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We report a case of a contraindicated attachment of a speaking valve to a tracheal tube with an inflated cuff, which rapidly resulted in the patient's death. The attached one-way valve allowed unrestrained inspiration through the tracheal tube but prevented physiological expiration. The increased pulmonary pressure resulted in alveolar rupture and replaced expiration with a steady release of air into the peribronchial sheaths and the mediastinum, resulting in what is commonly known as the Macklin effect. From the mediastinum, air inflated both pleural cavities, the peritoneum, and the subcutaneous tissue of the entire body. No gas was found in the blood vessels, the brain, the bones, or in the inner organs. The entire air volume was estimated by radiological segmentation to be more than 25 l. This implies continuous inspiration, while expiration turned into an aberrant pulmonary decompression by whole-body gas-enclosure. Death ultimately resulted from asphyxia following bilateral (tension) pneumothorax.

Background: The Sunderland Tracheosophageal Voice Perceptual scale (SToPS) is the only perceptual rating scale designed specifically for tracheosophageal voice [Hurren et al.: Clin Otolaryngol. 2009 Dec; 34(6): 533-8]., Objective: To investigate the inter rater reliability of the SToPS when analyzing alaryngeal voice., Methods: Prospective evaluation of inter rater reliability of the SToPS based on audio recordings of 230 voice samples from 41 laryngectomy patients rated by 3 experts. Interval data were analyzed using intraclass correlation coefficients (ICC) while categorical data were analyzed using Kappa., Results: ICC of above 0.6 was observed between raters for each prosthesis on a majority of parameters demonstrating a good level of reliability. Reliability was fair (ICC of between 0.40 and 0.59) on Q11 (Articulatory precision) and Q12 (Paralinguistics). Reliability was also fair (0.21-0.40) or slight (0.00-0.20) for Q2 (Tonicity), which was analyzed using Kappa. Kappa above 0.61 signified a good level of reliability., Conclusions: This study demonstrates good rater reliability for the majority of parameters on the SToPS scale, supporting the use of this tool within the clinical realm. However, further research is required to ascertain if any methods of increasing inter rater reliability on those parameters which did not reach good reliability can be identified., (© 2018 S. Karger AG, Basel.)

Tone is important in tonal languages, especially in Mandarin. However, there is presently no commercially available electrolarynx (EL) for laryngectomized Mandarin speakers. Moreover, few studies have focused on this area. Our purpose is to design an EL that produces the four Mandarin tones and to evaluate its performance. We designed a wheel-controlled pitch-adjustable EL and manufactured a prototype (Wheel-EL). Using monosyllables, disyllabic segments, and frequently used phrases, we evaluated speech produced by Wheel-EL and by monotone (M-TruTone) and variable-frequency modes (V-TruTone) of the commercially available TruTone EL. The pitch contours of the high-level (HL), middle-rising (MR), and falling-rising (FR) tones produced by Wheel-EL most closely matched the natural speech characteristics of a native speaker. However, redundant sounds were generated in the high-falling (HF) tone. The statistical accuracy of Wheel-EL's tone and word perception was significantly higher than that of other EL types. However, no significant differences existed in acceptability among the three EL speech types. Wheel-EL produces better HL, MR, and FR tones in Mandarin than either M-TruTone or V-TruTone. Nevertheless, redundant sounds affect HF phonation. Accurate tone judgment can improve the intelligibility of EL speech in Mandarin but has no obvious effect on acceptability.

Objectives: Voice prosthesis is the standard of care for postlaryngectomy voice rehabilitation. We aimed to assess functional outcomes of Provox voice prosthesis, to study the impact of several clinical factors (timing of Provox insertion, type of pharyngeal closure, requirement of reconstruction, performance of myotomy, and radiotherapy) on the functional outcomes, and to record the complications associated with Provox voice prosthesis., Study Design: Prospective nonrandomized cross-sectional observational study., Methods: Thirty patients with postlaryngectomy speech rehabilitation with Provox prosthesis were studied. After the procedure, the patients were evaluated by a speech-language pathologist and assessed at immediate postoperative period and 6-month and 1-year interval using the parameters of functional outcomes GRBAS scale, maximal phonatory duration (MPD), and words per breath (WPB). SPSS Version 19 was used for statistical analysis., Results: All patients had average good voice at the end of 1 year after Provox insertion with voice quality results improving with time. Number of patients having MPD more than 7 was 21, 29, and 30 at 0 months, 6 months, and 1 year, respectively. At the end of 1 year, 11 patients had WPB score between 15 and 19. Seven patients had complications: periprosthetic leak (4), central leak (1), hypertonic segment (1), and stricture of the neopharynx (1). Primary Provox insertion, nonrequirement of postoperative radiation, cricopharyngeal myotomy, and primary and vertical closure of neopharynx had a better influence on the outcome; however, the results were not statistically significant., Conclusions: Provox voice prosthesis provides consistent and good voice results, which improve with time. Periprosthetic leak is the most common complication., (Copyright © 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the diagnostic value of a novel device, the endoilluminator, in patients who can or cannot attain effective speech after application of voice prosthesis., Study Design: Prospective clinical study., Methods: Thirty-four patients who underwent total laryngectomy and whose insufflation test was positive were included. As a result of efforts to develop an insufflation test that includes a light apparatus, we attained a device that we call an endoilluminator. We found that the area it illuminated when a patient achieved effective speech was a predictive factor for the test result. That is, patients for whom the upper part of the tracheostomy (where the standard tracheoesophageal fistula will be opened) was illuminated were categorized as the positive test group, whereas those for whom the neck skin above this region was illuminated were categorized as the negative test group., Results: In 27 of the 34 patients, appropriate localization was determined using the endoilluminator, and these patients achieved effective speech. In the remaining seven patients, localization was inappropriate and they did not achieve effective speech during the first week, first month, or third month postpuncture. In further investigations of these seven patients, a pharyngoesophageal spasm was detected in five, and a pharyngoesophageal stricture was detected in two., Conclusion: Endoilluminator increases the success rate of the insufflation test by accurately predicting a patient's ability to achieve effective speech after application of voice prosthesis., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To investigate physiologic parameters, voice production abilities, and functional verbal communication ratings of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves., Study Design: Case series with planned data collection., Setting: Large, urban, tertiary care teaching hospital., Subjects and Methods: Referred sample of 30 consecutively enrolled adults requiring a tracheotomy tube and tested with Blom and Passy-Muir valves. Physiologic parameters recorded were oxygen saturation, respiration rate, and heart rate. Voice production abilities included maximum voice intensity in relation to ambient room noise and maximum phonation duration of the vowel/a/. Functional verbal communication was determined from randomized and blinded listener ratings of counting 1-10, saying the days of the week, and reading aloud the sentence, "There is according to legend a boiling pot of gold at one end.", Results: There were no significant differences (p>0.05) between the Blom and Passy-Muir valves for the physiologic parameters of oxygen saturation, respiration rate, and heart rate; voice production abilities of both maximum intensity and duration of/a/; and functional verbal communication ratings. Both valves allowed for significantly greater maximum voice intensity over ambient room noise (p<0.001)., Conclusions: The Blom low profile voice inner cannula and Passy-Muir one-way speaking valves exhibited equipoise regarding patient physiologic parameters, voice production abilities, and functional verbal communication ratings., Learning Outcomes: Readers will understand the importance of verbal communication for patients who require a tracheotomy tube; will be able to determine the differences between the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves; and will be confident in knowing that both the Blom and Passy-Muir one-way tracheotomy tube speaking valves are equivalent regarding physiological functioning and speech production abilities., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The use of the tracheoesophageal (T-E) silicone rubber voice prosthesis is the most effective and well-established procedure to restore the voice in patients after laryngectomy. The prosthesis is usually well-tolerated with only minor complications. Severe complications are rare. In this article we present our experience with the prosthetic technique at the Clinic of Otorhinolaryngology and Head and Neck Surgery in University Hospital in Martin, Slovakia between the years 2005-2013 and report a case of a 48-year-old man with secondary prosthesis inserted through a T-E shunt 16 months after laryngectomy. On the 6th day after the insertion, the shunt decayed. After prosthesis removal the tissue defect was sutured. Due to repetitive tissue decay, reconstruction of the trachea and esophagus became necessary. On the 10th day, peritracheoesophageal fistula developed and gastrostomy was performed. Because of intense fibrotic and inflammatory changes, further reconstruction was not indicated. After 6 months, esophageal stenosis occurred and endoscopic dilation under local anaesthesia was performed. The T-E voice prosthesis has become one of the choices for voice rehabilitation following total laryngectomy and may improve the patient's long-term quality of life. The overall risk of severe complications seems relatively low. Nonetheless, some complications might be challenging and might require specific management.

