Aerodynamic findings in esophageal voice

Effects of Adenotonsillectomy on Vocal Function

INTRODUCTION

Correct breathing is a fundamental condition for adequate vocal production. Respiratory dynamics are able to modify the growth of facial mass and lingual posture, i.e., of the skull, the mandibular one. For this reason, infant mouth breathing can cause hoarseness.

MATERIALS AND METHODS

We evaluated the actual changes in the characteristics of the voice and articulation of language in a group of subjects affected by adenotonsillar hypertrophy (grade 3-4), with frequent episodes of pharyngo-tonsillitis who underwent adenotonsillectomy. Our study included 20 children-10 boys and 10 girls-aged 4 to 11 years who had adenotonsillar hypertrophy and pharyngotonsillitis episodes exceeding 5-6 per year in the previous 2 years. The control group (Group B) included 20 children-10 boys and 10 girls-aged 4 to 11 years (average age of 6.4 years) who had not undergone surgery and shared the same degree of adenotonsillar hypertrophy as those in Group A but who did not experience recurrent pharyngotonsillitis episodes.

DISCUSSION

The hypertrophy of adenoids and tonsils significantly impacted breathing, vocal function, and speech articulation. All this is responsible for a state of tension in the neck muscles, which at the level of the vocal tract causes hoarseness. The changes objectively observed in our study in the pre- and post-operative phase demonstrate how adenotonsillar hypertrophy is responsible for an increase in resistance to the passage of air at the glottic level.

CONCLUSIONS

For this reason, adenotonsillectomy has an impact on recurrent infections and can also lead to an improvement in speech, breathing, and posture.

Bilabial Contact Pressure and Oral Air Pressure during Tracheoesophageal Speech

Objectives:

This study compared bilabial contact pressure (CPsp) and oral air pressure (Po) for /p/, /b/, and /m/ produced by tracheoesophageal (TE) versus laryngeal speakers. Nonspeech maximum bilabial contact pressures (CPmax) were measured to calculate the percentage of the range utilized for bilabial phonemes.

Methods:

Ten TE speakers and 10 laryngeal speakers produced syllables and sentences loaded with bilabial phonemes. The CPsp was measured with a miniature pressure transducer on the lower lip while the Po was simultaneously measured with a catheter in the corner of the mouth coupled to a differential pressure transducer. The speakers completed a non-speech lip-press task with the contact pressure transducer in place.

Results:

The TE speakers produced bilabial phonemes with significantly higher CPsp and Po than did laryngeal speakers. There was no difference in CPmax between the groups. The percentage of the contact pressure range utilized for bilabial phonemes was significantly higher for TE speakers.

Conclusions:

The increased CPsp and Po exhibited by TE speakers may reflect an attempt to overexaggerate articulation, although an alternate explanation related to neoglottal and oral aerodynamics must also be considered in future work. Subsequent studies evaluating the relationships between magnitude of articulatory contact pressure, phoneme intelligibility, and speaker's sense of effort should contribute to a better understanding of TE speech demands and may guide novel interventions to facilitate TE speech intelligibility.

Evaluation of Direct and Indirect Methods of Sub-Neoglottic Pressure Measurement in Tracheoesophageal Speakers: A Systematic Review and Meta-Analysis

OBJECTIVE

Tracheoesophageal (TE) prosthetic voice is one of the voice restoration options for individuals who have undergone a total laryngectomy. Aerodynamic analysis of the TE voice provides insight into the physiological changes that occur at the level of the neoglottis with voice prosthesis in situ. The present study is a systematic review and meta-analysis of sub-neoglottic pressure (SNP) measurement in TE speakers by direct and indirect methods.

PATIENTS AND METHODS

The screening of abstracts and titles was carried out for inclusion of articles using 10 electronic databases spanning the period from 1979 to 2016. Ten articles which met the inclusion criteria were considered for meta-analysis with a pooled age range of 40-83 years.

RESULTS

The pooled mean SNP obtained from the direct measurement method was 53.80 cm H2O with a 95% confidence interval of 21.14-86.46 cm H2O, while for the indirect measurement method, the mean SNP was 23.55 cm H2O with a 95% confidence interval of 19.23-27.87 cm H2O.

CONCLUSION

Based on the literature review, the various procedures followed for direct and indirect measurements of SNP contributed to a range of differences in outcome measures. The meta-analysis revealed that the "interpolation method" for indirect estimation of SNP was the most acceptable and valid method in TE speakers.

Correlation of maximum phonation time and vocal intensity with intraluminal esophageal and pharyngoesophageal pressure in total laryngectomees

OBJECTIVE

This study aimed to correlate maximum phonation time, vocal intensity, and dynamic extension with intraluminal esophageal and pharyngoesophageal segment pressure during tracheoesophageal phonation.

