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The investigators observed and analyzed the nonverbal and verbal reactions of 30 service station attendants who were exposed to alaryngeal speech produced with an electronic larynx and the reactions of another 30 attendants who heard normal speech. Although there was a significant difference between the patterns of response of the two groups of subjects, the difference was attributable primarily to responses on only three of the 16 behavior categories studied. Subjects who heard alaryngeal speech tended to stare more or speak louder or slower. The authors concluded that listener reactions should not be cited as an argument against the use of an artificial larynx; potential adverse reactions will be minimal, can be coped with easily, and will not interfere with effective communication.

Summary The authors have compared the therapeutic constructs of six authorities in alaryngeal speech. Three major and one minor type of post-laryngectomy speech are described, methods of air intake are reviewed, and therapy procedures are contrasted. Reasons for using an artificial larynx are given. An approach which meets the needs of the person is recommended.

An artificial larynx of the pneumatic type is presented with preliminary data from dog experimentation. A controlled communication can be made between the trachea and esophagus utilizing this apparatus. The device is well tolerated when placed below the level of cricopharyngeus muscle in the dog. An esophageal valve functions well to prevent aspiration. Air flow through the apparatus is sufficient so that utilization in the human laryngectomy patient may be feasible.

Speech samples obtained from a group of adult males and females while they articulated the tone produced by a single-frequency electrolarynx were played to a panel of listeners who were asked to determine the sex of each speaker. Formant frequencies for the vowels /i/ and /u/ produced in isolation by the same speakers were obtained by spectrographic analysis. The judges were able to correctly identify the sex of the speakers 88% of the time, and vowel formant frequency averages were closely associated with the degree of male or female quality in these voices. These findings indicate that in the absence of between-subject variations in laryngeal fundamental frequency, a distinct cue to speaker sex may be contained in the individual vocal tract resonances.

Prosthetic rehabilitation of a severely incapacitated cancer patient has been described. When the total cervical larynx, trachea, and esophagus have been lost, the problem of saliva entrapment must be dealt with by a device that will prevent aspiration of the oral fluids. A definitive esophageal prosthesis was designed which allowed the patient to enjoy a reasonably normal diet and again taste her food. At a later time, an artificial larynx was fitted, which enabled the patient to live at home in a fairly normal manner.

Every laryngectomized person can be vocally rehabilitated. The eso-phageal voice is consciously trained; its physiology and rehabilitation were described by the author in 1924. To facilitate and enhance the voluntary production of an esophageal ructus, transnasal insufflation of air into the esophagus is used. At the same time the tension at the upper esophageal orifice is measured because of its prognostic significance. The lesser the pressure values obtained on insufflation of air into the esophagus, the better are the results of vocal rehabilitation. If the patient is unable to acquire a loud phonation, an electrolarynx is prescribed. The best results were achieved with the model manufactured by Western Electric and Bell, which permits changing of vocal pitch. Psychic rehabilitation is described and its importance stressed. Early removal of the cannula is recommended with a view to freeing the patient of feelings of disability. After partial laryngectomy or cordectomy, vocal training is introduced imme...

Nowadays, we have a number of opportunities of operating on the laryngeal carcinoma; that is to say, the writers have been gradually meeting many tragedies of lost cases in voice function. Among a great many people suffering from laryngeetomies in Japan, an artificial larynx is in everyday use. Bearing in mind that the esophageal (speech) voice is superior in several respects, the author provided guidance of the esophageal voice method and it study, by gathering many laryngeetomies, for the purpose of taking proper measures to relieve these people. During 1955, and in August, 1960, we came into contact with 253 cases, 96 of which have been able to carry on smoothly conversation with normal people, 47 cases had undergone an operation of neck dissection.By the dermal cicatrice of operation, the writer grouped these cases into four classes: a surgical operation in which a lengthwise cut is made; a Utype cut; andothers. This order arranged according to the number of cases. The first three types account for the greatest nuumber of cases, with the exception of a few. However, they are not related to the esophageal speech. In years of ago, the order is 60's, 50's, 70's, and 40's.The patient was ordered to swallow air, and then the author tried to classify the esophageal speech into three groups of deglutition, injection, and suction methods. Deglutition is a methods that sends air to the gullet (esophagus) by swallowing normally. In the injection method, as soon as a light swallowing movement comes about at the root of the tongue and in the throat redius (pharyngis medium), the pharyngis inferior and the upper part of esophagus open largely. In the suction method the swallowing as well as injection method does not occur; it is possible to open the pharyngis inferior freely, and the esohagus at the upper part. Then, according to suck-action of thorax (pectus), the air lets in the esophagus at a stretch without pause. So the deglution method has greater possibilities than the injection method. Although in a great number of cases the injection method in the esophageal speech has been practiced, some of them, however, gradually turn into the suction method. Of course, there are some people who are able to try the suction method from the beginnig.The esophagus being filled with air is distended in the middle of gullet, both ends become a little narrow, and two hollows are formed at the place where the left bronchus and the aortic arch cross. In consequence of these changes, one distension is there all the time as a fixed form between the two hollows.The esophageal speech in substitute phonations is most excellent. When they attempt to utter a cry (word) strongly, they could speak as well as anyone.The air quantity breathing out of the esophagus was about 45cc - 140ee. In the esophageal phonation, we are nearly able to raise a voice within the limits of the C.D.E.F.G.A.H.C. (bass) clef in piano. And it was also possible with the esophageal phonation, in cases which had undergone an plastic neck operation of esophagus.Pseudoglottis of the esophageal phonation is the situation within the range that is suited to the height of about V cervical vertebra and VI cervical vertebra. In studying esophageal speech, we found that there are conspicuously individual differences among them, which are sure to succeed it constant efforts and appropriate guidance of the esophageal speech are given them.

