Overcoming The Hurdle Of Controlling Stoma Noise

Originally published in Advance for Speech-Language Pathologists & Audiologists, February 24, 1997.

Speech-Language Pathologists are constantly faced with therapeutic obstacles and patient challenges. For the speech clinician who works closely with laryngectomized individuals, the control of stomal noise is sometimes an issue and a hurdle to be overcome. Stoma noise, also referred to as “stoma blasts,” is the unwanted high-frequency noise generated from the tracheostoma in a tracheostomized person. Stoma noise is frequently observed in laryngectomees and stems from pulmonary air turbulence at the stoma site.

All people have the innate and over-learned need to fill the lungs prior to producing an utterance. This human function is deeply ingrained and is an integral part of speech communication. Due to major changes in the respiratory tract, laryngectomees must learn deliberate techniques to eliminate or sharply reduce stomal noise.

Stomal noise is not just a negative deviation of alaryngeal speech. It is also a deviation causing noisy and conspicuous breathing. Most laryngectomees undergo a period during which stomal noise is observed. For some it is an obvious aberration that is reckoned with and self-controlled. For others it is an uncontrolled, unconscious deviation of speech and breathing that has several negative facets. Not only does stomal noise dramatically and adversely call attention to the patient’s neck and tracheostoma, but it makes the individual more conspicuous in social and public situations. On a subjective level, both educated and lay persons often find stoma noise to be strange and even alarming. Stomal noise is also responsible for masking the attempts to communicate by using alaryngeal means, such as esophageal speech and speech using an artificial larynx. Frequently the unwanted noise generated from the tracheostoma is in direct competition with the speech signal. The result is a range of unintelligibility and conspicuousness which can vary in severity among patients.

A chief objective of laryngectomee rehabilitation is to approximate normal speech. Even though alaryngeal speech with an electronic larynx, esophageal or tracheoesophageal punctured speech deviates from normal voice, it is important to strive for a production that closely resembles normalcy.

Rehab goals should not only address functional communication but the control of stoma noise and its perception by others. This is not always easy to accomplish, due to such reasons as decreased cognitive function, poor new learning skills, impaired auditory/speech perception skills and stomal size.

Therapy to eliminate stoma noise starts with education. Provide the patient with a basic education of anatomy and the changes resulting from the laryngectomy surgery. For many patients this is the first meaningful description of the surgery and the problems that need to be overcome. It is usually helpful to include the patient’s spouse or helper in the educational process.

Early intervention and education is key to controlling stoma noise. Patients who do not have early contact with an alaryngeal speech professional are at risk for developing detrimental speech and secondary behaviors. Once these inferior habits are established, they are more difficult to change and eliminate. If the patient is fortunate enough to have pre-operative time with a therapist, this is a good time to briefly discuss stomal noise control. Afterward frequent mini-discussions and focused therapy can relate to stoma noise.

Several worthy techniques can be used together or individually to treat stomal noise. For patients who may have difficulty perceiving their own stomal noise, the use of a stethoscope or audio recording device as a feedback tool helps to demonstrate and highlight the problem.

Another helpful tool for patient feedback is a stomal whistle. This simple pneumatic device has a rubber flange attached to the oral end. When held to the tracheostoma, the whistle will sound at varying levels depending on the air moving through it. With the stomal whistle in place, the patient is instructed to produce sounds and words without sounding the whistle. To lighten-up the therapy process, it is humorous to tell the patient to not “blow the whistle on him/herself.”

Once an aided awareness of stomal noise has been established, the patient can be shown how to eliminate it. Carefully audio recording similar trials with and without stoma noise for the patient to review is helpful.

