Original article published in Headlines May 2003
Most people are impressed by the three ways laryngectomees can learn to speak after they have had surgery. These include speech produced using an electro or pneumatic larynx, esophageal production, and tracheoesophageal puncture. And in reality, these modalities of artificial voice are truly impressive. They give back the human voice that is so important to daily lives and they offer a link back to society. For those who have lost their true larynx, these modalities are the tools that give voice and re-create our being and personality.
But with these three modalities and all the various devices and techniques associated with them, how can laryngectomees and family members know which ones are best? Which ones will offer the clearest voice and the most natural sound? Which ones will be most accepted by spouse, family, friends, and co-workers? How will I learn and care for the system I use? What modality will sound the best over the phone and to strangers? Although this article will not answer these questions, they are ones that face new laryngectomees. With the assistance of a speech-language pathologist, they often can be answered.
It comes as no surprise that laryngectomees are under the impression that they have options when it comes to the alaryngeal system they will use to communicate. After all, they have been told that they have "options" and much of the laryngectomee literature refers to the "speech options" that are available to laryngectomees. In reality, however, many laryngectomees do not have an "option" or "choice" when it comes to the post-surgical voice they will use to communicate. Take the example of "Lucy" whose doctor insisted that she learn esophageal speech, the "gold standard." After earnest attempts and years of frustration, Lucy was unsuccessful in acquiring anything past a pharyngeal squeak. Now, after 27 years, she still uses a pencil and paper to communicate with family members. Lucy never leaves the house. And then there is "Bruno" who underwent several surgeries. Not only did Bruno have his larynx removed but he also lost two thirds of his tongue. Even though he purchased an electrolarynx, he was never able to make intelligible speech. And even though Bruno has a strong, sustained esophageal tone, it is useless for making speech. Since Bruno never finished school and never learned to read or write, he mouths words and uses gestures to communicate. Only his son can understand what he is saying. Finally, meet "John" who has tried numerous puncture prostheses. But because of excessive mucus and scarring, he has problems with the prosthesis plugging-up and dislodging. The device offers voice for a short period and then fails at inopportune times. After two years, John gave up and permanently removed the prosthesis. John's esophageal speech is too soft and inaudible and despite his desire to have hands free communication, he is forced to use an electrolarynx. In each of these scenarios, Lucy, Bruno, and John thought that they had options. They were wrong.
The misconception that laryngectomees have "speech options" is further perpetuated by those who use a particular technique. For example, some esophageal speakers are under the impression that anyone can learn good, functional, esophageal speech. They insist that achieving esophageal speech is a function of choice, motivation, practice, and pursuit. In fact, a recently published newsletter, reported that "Esophageal speech is easy if you exercise your speech muscles 5 minutes each hour of each day." Unfortunately, nothing could be further from the truth and this type of writing helps only to solidify a misconception. What about those individuals who do not have the physiological capacity to achieve functional esophageal speech? There are many variables besides choice that determine whether or not a person can achieve esophageal speech, or any system for that matter. And realistically, good, functional esophageal speech can be acquired in only about 40% of those who try to achieve it. What about the other 60 percent? An individual, who believes that he or she will speak using a given system, and then cannot achieve success, may feel cheated or think of themselves as a failure. Someone once said that perceptions are real through the eyes of the perceiver. Because of this, many users may believe that their particular system or device is the best option for everyone. This simply is not true.
In the earlier days of my career, I too used the phrase, "speech options" in an effort to share my knowledge. Several years ago, however, I learned that my laryngectomee patients and families were better served using the term "Speech Possibilities." Not only does this phrase minimize the idea that there are choices, but it also sets the stage for a system that is a match with the individual patient. Depending on a host of variables, the person can be best suited with an alaryngeal system that will work with and not against them. Until the various systems are considered for candidacy, evaluated, and tried, they are possibilities and not options.
This idea also dovetails with another concept. Clinically, I feel that laryngectomees should have two modalities for speech communication. Naturally, this is not always achievable but, on a rehabilitative level, it makes good sense to aim for this goal. Since 99% of laryngectomees can have relatively fast success with an artificial larynx, I set them up with one and begin instruction in their use and care. Then, if tracheoesophageal puncture is concurrently or consequently performed and functional, the patient will have two separate systems for speech communication. If the patient is a candidate for esophageal speech and is able to achieve success, along with the artificial larynx, there will be two systems available. Or perhaps the patient will simply have two artificial larynx devices; one as a primary device and another as a back up.
The goal of laryngectomee rehabilitation is to bring back the whole person, to completely restore speech communication, and to instruct compensatory strategies. Whichever speech modality is used, it should be one that is completely functional and one that is a best match between the person, the device, and/or the technique. I like the phrase, "Speech Possibilities" because it is realistic, truthful, and accurate.