Multidimensional Voice Program Analysis in Profoundly Deaf Children: Quantifying Frequency and Amplitude Control

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.

Primary versus Secondary Tracheoesophageal Puncture for Speech Rehabilitation in Total Laryngectomy: Long-Term Results with Indwelling Voice Prosthesis

OBJECTIVE: To evaluate the long-term use of indwelling Blom-Singer voice prosthesis (VP) for vocal rehabilitation of patients submitted to total laryngectomy (TL). The influence of the timing (primary or secondary) of tracheoesophageal puncture (TEP), use of radiotherapy (xRT), patient age, and length of follow-up were studied to evaluate the success rate of VP use.

STUDY DESIGN AND SETTING: Prospective clinical study in a tertiary referral center. Seventy-one patients were submitted to TL and rehabilitated with indwelling VP. All patients were evaluated for vocal functional issues by an otolaryngologist and a speech pathologist at 1 month, then at every 3 months up to 1 year, and then at every 6 months after 1 year of follow-up. The relative data on time of placement of VP, time of VP use, xRT, age, length of follow-up, and life span of each VP were recorded during the follow-up.

RESULTS: Eighty-seven percent of the patients underwent primary and 13%, secondary TEP. The follow-up varied from 12 to 87 months, with an average of 38 months for primary and 51 months for secondary TEP. Fifty-nine percent of the patients were submitted to xRT. The general rate of success was 94%, with 97% for primary and 78% ( P = 0.07) for secondary TEP; after 2 years, the success rate was 96% for primary and 75% for secondary ( P = 0.07) TEP. The use of xRT and patient age had no influence on the success of VP use for primary and secondary TEP, independently of the length of follow-up.

CONCLUSIONS: The success rate of voice rehabilitation with VP was 94%. In primary TEP, the success rate was 97%, whereas in secondary TEP it was 78%; 2 years later, it was 96% and 75%, respectively. A tendency for a higher success rate in voice rehabilitation after TL was observed in primary TEP. The use of xRT and age of patient had no influence on the success rate.

Verbal communication with the Blom low profile and Passy-Muir one-way tracheotomy tube speaking valves

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.

Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy

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.

Prevention of voice prosthesis biofilms: current scenario and future trends in prolonging prosthesis lifetime

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.

[Voice restoration and long-term progress in voice rehabilitation using the Provox2 voice prosthesis after total laryngectomy]

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.

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.

Development and perceptual evaluation of amplitude-based F0 control in electrolarynx speech

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.

Comparison of alaryngeal voice and speech

The aim of the research was to compare voice and speech in three groups of alaryngeal speakers: 1) patients using esophageal speech, 2) patients with electro-acoustical speech aids and 3) patients with voice prostheses. Acoustic analysis and pronunciation tests were used for the analysis. Acoustic analysis included fundamental frequency, maximum phonation time, jitter, shimmer and intensity. Pronunciation parameters were: phonetic block duration, number of syllables in a phonetic block, rate of speech, maximum number of syllables in a phonetic block and rate of articulation in a maximal phonetic block. Our results demonstrated the advantages of tracheoesophageal puncture with implantation of a voice prosthesis over the other two techniques of alaryngeal speech. Voice and pronunciation with voice prostheses were closer to normal in many parameters: fundamental frequency, maximum phonation time, jitter, shimmer, duration of a phonetic block, number of syllables in a phonetic block, rate of speech and rate of articulation in maximal phonetic block.

A numerical study of the flow-induced vibration characteristics of a voice-producing element for laryngectomized patients

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.

In vitro evaluation of a double-membrane–based voice-producing element for laryngectomized patients

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.

Development of a Double-Membrane Sound Generator for Application in a Voice-Producing Element for Laryngectomized Patients

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.

Acoustic Signal Typing for Evaluation of Voice Quality in Tracheoesophageal Speech

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.

Experimental results of the tracheoesophageal tissue connector for improved fixation of shunt valves in laryngectomized patients

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.

Enhancement of electrolarynx speech based on auditory masking

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.

Ventilator weaning using a fenestrated tracheostomy tube with a speaking valve

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.

Voice and speech after laryngectomy

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.

A quantitative and qualitative evaluation of an automatic occlusion device for tracheoesophageal speech: the Provox FreeHands HME

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.