Since stoma noise can be observed even while producing the most minute utterance, the clinician should start with basic sounds and advance as necessary. For example, the clinician may wish to have the patient produce a voiceless plosive while carefully monitoring for stoma noise. Then, as the patient is able, the therapist can advance the patient by having him or her produce monosyllabic words, counting and so on. The key is to advance and increase the patient’s utterance length while minimizing or eliminating stoma noise. Another strategy involves having patients empty their lungs of air prior to producing a sound or a short utterance. Still, for other patients, it may be useful to have them whisper an utterance. Since whispering in a normal speaker requires less pulmonary demand, the laryngectomee can more easily relate to this mode of speech, and stoma noise is dramatically reduced. The clinician working with stomal noise will quickly find the techniques that are most successful with a given patient.

Sometimes a patient will demonstrate decreased cognitive function and new learning problems. Since the control of stoma noise requires the recall, re-adaptation and use of special strategies, some patients have more difficulty finding success. It may be helpful to enlist a friend of the patient to assist with home practice and exercises. New Voice clubs in the area also can provide valuable help and encouragement to the patient who is experiencing problems. Occasionally, the clinician will encounter a patient who simply cannot control stoma noise. This is usually due to cognitive dysfunction or entrenched habit.

Having an abnormally small tracheostoma can affect a patient’s basic pulmonary function in addition to alaryngeal speech. Stenosis of the tracheostoma is not uncommon in the laryngectomee population, and it can give rise to stoma noise and respiratory compromise. Importantly, if a patient demonstrates perpetual stoma noise during restful breathing and speech tasks, the size of the stoma should be inspected. As a general rule, the tracheostoma that is smaller than a dime or ones that are continually growing smaller are suspect. An abnormally small tracheostoma sometimes can act like an air nozzle, creating stomal noise at rest or during some level of physical activity. If a patient complains of fatigue and air resistance at the stomal site, especially during light-to-moderate physical activity, stomal revision surgery for enlargement should be considered by a surgeon.

A small tracheostoma, however, is not necessarily indicative of a problem. The laryngectomee–depending on gender, stature and respiratory status-will be more or less affected by the size of the tracheostoma. For example, a female who is 5-foot tall and weighs 110 pounds with a stoma one centimeter in diameter may have little difficulty. But the same stoma dimension in a 6-foot male may be more problematic in terms of stoma noise and breathing during any activity. This problem may be further complicated if there are components of chronic obstructive pulmonary disease (COPD), asthma or other respiratory problems.

Nevertheless, stoma noise is an important aspect of rehabilitation that must be questioned and addressed in every laryngectomee. Since stoma blasts can affect intelligibility and attract negative attention, early intervention by a skilled professional is essential. Several successful techniques can be employed by the alaryngeal speech instructor to increase patient awareness and reduce, if not eliminate, this abnormal sound.

There’s Nothing Like the Sweet Spot: Placement of the Artificial Larynx

Original publication in the AKSHA Voice, October 1997.

A large proportion of laryngectomees find communicative success by using an artificial larynx (AL). While 40-60% of laryngectomees, or anyone for that matter, can learn functional esophageal speech or possibly be a candidate for tracheo-esophageal punctured speech, it is estimated that over 95% of this population can use an AL device. Other patients with conditions that render the vocal folds useless also benefit from the AL. Artificial larynges are typically electronic devices that generate a focused tone that penetrates the neck or cheek. It is this penetrating tone that is articulated for speech.

A chief objective of laryngectomy rehabilitation is to approximate normal speech. Even though speech with an electronic device deviates from normal production, there are a number of variables that will enhance the success with an AL device. One such variable is the optimal location of the AL device on the neck or submandibular area. Finding the Sweet Spot can be likened to back scratching; that one particular spot makes all the difference in the world!

Speech-language clinicians who introduce the new laryngectomee to an AL device are commissioned with finding the Sweet Spot. The Sweet Spot is a term that refers to the one or two locations on the patient�s neck that most effectively transfers the speech signal into the pharynx and mouth for speech. Without proper placement on the neck, the laryngectomee will experience, unintelligibility, excessive noise, poor signal transfer and frustration. So let�s take a closer look at how best to find the Sweet Spot.

