrolarynx: Voice restoration after total laryngectomy. Medical Devices: Evidence and Research, 10, 133–140. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5484568/

Khaila, H., House, J., Cavalli, L., & Nash, E. (2007). A phonetic and phonological study of so-called ‘buccal’ speech produced by two long-term tracheostomised children. Proceedings of the 16th International Congress of Phonetic Sciences (pp. 2033–2036).

Messing, B. (2016). Alaryngeal speech options for laryngectomy [Video]. American Speech-Language-Hearing Association. https://www.youtube.com/watch?v=iYqdIwP22MU&t=13s

Weinberg, B., & Westerhouse, J. (1971). A study of buccal speech. Journal of Speech and Hearing Research, 14(3), 652–658. https://doi.org/10.1044/jshr.1403.652

Weinberg, B., & Westerhouse, J. (1973). A study of pharyngeal speech. Journal of Speech and Hearing Disorders, 38(1), 111–118. https://doi.org/10.1044/jshd.3801.111