Assessment of alaryngeal speech using a sound-producing voice prosthesis in relation to sex and pharyngoesophageal segment tonicity

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.

Difficulties in the fixation of prostheses for voice rehabilitation after laryngectomy

In most patients with advanced or recurrent laryngeal or hypopharyngeal cancer, total laryngectomy is indicated. This means the loss of three main functions: phonation; respiration; and the prevention of aspiration during deglutition. Laryngectomy patients have various options to restore phonation: an oesophageal voice; an electrolaryngeal voice; or a tracheo-oesophageal voice. In the last case a silicone rubber shunt valve is placed in the tracheo-oesophageal wall and phonation is generated when exhaled air is forced through the oesophagus and neopharynx. This method is widely applied in Western Europe. In this paper we review the literature on fixation problems with shunt valves, tracheostoma valves and heat and moisture exchange (HME) filters. Tracheo-oesophageal speech without a valve is not considered. Despite 22 years of experience with the implantation of tracheo-esophageal shunt valves and many improvements in the design, problems still remain, such as biofilm formation with subsequent leakage through the valve, the need for frequent and inconvenient replacements, fistula enlargement leading to leakage around the device and reduced fixation, and infections. The high cost of shunt valves is a drawback to their use worldwide. To enable hands-free speech, different types of tracheostoma valve have been developed. These valves are fixed to the skin or to the tracheostoma by means of an intra-tracheal device. An HME filter is used to protect the airway and maintain physiological balance. Such devices are only suitable for a selected group of patients as fixation to the skin or trachea can be a major problem. Speaking and coughing cause pressure increases, which often result in mucous leakage and disconnection of the valve and/or HME filter. Recommendations are made for future improvements in fixation techniques.

Compliance, quality of life and quantitative voice quality aspects of hands-free speech

CONCLUSIONS

With the use of a new automatic stoma valve (ASV) it appears possible to rehabilitate patients who have previously been unsuccessful in acquiring hands-free speech. As well as making daily ASV use possible for an additional group of patients, this new device was also appreciated by many patients as an additional rehabilitation tool for specific occasions. Despite statistically significant improvements in aspects of voice and breathing using this novel ASV, improvement of peristomal adhesion is probably the main factor needed to further increase success rates. Nevertheless, our results show that it makes sense to keep trying to achieve hands-free speech, even if previous attempts have failed.

OBJECTIVE

To make a long-term (6 months) assessment of compliance and aspects of voice, breathing and quality of life using a new ASV: the Provox FreeHands heat and moisture exchanger (HME).

MATERIAL AND METHODS

This was a prospective clinical multicentre trial in 79 laryngectomized patients (8 regular ASV users, 58 previously unsuccessful users and 13 new users). Data were collected at baseline and after 1 and 6 months by means of European Organization for Research and Treatment of Cancer Quality of Life questionnaires and specific structured questionnaires concerning compliance, skin adhesion, voicing and pulmonary aspects. An objective assessment of voice parameters (maximum phonation time, maximum phonation time while counting, dynamic loudness range and number of pauses in a standard read-aloud text) was made for comparison of different stoma occlusion methods (digital occlusion via an HME and two different ASVs). A subjective assessment of overall voice quality was made.

RESULTS

After 6 months, 19% of patients used the new ASV on a daily basis (mean 5 h/day), while 57% used it on an irregular basis as an additional rehabilitation tool for special occasions. Two-thirds of the study group indicated that they would continue to use the new ASV after the study period. With respect to the objective parameters, statistically significantly better maximum phonation times and dynamic loudness ranges were observed with the new ASV compared to the Blom-Singer ASV. However, the best results for all the objective parameters were obtained with digital occlusion via the Provox HME.