The use of the electrolarynx to facilitate communication with patients having temporary tracheostomies is discussed. Five case histories are presented with a discussion of the indications and contraindications for the use of the electrolarynx. It is concluded that the electrolarynx can be used effectively by selected patients with temporary tracheostomy tubes.

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In a previous paper experiments were described in which the writer’s English vowel sounds were reproduced by means of double resonators tuned to give the two principal audible resonances heard when whispering or breathing the vowel in question. It was found that various consonant sounds could be produced by manipulating these models, as had been previously done by Kratzenstein, de Kempelen, Willis, and Wheatstone, in the case of a single resonator, but that all models did not behave similarly. Complete closure (by hand) and sudden release, under air pressure, of the ei (hay), a (calm), D (not), ou (no), and u (who) models, gave b at low pressure and p at high pressure. Partial closure (allowing a small leakage sufficient to enable the artificial larynx to operate) followed by rapid release, gave m . On the other hand, the same manipulation of the models i (eat), I (it), e (men), A (up), gave a sound like that of w in we, wit, wen, etc.

The recent advancement in the management of the laryngeal cancer has raised the overall cure rate to over 75%, which is uniquely high as a cancer cure rate. The number of laryngectomees going back to the society with various handicaps increases each year. The rehabilition of these people is an urgent problem.There are four problems in rehabilitation. The first is the management of problems related to the use of a new air way. The others are the rehabilitation of voice, mental rehabilitation and the management of the senile diseases.The department of otolaryngology, the university of Osaka has a laryngectomees' association, which consists of about 700 patients. These laryngectomees were questioned about the physical complaints. Besides the loss of speech, their complaints included intolerance of hot foods, aerophagia, difficult sipping, anosmia, tracheal bleeding in winter, abdominal blowing, frequent breaking wind, difficult straining, stenosis of tracheal stoma and urticaria.I). The most important problem of all is a tracheal bleeding in winter. The typical finding of tracheo-bronchitis sicca hemorrhagica diffusa is the obstruction of the trachea and the bronchi due to an accumulation of blood crusts. Endoscopic removal of crusts is necessary. Patients should be instructed to maintain an adequate temperature and humidity to the air way.II). The speech rehabilitation is the most important for laryngectomees. In Japan, Tapia's artificial larynx is widely used as an excellent substitute. Some improvements need to be directed for the easier use by begginers. The conventional type has to be raised from the tracheal stoma during each inspiration. The new type revised by us has an inspiratory valve in such a way that patient can inspire without releasing the pipe from the tracheal stoma.Of course, the ideal substitute for normal voice is esophageal speech. To obtain the data for the more effective way of teaching esophageal speech, the mechanism of speech was studied using X-ray cinematography in 50 patients with esophageal voice. The relation of esophageal speech to respiration was studied using an indicator, which showed the direction of air current during respiration. The direction thus recorded is shown as a line in the films.The author could obtain some additional informations from the present study, by correlating the air intake to the phase of respiration. The modes of air intake are best classified into these five types; injection during inspiration, direct inhalation without injection independent of respiration, injection during expiratory phase and combined type of inhalation and injection.The shape of the pseudoglottis can be classified into these five types; simle form, simple form with subglottic space, larynx-like form, multiglottic form and incomplete form.From the proficiency of speech, which was evaluated phonetically, the author summarized that good esophageal voice is produced by1). air intake by injection during inspiration, 2). pseudoglottis formation by simple form or simple form with subglottic space, and3). ejection of air by uniform contraction of the lower esophagus and“squeezing up”contraction of the upper esophagus.III). The mental rehabilitation of laryngectomees is an urgent problem in the social and clinical aspects, too, They can not laugh and speak emotionally. Doctors must lead them to be going back to the society with the normal mental condition.IV). In the management of the diseases of old age of the laryngectomees, there are several important problems. The most cardinal of them is the early diagnosis of lung metastasis and double cancer in other organs. Laryngectomees should be instructed to maintain a comfortable circumstances with an adequate temperature and humidity in winter.

