REGAINING THE ABILITY TO SPEAK VIA TECHNOLOGY

Sidney Schneider, M.S., CCC-SLP
Rehabilitation Dept.
Tallahassee Memorial Regional Medical Center
Magnolia Dr. and Miccosukee Rd.
Tallahassee,Florida 32308
FAX:(904)841-6477

Catherine Swanson, M.S., CCC-SLP
Rehabilitation Dept.
Tallahassee Memorial Regional Medical Center
Magnolia Dr. and Miccosukee Rd.
Tallahassee, Florida 32308
FAX: (904)841-6477

Web Posted on: December 12, 1997

Daniel Webster once said, "If all my possessions were taken from me with one exception, I would choose to keep the power of communication, for by it I would soon regain all the rest."

Cancer of the larynx is a diagnosis that causes fear and trepidation. Anyone having to face the loss of the larynx in order to save one's life at first is overwhelmed by changes that seem insurmountable. Our presentation will provide an understanding of the variations of the laryngectomy and the various means of speech rehabilitation. Several adults will share how they have gone on to live full and rich lives after undergoing a laryngectomy, which is the complete removal of the larynx, or voice box; and how they regained the ability to speak via technology. Each individual has a totally unique story, which hopefully, will assist others who may have experienced or who are now going through similar dilemmas. Included, will be demonstrations of the use of technology by a laryngectomy patient; also, handouts and a video presentation which will give you practical hints for dealing with communication deficits. This presentation may also be helpful to individuals who have lost speech skills due to neurogenic disease, (e.g., MS, ALS, etc.) In addition, we will discuss several forms of augmentative communication, which would be useful to anyone who has lost the ability to speak verbally.

Before surgery, one is able to produce a sound called a "laryngeal tone" by vibrating the vocal cords in the larynx. By moving the tongue, lips and jaw one is able to shape that laryngeal tone into words, phrases and sentences. Even though an individual is no longer able to produce the same tone after the larynx is removed, the ability to move the mouth and tongue is usually not affected. However, in our study, you will meet an individual who had most of her tongue removed during surgery, so regaining verbal communication was more complicated.

Speech therapy is an integral part of regaining your voice. We will discuss five ways with which we have had experience in assisting individuals with regaining oral communication. A selection process is involved; as well as the commitment of time, patience and practice. Some individuals may learn more than one method, or may start with one method and change to another. (1)the "esophageal voice" is produced by forcing air down the esophagus and releasing it in a controlled manner. Other viable alternatives include use of an (2)electrolarynx, (3)Tracheoesophageal Puncture (TEP); (4)the use of a speaking shunt which can sometimes be possible through surgery; or a (5)laptop computer or other communication device with appropriate software, as is the case of our patient who lost most of her tongue through surgery. Our case studies are as follows:

The first individual, who is now retired, was working as a Bureau Chief for the state of Florida when his cancer was discovered. He began radiation in November , which did not accomplish what his doctor had hoped; therefore, he underwent a complete laryngectomy in July of the next year. He became proficient with the electro larynx almost immediately after surgery. He had several surgerys to enlarge his stoma and to clear granulation and infection. Through additional surgery, he received a Blom Singer Tracheo Esophageal Puncture (TEP) prosthesis with a traceostoma valve, because he was unable to occlude his stoma due to its enlarged size; also, because he is very active and considered the electrolaryx a "bother". His wife reports that he has always been "upbeat and positive" and otherwise in good health, factors which certainly have improved his return to a "normal" life. This patient and his wife work with our Rehabilitation Dept. in counseling other patients. They stress that "life goes on and it can be a good life, if you want it to be; you must adjust to accomodate a new way of speaking."

The next individual was, and still is, a highly successful real estate salesman; #10 salesman in the USA for Century 21 Real Estate. He received a TEP five years ago, and was able to start back in his same position two years ago, with a most effective, efficient voice. He was a heavy smoker until his late 30's, ignoring warnings from his doctor and signals from his body, which included experiencing poor circulation in his upper extremities, as well taste/gustatory changes. He finally quit, in his late 40's, but by that time, he had a positive diagnosis of cancer. He underwent 13 operations in a two and a half year period, between l990-1993. At first, he underwent a partial laryngectomy, and could still speak, although he could eat/drink nothing, and received his nutrients via a PEG or stomach tube. His doctors unsuccessfully injected teflon to "build" vocal cords. Mr. Arrowood could still not eat/drink safely, and therefore elected to undergo a total laryngectomy. He now is very successful using his prosthesis, to communicate verbally, as you will be able to observe via videotape during the presentation. Not only has he returned to his job as a successful real estate salesman; he also is able to counsel with other patients and make talks in schools and universities. He reports that he does not get stage fright when sharing information re: his personal experiences with individuals and groups, even though he was not adept at public speaking prior to his laryngectomy.

The third individual, whose story we'd like to share, was and still is a state attorney in Florida. After surgery, he underwent 5 weeks of radiation therapy to improve the chances of avoiding a recurrence of the cancer, which after almost two years has proven to be successful. He reported that "the most startling and mentally traumatic events are when you first become conscious following surgery and you attempt to speak, not realizing that you are unable to do so. At first there is fear because no one can understand you, you immediately realize that you will have to use written communication to make known your needs. While this is a means of communicating with others, it is rather cumbersome, slow and frustrating." After about three days when the soreness and swelling in his neck subsided, he was provided with an electrolarynx, which is a vibrator that one can place under the chin against the skin covering his/her vocal cords, and press a button causing a sound vibration to produce sound waves inside the mouth. One can form words as you would normally and are thus able to speak so that individuals can understand what you are saying. He noted that "this method of speech is rather easy to learn and when done properly, can be understood by almost everyone with whom you speak." He also stated that the "electrolarynx is a Godsend for laryngectomy patients until they can acquire the ability to use esophageal speech, which takes a long time to master and may not be effective if the individual cannot produce adequate volume." Within a year of his surgery, he was able to orally argue in court effectively. He noted that the court reporters and judges were able to understand his speech without difficulty. This patient told us that everyone with whom he has come in contact has been understanding and kind, which makes living with the loss of his normal voice possible. He also stated that he "could imagine a person easily becoming a recluse without this technological means of verbal communication."

The last story we would like to share, is that of a 68 year old mother and grandmother, who underwent total laryngectomy 12 years age, in which she had most of her tongue removed. While in the hospital after surgery she found the Magic Slate to be very helpful (as it still is); as her surgeon had told her she would not be able to use the electrolarynx. She also began using the Vocaid and TDD (for the telephone); she and family members also learned sign language. She was fitted with a tongue prosthesis by her dentist, and received months of speech therapy, and her speech was still not sufficient for conversation. This patient found that "people could not take time to listen, especially when busy or tired. I learned to listen instead of talk. You can learn a lot doing that." Alas, after all these years, technology has advanced to the point of giving this individual a female voice, via laptop computer and software (i.e., Keywi, from the Consultants for Communication Technology in Pittsburgh, Pa.), so that she may have the independence and power only achieved by communicating verbally; also, to realize her dream....of talking with her young grandchildren over the phone! The challenges this individual reported are as follows: returning to her work as a volunteer at Tallahassee Memorial Regional Medical, which includes meeting the public for sales transactions in the Gift Shop, going to traditional speech therapy sessions with little success, putting on two weddings in one summer, the computer and becoming a faster typist, and thinking of flying across the country alone!

Each of these cases has a happy ending, thanks to the individual's diligence, excellent medical care, speech therapy provided by the Rehabilitation Team at Tallahassee Memorial Regional Medical Center and wonderful familial support. We truly hope that others will be able to benefit from this presentation.