Begin with a powerful artificial larynx that has a fresh battery and charge. Each laryngectomee is different. It is helpful to palpate the neck to locate the most supple tissue. Palpation will also announce the sensitivity of the neck and the patient�s tolerance or intolerance of this procedure. In some cases, one side of the neck will be more tender than the other. In other situations, the neck will be completely numb and void of discomfort. With the patient sitting upright, have him/her form the posture of the neutral vowel. Be certain that the patient�s tongue remains downward and that it does not occlude the pharynx. With the device at 3/4 volume, place the AL firmly on the neck first starting at the most supple areas. Systematically go around the neck with firm and flush pressure seeking the strongest oral signal. Depending upon the handedness of the patient, good early habits can be made. Generally it is best to free-up the dominant hand for activities (ie., writing) that may eventually accompany use of the AL. While use of the AL requires some fine motor skills, other activities require more and demand the dominant hand.

An increase in volume and clarity will be observed by the clinician and usually the patient when the Sweet Spot(s) are found. Importantly, the tongue and oral cavity may be swollen and range of motion may be decreased after surgery. Usually, over a short period this condition improves and speech articulation becomes easier.

After surgery, the Sweet Spot may be elusive and changing. This is largely due to the accumulation of cellular fluid or edema in the head and neck region which can remain for weeks or months after the surgery. This edema will act as an insulator or pillow and absorb the energy coming off the AL device. As the edema dissipates, the Sweet Spot may move. Because of this change it is good to recheck for the optimal device placement. Scar tissue from the surgery and/or radiation therapy may also result in a thickened, woody tissue that is impervious to the AL signal. Unlike edema, scarred or radiated tissue may not soften over time.

For patients who cannot tolerate neck placement or perhaps those who do not have a discernable Sweet Spot on the neck, the use of cheek placement is recommended. When indicated, begin your test trials on the fleshy portion of the cheek and work towards the lip corner looking for the clearest and strongest signal. Some patients will complain that the AL rattles their dentures. Instead of allowing the patient to remove their important teeth, try reducing the volume of the AL and recommend a high quality denture adhesive. Sometimes a slight pitch adjustment will remedy any unwanted vibration. Again start with the neutral vowel and then move to short words and so on. If the cheek becomes a functional location, it is good to explain to the patient that it is only temporary. Over time either edema or hyper-sensitivity will diminish thus allowing for neck placement. Neck placement is considered optimal because it is less conspicuous and because it does not hide the movement of the lips. Intraoral adaptors are also available for most AL devices. This simple rubber cap and tube assembly delivers the signal directly into the mouth, therefore eliminating the need for neck or cheek placement. Like cheek placement, use of the intraoral adaptor is usually temporary.

Once a Sweet Spot is located, therapy can address having the patient consistently and naturally place the device. The use of a mirror and red adhesive dot are helpful tools in achieving this objective. Ear training and audio-recording can also assist the patient in consistently locating the Sweet Spot– especially where auditory perception skills are decreased. Other goals for therapy will usually address over-articulation, intraoral consonant production, control of stoma noise and use of gestures.

The artificial larynx remains an excellent possibility for alaryngeal speech communication. Therapy and encouragement for how best to use the AL device is essential for the rehabilitation of laryngectomees and others using such a device. Identification of the Sweet Spot, amongst other goals, can often make a difference in communication by improving overall intelligibility, volume, clarity, and by reducing frustration.

Current Trends in Electronic Larynges

Originally published in Advance for Speech-Language Pathologists & Audiologists, July 25, 1994.

Advancements in technology over the last decade have had considerable impact on the new generation of electronic voice aids. Known to many as the artificial larynx (AL), these machines provide functional voicing for an estimated 30,000-35,000 laryngectomees in the United States. Ranging in cost from $400 to $650, the electronic larynx is a useful communication device that the laryngectomee can use quickly. After a comparably short amount of practice and therapy time, the AL offers functional communication to the new laryngectomee and others who have lost function of their vocal folds.