A description is given of the normal vocal tract and the action of the vocal cords in generating sound waves from the steady flow of air from the lungs. For persons whose larynx has been removed the flow of air from the lungs is changed into sound by a device external to the body and this sound is converted into speech by introducing it into the mouth and carrying on the ordinary speech‐producing motions with the lips, tongue, teeth, etc. A description is given of a recently developed vibrating reed type of artificial larynx for accomplishing the above. While using this instrument for producing a sustained vowel the rate of expulsion of air is about 125 cc per second and the excess pressure in the lungs is about .005 atmospheres, giving the rate at which the lungs do work as .06 watts. Using Saccia's measurements of the rate of radiation of acoustic energy from the lips of a speaker it is calculated that of the energy used by the lungs in forcing air through the glottis only about 0.17% is converted into useful acoustic energy.

The damping constants of vowel formants, as expressed in the half‐power bandwidths, have been studied from the reports of several investigators. The accuracies of methods of measurement used have been estimated through application of the same methods to an electrical analog of the vocal tract. Two new sets of measurements are presented, one on spectrograms of real speech, the other making use of an artificial larynx, applied to real subjects. It is concluded that, while wide individual variations occur, the average bandwidths for male voices probably lie in the lower range of those which have been reported.

The author has found that each of the whispered vowel sounds comprises two characteristic audible resonant components. Each component may vary over a range of a few semitones, and the upper and lower components are separated in the case of different vowels by intervals of from about 36 to 6 semitones. The voiced vowels are produced by passing vibrating air (from the larynx) through the oral cavity when adjusted to give the approximate pair of resonances. The devices shown for reproducing vowels consisted in their simplest form of pairs of resonators tuned to the tones characteristic of various vowels and so arranged that the sound from an artificial larynx or squeaker could be passed through them in series or in parallel. Certain vowels in which the upper resonance is a harmonic of the lower can also be produced by means of a single resonator. The author, in illustration, arranged his hands to form a double resonator in imitation of the human mouth, and passed through them the sound from a squeaker representing the larynx. By manipulating the fingers and hands, he was able to pronounce the various vowel sounds, and some recognisable sentences.

In view of the increasing incidence and decreasing mortality due to larynx cancer, the constant 2:1 ratio of esophageal speakers to nonspeakers among laryngectomees, and the widespread argeement that psychological factors are prime considerations in esophageal speech attainment, the investigation was designed to delineate certain psychological, physical, and sociological variables which might relate to attainment of alaryngeal speech. Ninety-four male laryngectomees responded to the Tennessee Self-Concept Scale, the IPAT Anxiety Scale Questionnaire, and a standardized personal interview including a voice recording. Five variables (self-concept, body-concept, anxiety level, age at surgery, and defensive distortion of self-concept responses) were found to be significant in differentiating groups of nonesophageal, below-average, average, and above-average esophageal speakers. A significant difference in self-concept and body-concept appeared between the two high and the two low speaker groups. The below-average speakers were more anxious than were the average speakers or the above-average speakers. The above-average speakers were younger in age at surgery than were the subjects in the other three groups. The higher self-concept and body-concept scores of the better speakers may have been a function of a defense mechanism, as indicated by their defensive distortion scores which were higher than those of the below-average group. It was found that the variables of self-concept, body-concept, and anxiety were about three times more influential than those of age at surgery and defensive distortion in identifying groups of speakers. The conclusions warranted were that necessary psychological counseling and immediate postoperative use of an artificial larynx before the institution of esophageal speech therapy would help raise the ratio of esophageal to nonesophageal speakers.