Objectives/hypothesis: The majority of laryngectomy patients fail to use a hands-free valve on a daily basis, mainly due to fixation problems of the adhesive baseplate housing. To support adhesive housings during hands-free speech a new external neck brace (ENB 2.0) was developed. The effect of the brace was assessed in terms of a qualitative assessment, adhesive lifetime, maximum phonation time and patient self-reports., Study Design: Twenty laryngectomees participated in this randomized, prospective, crossover trial., Methods: All participants used the Provox hands-free HME valve with an Xtrabase adhesive for 1 month, 2 weeks with an ENB 2.0, and 2 weeks without. Outcomes were compared with the previous model of the external neck brace (ENB 1.0)., Results: The average total number of adhesive baseplates used during the trial was 16.7 in the non-brace group versus 10.9 in the brace group (P = 0.05). The number of daily replacements was 1.4 in the non-brace group and 1.1 in the brace group (P = 0.025). The average time a hands-free valve was worn per baseplate was 9.5 hours when wearing a neck brace versus 7.3 hours without brace (P = 0.09).The majority (81%) of the patients considered the neck brace 2.0 as a welcome addition to improve hands-free speech after laryngectomy and would use it if prescribed (88%)., Conclusion: The new model of the neck brace reduces the number of baseplate replacements during hands-free speech and is considered as a helpful device by 81% of the participants., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Foreign body aspiration (FBA) is a relatively common and serious condition that can result in a spectrum of presentations ranging from incidental to acutely life-threatening. Described here is a case of aspiration of a tracheo-oesophageal speaking valve through a permanent tracheostomy that went unnoticed for a number of years, and an overview of the technique used for its removal. A 70-year-old ex-heavy smoker with a permanent tracheo-oesophageal fistula presented with a relatively recent history of increasing shortness of breath, sputum purulence and haemoptysis. Further investigation with a CT scan and bronchoscopy revealed the presence of a foreign body within his right lower lobe bronchus which was later removed by advancing a flexible bronchoscope over a rigid one.

Electrolarynx (EL) is a medical speech-recovery device designed for patients who have lost their original voice box due to laryngeal cancer. As a substitute for human larynx, the current commercial EL voice source cannot reconstruct natural EL speech under laryngectomy conditions. To eliminate the abnormal acoustic properties of EL speech, a supraglottal voice source with compensation of vocal tract characteristics was proposed and provided through an experimental EL(SGVS-EL) system. The acoustic analyses of simulated EL speech and reconstructed EL speech produced with different voice sources were performed in the normal subject and laryngectomee. The results indicated that the supraglottal voice source was successful in improving the acoustic properties of EL speech by enhancing low- frequency energy, correcting the shifted formants to normal range, and eliminating the visible spectral zeros. Both normal subject and laryngectomee also produced more natural vowels using SGVS-EL than commercial EL, even if the vocal tract parameter was substituted and the supraglottal voice source was biased to a certain degree. Therefore, supraglottal voice source is a feasible and effective approach to improving the acoustic quality of EL speech.

