Rehabilitation : Esophageal
speech & Artificial larynx
KUNNAMPALLIL GEJO JOHN
BASLP,MASLP
AUDIOLOGIST
KUNNAMPALLIL GEJO JOHN
KUNNAMPALLIL GEJO JOHN
ESOPHAGEAL SPEECH
• Air is compressed within
the oropharynx
• This dense air is injected
into the esophagus
• Denser air moves in
towards more rarefied
bodies of air
• This sets up a vibration of
the pharyngo-esophageal
segment
• These vibrations act as
„voice‟
KUNNAMPALLIL GEJO JOHN
PHARYNGO-ESOPHAGEAL SEGMENT
• Portion of the pharynx and esophagus where
muscle fibres from esophagus, inferior constrictor
and cricopharyngeus blend together
• These fibres are under voluntary control of the
individual
• Anterior fibres of cricopharyngeus are sutured,
creating a complete muscle sphincter around the
esophagus
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• Normal tonicity of PE segment is essential for
the acquisition of esophageal speech or TEP
speech
• Candidacy for esophageal or TEP speech can
be determined by administering the Air
Insufflation Test
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• Esophageal speech is based on the technique in
which the patient transports a small amount (±75
ml) of air into the esophagus.
• Probably due to an increased thoracic pressure,
the air is forced back past the pharyngo-
esophageal (PE) segment to induce resonance.
• This resonance is the sound source that allows
speech. Rapid repetition of the aforementioned
air transport can produce understandable speec
KUNNAMPALLIL GEJO JOHN
Esophageal speech
Goals of esophageal speech( A. E. Aronson 85)
• Reliable phonation on demand
• Rapid air intake
• Short latency between air intake and phonation
• 4-9 syllables per air charge
• 2-3 secs of voice duration per air intake
• Good intelligibility
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KUNNAMPALLIL GEJO JOHN
KUNNAMPALLIL GEJO JOHN
• Air at atmosphere continues to circulate
with in the nasal , oral and pharyngeal
cavities.
• The PE segment is tonically contracted
and registered positive pressure while the
oesophagus is closed down and registered
negative air pressure
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• Air must pass through PE segment and
enter into the esophagus which will then
register a positive presdsure relative to
that in the oral and pharyngeal cavities
KUNNAMPALLIL GEJO JOHN
• The tonicity of the PE segment may be
overcome by voluntary relaxation ( Inhalation
technique is based on this ) or by applying
pressure by forcing the air into the esophagus (
Injection technique )
KUNNAMPALLIL GEJO JOHN
AIR INSUFFLATION TEST
• The oral and nasal cavities are anaesthetized using
a local anesthetic.
• A catheter is inserted through the nostril till the PE
segment
• The person is asked to phonate
• The clinician blows in through the open end of the
catheter and the individual has to phonate again,
keeping the stoma closed
• Strained, effortful voice: Hypertonic
• Breathy voice: Hypotonic
• Esophageal speech is not advised in either of the
above cases KUNNAMPALLIL GEJO JOHN
METHODS OF AIR INTAKE
INHALATION INJECTION
CONSONANT
INJECTION GLOSSAL
PRESS
KUNNAMPALLIL GEJO JOHN
INHALATION
• The patient is told to “close his mouth and imagine
he is sniffing through his nose” (Diedrich and
Youngstrom, 1966)
• The sniffing is often accompanied by esophageal
dilation
• Air rushes into the esophagus
• This air is expelled by belching it out, vibrating the
PE segment as it is expelled
KUNNAMPALLIL GEJO JOHN
CONSONANT INJECTION
• A plosive or affricate is used to inject air into the
esophagus
• /p/, /t/, /k/, /s/, /∫/ and /t∫/ are the recommended
phonemes (Diedrich & Youngstrom, 1966;
Moolenaar-Bijl, 1953; Stetson, 1937)
• Production of the consonants facilitates the transfer
of air into the esophagus
KUNNAMPALLIL GEJO JOHN
GLOSSAL PRESS( Gateley 71)
• Tongue is elevated against the hard palate
• Tongue body is swept backwards towards the
pharynx, loading air into the esophagus till a „klunk‟
is heard
• Carbonated beverages and water may assist in
creating a pocket of air in the esophagus
• Thoracic compression forces the air out
KUNNAMPALLIL GEJO JOHN
GLOSSAL PRESS
• Tongue is elevated against the hard palate
• Tongue body is swept backwards towards the
pharynx, loading air into the esophagus till a „klunk‟
is heard
• Carbonated beverages and water may assist in
creating a pocket of air in the esophagus
• Thoracic compression forces the air out
KUNNAMPALLIL GEJO JOHN
ADVANTAGES OF
ESOPHAGEAL SPEECH
• No external devices necessary
• More “natural” voice compared to that produced
using an artificial larynx
• To some extent, pitch and intensity can be varied
• No dependence on batteries, chargers, etc
• No costs involved
• Hands free speech
KUNNAMPALLIL GEJO JOHN
DISADVANTAGES OF
ESOPHAGEAL SPEECH
• Takes long to learn and master
• Must have good articulatory abilities, or else speech
will be extremely unintelligible
• Listeners reportedly find esophageal speech least
preferable compared to other types of alternate
sound production (Carpenter, 1991)
• Voice may be too soft to be heard above
background noise