Statistical observation on 103 cases of the laryngeal cancer consisted of 90 males and 13 females, admitted to the otorhinolaryngological clinic of University of Nagasaki between 1949 and 1962 were reported. 93 cases were treated with operative procedure, total laryngectomy with or without radical neck dissection. The youngest was 36 years old; the eldest was 79 while the peak in occurence was seen in sixth decade. Classification of oFFur cases according to site of cancer shows the following distribution : 38 supra- glottic, 19 glottis. 17 marginal, 9 subglottic, 9 tran- sglottic and 7 hypopharyngeal forms. The perfect curability was obtained in glottic and subglottic form. In this series, 96% of all patients complained hoarsness. Postoperative recurrence occured in 24 persons, in which 19 cases suffered from cervical lymph node recurrence. Concerning the development of speech after laryngectomy 22 cases have been able to use esop- hageal voice and 5 cases to speak with the aid of artificial larynx. 5 years survival rate was 52.4% and this result was better than that of other carcinoma in our clinic.

Laryngo-esophagectomy was performed with a colon transplant to replace the excised esophagus. The patient did not develop functional “colonic” speech but does function adequately using an artificial larynx. Cineradiologic evidence reveals that the transplanted segment of colon permits development of a pseudoglottis to produce sound. He was capable of injecting air and forming the pseudoglottis, but he interfered with the production of colonic voice by retropositioning his tongue to close the hypopharynx.

This report provides basic information about a relatively unknown pneumatic artificial larynx called the Tokyo artificial larynx. Part of the report describes a clinical study of a highly skilled American user of the Tokyo larynx. Descriptive information is provided about important acoustic and perceptual characteristics of speech produced with this Japanese-made device.

A new experimental artificial larynx, which makes use of transistors and miniaturized components to provide a voice for those who have lost the use of their vocal cords by surgical removal or paralysis, is described. The larynx operates by introducing a substitute for the sound of the vocal cords into the pharyngeal cavity by means of a vibrating driver held against the throat. The acoustic principles of normal and artificial speech production that were followed in arriving at the new design are presented, along with descriptions of the transistor circuit and its operating characteristics.

With the improvement of surgical technic in total extirpation of the larynx has gone an increasing interest in methods of restoring voice to larynxless persons. Operative methods have made by far the greater progress. Perhaps the surgical laryngologist has considered it more important to eliminate satisfactorily a diseased organ than to restore the function which the organ discharged. Whatever the reason for the minor interest in functional recovery, the patient whose larynx was removed, deprived of speech, found himself restored to health which was well nigh identical with social helplessness. The chief step toward the mitigation of this serious handicap was the invention of the artificial larynx. For many years laryngectomized persons have been carrying about these cumbersome and difficult machines. Only comparatively recently has attention been turned to the development in the patient of a vicarious voice by the use of organs other than the larynx. This has been

To provide information about the ultimate acceptability of various types of alaryngeal speech, 37 listeners rated nine speakers with normal phonation in relation to two groups of superior alaryngeal speakers: five who used esophageal speech and four who used artificial larynges. Normal speech was rated significantly more acceptable than any form of alaryngeal speech studied. Speech produced with a Tokyo artificial larynx was rated significantly more acceptable than all other types of alaryngeal speech. Superior esophageal speech was significantly preferred over Western Electric reed and Bell electrolarynx speech. Listeners also categorized each of the 18 speakers as a normal speaker or not a normal speaker. The nine alaryngeal speakers were all classified as nonnormal, while eight of the nine normal subjects were classified as normal.

A study of several papers on the subject of the psychological aspects of laryngectomy shows a unanimity of opinion among the authors concerning the importance of the psychic trauma incident to laryngectomy. Figi and Devine1and Greene2agree that the psychic trauma is easily as serious as the physical trauma itself and should never be underestimated in dealing with the patient after the operation. Pitkin3regards it as one of the most serious problems in the management of patients with carcinoma of the larynx. Reference is made herein to the relatively high percentage of patients who, because of either physical or psychological reasons, do not attain the ability to produce adequate and acceptable esophageal speech. This significant number should elicit the interest of those dealing with the laryngectomy patient—the surgeon and the speech teacher. Levin4suggests several physical and psychological reasons for failure to learn esophageal

Cine-radiographic studies show that good speaking laryngectomees do not ‘swallow air and burp it up.’ They inflate the esophagus, with motions quite different from swallowing dynamics, and gradually release air past a sphincter usually located at C5 or between C5 and C6. The good speakers can usually sustain phonation of a vowel (as an exercise) for periods of 1.3–5.5 seconds and sometimes higher. Poor speakers may be likely to have hearing losses and palatal pareses. They are also likely to be older at the time of surgery, although this cannot be completely confirmed. Limited education does not seem to impede learning of esophageal speech of the patients studied, and little data are available regarding intelligence as a factor in the learning of esophageal speech. It was noted that rehabilitation of the laryngectomee is not simply a matter of sending him for ‘esophageal speech lessons.’ Coordinated professional guidance from medical specialists, audiologists and speech pathologists, social workers, and psychologists can be of service to many patients. Working with local lost chord clubs has been reported beneficial for certain other patients. Certainly these two approaches, the professional approach versus the lay treatment approach, need not be mutually exclusive. A special plea is made for less prejudice against the artificial larynx, and toward the reliance on any procedure which will facilitate the patient's early and complete communication. In general, cooperation is called for between physicians and non-medical specialists in the research and clinical aspects of work with the laryngectomee. Attention is called to a listing of certified speech and hearing specialists available for work with laryngectomees. This list can be obtained from the American Cancer Society, as detailed in the footnote on page 683.