Objective: To realize an accurate and automatic on/off control of electrolarynx (EL), an artificial neural network (ANN) was introduced for switch identification based on visual information of lips and implemented by an experimental system (ANN-EL). The objective was to confirm the feasibility of the ANN method and evaluate the performance of ANN-EL in Mandarin speech., Study Design and Methods: Totally five volunteers (one laryngectomee and four normal speakers) participated in the whole process of experiments. First, trained ANN was tested to assess switch identification performance of ANN method. Then, voice initiation/termination time, speech fluency, and word intelligibility were measured and compared with button-EL and video-EL to evaluate on/off control performance of ANN-EL., Results: The test showed that ANN method performed accurate switch identification (>99%). ANN-EL was as fast as normal voice and button-EL in onset control, but a little slower in offset control. ANN-EL could provide a fluent voice source with rare breaks (<1%) for a continuous speech. The results also indicated that on/off control performance of ANN-EL had a significant impact on perception, lowering the word intelligibility compared with button-EL. However, the words produced by ANN-EL were more intelligible than video-EL by approximately 20%., Conclusions: The ANN method was proved feasible and effective for switch identification based on visual information of lips. The ANN-EL could provide an accurate on/off control for fluent Mandarin speech., (Copyright © 2013 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objectives/hypothesis: Assessment of a novel adhesive baseplate (Provox StabiliBase) for heat and moisture exchanger (HME) and/or automatic speaking valve (ASV) application., Study Design: Prospective, clinical, multicenter trial., Methods: This was a trial in laryngectomized patients comparing their usual adhesive with the trial adhesive. Primary outcome measure was overall patient preference; additional outcome parameters possibly explaining patients' preferences were 1) patient tolerance and preference with respect to daily handling of the adhesive; 2) adhesive lifespan, and 3) voice and speech with the adhesives. Study specific questionnaires, visual analog scales, patients' diaries, and stoma assessments were used for data collection., Results: In total, 58 of the 65 laryngectomized individuals entered in the study completed the trial. Patients' overall preference for the new device was high (76%; P < .001). Significantly better performance was found for the trial adhesive with respect to ease of application (P = .034), fit (P < .001), and air leakage through the adhesive (P < .001). Comfort and stoma depth correlated weakly (r = 0.297; P = .024; deeper stoma-more comfort with StabiliBase). The adhesive lifespan with HME is significantly increased (1.7 times and 15.7 hours-plus airtight use; P < .001). This longer lifespan coincided with somewhat increased dirtying of the adhesive (P = .02). There were no serious adverse events., Conclusions: The StabiliBase adhesive for peristomal attachment of HMEs and/or ASVs was preferred by 76% of study participants and showed a promising prolonged lifespan. This new device further increases the options for stoma attachment in laryngectomized individuals, and subsequently the availability of optimal voice and pulmonary rehabilitation for a larger proportion of patients., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: The objective of this work was to obtain a controlled subjective and objective in vivo clinical comparison of the Passy-Muir, Shiley, and Ball speaking valves., Methods: Ten patients free of laryngeal pathology but dependent on tracheotomy for respiration were tested with each of the speaking valves. Olfaction was assessed for each patient using the University of Pennsylvania Smell Identification Test (UPSIT). Acoustic and perceptual analyses included subjective assessments, noninstrumental objective assessments (including maximum phonation time, and S:Z ratio), and instrumental objective assessments (including fundamental frequency:maximum phonation range, vocal intensity, perturbation, naturalness, and turbulence). Oxygen saturation was assessed by pulse oximetry., Results: There was a highly significant statistical difference in olfaction and speech naturalness, in favor of the Ball valve (The Airway Company, Forest Hill, MD). The Ball valve's speech parameters were generally better than with the Passy-Muir and Shiley valves, including maximum phonation, S:Z ratio, jitter, noise, and turbulence, although the differences were not statistically significant. There were no differences among the valves in oxygen saturation levels., Conclusion: This study illustrates that olfaction and certain speech parameters, most noticeably speech naturalness, are significantly improved with the Ball valve as compared to the Passy-Muir and Shiley valves., (Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Objectives/hypothesis: Time of adherence of adhesive baseplate housings to the neck of a laryngectomized patient is one of the main problems that account for the low number of laryngectomy patients who benefit from hands-free speech. An external neck brace (ENB 1.0) was introduced to support peristomal fixation of adhesive baseplates., Study Design: A prospective randomized controlled clinical cross-over trial., Methods: A total of 28 laryngectomy patients participated in this randomized, prospective, crossover trial. All used the Provox hands-free heat and moisture exchanger (HME) valve for 1 month: 2 weeks with an ENB and 2 weeks without., Results: The median lifetime of an adhesive baseplate without a brace was 52.5 minutes versus 210 minutes with a brace (P = .03). Four participants considered the ENB as "a little" bit of a welcome addition, nine as "quite a bit," and six as "very much" (79%) to improve hands-free speech., Conclusions: The ENB significantly increases the lifetime of an adhesive baseplate and therefore contributes to achieving hands-free speech for a greater number of patients with laryngectomy., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objective: One aspect of voice and speech evaluation after laryngeal cancer is acoustic analysis. Perceptual evaluation by expert raters is a standard in the clinical environment for global criteria such as overall quality or intelligibility. So far, automatic approaches evaluate acoustic properties of pathologic voices based on voiced/unvoiced distinction and fundamental frequency analysis of sustained vowels. Because of the high amount of noisy components and the increasing aperiodicity of highly pathologic voices, a fully automatic analysis of fundamental frequency is difficult. We introduce a purely data-driven system for the acoustic analysis of pathologic voices based on recordings of a standard text., Methods: Short-time segments of the speech signal are analyzed in the spectral domain, and speaker models based on this information are built. These speaker models act as a clustered representation of the acoustic properties of a person's voice and are thus characteristic for speakers with different kinds and degrees of pathologic conditions. The system is evaluated on two different data sets with speakers reading standardized texts. One data set contains 77 speakers after laryngeal cancer treated with partial removal of the larynx. The other data set contains 54 totally laryngectomized patients, equipped with a Provox shunt valve. Each speaker was rated by five expert listeners regarding three different criteria: strain, voice quality, and speech intelligibility., Results/conclusion: We show correlations for each data set with r and ρ≥0.8 between the automatic system and the mean value of the five raters. The interrater correlation of one rater to the mean value of the remaining raters is in the same range. We thus assume that for selected evaluation criteria, the system can serve as a validated objective support for acoustic voice and speech analysis., (Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objectives: This study evaluates the relation between stoma volumes by means of objective three-dimensional measurements of laryngectomised individuals and peristomal fixation of adhesive baseplates during hands-free speech., Design: A three-dimensional stereophotogrammetrical image was captured of the tracheostoma and its surrounding tissue for each participant. The placement of a baseplate adhesive was virtually simulated. Individual stoma volumes were calculated and related to the duration of lifetime of adhesive baseplates., Setting: Prospective trial in a university hospital setting., Participants: Twenty-four laryngectomised patients., Main Outcome Measures: Stoma volume in cm(3) and adhesive baseplate adherence in minutes., Results: For the 24 three-dimensional images captured, the mean volume of the area under the adhesive (stoma volume) was 9.5 cm(3) (range 3.5-22.5). After relating the different volumes of all patients to their individual fixation score, a significant decrease in duration of adhesive lifetime was found with increasing volumes of the stoma (P = 0.001). An increase of 1 cm(3) in tracheostoma volume resulted in a decrease of 21% in median adhesive lifetime (95% confidence interval 10-31%)., Conclusions: Longer lifetime of the adhesive baseplate in patients with smaller volume outcomes suggests that a more accurate fit between baseplate and stoma leads to better fixation. This should be taken into account when shaping a stoma during laryngectomy. On the other hand, a more custom-made patch that has a more accurate fit could increase the lifetime of fixation. We believe that our three-dimensional volumetric data can contribute to the development of such an adhesive., (© 2012 Blackwell Publishing Ltd.)

Background: Enlarged tracheoesophageal puncture (TEP) is a challenging complication of surgical prosthetic voice restoration. Prevention of this complication requires identification of high-risk individuals, and surgical and prosthetic correlates of TEP enlargement., Methods: Multivariable logistic regression methods were used to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP in a 5-year retrospective cohort., Results: Enlarged TEP only occurred in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced (N2 or N3) nodal disease (odds ratio [OR](adjusted) , 4.3; 95% confidence interval [CI], 1.0-19.1), postoperative stricture (OR(adjusted) , 3.2; 95% CI, 1.2-8.6), and diagnosis of locoregional recurrence or distant metastasis after laryngectomy (OR(adjusted) , 6.2; 95% CI, 2.3-16.4) increased risk of enlarged TEP. Extended resection and preoperative nutritional status were also significantly associated with enlarged TEP. Prosthetic parameters did not significantly correlate with enlargement., Conclusion: Development of enlarged TEP is a multifactorial process related to both baseline and postoperative factors., (Copyright © 2011 Wiley Periodicals, Inc.)

