Laryngectomees have traditionally had four communicative alternatives. The first and least intrusive is any form of nonverbal communication… writing, gesture/pantomime, or communication boards. While effective, these methods are quite time consuming, tiring, and are only effective for face-to-face situations.
The second alternative has been esophageal speech. On the average less than 20% of all laryngectomee patients do succeed in acquiring esophageal speech. Reasons for this lack of success may include difficulty with air injection, tracheoesophageal fistulas, and cardiopulmonary disease, resulting in decreased breath support and endurance.
The third choice has been the electrolarynx. Devices cost anywhere from $400 to $800. Subsequent therapy to master use of the device averages three to six months, twice per week, with the average cost of a session being $120. Many patients achieve successful verbal communication in a timely manner. Intraoral electrolarynxes are particularly useful immediately after surgery, providing a means for verbal expression. However, intelligibility is generally poor. The patient may choose to use the oral adapter, essentially a rubber straw fitted to the electrolarynx to route the sound into the mouth without having the unit contact the neck which may be sore from surgery or have scarring. In addition intelligibility is generally poor and hygienic concerns are high due to the continual introduction and removal of the straw from the oral cavity.
Neck-held electrolarynxes also present contraindications. These include:
- post-surgical swelling, making it difficult to achieve adequate placement for sound transmission.
- post-surgical stiffness in the tissue surrounding the incision, resulting in greatly decreased sound transmission.
- skin irritation, often caused by radiation therapy, which is exacerbated by the continual use of the electrolarynx.
- arthritis in the hand, wrist, and/or elbow, resulting in decreased ability or inability to sustain placement, sustain pressure on the on/off button, or hold the prosthesis in place.
- radiation fibrosis, edema, or neck thickness, resulting in reduced transmission of sound
In addition, other difficulties may prohibit the use of the electrolarynx including:
- difficulty achieving a consistent adequate placement, which severely reduces sound quality.
- neck pain during use of the prosthesis, as experienced by radical neck dissection patients.
- lack of an adequate sound transmission site, as experienced by radical neck dissection patients. Finally, many patients forego use of an electrolarynx purely due to the robot-like sound quality and subsequent self-consciousness.
The fourth alternative had been Tracheoesophageal Puncture (TEP). Cost of the surgical procedure to create the puncture averages $ 2000 to $3000, not including pre- and post-operative visits, medications, supplies (prosthesis, French Catheters, saline solutions, etc.) and ensuing speech therapy. Total costs can easily exceed $6000. Many patients have successfully undergone this procedure since its inception. Perhaps the greatest asset of TEP is the tremendous volume that some patients are able to achieve. Clarity is also judged to be good to excellent, depending on the patient.
Contraindications to TEP include:
- patient age.
- extensive neck scarring.
- radiation treatments, resulting in tightening of the surrounding tissues and possible shrinkage of the stoma site.
- insufficient pulmonary strength due to cardiac or pulmonary disease.
- constricted esophageal pathway.
In addition, the success of the TEP can be hindered by a patient’s failure to properly care for the prosthesis, improper fitting of the prosthesis with subsequent air leakage and fungi build up. It is not uncommon for a patient to drop the prosthesis into the trachea or lung creating a traumatic and painful situation for the patient until it is removed by a doctor. Unfortunately about four people in ten (40%) are not successful with the T.E.P. long term. This additional surgery with a relatively low success rate can also lead to longer problems such as infection and fistula as well as requiring admission to the emergency room when voice prostheses fall into the lung. As a result many laryngectomees opt not to undergo this treatment.
THE ULTRAVOICE OPTION
A new speech generating device, UltraVoice Plus has been developed which presents another option enabling laryngectomees to speak. This new device consists of an oral unit which is worn inside the mouth and a controller which transmits radio waves to the oral unit. The radio waves carry the tone of the human voice which is reproduced in the mouth by the oral unit. Because the sound is created within the vocal tract, it is significantly more natural and intelligible than external units. In addition, it has been designed to alleviate some of the contraindications associated with the other technologies.
As the UltraVoice is worn in the oral cavity, typical considerations such as edema, fibrosis, and placement sites are eliminated. Worries about adequate sound transmission and skin irritation secondary to radiation treatments are also eliminated. For arthritic patients, the control unit can be operated with the side of the hand or wrist, or it can be equipped with an adaptive device, i.e. built-up button, toggle switch, etc.
The UltraVoice is worn all day like a regular denture or retainer, including for meals. This provides the laryngectomee with the ability to eat and talk simultaneously, a skill not attainable with esophageal speakers. It also eliminates hygienic concerns, such as those involved with the intraoral electrolarynxes.
In order to maximize usage of the UltraVoice, a short course of therapy with a certified speech/language pathologist is highly recommended. However, the laryngectomee is able to begin speaking intelligibly with the UltraVoice from the moment it is inserted. Clarity is judged to be excellent. Patients incorporating esophageal speech, electrolarynxes, and sometimes TEP’s are unable to achieve independent verbal communication until further into their course of treatment.
The only contraindication for the UltraVoice is intolerance to an intraoral prosthesis. Age, fistulas, and cardiopulmonary status do not affect the laryngectomee’s success. Conversely, the UltraVoice is quite helpful for those patients with cardiopulmonary disease, as the UltraVoice serves as an energy conservation device for these patients and provides them with the ability to speak significantly longer without fatigue.
Compared to procedures like the TEP, the UltraVoice is markedly less expensive. While TEP costs include preoperative visits, surgery, physician’s fees, supplies, medications, post-operative visits, and a course of speech therapy, the UltraVoice is all inclusive. The UltraVoice fee includes the cost of the dental fittings, the denture, and the actual prosthetic elements. The only extra expenditure is a brief course of therapeutic instruction. Furthermore, the average course of therapy for the UltraVoice is significantly shorter than that for esophageal speakers, resulting in comparable total costs between these two rehabilitative means. The UltraVoice is also significantly less expensive than electronic communication boards, which average $5,000 to $6,000 not including the cost of therapeutic instruction.