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Some people with cancers of the head and neck may need speech therapy to learn how to speak again after treatment. Speech therapists (speech-language pathologists) assess and treat speech problems. They work closely with surgeons and oncologists to make sure you get the help that you need.
Speech is produced when air flows out of the lungs and through the throat. The air vibrates the vocal cords. These vibrations are then formed into words by the throat, tongue, teeth, nasal passages, mouth and lips.
Cancer of the voice box (larynx), throat (pharynx), mouth, tongue or brain can affect a person’s ability to speak. Some cancer treatments can also cause problems. Both the voice itself (frequency, pitch and intensity) and the ability to speak can be affected by cancer and its treatments. Surgery for head or neck cancer may cause permanent changes that make communication or speaking difficult. Radiation can cause problems ranging from short-term swelling of tissue (edema) and pain to long-term scarring and stiffening of tissue.
During a total laryngectomy, the larynx, including the vocal cords, is completely removed. A person who had a total laryngectomy must learn new ways to speak using a different vibration source to replace the vibrations of the vocal cords.
People who have radiation therapy or a partial laryngectomy can still speak using the vocal cords. There may be some changes to the quality of the voice, including hoarseness, breathy voice and voice fatigue. Speech therapy can help these people improve the quality of their speech.
For people who haven’t had a total laryngectomy, laryngostroboscopy may be used to examine the vocal cords during speech. A camera is attached to a laryngoscope, and flashing lights are used to slow down the image of the cords moving. Laryngostroboscopy may be used to assess speech before, during and after treatment.
A person who has had the larynx removed (a laryngectomee) can learn to speak again, but it takes time, patience and practice. The length of time that it will take to learn to speak again will be different for each laryngectomee. Some people learn quickly, while others find it more difficult due to individual differences in anatomy after surgery or radiation treatment.
Different speech rehabilitation techniques may be used to help a laryngectomee speak or communicate. A speech-language pathologist will help find the method or combination of methods that will work best for each person.
Artificial larynx speech
Artificial larynx speech involves using an electrolarynx, or artificial larynx, to speak. An electrolarynx is a battery-operated device that produces vibrations, which are then formed into speech by the mouth, tongue, teeth and lips.
There are 2 types of electrolarynxes. Both types of electrolarynxes can be used almost immediately after surgery, so there is little or no time when the laryngectomee is without a voice. The devices are simple to use and maintain.
Although both types of electrolarynxes help a person speak, the speech that is produced sounds very mechanical or electronic. Battery maintenance is required and the electrolarynx may need repair occasionally. Some people may not be able to use intra-oral devices because saliva and mucus may plug the sound tube.
A neck type of electrolarynx is an external device that looks like a small flashlight. The end of the electrolarynx is placed against the neck or cheek and, when turned on, it produces vibrations that are transmitted through the tissues of the neck or cheek into the throat or mouth. The vibrations are then shaped into the sounds of speech by movements of the mouth, tongue, teeth and lips. A speech therapist will work closely with the laryngectomee to use the electrolarynx properly.
An intra-oral electrolarynx has a small tube that is placed inside the mouth and is connected to a transmitter that produces vibrations. The transmitter may be held in the hand or it may be attached to a denture or dental plate in the mouth. A switch is turned on to produce vibrations when the person wishes to speak.
Tracheoesophageal (TE) speech involves using a prosthesis inserted in an opening in the wall that separates the trachea and esophagus. TE voice restoration surgery or TE surgery may be done at the same time as total laryngectomy or it may be done as a second surgery at a later time.
During the surgery, a small opening (fistula) is created between the trachea (windpipe) and the esophagus. The surgeon places a small prosthesis with a one-way valve into this hole. The valve is the voice prosthesis. This one-way valve allows air to move from the trachea into the esophagus but prevents food passing from the esophagus into the trachea.
To create speech, the laryngectomee breathes air in through the stoma and then covers the stoma with a finger. Air is redirected through the valve into the esophagus, causing it to vibrate. Speech is then formed with the mouth, teeth, tongue and lips. A speech therapist will work closely with the laryngectomee to learn this technique.
There are a number of different types of speech prostheses. Some voice prosthesis valves are attached to the stoma (ex-dwelling valves). These devices are hands-free and do not require the stoma to be covered. Ex-dwelling valves have a strap outside the stoma and can be changed by the laryngectomee or their caregiver. Other types of prosthesis valves are completely within the laryngectomy stoma (in-dwelling valves) and will need to be changed by a doctor, speech therapist or nurse.
The voice produced by TE speech sounds very natural. Most people can speak in as little as 2 weeks after surgery. It is easier to learn how to speak by TE speech than esophageal speech.
TE speech also has some disadvantages. The voice prosthesis must be cleaned and maintained on a regular basis. It requires a second surgery if the TE surgery is not done at the same time as the total laryngectomy. There is the possibility that the one-way valve could fail and allow food or liquid into the trachea and lungs (aspiration). Some people may not be able to use TE voice rehabilitation because of damage to the tissues of the esophagus or throat during surgery or radiation therapy.
Esophageal speech is a method of inhaling air into the upper esophagus and using it to create the vibrations necessary for speech. Esophageal speech is the least common method used in speech rehabilitation for adults. However, it may be used more often for children because they are sometimes better able to adapt to it than adults.
- Air is taken in through the mouth and then is pushed down into the esophagus. The tongue is placed against the roof of the mouth to hold the air down.
- When the person is ready to speak, the air is then forced back into the mouth from the upper esophagus. This causes the esophagus to vibrate.
- Speech is created using the tongue, lips, teeth and mouth to change the vibration into sounds and words.
Esophageal speech produces a low-pitched or gruff voice that sounds close to normal voice quality. It doesn’t require more surgery. There is no equipment to maintain or that might break down.
It is a difficult technique to learn. Esophageal speech often requires 4–12 months of speech therapy and a significant amount of practice and motivation. Some people are never successful in learning this way of speaking. Because of the length of time it takes to master the technique, there is a delay in regaining the ability to speak. The voice produced can be difficult to hear and understand because it may be low in volume. Amplifiers can be used to increase the volume.
Some people cannot use esophageal speech because of the amount of tissue removed during surgery or because of other physical conditions.
Learning to speak again can be very difficult. Some people find it helpful to have emotional and practical support from other cancer survivors. The International Association of Laryngectomees has a number of support groups in Canada.
Establishing a national caregivers strategy
The Canadian Cancer Society is actively lobbying the federal government to establish a national caregivers strategy to ensure there is more financial support for this important group of people.