Since Billroth’s first laryngectomy in 1873 until three decades ago, the mortality rate from laryngectomy was high so that major emphasis necessarily centered around improvements in surgical technic, anesthesia, blood transfusion, and the like. Little attention was paid to the rehabilitation of speech. The operation that saves the patient’s life poses new and difficult problems. Loss of voice is a social barrier, especially in a developing country, since speech is a major means of communication. Hence many patients are considerably reluctant to undergo the major life-saving procedures of total laryngectomy or laryngopharyngectomy. Although great strides have been made towards the development of esophageal speech, the literacy rate is quite low in the majority of our people and thus, many of the patients are unable to cope with the deformity. Compensation for the loss of laryngeal voice was attempted after the first successful laryngectomy. In 1874, Gussenbauer, working with Billroth, succeeded in developing an apparatus for phonation. Laryngectomy as then performed left a communication between the trachea and the pharynx and Gussenbauer’s artificial larynx fitted into the space, the upper tube reaching into the pharynx and the lower extending into the trachea. Expired air from the trachea was set into vibration by the artificial larynx and produced sound waves at the back of the mouth. Since the articulating mechanism, that is, the tongue, jaws, lips, and teeth, were intact, it was possible to convert these sound waves into speech by the normal actions of articulation. However, because the passageway between the upper and lower parts of the digestive tract is broken, food, liquids, and secretions found their way into the lower respiratory mechanism, causing pulmonary complications. Solis-Cohen in 1892 introduced the revolutionary procedure of making an opening in front of the neck and suturing the severed end of the trachea there, thus separating the food and air passages. With this procedure, Gussenbauer’s idea became obsolete. The patient was thus deprived not only of a vibrating mechanism, but also of the second essential for producing speech, that is, a flow of air through the vibrating mechanism from the trachea into the oropharynx for the production of sound waves. Since then, the production of speech after laryngectomy has been a problem. Over the past twenty years, there has been an increasing interest in the reconstruction of the larynx and trachea for the production of voice after total laryngectomy [I]. Montgomery, Norris, Holinger, and Ogura have contributed to the study of laryngotracheal reconstruction [I]. However, all these technics have been complicated with multiple staged procedures. In this paper we wish to describe and present observations in ten patients who underwent a simple one stage procedure for the production of speech after total laryngectomy.

To the Editor.— Communication with a patient who is intubated or who has a tracheostomy and is receiving ventilatory support is difficult. Even alert patients find writing cumbersome; emotions are best conveyed by speaking. We have found the artificial larynx to be helpful in restoring spoken communication to many tracheostomy patients. This device, originally designed for laryngectomy patients, has proven effective and practical except when an oral endotracheal tube exists (Figures). Successful use of the artificial larynx requires coordination with patient mouth movement as well as proper placement on the neck. Although the technique cannot be used in all patients, its further application in intensive care units can be helpful.

Since the development of the Western Electric reed type artificial larynx (Model 2) about thirty years ago, there has been a number of developments in the general fields of acoustics and electronic circuitry which are applicable to the design of an improved artificial larynx. An experimental model using some of these developments will be described and demonstrated. This new model is inconspicuous in use, and, as indicated by sound spectrographic analyses and articulation tests, has improved speech quality.

Accurate measurements of the human vocal tract damping, or the associated formant bandwidths, are not easy. Several different methods have been used by experimenters, with rather widely divergent results. Some of these methods are examined for sources of error, and the conclusions are checked by applying the same methods to the electrical vocal tract. This analog of the human tract can be held constant during a test, can be adjusted in damping, and can be measured accurately by single frequencies. More exact measurement of the real tract would seem to require an artificial source, applied in the pharyngeal cavity, having a lower fundamental and a more accurately known spectrum than the vocal cord tone. A few measurements are reported, obtained by means of an artificial larynx at 30 pulses/sec, applied to the outside of the throat wall. Analysis is made from a tape loop, by means of a narrow band wave analyzer. The results are not wholly satisfactory because the spectrum inside the tract is not accurately known.