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.