KUNNAMPALLIL GEJO JOHN
Artificial larynx
KUNNAMPALLIL GEJO JOHN
Artificial Larynx
• Is a device which is placed externally for
the purpose of sound production in those
cases from which the real larynx is
removed
• As a device that replaces the laryngeal
source with an external sound producing
mechanism
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The essential components
• Power supply
• Oscilltor which vibrates
• Diaphragm
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Control
• On / off
• Volume control
• Tone control
• Pitch control
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Types
• Pneumatic type
• Electronic type
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Pneumatic type
• Utilizes pulmonary air as its power source
• A cuff that contains reed or a membrane fits over
the stoma
• As the patient expels the air from stoma for
speech , the vibrations from the membrane arte
transmitted by a flexible rubber or plastic tube
into the patients mouth
• The patient articulates as the sound is produced
KUNNAMPALLIL GEJO JOHN
• F0 is determined by the width and the
tension of the membrane
• Pitch and loudness can be achieved by
varying the force of air expelled from the
lungs
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Components
• Neck tube
• Stoma tube
• Stoma cover – fits into the stoma
• Mouth Tube – placed in the mouth
between lips and cheek
• Vibrating structure made up of rubber
strings- kept in the pocket
KUNNAMPALLIL GEJO JOHN
Types
• Tokyo
• Van Humen
• OSAKA
• Western type
• Memacan
KUNNAMPALLIL GEJO JOHN
Tokyo Type
KUNNAMPALLIL GEJO JOHN
Advantages
• Sound quality from the pneumatic larynx is
more pleasing than the electro mechanical
devics
• No electronic noise or buzzing sound
• Less expensive
KUNNAMPALLIL GEJO JOHN
Disadvantage
• Presence of the tube in the mouth
• Which interferes with articulation and
collect saliva
• Cuff may clogged with mucous
• Does require the use of one hand for
placement of the cuff
KUNNAMPALLIL GEJO JOHN
Electronic type
• Is a battery powered sound generator
• These devices may differ in size and
shape, quality of sound, ability to control
pitch ,volume, type of batteries
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Types
• Intra oral devices
• Neck type
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Components of intra oral devices
• Battery compartment
• Pulse generator
• Mouth tube to vibrator
• Vibrator
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Models of Intra oral devices
• Cooper rand 15 volt electronic speech aid
• Cooper rand 9 volt electronic speech aid
• Aurex neovox M -550
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Advantage
• Is ideal for patients who has scar tissue or
edema of the neck
• Can use immediately after following
surgery
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Disadvantage
• Presence of the tube in the mouth
• Which interferes with articulation and
collect saliva
• Cuff may clogged with mucous
• Does require the use of one hand for
placement of the cuff
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KUNNAMPALLIL GEJO JOHN
KUNNAMPALLIL GEJO JOHN
NU-VOIS III Digital Artificial Larynx
KUNNAMPALLIL GEJO JOHN
Neck Type
• Are popular devices
• Relatively easy to learn to use
• Provides immediate speech Restoration
• Placing the head of the device firmly against the
neck allowing for the sound to be transmitted to
through the tissue of the neck and into the oral
cavity
• It allows variation in volume and pitch
KUNNAMPALLIL GEJO JOHN
types
• Western electronic 5 A
• AT & T 5e electronic artificial larynx
• Denrick DR-1 speech aid
• Aurex “ nevox “ electronic artificial larynx
• Servox electronic artificial larynx
• Servox Inton
• Romet electronic speech aid
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KUNNAMPALLIL GEJO JOHN
How to teach
• Acceptance
• Orientation
• Selection
• Placement
• On-off timing
• Articulation
• Rate
• Phrasing
• Modification of Pitch & loudness
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Advantages
• Immediate restoration & easy to learn
• Early return to the work is possible
• Can be used as a initial method for the
restoration of esophageal speech
• Free from stoma noise
KUNNAMPALLIL GEJO JOHN
Disadvantage
• Produces unexpectable sounds because
of which sound becomes unintelligeble
• Causes attention& bulky
• Acts as a crutch and not hands free
speech
• Costly & maintenance is a problem
KUNNAMPALLIL GEJO JOHN
• The major disadvantages of these
electromechanical devices is the distinct
voice quality. The voice production sounds
mechanical and even robot like, distracting
the listeners attention. The electrolarynx
requires the use of a hand and has a
conspicuous appearance
KUNNAMPALLIL GEJO JOHN
• Electromechanical devices can be a useful
treatment option in the early post-
operative phase when the patient can not
use other voice rehabilitation techniques,
thereby limiting the frustration of
speechlessness. Electrolarynx devices
can also be of value in addition to other
voice rehabilitation methods
KUNNAMPALLIL GEJO JOHN