Voice rehabilitation after a total laryngectomy is an important requisite for patients' rehabilitation. Oesophageal speech using tracheo-oesophageal-valved prostheses is now considered the state-of-art in postlaryngectomy voice rehabilitation. One of the major drawbacks of voice prostheses is their limited device lifetime. This is due to the deterioration of the silicone rubber material by different bacterial and yeast species, which are organised in the form of a biofilm resulting in internal leakage, increased airflow resistance, impeding speech, respiration and swallowing. The use of antimicrobials though easily applicable is associated with development of resistance if used on long-term basis. Other techniques in the form of modification of physicochemical properties of the silicon surface or covalent binding of antimicrobial agents to the silicon surface have been employed. This article reviews the different strategies investigated until now and the future trends in preventing biofilm formation for prolonging the lifetime of the silicon voice prostheses. Data was collected by conducting a computer aided search of the MED-LINE and PUBMED databases, supplemented by hand searches of key journals. Over 35 articles in the last two decades on the topic have been reviewed out of which 27 were found to be of relevant value for this article.

Objectives: We performed in vitro evaluation of a novel, disposable, automatic hands-free tracheostoma speech valve for laryngectomy patients based upon the principle of inhalation. The commercially available automatic speech valves close upon strong exhalation and open again when the pressure drops. This method makes long sentences or pauses difficult. The novel iValve is designed to allow almost natural speech, with mid-sentence pausing and whispering., Methods: The inhalation closing flows and exhalation opening pressures of 6 iValve prototype versions at different settings were compared with physiological values. The airflow resistance at inhalation was compared to physiological values and to commercial valve values., Results: The iValve prototypes showed flow and pressure ranges in concordance with the physiological values in the literature. The airflow resistance in the breathing mode was within the physiological airflow resistance range, yet above the values from the two commercial valves. The resistance in the speaking mode was above the physiological airflow resistance range., Conclusions: In vitro tests show that the iValve versions can be selected and adjusted to operate within the physiological range. The airflow resistance in the breathing mode is good. In speaking mode, inhalation should, and can, be decreased. The iValve should offer the patient a more intuitively useable alternative with more dynamic speech. Its low cost allows disposability and wider use.

Objective: To compare the short-term speech success of voice prosthesis (VP) among patients who underwent total laryngectomy or total laryngectomy in combination with neck dissection and those who received postoperative radiotherapy., Materials and Methods: Thirty-two male patients treated for laryngeal squamous cell carcinoma were included. Nine patients underwent total laryngectomy and 23 underwent total laryngectomy combined with neck dissection, and 17 of the 23 with neck dissection were managed with postoperative radiotherapy (45-75 Gy). All of the patients had indwelling intraoperative placement of the Provox VP (Atos Medical AB, Horby, Sweden; and Entermed BV, Woerden, The Netherlands) at the time of the primary tracheoesophageal puncture (TEP) completed in conjunction with total laryngectomy. Patients with pharyngoesophageal myotomy and pharyngeal plexus neurectomy were excluded. Patients' speech success was perceptually evaluated 3-4 weeks after the surgery and 3-4 weeks after the cessation of radiotherapy, using a 1-3 scale (1 = failure to develop speech (aphonia); 2=communicate with short phrases only; and 3 = communicate with fluency and long sentences)., Results: No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. Eighteen of 32 patients (56%) demonstrated successful speech (rating of 3). Nine patients (28%) demonstrated less successful speech (rating of 2). Five patients (16%) were found to be aphonic (P > 0.05). Of the nine patients who underwent total laryngectomy only, six were found to have successful speech (66.6%), one (11.1%) was found to have less successful speech quality, and two (22.2%) patients were aphonic (P > 0.05). Of the six patients who underwent total laryngectomy in combination with neck dissection, three had successful speech (50%), one (16.6%) had less successful speech, and two (33.3%) were aphonic (P > 0.05). Of the 17 patients who received postoperative radiotherapy, nine (52.9%) had successful speech, three (17.6%) had less successful speech, and five (29.4%) were aphonic (P > 0.05)., Conclusion: Neck dissection and postoperative radiotherapy have no significant influence on short-term speech success in VP restoration patients. Primary TEP should be preferred in patients who have laryngectomy in combination with neck dissection and/or will have postoperative radiation therapy, as it provides early and successful voice restoration without interfering with radiation treatment and avoids a second surgical intervention., (Copyright © 2011 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

The most common artificial voice source for post-laryngectomy speech rehabilitation is the handheld buzzer or electrolarynx (EL). EL speech is often described as mechanical-sounding (robotic), and typically lacks pitch variation, making it monotone and unnatural. Prior studies have shown improved perceptual ratings of speech naturalness when pitch variation is added to EL speech, and a proof-of-concept EL prosthesis has been developed to provide pitch variation and voice on/off control in relation to neck muscle electromyographic (EMG) signals. The goal of the present study was to design a new wireless version of the EMG-controlled EL (EMG-EL) that could provide a flexible mixture of manual (push button) and automatic (EMG-based) control options for voice onset/offset and pitch, and that could be manufactured at a reasonable cost for widespread patient use. This paper describes both technical and human factors considered while designing the new EMG-EL voice prosthesis.

Background: Laryngeal cancer has a significant impact on patients. This study compared the Voice-Related Quality of Life (V-RQOL) outcomes specific to 3 different postlaryngectomy voice rehabilitation methods., Methods: We conducted a retrospective review of 75 patients with laryngectomy from our V-RQOL questionnaire database., Results: The database included 18 electrolaryngeal speech (ELS), 15 esophageal speech (ES), and 42 tracheoesophageal speech (TES) patients. Pairwise comparisons of V-RQOL outcomes showed that TES was perceived to be better than ELS (p < .001). ES was perceived as better than ELS, but this was driven by a difference in the total and social-emotional V-RQOL scores (p < .05). There was no difference between TES and ES groups. Only ELS showed a positive correlation with time after surgery and older age., Conclusions: Patients using TES had similar V-RQOL outcomes compared to ES and both performed significantly better than ELS. For ELS, the total V-RQOL score was better with longer time after surgery and older age., (© 2010 Wiley Periodicals, Inc. Head Neck, 2011.)