DESIGN

Prospective analysis.

SETTING

Tertiary academic hospital.

METHODS

The study was conducted on 20 total laryngectomees with alaryngeal speech and with secondary insertion of a tracheoesophageal prosthesis who were submitted to vocal recording of maximum phonation time and vocal intensity (minimum, habitual, and maximum). The participants were then submitted to manometry for the determination of the amplitude of intraluminal esophageal (proximal, middle, and distal) and pharyngoesophageal segment pressure during phonation.

RESULTS

A significant positive correlation was detected between habitual vocal intensity and the middle (0.004) and distal (0.05) esophagus, in addition to a correlation of maximum intensity with the middle esophageal portion (0.03). Dynamic extension showed correlation with the amplitude of esophageal pressure. There was no significant correlation between the variables studied and pressure of the pharyngoesophageal segment or between maximum phonation time and esophageal pressure amplitude.

CONCLUSION

The middle and distal regions of the esophagus were found to be compliant, permitting an adjustment of vocal intensity. There was no correlation between maximum phonation time and the amplitude of esophageal and pharyngoesophageal segment pressure.

Chest Wall Kinematics during Speech Breathing in Tracheoesophageal Speakers

Objectives:

The purpose of the present study was to determine how tracheoesophageal (TE) speakers manipulate the chest wall (rib cage and abdomen) to speak and how respiratory compromise (chronic obstructive pulmonary disease; COPD) and task variables influence those behaviors.

Methods:

The chest wall movements of 11 male TE speakers (5 with COPD and 6 without COPD) were measured during tidal breathing, spontaneous speech, and reading. Repeated-measures multivariate analyses were used to compare breathing behaviors across speech tasks and by respiratory health. Additional repeated-measures multivariate analyses and 1-way analyses of variance were conducted on temporal, aerodynamic, and linguistic measures.

Results:

There was a significant main effect of task and a significant interaction effect of COPD and task on chest wall movements. Rib cage movements varied by task, whereas abdominal movements were as predicted. There was a significant difference in utterance length by task. There were no main effects of COPD on the chest wall and no significant group differences in utterance length, aerodynamic measures, or intelligibility. The TE speakers were generally accurate in inspiring at appropriate linguistic boundaries.

Conclusions:

The results suggest that there is robust control for speech breathing following laryngectomy, but that there is also increased effort within the chest wall. Implications for future research considerations are discussed.

Lung Volumes Used during Speech Breathing in Tracheoesophageal Speakers

Objectives:

The purpose of this study was to determine how tracheoesophageal (TE) speakers manipulate lung volumes to meet speech demands and how respiratory compromise (chronic obstructive pulmonary disease [COPD]) and task variables influence these behaviors.

Methods:

The lung volumes of 9 male TE speakers (4 with COPD, 5 without) during tidal breathing, spontaneous speech, and reading were investigated. Repeated-measures multivariate analyses of variance were used to compare lung volumes and utterance length across speech tasks and by respiratory health. A one-way analysis of variance was used to compare aerodynamic measures and intelligibility by COPD diagnosis.

Results:

There was a significant main effect of task and a significant interaction effect of COPD and task on lung volumes at initiation and termination of speech. The TE speakers terminated speech exclusively below the resting expiratory level (REL) in both speech tasks because of elevated RELs, which are often present after laryngectomy. There were no main effects of COPD on any lung volume measures and no significant group differences in utterance length, aerodynamic measures, or intelligibility.

Conclusions:

Intelligibility and aerodynamic measures were not influenced by lung volumes and were comparable to findings of previous research. Speaking past the REL might be a compensation to optimize expiratory control for speech in a compromised system and a marker for the increased effort often anecdotally described by TE speakers.

Aerodynamic characteristics of the slit-like trachea-esophagus puncture for voice rehabilitation following total laryngectomy

CONCLUSIONS

The slit-like trachea-esophagus puncture is a reliable procedure to restore the voice in the patient who has undergone a total laryngectomy. The new voice quality could be similar to normal and could meet the patient's daily needs.

OBJECTIVES

We report a new method of tracheoneoesophageal (TE) voice rehabilitation. A slit-like trachea-esophagus puncture was made in the tracheoesophageal wall after the total laryngectomy. No voice prosthesis was used. The purpose of this study was to observe its aerodynamic characteristics.

METHODS

All 60 patients received voice rehabilitation with the slit-like fistula after total laryngectomy. All patients' voices were evaluated as excellent. The aerodynamic characteristics of trachea-esophagus voices were observed.