Alaryngeal speech aid using an intra-oral electrolarynx and a miniature fingertip switch

We developed and evaluated an intra-oral electrolaryngeal speech aid system for those who could not acquire common alaryngeal speech or for early post-surgery speech rehabilitation. Our system consisted of a denture-base intra-oral vibrator, a wireless miniature fingertip switch and a controller. To produce natural speech, the fingertip switch produced binary commands of voicing and accent and the controller implemented the pitch generation model using the commands. We first estimated the intelligibility of consonant-vowel syllables produced by our system. We then obtained the feedback about the system from the Japanese users on the basis of their daily life use, and evaluated the possibility and acceptability as an alaryngeal speech aid. Although the users were less satisfied at the intra-oral electrolarynx, the intelligibility of the intra-oral electrolarygeal speech was comparable to that of transcervical electrolaryngeal speech, and most of them were willing to employ it if they lost their current electrolaryngeal speech. According to the feedbacks from the users, a completely wire-free system and less eye-catching designs would make the prosthesis more acceptable. These results placed the intra-oral electrolarynx as a useful option of alaryngeal speech aids and encouraged the further development of the intra-oral electrolarynx.

Automatic speaking valve in speech rehabilitation for laryngectomized patients

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.

VoiceRelay: voice key operation using visual basic

Using a voice key is a popular method for recording vocal response times in a variety of language production tasks. This article describes a class module called VoiceRelay that can be easily utilized in Visual Basic programs for voice key operation. This software-based voice key offers the precision of traditional voice keys (although accuracy is system dependent), as well as the flexibility of volume and sensitivity control. However, VoiceRelay is a considerably less expensive alternative for recording vocal response times because it operates with existing PC hardware and does not require the purchase of external response boxes or additional experiment-generation software. A sample project demonstrating implementation of the VoiceRelay class module may be downloaded from the Psychonomic Society Web archive, www.psychonomic.org/archive.

Effects of speech and print feedback on spelling by children with autism

In this systematic replication of a previous study (R. W. Schlosser, D. M. Blischak, P. J. Belfiore, C. Bartley, and N. Barnett, 1998), the effects of speech and print feedback on spelling performance were evaluated. Four children with autism and no functional speech were taught to spell words with a speech-generating device under 3 feedback conditions. In the auditory-visual condition, children received both speech and print feedback, whereas in the auditory and visual conditions, only 1 type of feedback was provided. An adapted alternating treatments design was used. All 4 children reached criterion across conditions. Although 3 children reached criterion first with print or speech-print feedback, 1 child was most efficient with speech-print followed by speech feedback. Based on the findings of both studies, 2 distinct profiles of feedback efficiency are proposed. Children that exemplify the primarily visual profile spell words most efficiently when feedback involves print. Children that fit the auditory profile spell words most efficiently when feedback involves speech. The implications for understanding the learning characteristics of children with autism, as well as those for practice and further research are derived.

[Tracheostoma valve with integrated cough lid for improvement of hands-free speech in laryngectomees - long term results]

BACKGROUND

Tracheostoma valves for laryngectomized patients were introduced to enable the laryngectomee after successful surgical voice restoration either by a voice prosthesis, a surgical shunt or microvascular laryngoplasty, to speak without using his fingers to close the tracheostoma. The basic principle of these aids is a mobile valve, which closes automatically at a certain air flow, directing the expired air of the lungs into the pharynx. In spite of the clear advantage of enabling a hands-free speech, the long term acceptance rate is still rather low, which is mainly caused by problems of an airtight fixation within or at the tracheostoma. Another important disadvantage of these tracheostoma valves is the necessity of removing the valve during coughing. The new tracheostoma valve "Window" (ADEVA Company, Lübeck, Germany) offers a clear improvement regarding this point. It is constructed with an additional coughing lid, which opens at a certain airflow and closes automatically after the coughing attack. After successful development and clinical testing of the new aid in 1999 and 2000, it was now the question, if the previously low acceptance rate of tracheostoma valves could be improved in the long term use by this new type of valve.

PATIENTS

Within the last 4 years 70 patients were provided with the "Window" tracheostoma valve. Patients were followed up at regular intervals in order to evaluate the function, the acceptance and the durability of the new device. Additional to the clinical examination patients had to fill in a questionnaire in order to investigate the subjective estimation by each patient himself. 15 patients did not send back their questionnaire or did not fill it in correctly, 5 patients refused clinical supervision after adjustment of the device, so finally the long term use in 50 patients could be analysed.