Background: Enlargement of the tracheoesophageal puncture (TEP) is a challenging complication after laryngectomy with TEP. We sought to estimate the rate of enlarged puncture, associated pneumonia rates, potential risk factors, and conservative treatments excluding complete surgical TEP closure., Methods: A systematic review was conducted (1978-2008). A summary risk estimate was calculated using a random-effects meta-analysis model., Results: Twenty-seven peer-reviewed manuscripts were included. The rate of enlarged puncture and/or leakage around the prosthesis was reported in 23 articles (range, 1% to 29%; summary risk estimate, 7.2%; 95% confidence interval [CI], 4.8% to 9.6%). Temporary removal of the prosthesis and TEP-site injections were the most commonly reported conservative treatments. Prosthetic diameter (p = .076) and timing of TEP (p = .297) were analyzed as risk factors; however, radiotherapy variables were inconsistently reported., Conclusion: The overall risk of enlarged puncture seems relatively low, but it remains a rehabilitative challenge. Future research should clearly establish risk factors for enlarged puncture and optimal conservative management., (© 2010 Wiley Periodicals, Inc. Head Neck, 2011.)

There are a number of situations where individuals wish to communicate verbally but are unable to use conventional means-so called 'silent speech'. These include speakers in noisy and covert situations as well as patients who have lost their voice as a result of a laryngectomy or similar procedure. This paper focuses on those who are unable to speak following a laryngectomy and assesses the possibility of speech recognition based on a magnetic implant/sensors system. Permanent magnets are placed on the tongue and lips and the changes in magnetic field resulting from movement during speech are monitored using a set of magnetic sensors. The sensor signals are compared to sets of pre-recorded templates using the dynamic time warping (DTW) method, and the best match is identified. Experimental trials are reported for subjects with intact larynx, typically using 500-1000 utterances used for speaker dependant training and testing. It is shown that recognition rates of over 90% are achievable for vocabularies of at least 57 isolated words: sufficient to drive command-and-control applications., (Copyright © 2010 IPEM. Published by Elsevier Ltd. All rights reserved.)

From January 2000 to December 2008, we conducted voice rehabilitation using the Provox2 voice prosthesis total-laryngectomy subjects. Of these, 36 attained restoration of 90.0%. Mean maximum phonation time (MPT) was 14.5s, ranging from MPT was not influenced by age, radiotherapy use, primary tumor site, or reconstructive surgery use. Voice prosthesis replacement averaged 25 weeks (5.8 months), ranging from 9 to 74 weeks. Complications occurred in 16 caces (40.0%), mainly granulation tissue formation and prosthesis-site infection, also aspiration pneumonia, prosthesis-site salivary leakage, inability to replace the prosthesis, tracheomalacia, bodies in the trachea. Management rather than medical problems included cost, frequent hospital visits, and lack of motivation to use a prosthesis. The Provox2 voice prosthesis speech provides a higher rate of speech restoration, longer phonatory better intelligibility. Management problems, however, require that we work to understand subjects' living environments and family situations better for evaluating Provox2 voice prosthesis indication more effectively.

Whispered speech can be useful for quiet and private communication, and is the primary means of unaided spoken communication for many people experiencing voice-box deficiencies. Patients who have undergone partial or full laryngectomy are typically unable to speak anything more than hoarse whispers, without the aid of prostheses or specialized speaking techniques. Each of the current prostheses and rehabilitative methods for post-laryngectomized patients (primarily oesophageal speech, tracheo-esophageal puncture, and electrolarynx) have particular disadvantages, prompting new work on nonsurgical, noninvasive alternative solutions. One such solution, described in this paper, combines whisper signal analysis with direct formant insertion and speech modification located outside the vocal tract. This approach allows laryngectomy patients to regain their ability to speak with a more natural voice than alternative methods, by whispering into an external prosthesis, which then, recreates and outputs natural-sounding speech. It relies on the observation that while the pitch-generation mechanism of laryngectomy patients is damaged or unusable, the remaining components of the speech production apparatus may be largely unaffected. This paper presents analysis and reconstruction methods designed for the prosthesis, and demonstrates their ability to obtain natural-sounding speech from the whisper-speech signal using an external analysis-by-synthesis processing framework.

Introduction: Approximately 30% of all patients show periprosthetic leakage or severe fistula enlargement after laryngectomy and prosthetic voice restoration. In a prospective study, we investigated the role of aggressive anti-reflux therapy in fistula complications., Patients and Methods: A total of 48 patients were assigned to one of two groups. Group A consisted of 16 patients with recurrent periprosthetic leakage. Group B comprised 32 patients without periprosthetic leakage. The presence of reflux was objectively assessed using 24-h dual-probe pH monitoring. All patients with pathological reflux underwent proton pump inhibitor (PPI) therapy. After 6 months, patients were re-evaluated for fistula complications and objective reflux parameters., Results: The mean absolute number of reflux events was 202.8 (+/-44) before and 74.5 (+/-22.9) after PPI therapy (p=0.025). The reflux area index decreased from 419.5 (+/-112.5) before treatment to 105.8 (+/-54.7) after treatment (p=0.0005). The mean DeMeester score was 104.4 (+/-21.3) without PPIs and 43.5 (+/-9.3) after 6 months with PPIs (p=0.028). A risk analysis for patients with both periprosthetic leakage and pathological reflux (15 patients at the beginning of the study, four patients after therapy) showed that the relative risk of periprosthetic leakage decreased to 0.3 (p=0.0054) with PPI therapy., Conclusion: Patients with recurrent periprosthetic leakage in the region of the fistula showed a significantly higher number of supra-oesophageal reflux episodes. Rigorous anti-reflux treatment can help manage or prevent leakage problems in a large proportion of patients.

Unlabelled: Speakers who use an electrolarynx following a total laryngectomy no longer require pulmonary support for speech. Subsequently, chest wall movements may be affected; however, chest wall movements in these speakers are not well defined. The purpose of this investigation was to evaluate speech breathing in speakers who use an electrolarynx during speech and reading tasks. Six speakers who use an electrolarynx underwent an evaluation of chest wall kinematics (e.g., chest wall movements, temporal characteristics of chest wall movement), lung volumes, temporal measures of speech, and the interaction of linguistic influences on ventilation. Results of the present study were compared to previous reports in speakers who use an electrolarynx, as well as to previous reports in typical speakers. There were no significant differences in lung volumes used and the general movement of the chest wall by task; however, there were differences of note in the temporal aspects of chest wall configuration when compared to previous reports in both typical speakers and speakers who use an electrolarynx. These differences were related to timing and posturing of the chest wall. The lack of differences in lung volumes and chest wall movements by task indicates that neither reading nor spontaneous speech exerts a greater influence on speech breathing; however, the temporal and posturing results suggest the possibility of a decoupling of the respiratory system from speech following a total laryngectomy and subsequent alaryngeal speech rehabilitation., Learning Outcomes: The reader will be able to understand and describe: (1) The primary differences in speech breathing across alaryngeal speech options; (2) how speech breathing specifically differs (i.e., lung volumes and chest wall movements) in speakers who use an electrolarynx; (3) How the coupling of speech and respiration is altered when pulmonary air is no longer used for speech., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Purpose: Current electrolarynx (EL) devices produce a mechanical speech quality that has been largely attributed to the lack of natural fundamental frequency (F0) variation. In order to improve the quality of EL speech, in the present study the authors aimed to develop and evaluate an automatic F0 control scheme, in which F0 was modulated based on variations in the root-mean-square (RMS) amplitude of the EL speech signal., Method: Recordings of declarative sentences produced by 2 male participants before and after total laryngectomy were used to develop procedures for calculating F0 contours for EL speech. Specifically, the positive linear relationship between F0 and RMS amplitude observed in pre-laryngectomy speech was used as the basis for generating an F0 contour based on the amplitude variation of EL speech. An analysis-by-synthesis approach was used to modify the F0 contour, and a perceptual experiment was conducted to examine its impact on the quality of the EL speech., Results: The results of perceptual experiments showed that modulating the F0 of EL speech using a linear relationship between amplitude and frequency made it significantly more natural sounding than EL speech with constant F0., Conclusions: The current study provides preliminary support for amplitude-based control of F0 in EL speech.

