Patients after total laryngectomy have their vocal cords, which normally pronounce sounds, removed at the same time as the tumor is removed. While suffering from physical blows, their usual speech communication function is also lost, and their quality of life is greatly reduced. Therefore, how to make the patients after total laryngectomy sound and give them a normal life has become a long-standing direction for otorhinolaryngology head and neck surgeons to work on. Unlike normal exhalation through the mouth and nose, post-total laryngectomy patients breathe through an anterior cervical stoma. In order to flow with others, these patients must learn a new method of articulation for them.
At present, there are three main articulation methods, one is electronic larynx, the second is esophageal articulation, and the third is tracheoesophageal articulation, and these three methods are introduced one by one below.
I. Pronunciation reconstruction after total laryngectomy – electronic larynx
The electronic larynx is a hand-held semiconductor device with a plastic vibrating membrane, similar in size to an electric razor. In order to make sound, the end of the electronic larynx is placed on the best articulation point on the front side of the neck to transmit sound into the pharynx to constitute the language It is clean and convenient to use, but slightly expensive, the battery needs to be recharged, and the articulation is not ideal for those who have undergone cervical lymphatic drainage or radiotherapy.
Some patients need some time training to put the electronic larynx in the right position of the neck, and to achieve clear pronunciation also needs some training, although the sound from the electronic larynx is a mechanical sound, if the pronunciation is correct, it will be easily understood, whether face to face or by telephone.
1.The advantages of electronic larynx
(1) You can speak for a long time and be easily understood.
(2) No other care is needed, just put the electronic larynx on the neck.
(3) The electronic larynx can be adapted to basically anyone, although the method of neck surgery may be different, and in some cases when it cannot be used due to wound scar formation, the intraoral type electronic larynx can be applied.
2.Disadvantages of electronic larynx
(1) The sound of the electronic larynx sounds a bit mechanical and metallic, which is not so natural sounding.
(2) You need to hold the electronic larynx with your hand when using it.
II. Pronunciation after total laryngectomy – esophageal pronunciation
The basic principle is to use the esophagus to store a certain amount of air and force the air out of the esophagus with the help of intrathoracic pressure, just like burping, to impact the upper end of the esophagus or the mucous membrane of the pharynx and pronounce. Practice method: When inhaling, use the negative pressure in the esophagus and move the tongue to the back to press the air into the esophagus, then practice the contraction of abdominal muscles to make the diaphragm rise, increase the pressure in the chest, compress the esophagus and expel the air from the upper mouth to pronounce. Practitioners must go through two to three weeks of training, and some of the patients can achieve the same effect as normal people. The Department of Head and Neck Surgery of Cancer Hospital of Chinese Academy of Medical Sciences holds a class on esophageal articulation every year to help patients without larynx to practice esophageal articulation.
The advantage of esophageal articulation is that it is possible to speak without additional surgery and is generally easier to master. The tone is good and close to the normal laryngeal sound. The main disadvantage of esophageal articulation is that the duration of articulation is short and the consistency is poor.
III. Post-total laryngectomy articulation – tracheoesophageal articulation
Through the surgical method to create a tube or based on the posterior wall of the trachea and the anterior wall of the esophagus or pharyngeal stoma, a ventilation tube is installed, and the air enters the esophagus or pharyngeal cavity through the tube during the articulation, and then through the movement of the lips and tongue, it finally becomes speech. The new laryngeal reconstruction and new laryngeal surgery in China in recent years can selectively perform articulation reconstruction under the condition of tumor removal. There are various methods of reconstruction, which will not be described here. One is to make an articulatory tube directly between the trachea and esophagus through surgical methods, and the articulation will be performed through this tube in the future. The other method is to install a device between the trachea and esophagus – a pronunciation button. To do this, a fistula is made between the trachea and the esophagus and a one-way valve is placed on the fistula to prevent food from entering the trachea.
A tracheoesophageal interstitial fistula can be performed at the same time as a total laryngectomy or again as a minor postoperative procedure.
When speaking, the neck stoma must be covered with the thumb during exhalation. Note that when the thumb blocks the neck stoma, the gas can enter the esophagus through the tube between the tracheoesophagus, and with practice, the patient can use this gas to vibrate the esophagus and make a more normal sound after the mouth and lips are moistened.
1.Advantages of tracheo-esophageal pronunciation
(1) The quality of pronunciation is good and close to the normal laryngeal pronunciation, while the sound made by using electronic larynx is more mechanical.
(2) Because the gas from the esophagus comes from the lungs, the pronunciation time increases significantly, while the pronunciation through the esophagus alone is through the gas in the stomach, and the pronunciation time is shorter, and in addition, it is better than the pronunciation through the esophagus alone in controlling the airflow.
2.Disadvantages of tracheal-esophageal articulation
(1) Not all patients are suitable for tracheoesophageal articulation. In some patients, the wall of esophagus is constricted so that the air cannot pass easily, and when exhalation is performed, the gas cannot be expelled outward, just like blowing a test tube without an opening, so it is necessary to check whether the esophagus can perform such articulation before performing tracheoesophageal articulation surgery.
(2) The voice prosthesis placed in the middle of the tracheoesophagus must be removed and cleaned periodically, which requires some skill, especially when inserting the prosthesis, but now there is a built-in prosthesis that can be placed for several weeks to months at a time.
(3) The cervical stoma must be capped tightly to allow air to enter the esophagus during pronation, which requires good arm movement, and doing this may be difficult if the patient has cranial nerve damage at the time of surgery. There are also often problems with the valves on the prosthesis that prevent air from entering and causing failure of articulation.
(4) Sometimes food can enter the trachea. This can cause choking and coughing or pneumonia.
(5) If the prosthesis is dislodged, the fistula will be closed after 24 hours and a second surgery is needed. If it falls into the bronchus, it must be removed in time to avoid breathing difficulties.
It is believed that through different compensation methods, people without larynx will overcome the pain of having a mouth and live and work like able-bodied people.