RESULTS

When a patient attempted to phonate, the upper esophagus was closed. Then, the hypopharyngeal cavity expanded. Just before phonating, the upper esophagus was full of air as a ball. The air flow escaped through the segment of the trachea-esophagus slit and entered the pharyngoesophageal segment (PES). The esophageal meatus opened. It was vibrated together with nearby mucus and mucosa to form the voice. The maximum phonation time of the slit-like fistula voice was not significantly different from the Blom-Singer prosthesis voice. Its sound intensity was similar to the normal voice.

Aerodynamic characteristics associated with oesophageal and tracheoesophageal speech of Cantonese

The present study investigated the aerodynamic differences between standard oesophageal (SE) and tracheoesophageal (TE) speech. Airflow and air pressure values below the pharyngoesophageal segment were obtained from 10 SE and 12 TE superior speakers of Cantonese. Airflow data were directly measured from sustained vowels, and sub-pharyngoesophageal segment pressure was estimated from /ip(h)ip(h)i/ syllables produced by the alaryngeal speakers. Results indicated that SE speech was associated with a lower rate of airflow and a higher pressure below the pharyngoesophageal segment than TE speech. SE and TE speakers exhibited an average airflow and sub-pharyngoesophageal segment pressure values of 70.50 mL/s and 134.15 mL/s, and 25.13 cm H(2)O and 22.61 cm H(2)O, respectively. Using the airflow and sub-pharyngoesophageal segment pressure, neoglottal resistance values were derived. The estimated neoglottal resistance was greater in SE speakers than in TE speakers. It is speculated that such difference in neoglottal resistance may be related to the use of different air reservoir mechanisms between SE and TE speakers. Such information will help speech-language pathologists design better speech therapy regimes for SE and TE speakers by understanding more about the difference between SE and TE phonation.

Acoustic markers of prosodic boundaries in Spanish spontaneous alaryngeal speech

Prosodic information aids segmentation of the continuous speech signal and thereby facilitates auditory speech processing. Durational and pitch variations are prosodic cues especially necessary to convey prosodic boundaries, but alaryngeal speakers have inconsistent control over acoustic parameters such as F0 and duration, being as a result noisy and less intelligible than normal speech. This case study has investigated whether one Spanish alaryngeal speaker proficient in both oesophageal and tracheoesophageal speech modes used the same acoustic cues for prosodic boundaries in both types of voicing. Pre-boundary lengthening, F0-excursions and pausing (number of pauses and position) were measured in spontaneous speech samples, using Praat. The acoustic analysis has revealed that the subject has relied on a different combination of cues in each type of voicing to convey the presence of prosodic boundaries.

Speech breathing in speakers who use an electrolarynx

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.

The effects of a total laryngectomy on speech breathing

PURPOSE OF REVIEW

Alaryngeal speech rehabilitation following a total laryngectomy is a multifactorial disorder that includes changes in phonation, respiration, and overall general health. Tracheoesophageal speech is the preferred method of rehabilitation. In this approach, pulmonary air support is diverted from the trachea into the esophagus to generate voicing. Tracheoesophageal speakers must overcome radical upper airway changes, increased resistance in the phonatory source, reduced sensory feedback from the respiratory system, and probable respiratory compromise. This review integrates previous laryngectomy research with recent studies investigating kinematics in tracheoesophageal speakers.

RECENT FINDINGS

Tracheoesophageal speakers are often very intelligible and communicate effectively, but little has been done to investigate the physiological demands of tracheoesophageal speech on speakers. Two recent studies have specifically investigated speech breathing behaviors in tracheoesophageal speakers. Both investigations reported increased effort and differences in speech breathing compared to laryngeal speakers; however, continued research is needed to understand the effects of a total laryngectomy on speech breathing.

SUMMARY

The physiological changes following a laryngectomy, especially in the ability to produce tracheoesophageal speech, are not well known. Rehabilitation for these individuals requires an understanding of the changes in respiration that might influence speech breathing behaviors.

[Acoustic and aerodynamic characteristics of the oesophageal voice]

OBJECTIVE

The aim of the study is to determine the physiology and pathophisiology of esophageal voice according to objective aerodynamic and acoustic parameters (quantitative and qualitative parameters).

MATERIAL AND METHODS

Our subjects were comprised of 33 laryngectomized patients (all male) that underwent aerodynamic, acoustic and perceptual protocol.

RESULTS

There is a statistical association between acoustic and aerodynamic qualitative parameters (phonation flow chart type, sound spectrum, perceptual analysis) among quantitative parameters (neoglotic pressure, phonation flow, phonation time, fundamental frequency, maximum intensity sound level, speech rate).

CONCLUSION

Nevertheles, not always such observations bring practical resources to clinical practice. We consider that the facts studied may enable us to add, pragmatically, new resources to the more effective vocal rehabilitation to these patients. The physiology of esophageal voice is well understood by the method we have applied, also seeking for rehabilitation, improving oral communication skills in the laryngectomee population.