Objective: To compare the rate of postoperative wound-healing complications and voice fluency in primary vs secondary tracheoesophageal puncture (TEP) following chemoradiation., Methods: Between 1998 and 2005, 30 patients underwent laryngectomy after chemoradiation therapy. Twenty patients underwent primary TEP and 10 patients underwent secondary TEP. Comorbidities, postoperative complications, speech fluency, and time to speech fluency were evaluated in each patient., Results: Pharyngocutaneous fistula (PCF) occurred in 10 of 20 (50%) patients who underwent primary TEP and in 0 of 10 (0%) patients in the secondary TEP group (P < 0.05). Overall, 25 of 25 (100%) patients who had placement of a tracheoesophageal prosthesis achieved fluent speech. Median time to fluency was 63 days in the primary TEP group and 125 days in the secondary TEP group., Conclusion: There is an increased risk of PCF in patients undergoing primary TEP compared with secondary TEP following chemoradiation. No difference in acquisition of speech fluency was identified between the two groups. Patients undergoing primary TEP achieved fluent speech 62 days sooner than their secondary TEP counterparts.

Unlabelled: Tracheotomy is performed in cases of upper airway obstruction or chronic pulmonary disorders. The Tracheotomy Speech Valves (TSV) improve communication and airway hygiene and humidification of tracheotomized patients., Aim: To show the low cost Brazilian TSV and its use in speech rehabilitation of tracheotomized patients, to evaluate diaphragm opening resistance and comfort to the patient., Study Design: Experimental, contemporary cohort., Materials and Methods: The TSV was used in 32 patients. The valve has a diaphragm within a stainless steel body with plastic fittings. We studied the level of respiratory comfort according to the degree of valve diaphragm resistance, 40, 50 and 60 shores., Results: All the patients used the TSV coupled to the cannula in a regular basis, 26 of them did it for more than 12 hours daily and from these, 14 used it for 24h daily. The diaphragm pressure obtained was that of 40 shores for 13 patients and 50 shores for 19 patients. 60 shores was never used., Conclusion: the metal TSV helps with speech without the need for closing the cannula with one's finger, and breathing was comfortable. We achieved standard diaphragm resistance. Currently all the patients from this study use this TSV with speech and 43.75% use it full time.

Background: A newly developed artificial voice source was clinically evaluated in laryngectomized women for voice quality improvements. The prosthesis was placed in a commercially available, tracheoesophageal shunt valve., Methods: In 17 subjects, voice-producing element (VPE) prototypes were compared with the subject's regular tracheo-esophageal shunt voice in a randomized cross-over trial. The evaluation was based on aeroacoustic measurements and perceptual analysis., Results: Considerably higher fundamental frequencies were attained with the use of the VPE. The sound pressure level also increased for most subjects. The required driving pressures of the lung and air flow rates were altered, allowing significantly longer phonation times in 1 breath. Accumulation of mucus did not interfere with the proper functioning of the device during these tests., Conclusion: A VPE with sound-generating membranes is suitable for providing a substitute voice source for laryngectomized patients, especially patients suggestive of a severely hypotonic or atonic pharyngoesophageal segment who can benefit from a more melodious and louder voice.

Background: total laryngectomy has several consequences such as loss of the laryngeal voice and alterations in the respiratory system., Aim: to evaluate the influence of a tracheostoma humidifier (heat moisture exchanger - HME) on the control of lung secretion and esophageal and tracheoesophageal vocal quality in patients with total laryngectomy., Method: nine male individuals, aged between 46 to 67 years, submitted to total laryngectomy. The patients answered a protocol containing subjective questions related to lung secretion in three different moments: T1 (pre-use assessment of the HME), T2 (pre-use assessment of the HME six weeks after the first assessment) and T3 (assessment six weeks after the use of the HME). Voice samples were recorded during these 3 different assessments and were evaluated by three speech-language pathologists, in a blind study format, according to a perceptual auditory vocal analysis protocol. The non-parametric test of Wilcoxon was used to compare results of both protocols., Results: no significant differences were observed for tracheoesophageal and esophageal vocal quality in the three different moments of assessment: T1 (pre-use assessment of the HME), T2 (pre-use assessment of the HME six weeks after the first assessment) and T3 (assessment six weeks after the use of the HME). On the other hand, there were significant differences, after the period of the HME use, regarding occurrence of cough and forced expectoration during the day time., Conclusion: The use of the HME during the period of six weeks reduced cough and expectoration of patients with total laryngectomy. However, the use of the humidifier did not have any influence on the tracheoesophageal and esophageal vocal quality of these patients.

Electrolarynx devices have restored the voice of many who would otherwise be unable to speak. Current intraoral electrolarynx devices either have unappealing transoral tubes or are too large to easily fit in the mouth. We introduce a novel, remotely powered and wirelessly controlled intraoral electrolarynx that addresses these issues. Due to its size, the intraoral part of the device is easily embedded into a maxillary denture or a dental appliance. Characteristics of the device, including operating distance, positional sensitivity and orientation sensitivity were investigated. The results show that the device can be remotely powered and wirelessly controlled for use as an intraoral electrolarynx. Speech intelligibility of the device is not presented, but will be in future studies.

