Originally published in Advance for Speech-Language Pathologists & Audiologists, February 24, 1997.
Speech-Language Pathologists are constantly faced with therapeutic obstacles and patient challenges. For the speech clinician who works closely with laryngectomized individuals, the control of stomal noise is sometimes an issue and a hurdle to be overcome. Stoma noise, also referred to as "stoma blasts," is the unwanted high-frequency noise generated from the tracheostoma in a tracheostomized person. Stoma noise is frequently observed in laryngectomees and stems from pulmonary air turbulence at the stoma site.
All people have the innate and over-learned need to fill the lungs prior to producing an utterance. This human function is deeply ingrained and is an integral part of speech communication. Due to major changes in the respiratory tract, laryngectomees must learn deliberate techniques to eliminate or sharply reduce stomal noise.
Stomal noise is not just a negative deviation of alaryngeal speech. It is also a deviation causing noisy and conspicuous breathing. Most laryngectomees undergo a period during which stomal noise is observed. For some it is an obvious aberration that is reckoned with and self-controlled. For others it is an uncontrolled, unconscious deviation of speech and breathing that has several negative facets. Not only does stomal noise dramatically and adversely call attention to the patient's neck and tracheostoma, but it makes the individual more conspicuous in social and public situations. On a subjective level, both educated and lay persons often find stoma noise to be strange and even alarming. Stomal noise is also responsible for masking the attempts to communicate by using alaryngeal means, such as esophageal speech and speech using an artificial larynx. Frequently the unwanted noise generated from the tracheostoma is in direct competition with the speech signal. The result is a range of unintelligibility and conspicuousness which can vary in severity among patients.
A chief objective of laryngectomee rehabilitation is to approximate normal speech. Even though alaryngeal speech with an electronic larynx, esophageal or tracheoesophageal punctured speech deviates from normal voice, it is important to strive for a production that closely resembles normalcy.
Rehab goals should not only address functional communication but the control of stoma noise and its perception by others. This is not always easy to accomplish, due to such reasons as decreased cognitive function, poor new learning skills, impaired auditory/speech perception skills and stomal size.
Therapy to eliminate stoma noise starts with education. Provide the patient with a basic education of anatomy and the changes resulting from the laryngectomy surgery. For many patients this is the first meaningful description of the surgery and the problems that need to be overcome. It is usually helpful to include the patient's spouse or helper in the educational process.
Early intervention and education is key to controlling stoma noise. Patients who do not have early contact with an alaryngeal speech professional are at risk for developing detrimental speech and secondary behaviors. Once these inferior habits are established, they are more difficult to change and eliminate. If the patient is fortunate enough to have pre-operative time with a therapist, this is a good time to briefly discuss stomal noise control. Afterward frequent mini-discussions and focused therapy can relate to stoma noise.
Several worthy techniques can be used together or individually to treat stomal noise. For patients who may have difficulty perceiving their own stomal noise, the use of a stethoscope or audio recording device as a feedback tool helps to demonstrate and highlight the problem.
Another helpful tool for patient feedback is a stomal whistle. This simple pneumatic device has a rubber flange attached to the oral end. When held to the tracheostoma, the whistle will sound at varying levels depending on the air moving through it. With the stomal whistle in place, the patient is instructed to produce sounds and words without sounding the whistle. To lighten-up the therapy process, it is humorous to tell the patient to not "blow the whistle on him/herself."
Once an aided awareness of stomal noise has been established, the patient can be shown how to eliminate it. Carefully audio recording similar trials with and without stoma noise for the patient to review is helpful.
Since stoma noise can be observed even while producing the most minute utterance, the clinician should start with basic sounds and advance as necessary. For example, the clinician may wish to have the patient produce a voiceless plosive while carefully monitoring for stoma noise. Then, as the patient is able, the therapist can advance the patient by having him or her produce monosyllabic words, counting and so on. The key is to advance and increase the patient's utterance length while minimizing or eliminating stoma noise. Another strategy involves having patients empty their lungs of air prior to producing a sound or a short utterance. Still, for other patients, it may be useful to have them whisper an utterance. Since whispering in a normal speaker requires less pulmonary demand, the laryngectomee can more easily relate to this mode of speech, and stoma noise is dramatically reduced. The clinician working with stomal noise will quickly find the techniques that are most successful with a given patient.
Sometimes a patient will demonstrate decreased cognitive function and new learning problems. Since the control of stoma noise requires the recall, re-adaptation and use of special strategies, some patients have more difficulty finding success. It may be helpful to enlist a friend of the patient to assist with home practice and exercises. New Voice clubs in the area also can provide valuable help and encouragement to the patient who is experiencing problems. Occasionally, the clinician will encounter a patient who simply cannot control stoma noise. This is usually due to cognitive dysfunction or entrenched habit.
Having an abnormally small tracheostoma can affect a patient's basic pulmonary function in addition to alaryngeal speech. Stenosis of the tracheostoma is not uncommon in the laryngectomee population, and it can give rise to stoma noise and respiratory compromise. Importantly, if a patient demonstrates perpetual stoma noise during restful breathing and speech tasks, the size of the stoma should be inspected. As a general rule, the tracheostoma that is smaller than a dime or ones that are continually growing smaller are suspect. An abnormally small tracheostoma sometimes can act like an air nozzle, creating stomal noise at rest or during some level of physical activity. If a patient complains of fatigue and air resistance at the stomal site, especially during light-to-moderate physical activity, stomal revision surgery for enlargement should be considered by a surgeon.
A small tracheostoma, however, is not necessarily indicative of a problem. The laryngectomee--depending on gender, stature and respiratory status-will be more or less affected by the size of the tracheostoma. For example, a female who is 5-foot tall and weighs 110 pounds with a stoma one centimeter in diameter may have little difficulty. But the same stoma dimension in a 6-foot male may be more problematic in terms of stoma noise and breathing during any activity. This problem may be further complicated if there are components of chronic obstructive pulmonary disease (COPD), asthma or other respiratory problems.
Nevertheless, stoma noise is an important aspect of rehabilitation that must be questioned and addressed in every laryngectomee. Since stoma blasts can affect intelligibility and attract negative attention, early intervention by a skilled professional is essential. Several successful techniques can be employed by the alaryngeal speech instructor to increase patient awareness and reduce, if not eliminate, this abnormal sound.