RESULTS

82 % of the patients reported, that the coughing lid worked safely and opened immediately during the coughing attack. Most of the patients were satisfied with their device, but had nevertheless some proposals for a further improvement: although they cover the tracheostoma either with their clothes or a protection scarf, most of the patients would prefer a device which is smaller than the current model. Some patients reported on an insufficient stability of the plastic material, which led to a defect at the sliding mechanism of the coughing lid. The greatest problem regarding the regular use of the valve was - comparable to conventional tracheostoma valves - the occurrence of an air leakage around the tracheostoma. Although there are three different models of the "Window" tracheostoma valve available, only patients being fitted with the "standard-T-type" version could wear the device 10 hours a day or longer without any problems of air leakage.

CONCLUSIONS

The "Window" tracheostoma valve with an integrated coughing lid provides further improvement in speech rehabilitation of laryngectomees. The actual rate of acceptance of 62 % for all "Window" patients (1 month daily use for at least 2 hours) is superior to other reports on the use of tracheostoma valves and probably caused by the additional comfort provided by the coughing lid. Another important factor for the long term use of tracheostoma valves is however the safe fixation of the device in or around the tracheostoma. In this point further improvement is necessary, as only the model with the fixation within the trachea (T-type) led to a satisfactory long term airtight fixation.

A new problem-solving indwelling voice prosthesis, eliminating the need for frequent Candida- and "underpressure"-related replacements: Provox ActiValve

OBJECTIVES

To develop and clinically assess a new prosthesis for voice rehabilitation after total laryngectomy that solves the problem of frequent Candida- and "underpressure"-related replacements.

MATERIAL AND METHODS

We designed a voice prosthesis with a new valve mechanism, applying Candida-resistant fluoroplastic (Teflon-like) material for the valve and valve seat and magnets to generate an active closing force, preventing inadvertent opening of the valve during swallowing or deep inhalation. Several prototypes were tested in 13 laryngectomized patients and, subsequently, the final design was assessed in a prospective clinical trial in a cohort of 18 patients with a short device lifetime of their standard indwelling voice prosthesis (mean 30 days).

RESULTS

Prototype testing and the long-term clinical trial confirmed that the new valve material remained free of Candida growth and that the use of magnets can prevent inadvertent opening of the valve during swallowing and/or deep inhalation. This resulted in a highly significant increase in device lifetime in the 18 laryngectomized patients in the prospective trial (14-fold increase on average, range 3-39-fold; p < 0.001). Lubrication with special medical-grade fluoridated silicone oil is favorable in patients who experience possible adhesion of the valve to the valve seat.

CONCLUSIONS

This new voice prosthesis, the Provox ActiValve, represents a solution for patients who have the problem of requiring very frequent voice prosthesis replacements due to excessive Candida growth and/or inadvertent opening of the valve by swallowing and inhalation-related underpressure in the esophagus.

Custom modification of the Blom-Singer tracheostoma valve housing

A technique is presented for modifying the Blom-Singer tracheostoma valve housing to improve peristomal skin adherence for hands-free tracheoesophageal speech production following total laryngectomy. The finished product is thin, flexible, and maintains enhanced tear strength. The edges of a standard housing device for the Blom-Singer valve are trimmed to allow for better accommodation to the tissue surface without distortion. A punch biopsy instrument is used to cut uniform holes around the housing device to allow for permeation of the silicone mixture for better mechanical adherence of the materials.

Voice Rehabilitation after Total Laryngectomy Using the Provox R Voice Prosthesis

Esophageal speech is the first choice for vocal rehabilitation in laryngectomized patients. However, shunt speech is a needed alternative for patients who cannot succeed at esophageal speech. Many kinds of voice prostheses, with good results, have been reported. Provox was selected for 15 laryngectomized patients who were treated in our department. Voice rehabilitation was successful in 13 patients. However, removal of the prosthesis was required in one patient because of stomal stenosis. Voice rehabilitation was not successful in one patient who exhibited esophageal stenosis. The rate of voice rehabilitation was not influenced by the extent of surgery, the dose of radiation, etc.. The maximum phonation time was more than 10 minutes in the 13 patients who succeeded at shunt speech. Prosthetic rehabilitation was requested by two patients who had been successful at esophageal speech. These results suggest that prosthetic voice rehabilitation may be indicated for a wide range of conditions.