FOR PATIENTS who cannot achieve functional esophageal or tracheo-esophageal punctured (TEP) speech, the AL remains an excellent option for alaryngeal speech communication. Even with functional esophageal or TEP speech, many laryngectomees find the AL a comforting option.

Speech with an AL is typically louder, faster and often more intelligible than esophageal production. Other then a device that simply emits a buzz tone, how does the electronic voice aid work, and what makes it different from the machines of yesteryear?

Overall the neck-type AL is an oscillator that generates a focused signal that penetrates the neck for voice. It is this penetrating tone or new voice that is articulated for communication. When a patient loses vocal function of the true larynx, the AL simply provides a tone replacement for speech. The signal from the AL moves through the neck and into the mouth and is used to produce the vowels and voiced consonants in speech.

While most users press the device on the neck for signal transfer, a minority of laryngectomees utilize an intraoral tube. This simple rubber cap and tube assembly delivers the signal directly in the mouth, thus eliminating the need for neck placement. Most neck-type AL devices can be changed easily for neck or intraoral applications.

THE MOST common new generation of electronic voice aids are lighter and smaller and generate a tone that is termed, periodic or consistent. Actual tone production is accomplished by an electromagnetic plunger that repeatedly strikes a hard membrane or drum.

The hard membrane, located in the head of the machine and on the outer side, has contact with the patient’s neck. In order to create an oscillated signal, the device must automatically turn on and off so the plunger creates a cycle of repeatedly hitting the drum. Depending on the speed and force in which the plunger strikes the drum, variations in pitch and volume are controlled.

Rather than using the once bulky electronic parts to create an on-off cycle for oscillation, the new style machines use a silicone chip that serves as a timer. These timers are smaller than a penny and weigh less than a gram.

electroniclar.gif
  1. Battery
  2. Timer
  3. Pitch Control
  4. On/Off Switch
  5. Volume
  6. Electromagnetic Plunger
  7. Hard Membrane/Drum

TYPICALLY, these silicone timers use very little energy to operate, thus smaller, lighter and more efficient batteries can be used. One device utilizes surface-mount electronic components that are extremely light and small. The ability for artificial larynx manufacturers to reduce overall weight and size while maintaining good tone quality is largely the result of micro-electronics. Many patients are at an age where arthritis and muscle weakness is prevalent. Aside from age, the laryngectomy surgery itself may leave a patient with weakened upper extremity movement and limited range of motion on one or both sides. When considering these issues, it is not surprising that a light-weight device is easer to hold an operate. For the non-laryngectomee, having to communicate with a hefty machine can be likened to writing with a heavily weighted pencil.

The use of space age materials also has improved the current type of machine. The incorporation of micro and silicone electronics give rise to a machine that is more durable and forgiving to shock damage.

Some manufacturers now are encasing electronic components in resilient material to resist shock and damage from water. New plastic materials and molding techniques offer a device that is easy to hold and manipulate.

Although not considered a neck-type device, one manufacturer has molded a tiny sound generator in an upper denture plate for limited voice production. Another device utilizes a lightweight titanium shroud to protect the components within and to dampen extraneous noise emitted from the body of the machine.

CONTROLS on several devices now allow for easier operation. Small, low-friction micro-switches and dials are presently used on most models to easily adjust pitch and volume, replacing the trigger or large switches of old style machines. Pitch range can be adjusted quickly to approximate a male or female voice. Most controls are easily accessible on the external case and are user friendly.

Aside from pitch and volume controls, some models allow for limited pitch inflection. One manufacturer provides internal adjustments that alter tone decay–the variance of tone that automatically changes downward after the machine is initially turned on. Still other models offer a variable head that physically adjusts the distance between the plunger and drum. This feature provides limited fine tuning and, on one model, alters the softness of tone.

Power sources for AL devices also have changed. Once limited to disposable 9-volt radio batteries, mercury batteries or a heavy battery pack, the electronic voice aids of today offer rechargeable batteries for months of service. Some machines utilize high capacitance, barrel-type batteries while others can use 9-volt rechargeable batteries or alkaline batteries. One device can be used with household current or an electrical source from an automobile cigarette lighter.