Objective: Evaluate the effects of the improvement of filtration, heating and humidification of inspired air with Cyranose heat and moisture exchanger (HME) on voice quality, breathing, and secretion handling in laryngectomized patients., Design: Prospective study., Setting: Fifteen laryngectomized patients, mean age 68, ages ranging from 50 to 91 years., Methods: Information was given to patients through video and brochures. Patients were selected if they had minimal understanding, permanent decanulization, no tumour progression or bronchopulmonary infections, and received no recent radiation therapy treatment. They were given the prosthesis and a starter kit. They were then evaluated by a speech pathologist with a structured questionnaire after one week, one month, and three months., Main Outcome Measures: The outcomes measured were comfort, breathing, secretions, and ease of use of the prosthesis as well as its effect on voice. Impressions of patients on humidification, filtration, and heating of inspired air were also recorded., Results: At conclusion of trial, 75% of patients wore the prosthesis on a daily basis and they all found it easy to use. All patients who completed the trial found breathing and handling of secretions easier as they thought humidification and filtration of air had improved. Quality of voice improved for 50% while remaining unchanged for 37%. The positive effect of the prosthesis progressed throughout the trial. Seven patients dropped out of the trial, mainly because of adhesive-related issues., Conclusion: Laryngectomized patients from the Montreal area could benefit from Cyranose artificial nose following an adaptation period during our cold winter.

Background: A sound generator based on a double-membrane design that fits into a regular tracheoesophageal shunt valve may improve voice quality after total laryngectomy in patients rehabilitated with surgical voice prostheses., Methods: Voice-producing element (VPE) prototypes were manufactured using medical grade biocompatible materials and tested in vitro under physiological conditions., Results: Basic sound, containing multiple harmonics, was successfully produced under physiologic air pressure and airflow conditions. The fundamental frequency and sound pressure level (SPL) is controlled by changing the driving pressure, thus enabling sufficient intonation for day-to-day speech. The obtained frequency range (190-350 Hz) is appropriate for producing a female voice. The low noise-to-harmonics ratio (mean 0.15) and also the efficiency of sound production (5.5 x 10(-5) at 80 dB(A) and 0.15 m microphone distance) is comparable to that of normal vocal folds., Conclusions: Functional restoration of the voice after laryngectomy with a double-membrane VPE appears to be a feasible concept for female laryngectomized patients with a hypotonic, or atonic pharyngoesophageal segment.

An electro-larynx is one of speech-substitute devices for patients who have lost laryngeal function. Unfortunately, the voices produced by a conventional electro-larynx are completely flat, unlike a human voice. In order to improve it, we developed a pitch-controlled electro-larynx that allows patients to control a voice intonation using their exhalation. The pitch-controlled electro-larynx has been manufactured in Japan and about 3500 patients have used the device since 1998. However, most patients have strongly requested a further advanced electro-larynx so that they can use it without their hands occupied. We designed a wearable electro-larynx so that it contributes to increase their quality of life. The new electro-larynx can be attached to the patient's neck using a thermo-plastic brace on which a thin-vibrator can be mounted. In this report, we mentioned how to design the wearable electro-larynx and the new electro-larynx was evaluated from a view-point of its sound quality and the usability. Although our wearable electro-larynx has not yet been equipped with the pitch-control function, it was ascertained that it works well while the users are moving their head in the various direction.

A computational model for exploring the design of a voice-producing voice prosthesis, or voice-producing element (VPE), is presented. The VPE is intended for use by laryngectomized patients who cannot benefit from current speech rehabilitation techniques. Previous experiments have focused on the design of a double-membrane voice generator as a VPE. For optimization studies, a numerical model has been developed. The numerical model introduced incorporates the finite element (FE) method to solve for the flow-induced vibrations of the VPE system, including airflow coupled with a mass-loaded membrane. The FE model includes distinct but coupled fluid and solid domains. The flow solver is governed by the incompressible, laminar, unsteady Navier-Stokes equations. The solid solver allows for large deformation, large strain, and collision. It is first shown that the model satisfactorily represents previously published experimental results in terms of frequency and flow rate, enabling the model for use as a design tool. The model is then used to study the influence of geometric scaling, membrane thickness, membrane stiffness, and slightly convergent or divergent channel geometry on the model response. It is shown that physiological allowable changes in the latter three device parameters alone will not be sufficient to generate the desired reduction in fundamental frequency. However, their effects are quantified and it is shown that membrane stiffness and included angle should be considered in future designs.

For voice rehabilitation after total laryngectomy a shunt valve is usually placed in the tracheo-esophageal (TE) wall, thereby enabling the production of a TE voice. Some patients, however, are unable to produce a voice of sufficient quality. Furthermore, the TE voice is low pitched, which presents a problem especially for female laryngectomized patients. The voice quality after laryngectomy might be improved by introducing a voice-producing element (VPE) into the TE shunt valve. In this study a sound generator was developed that is suitable for application in such a VPE. This sound generator consists of two elastic membranes placed parallel inside a circular housing. A substitute voice source is created when the membranes start to vibrate via a constant flow of air passing between them. To determine the optimal membrane configuration for proper functioning under physiological conditions, up-scaled physical VPE models with different membrane geometries were evaluated using in vitro experimental tests. For certain membrane geometries the tests showed that a basic sound, containing multiple harmonics, could be successfully produced under physiological air pressure and airflow conditions. The fundamental frequency (60-95 Hz) and sound pressure level (57-78 dB, at 15 cm microphone distance) were regulated via changes in the driving pressure, thereby enabling the possibility of intonation in laryngectomized patients' speech. The obtained frequency range is considered appropriate for producing a substitute voice source for female patients. The geometry considerations in this study can be used for the development of a true scale VPE that can be evaluated clinically, to eventually replace the voice after laryngectomy.

Background: After total laryngectomy and voice rehabilitation using a tracheoesophageal shunt valve, patients often have valve-related complications such as leakage. To solve these problems, a tracheoesophageal tissue connector (TE-TC) was devised to serve as an interface between the patient's tissue (trachea and esophagus) and the shunt valve., Methods: The TE-TC is a permucosal connection constructed from a titanium ring (filled with a silicon rubber plug) combined with polypropylene or titanium mesh. After implantation in adult goats for 12 weeks the implants were submitted to histologic investigation., Results: Firm implant fixation was achieved. In nearly all (18/19), no signs of infection of the implant were seen; 11 of 19 animals died before the end of the experiment owing to complications not related to the implant., Conclusions: The TE-TC is a new device with potential in the solution for fixation-related problems in tracheoesophageal voice rehabilitation.

Summary: Because of the aperiodicity of many tracheoesophageal voices, acoustic analysis of the tracheoesophageal voice is less straightforward than that of the normal voice. This study presents the development and testing of an acoustic signal typing system based on visual inspection of a narrow-band spectrogram that can be used by researchers for classification of voice quality in tracheoesophageal speech. In addition to this classification system, a selection of acoustic measures [median fundamental frequency, standard deviation of fundamental frequency, jitter, percentage of voiced (%Voiced), harmonics-to-noise ratio (HNR), glottal-to-noise excitation (GNE) ratio, and band energy difference (BED)] was computed to provide more insight into the acoustic components of tracheoesophageal voice quality. For clinical relevance, relationships between the acoustic signal types and an overall judgment of the voice were investigated as well. Results showed that the four acoustic signal types form a good basis for performing more acoustic analyses and give a good impression of the overall quality of the voice.