Laryngopharyngectomy with reconstruction

A wide range of reconstructive options allows the ablative surgeon to resect tumors completely with wide margins. Wide resection is especially important because of the rich lymphatic drainage and submucosal spread seen with carcinomas in the hypopharyngeal area. Postoperative stenosis can be a difficult, recurring problem if the neopharynx does not have enough tissue incorporated into the closure. Therefore, most laryngopharyngectomy procedures benefit from the addition of transposed tissue, either pedicled or using free tissue transfer microvascular techniques. Often the location of the tumor is a major factor in determining which reconstruction is best for the patient. Minimizing the donor-site morbidity must be carefully considered, also.

Functional characteristics of a new electrolarynx "Evada" having a force sensing resistor sensor

Electrolarynxes have been used as one of the rehabilitation methods for laryngectomees. Earlier electrolarynxes could not alter frequency and intensity simultaneously during conversation. Recently, we developed an electrolarynx named "Evada" (prototype so far) using a force sensing resistor (FSR) sensor that can control both frequency and intensity simultaneously during conversation. Employing three types of electrolarynxes (Evada, Servox-inton, Nu-vois), this study was undertaken to examine the functional characteristics of Evada for the normal control group and for laryngectomess. Five laryngectomees and five normal adults were asked to express three sentences (declarative sentence, "You stay here.", interrogative sentence, "You stay here?", and imperative sentence, "You! Stay here.") using three types of electrolarynxes. Frequency and intensity changes between the first and last vowels in the three sentences were calculated and analyzed statistically by paired t test. The frequency changes in the interrogative and imperative sentences were more prominent in Evada than in Servox-inton and Nu-vois. The intensity changes in the interrogative and imperative sentences were also more prominent in Evada than in Servox-inton and Nu-vois. Evada controls frequency and/or intensity by having the subject press the control button(s). Therefore, Evada appears to be better at producing intonation and contrastive stress than Nu-vois and Servox-inton.

[Tracheostomy valve with integrated cough flap for improving hands-free speech in laryngectomized patients--development and clinical applications]

BACKGROUND

Following successful voice restoration after laryngectomy either by a voice prosthesis, a surgical shunt or microvascular laryngoplasty, a further goal in rehabilitation is the insertion of a tracheostoma valve, which enables the patient to speak without using his fingers for closure of the tracheostoma. One important disadvantage of the tracheostoma valves, which are available today, is the necessity of removal of the valve in case of coughing, because the valve could be thrown from the stoma by the strong air flow during coughing. As many laryngectomies suffer from chronic bronchitis, this coughing problem is one of the reasons why only few patients could be provided with this useful aid.

METHOD

At the department of biomedical engineering of the faculty of medicine at the university of Groningen, the Netherlands, 1994 two prototypes of a tracheostoma valve with an integrated cough lid were developed. These devices contain two separate valve systems: the normal speaking valve and a special coughing valve, which opens at a certain air flow and closes automatically after the coughing attack. Thus no manipulations are necessary during coughing, the patient can speak undisturbed. The ADEVA company (Lübeck, Germany) undertook the industrial production of this new type of tracheostoma valve creating different modifications of the prototype #2.

PATIENTS

In four series with 6-8 patients per group the modified tracheostoma valves were tested clinically and the occurring faults or lack of correct function eliminated by small changes in the production.

RESULTS

Meanwhile a suitable model for routine use is available, which was tested in 30 patients so far. This suitability was achieved by improvements in the valve mechanism, the valve seal and the adjustment mechanisms for the individual pressure level of the speaking and the coughing valve.

CONCLUSION

The newly developed tracheostoma valve with integrated coughing lid (Window, ADEVA-medical Company, Lübeck, Germany) provides further improvement in speech rehabilitation of laryngectomies. The low acceptance of tracheostoma valves, which enable the patient to speak without using his fingers for closure of the tracheostoma, possibly may be raised by this new aid.

Custom retainer for the Blom-Singer adjustable tracheostoma valve

This article presents a procedure that allows the laryngectomy patient to be fitted with a well-sealed custom device. The custom device provides near-normal speech during a variety of activities. The custom retainer for the Blom-Singer adjustable tracheostoma valve can be fabricated with medical grade silicone using routine prosthodontic techniques.

