rehabilitation esophageal speech & artificial larynx

Rehabilitation : Esophageal

speech & Artificial larynx

KUNNAMPALLIL GEJO JOHN

BASLP,MASLP

AUDIOLOGIST


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‟


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


• 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


• 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


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


• 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


• 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


• 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 )


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


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


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


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


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


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


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


Artificial larynx


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


The essential components

• Power supply

• Oscilltor which vibrates

• Diaphragm


Control

• On / off

• Volume control

• Tone control

• Pitch control


Types

• Pneumatic type

• Electronic type


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


• 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


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


Types

• Tokyo

• Van Humen

• OSAKA

• Western type

• Memacan


Tokyo Type


Advantages

• Sound quality from the pneumatic larynx is

more pleasing than the electro mechanical

devics

• No electronic noise or buzzing sound

• Less expensive


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


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


Types

• Intra oral devices

• Neck type


Components of intra oral devices

• Battery compartment

• Pulse generator

• Mouth tube to vibrator

• Vibrator


Models of Intra oral devices

• Cooper rand 15 volt electronic speech aid

• Cooper rand 9 volt electronic speech aid

• Aurex neovox M -550


Advantage

• Is ideal for patients who has scar tissue or

edema of the neck

• Can use immediately after following

surgery


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


NU-VOIS III Digital Artificial Larynx


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


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


How to teach

• Acceptance

• Orientation

• Selection

• Placement

• On-off timing

• Articulation

• Rate

• Phrasing

• Modification of Pitch & loudness


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


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


• 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


• 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


rehabilitation esophageal speech & artificial larynx

Documents

air charge

dense air

esophagus denser air

esophageal dilation

hypotonic esophageal

aforementioned air transport

rarefied bodies of air

pharyngoesophageal pe