MOST AL devices today come with a charger that rejuvenates a rechargeable battery for many cycles of use. Various factors including volume/pitch settings, actual on-time and battery care essentially will determine the frequency of recharging. Typically these battery chargers will fully recharge a battery in 10-14 hours. Some units offer an automatic shutoff that reduces most problems with over-charging. Some charging units also vary in their ability to charge more than one battery at a time. This feature conveniently allows the patient to carry a fully-charged alternate battery. Like automobiles, the artificial larynges of today have become smaller, lighter, more efficient and user friendly. If we continue this trend into the future, we will likely encounter electronic devices that are more compact and energy efficient. They will possibly be implanted at the time of surgery and recharged monthly by way of a subcutaneous recharging coupler while the patient sleeps. They might utilize the existing musculature to control voice initiation and intonation.

PERHAPS such devices will harness the naturally existing electrical voltage of the body for operation. Devices in the future might allow for more normal sound production and vocal inflection, making it difficult to differentiate between normal and synthetic alaryngeal voice. With some amount of imagination, maybe the ultimate possibility will be observed: the need for an artificial larynx will be eliminated completely.

Welcome

Greetings to you!
Life is a very busy place for most people and I appreciate your visit here. I am a Speech-Language Pathologist, Therapeutic Massage Practitioner, historian, researcher, and writer. Here you will find a springboard to my other sites and a hodgepodge of information that you may find useful. Some of it deals with artificial larynx devices and laryngectomees; a little on delayed auditory feedback as a fluency tool; and an information base revolving around the historical Franklin Elementary School in Spokane, Washington.
If you are looking for information on my therapy/evaluation services, therapeutic massage, voice and fluency equipment, or artificial larynx repairs, please visit me at Inland Speech Pathology.
Larynx Man (WinCE).jpg
1929 photo of a laryngectomee using a pneumatic speech device,
(Fletcher, Harvey, Bell Telephone Laboratories, Inc. 1929)

If you are looking for information about the Franklin School, or perhaps a picture of someone who attended there long ago, the Franklin Connection button is a good spot to dig around. Content found on this site reflect some research and professional interests and over 30 years of speech-language pathology services in our community. The blog is occasional and omnidirectional.
Finally, if you are here looking for farm, soap, or egg information please visit our ranch site, Newman Bluffs.
Feedback and comments are always invited. Thanks again for visiting.