Fabrication of a custom silicone tracheostomal prosthesis

Patients with a tracheostomy stoma experience compromised speech due to the associated changes in airflow patterns. Prosthetic obturation of the stoma restores the normal airflow patterns required for proper speech. Standard stent tubes may not adequately obturate the defect and may be uncomfortable to wear. The fabrication of a custom silicone tracheostomal prosthesis, incorporating a speaking valve, provides proper obturation of the defect and improved patient comfort, fit, and function. This article presents the procedures used to make a functional impression of a tracheostomy stoma and to fabricate a custom tracheostomal prosthesis.

Comprehensive rehabilitation after total laryngectomy is more than voice alone

Comprehensive rehabilitation after total laryngectomy is more than voice alone. The removal of the larynx and the subsequent disconnection of the upper and lower airways not only has consequences for the vocal function but also for the respiratory system, and for the olfactory acuity of the patient. The results of the research program on these three subjects in the Netherlands Cancer Institute over the last 12 years are discussed in detail along with some of the relevant other literature on the topics. The considerable progress in these areas over the last 2 decades has clearly improved the quality of life of laryngectomized patients.

Biofilm formation on voice prostheses: influence of dairy products in vitro

Laryngectomized patients use silicone rubber voice prostheses to regain their speech, however, the lifetime of these devices is limited due to biofilm formation. Following anecdotal evidence, the influence of various dairy products on biofilm formation on voice prostheses was studied, using the artificial throat-model. Biofilms were grown on Groningen and Provox2 voice prostheses by inoculating two artificial throats with the total microflora isolated from an explanted Groningen voice prosthesis. After 3 days, one throat was perfused three times daily with 650 ml dairy product; the other was perfused with phosphate buffered saline, used as a control. After 12 days the microflora on each voice prosthesis was determined. Perfusion of the artificial throat with buttermilk three times daily for 9 days reduced the amount of bacteria and yeasts in the biofilm on Groningen voice prostheses to 3% and 15% of the control, respectively. These effects were not observed with a pasteurized conservable buttermilk product. Yakult fermented milk drink, Mona mild yoghurt, Mona vifit yoghurt, semi-skimmed milk and low-fat yoghurt reduced the amount of bacteria by various degrees, ranging from 12% (Yakult) to 88% (Mona mild) of the control, but these products did not inhibit, and sometimes even stimulated, yeast growth. A combination of buttermilk and Yakult did not show a synergistic effect, as expected. Effects for the Provox2 voice prosthesis were less pronounced. These in vitro experiments in the artificial throat demonstrated that the formation of the biofilm on voice prostheses can be lessened by the daily use of certain dairy products, of which buttermilk had the strongest inhibitory effect, followed by Yakult.

Passy-Muir valve in children with tracheotomy

INTRODUCTION

Early vocalization and speech production remains a goal in children who require tracheotomy for airway obstruction or chronic ventilation. Although studies document the efficacy of the Passy-Muir valve (PMV) in adults, none have reviewed its efficacy in children. We performed this study to better understand the clinical complexity of its use in children.

MATERIALS AND METHODS

Retrospective evaluation of 55 consecutive cases of children with tracheotomy using the PMV.

RESULTS

The children ranged in age from 3 days to 18 years at the time of their tracheotomies, and nearly half were 12 months old or younger. Successful use often requires patient and family conditioning. Overall, 52 children out of the 55 who were evaluated as candidates for the PMV tolerated its use. Many required two or more trials prior to the patient and family being comfortable with its use.

CONCLUSIONS

The PMV may be used successfully in children with a variety of airway pathologies as well as diverse medical problems. Discussed is the current protocol for the evaluation of the patient and the introduction of the valve.

The ultra-low resistance Groningen voice prosthesis: aerodynamic properties

Post-laryngectomy voice rehabilitation using the low resistance (LR) Groningen voice prosthesis has over the past years provided good voice and speech results. The valve part of the prosthesis is largely responsible for the airflow resistance of the prosthesis. This study was performed to evaluate if by modifying the valve part of the LR Groningen prosthesis a lower airflow resistance in vitro could be achieved. Several prototypes with modified valves were tested. Based on the aerodynamic measurements the prosthesis with a single slit of 200 degrees in the 'hat' of the esophageal flange was selected for further evaluation and named the ultra-low resistance (ULR) Groningen voice prosthesis. Aerodynamic measurements were performed and showed the airflow resistance of the ULR Groningen voice prosthesis to be significantly lower than the resistance of the LR Groningen and the Provox voice prostheses.