Evaluación espectral cualitativa de la voz esofágica

OBJECTIVES

The aim of the study is to determine the accuracy of acoustic spectrography as an outstanding tool in the characterization and monitoring of esophageal voice.

MATERIAL AND METHODS

Our subjects were comprised of 33 laryngectomized patients (all male) that underwent qualitative acoustic (spectrography of vowel /a/ and a sentence), quantitative acoustic (phonation time, fundamental frequency, maximun intensity sound level, speech rate) and perceptual protocol.

RESULTS

There is a significant statistical relationship among Yanagihara-like spectrographic chart classification, psycho-acoustical perception and quantitative acoustic parameters.

CONCLUSION

We consider that acoustic spectrography is an easy, effective method for studying esophageal voice, seeking for improving oral communication skills and rehabilitation in the laryngectomee population.

Aerodynamic characteristics of laryngectomees breathing quietly and speaking with the electrolarynx

The primary purpose of this study was to investigate the aerodynamic characteristics of laryngectomees under two conditions: breathing quietly and speaking with electrolarynx. Twenty male adult subjects, 8 normal speakers, and 12 laryngectomees participated the experiment. Airflow, pressure, and speech data were obtained simultaneously. The acceptability of electrolarynx speech under different conditions was also evaluated by 20 listeners (14 men, 6 women). Results indicated a higher peak expiration airflow and pressure among the laryngectomees as compared with the normal during breathing. Three different breathing patterns appeared among the laryngectomees when speaking with the electrolarynx: holding breath, exhaling, and breathing. Four long-time electrolarynx users held breath during speaking. Seven of 12 laryngectomees kept exhaling, whereas only 1 could breathe during speech production. In addition, (1) the acceptability of electrolarynx speech was the highest when speaking breathlessly; (2) no significant difference was found in the acceptability between the patterns of exhaling and breathing smoothly; and (3) the acceptability decreased if breathing quickly during phonation with the electrolarynx. It also suggests that the laryngectomees who can breathe during speaking may be more appropriate to use the new electrolarynx controlling the pitch by expiration pressure.

Velopharyngeal aerodynamics of /m/ and /p/ in tracheoesophageal speech

The purpose of this study was to compare oral pressure (P(o)), nasal airflow (V(n)), and velopharyngeal (VP) orifice area estimates from 12 tracheoesophageal (TE) and 12 laryngeal speakers as they produced /p/ and /m/ in syllable series. The findings were as follows: (1) TE speakers produced greater P(o) than the laryngeal speakers; (2) for /p/, TE speakers generated V(n), and VP orifice area estimates comparable with, or less than, the laryngeal speakers; and (3) for /m/, TE speakers had V(n) and VP orifice area estimates greater than the laryngeal speakers. The elevated P(o) could be the result of several factors such as high source driving pressures and vocal tract volume changes postlaryngectomy. Attempts at more precise articulation, and subsequently less coarticulation, by the TE speakers may explain the V(n) and VP orifice area estimates for /p/ and /m/. TE speakers may be limiting the oral-nasal cavity coupling for /p/ (smaller VP gap, less V(n)) in an attempt to produce a very precise oral /p/. For /m/, TE speakers may be attempting to overtly mark the consonant as a nasal (greater V(n), larger VP gap). Further studies are needed to confirm/refute the explanations postulated here regarding the VP aerodynamic differences that were identified.

Phonation offset in tracheoesophageal speech

Tracheoesophageal (TE) speakers often have difficulty producing the voiced-voiceless distinction. Phonation offset (POff) as a TE speaker transitions from a vowel to a stop consonant may be altered, possibly contributing to listener misperceptions. The purposes of this study were to: (1) compare the duration of POff in TE versus laryngeal speakers, and (2) compare POff between TE productions that were accurately versus inaccurately perceived. Phonation offset and offset duration as a proportion of the stop gap (%POff) were greater for the TE versus the laryngeal samples. There was no difference in POff or %POff when comparing accurately to inaccurately perceived TE samples. Tracheoesophageal speakers may have less ability to halt neoglottal vibration compared to laryngeal speakers' ability to stop glottal vibration. Comparable POff for accurately and inaccurately perceived TE samples suggests that POff may not be a particularly salient acoustic feature to the voicing distinction, at least for stop consonants.

LEARNING OUTCOMES

(1) As a result of this activity, participants will be able to describe what phonation offset is relative to the voicing distinction. (2) As a result of this activity, participants will be able to describe phonation offset in tracheoesophageal speakers relative to laryngeal speakers. (3) As a result of this activity, participants will be able to describe whether phonation offset in tracheoesophageal speech has perceptual saliency for listeners.