Characterization of the vocal profile of profoundly deaf children using an objective voice analysis was carried out in a university-based pediatric otolaryngology clinic. 21 persons ages 3.5 to 18 years were assessed. From each sustained phonation of the vowel /a/ the following acoustic variables were extracted: fundamental frequency (F0), jitter percentage, shimmer percentage, fundamental frequency variation (vF0), peak amplitude variation (vAM), and first, second, and third formant frequencies (F1, F2, F3). Mean F0 was 267.8 Hz and consistent with established normative data. Mean measurements of jitter (0.88%) and shimmer (3.5%) were also within normal limits. The notable feature of the acoustic analysis was a statistically significant elevation in vF0 (2.81%) and vAM (23.58%). With the exception of one subject, the F1, F2, and F3 formant frequencies were comparable to those for normal hearing children. Auditory deprivation results in poor long-term control of frequency and amplitude during sustained phonation. The inability to maintain a sustained phonation may represent the partial collapse of an internal model of voice and speech.

We describe two patients with tracheostomies who showed difficulty in weaning from mechanical ventilation, but were eventually weaned after use of a fenestrated tracheostomy tube with a speaking valve. The first patient underwent mechanical ventilation after pulmonary bleeding, while the second needed ventilator support because of tracheomalacia. Both patients needed only slight ventilator support but developed respiratory distress when it was discontinued. When the standard tracheostomy tube was replaced by a fenestrated tracheostomy tube with a speaking valve, each patient was easily weaned from mechanical ventilation. With a valved tube, vocal cords can exert part of their original function during expiration. The valved tube allowed the first patient to control breath-holding, and the second to avoid tracheal collapse. Regaining vocal cord function improved their pulmonary mechanics, which was demonstrated by dramatic improvement of findings on chest x-ray and computed tomography. A fenestrated tracheostomy tube is usually used to improve daily activities of patients with tracheostomies, but might be worth trying for difficult ventilator weaning.

Background: A pneumatic artificial sound source incorporated in a regular tracheoesophageal shunt valve may improve alaryngeal voice quality., Methods: In 20 laryngectomees categorized for sex and pharyngoesophageal segment tonicity, a prototype sound-producing voice prosthesis (SPVP) is evaluated for a brief period and compared with their regular tracheoesophageal shunt speech., Results: Perceptual voice evaluation by an expert listener and acoustical analysis demonstrate a uniform rise of vocal pitch when using the SPVP. Female laryngectomees with an atonic pharyngoesophageal segment gain vocal strength with the SPVP. Exerted tracheal pressure and airflow rate are equivalent to those required for regular tracheoesophageal shunt valves. However, communicative suitability and speech intelligibility deteriorate by the SPVP for most patients. Tracheal phlegm clogging the SPVP is a hindrance for most patients., Conclusions: The SPVP raises vocal pitch. Female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment can benefit from a stronger voice with the SPVP., (Copyright 2005 Wiley Periodicals, Inc.)

Electrolarynx (EL) speech provides a valuable means of verbal communication for the laryngectomees. Yet EL speech tends to be less intelligible speech due to the presence of background noise. This paper addresses the issue of EL speech enhancement. The proposed approach takes into account the frequency-domain masking properties of the human auditory system for a subtractive-type enhancement process. Subtractive-type algorithms can efficiently reduce the radiated noise of EL speech but not to reduce the additive noise from the environment due to the use of fixed subtraction parameters. Considering the particular characteristics of EL speech, a new computationally efficient algorithm based on the perceptual weighting technique is developed to adapt the subtraction parameters. This leads to a significant reduction of the unnatural structure of the residual noise. Acoustic and perceptual experiments confirm that the enhanced EL speech is more pleasant to human listeners and the proposed algorithm results in improved performance over classical subtractive-type algorithms.

The aim of the investigation is to compare voice and speech quality in alaryngeal patients using esophageal speech (ESOP, eight subjects), electroacoustical speech aid (EACA, six subjects) and tracheoesophageal voice prosthesis (TEVP, three subjects). The subjects reading a short story were recorded in the sound-proof booth and the speech samples were acoustically analysed. Speech sound production was judged by 15 students of phonetics. The following variables were considered: (1) voice quality: fo, jitter, shimmer and harmonic-to-noise ratio, (2) speech sound production: number of recognized VCV syllables, and (3) temporal organization of speech: duration of the phonetic block, number of syllables in the phonetic block, rate of speech, rate of articulation and number of syllables in the longest phonetic block. The results showed that nearly normal air-stream source (lungs) in speech production of speakers with tracheoesophageal prosthesis significantly contributed to the speech timing and speech intelligibility of the alaryngeal speakers.

This study aimed to evaluate a new automatic tracheostoma valve: the Provox FreeHands HME (manufactured by Atos Medical AB, Sweden). Data from four laryngectomee participants using automatic and also manual occlusion were subjected to acoustic and perceptual analysis. The main results were a significant decrease, from the manual to automatic occlusion condition, in maximum phonation time, mean intensity of read speech and percentage pause time. There was an increase in random noise in the speech signal and a significant increase in extraneous noise caused by the device. Perceptual analysis revealed no clear functional impact of these differences. Data from a questionnaire and diary suggested the main advantage of automatic occlusion was the freedom to speak while performing manual tasks. The principal disadvantage appeared to be a decrease in base-plate seal duration. The results suggest that, for some clients, the FreeHands valve is a useful option for use alongside manual occlusion.

For speech rehabilitation after total laryngectomy, the Provox FreeHands Heat and Moisture Exchanger (FreeHands HME; Atos Medical AB, Hörby, Sweden) was compared with the Provox Heat and Moisture Exchanger (HME), and the patients' Health-Related Quality of Life (HRQoL) was assessed. A review of the English literature was performed considering automatic speaking valves. The study design was a cohort study. Fourteen laryngectomized male patients who had used the HME successfully before receiving the FreeHands HME entered the study. An ENT specialist and a speech pathologist examined these patients. Data concerning voicing, breathing, skin adhesion, voice and speech quality, and HRQoL were collected by a structured questionnaire. Voice recordings were performed for evaluation of the quality of the voice. A computer-aided search of the MED-LINE database was conducted, supplemented by hand searches of key journals. Twelve patients had used the FreeHands HME on special social occasions and reported three main reasons why FreeHands HME was unsuitable for continuous use: heavier breathing, more difficult speaking, and worse subjective quality of voice. With HME, phonation time tended to be longer and the softest phonation softer ( P =0.034). The loudest phonation was louder with FreeHands HME ( P =0.015). Patients' HRQoL assessed by the 15D profile was similar to that of the age- and sex-matched male Finnish general population (patients 0.877, population 0.884). A review of the literature showed few works dealing with automatic speaking valves. The FreeHands HME is a useful additional device in a selected group of laryngectomized patients. Total laryngectomy did not lower patients' HRQoL notably.