The influence of stoma occlusion on aspects of tracheoesophageal voice

In this study, speech of 21 laryngectomized patients is investigated under 2 different stoma occlusion conditions, i.e. direct digital occlusion of the stoma (by thumb or finger), and digital occlusion (by finger) via a special heat and moisture exchanger with speech valve (Provox Stomafilter). For both conditions, acoustical analyses of voice quality (various pitch, amplitude, tremor and harmonicity measures) were performed on a sustained /a/, the mean maximum phonation time was calculated, and a phonetogram was made. Acoustical analysis was possible in 13 of the 21 voices (for the other voices, the pitch was too low or the voice was too aperiodic), but no statistical significant differences were found for any of the acoustical parameters studied. However, the maximum phonation time was significantly longer, and the dynamic range significantly larger, under the Stomafilter occlusion condition. The maximum phonation time showed a relevant improvement in 57% of the patients, while the dynamic range showed a relevant improvement in 35% of the patients. In total, 75% of the patients experience an improvement in one or both of these speech characteristics when using the Stomafilter occlusion. It can be concluded that optimal stoma occlusion by means of a specialized device has a positive influence on two relevant parameters of prosthetic voice production: maximum phonation time and dynamic loudness range.

An easier way to speak again

This article looks in detail at evaluation of the use of the Provox 2 voice prosthesis. Use of the device in selected patients has had a number of benefits including less mucus production, less awareness of the valve, reduction in the effort needed to produce sound, and easy and quick removal and insertion of the device.

Airflow and pressure characteristics of three different tracheostoma valves

Tracheoesophageal speakers can achieve speech without digital occlusion by using a tracheostoma valve. Laryngectomized patients who are successful with this device can regain considerable freedom. However, little is known about which valve suits the patient best. Valve aerodynamics may give a guideline for its use. Three major tracheostoma valves, each divided into four subtypes, were repeatedly measured in this study. Dynamic pressure and airflow rate signals were sampled through an analog-digital interface into a computer. Considerable aerodynamic differences were observed between the tested valves. The maximum airflow rates, closing pressures, and resistances at low velocities were compared. The presented data may help increase the successful use of tracheostoma valves in tracheoesophageal speakers. Patient factors and additional valve factors should always be taken into account. Further clinical study to validate the clinical relevance of the data is needed.

Analysis of the mechanical behavior of the Nijdam voice prosthesis

The valveless Nijdam prosthesis is a new voice prosthesis for laryngectomized patients using tracheoesophageal speech. An "umbrella-like hat" covers the esophageal side of the tracheoesophageal fistula and is deformed during speech by air pressure. To decrease pressure loss during speech, a good understanding of the mechanical behavior is essential. In the present study, the Finite Element Method (FEM), used in engineering to analyze the mechanical behavior of complex structures, was applied to analyze eight possible improvements of the Nijdam prosthesis. This study found that, during speech, deformation of hat and soft tissue occur. Distinct differences in the hat's deformation of the eight models also were found. It is concluded that complex structures like the Nijdam prosthesis can be analyzed by FEM. An optimal model was found to decrease pressure loss while stresses in the device remain safe.

Tolerance of the Passy-Muir Speaking Valve in infants and children less than 2 years of age

Research literature confirms the intuitive reasoning that tracheotomy may adversely influence speech acquisition in infants and children. The Passy-Muir Speaking Valve (PMSV) permits inspiration through the tracheotomy stoma and expiration through the glottis, allowing for phonation. Although adults with tracheostomies have demonstrated the ability to speak using the valve without respiratory compromise, there is scant literature regarding the use of this valve in the infant or child population. A retrospective review of 64 charts was conducted to examine documented evidence of tolerance of the PMSV in infants and children 2 years of age and less. Of the 29 children trialed, 24 (83%) tolerated the PMSV and 75% of those children produced vocalization on the first trial. Another 21% produced vocalization on a subsequent trial. The implications of this study indicate that the speaking valve is safe for use in infants as young as 13 days of age when the child is trialed in a monitored setting using appropriate guidelines.