Speech Options: Myth or Fact

Original article published in Headlines May 2003
Most people are impressed by the three ways laryngectomees can learn to speak after they have had surgery. These include speech produced using an electro or pneumatic larynx, esophageal production, and tracheoesophageal puncture. And in reality, these modalities of artificial voice are truly impressive. They give back the human voice that is so important to daily lives and they offer a link back to society. For those who have lost their true larynx, these modalities are the tools that give voice and re-create our being and personality.
But with these three modalities and all the various devices and techniques associated with them, how can laryngectomees and family members know which ones are best? Which ones will offer the clearest voice and the most natural sound? Which ones will be most accepted by spouse, family, friends, and co-workers? How will I learn and care for the system I use? What modality will sound the best over the phone and to strangers? Although this article will not answer these questions, they are ones that face new laryngectomees. With the assistance of a speech-language pathologist, they often can be answered.
It comes as no surprise that laryngectomees are under the impression that they have options when it comes to the alaryngeal system they will use to communicate. After all, they have been told that they have “options” and much of the laryngectomee literature refers to the “speech options” that are available to laryngectomees. In reality, however, many laryngectomees do not have an “option” or “choice” when it comes to the post-surgical voice they will use to communicate. Take the example of “Lucy” whose doctor insisted that she learn esophageal speech, the “gold standard.” After earnest attempts and years of frustration, Lucy was unsuccessful in acquiring anything past a pharyngeal squeak. Now, after 27 years, she still uses a pencil and paper to communicate with family members. Lucy never leaves the house. And then there is “Bruno” who underwent several surgeries. Not only did Bruno have his larynx removed but he also lost two thirds of his tongue. Even though he purchased an electrolarynx, he was never able to make intelligible speech. And even though Bruno has a strong, sustained esophageal tone, it is useless for making speech. Since Bruno never finished school and never learned to read or write, he mouths words and uses gestures to communicate. Only his son can understand what he is saying. Finally, meet “John” who has tried numerous puncture prostheses. But because of excessive mucus and scarring, he has problems with the prosthesis plugging-up and dislodging. The device offers voice for a short period and then fails at inopportune times. After two years, John gave up and permanently removed the prosthesis. John’s esophageal speech is too soft and inaudible and despite his desire to have hands free communication, he is forced to use an electrolarynx. In each of these scenarios, Lucy, Bruno, and John thought that they had options. They were wrong.
The misconception that laryngectomees have “speech options” is further perpetuated by those who use a particular technique. For example, some esophageal speakers are under the impression that anyone can learn good, functional, esophageal speech. They insist that achieving esophageal speech is a function of choice, motivation, practice, and pursuit. In fact, a recently published newsletter, reported that “Esophageal speech is easy if you exercise your speech muscles 5 minutes each hour of each day.” Unfortunately, nothing could be further from the truth and this type of writing helps only to solidify a misconception. What about those individuals who do not have the physiological capacity to achieve functional esophageal speech? There are many variables besides choice that determine whether or not a person can achieve esophageal speech, or any system for that matter. And realistically, good, functional esophageal speech can be acquired in only about 40% of those who try to achieve it. What about the other 60 percent? An individual, who believes that he or she will speak using a given system, and then cannot achieve success, may feel cheated or think of themselves as a failure. Someone once said that perceptions are real through the eyes of the perceiver. Because of this, many users may believe that their particular system or device is the best option for everyone. This simply is not true.
In the earlier days of my career, I too used the phrase, “speech options” in an effort to share my knowledge. Several years ago, however, I learned that my laryngectomee patients and families were better served using the term “Speech Possibilities.” Not only does this phrase minimize the idea that there are choices, but it also sets the stage for a system that is a match with the individual patient. Depending on a host of variables, the person can be best suited with an alaryngeal system that will work with and not against them. Until the various systems are considered for candidacy, evaluated, and tried, they are possibilities and not options.
This idea also dovetails with another concept. Clinically, I feel that laryngectomees should have two modalities for speech communication. Naturally, this is not always achievable but, on a rehabilitative level, it makes good sense to aim for this goal. Since 99% of laryngectomees can have relatively fast success with an artificial larynx, I set them up with one and begin instruction in their use and care. Then, if tracheoesophageal puncture is concurrently or consequently performed and functional, the patient will have two separate systems for speech communication. If the patient is a candidate for esophageal speech and is able to achieve success, along with the artificial larynx, there will be two systems available. Or perhaps the patient will simply have two artificial larynx devices; one as a primary device and another as a back up.
The goal of laryngectomee rehabilitation is to bring back the whole person, to completely restore speech communication, and to instruct compensatory strategies. Whichever speech modality is used, it should be one that is completely functional and one that is a best match between the person, the device, and/or the technique. I like the phrase, “Speech Possibilities” because it is realistic, truthful, and accurate.

Interests

  • Communication surrounding NDE, coma, and vegetative states
  • American cultures and persecution of the innocent: Japanese-Americans, Wobblies, American Indians and others
  • Reliability of artificial larynx devices according to laryngectomees and speech-language pathologists
  • The Franklin School: Historical interests
  • Fluoroquinolone drugs, Stevens-Johnson Syndrome, and damage to speech-swallowing structures
  • Training with artificial larynx devices
  • Laryngectomee rehabilitation
  • Pneumatic devices and voice production
  • Voice-Spectral patterns and stereotypes
  • Barium viscosity, density, and adsorption
  • Professional burnout