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Original Article Assessment of Alaryngeal Speech Using ORIGINAL ARTICLE ASSESSMENT OF ALARYNGEAL SPEECH USING A SOUND-PRODUCING VOICE PROSTHESIS IN RELATION TO SEX AND PHARYNGOESOPHAGEAL SEGMENT TONICITY M. van der Torn, MD,1 C. D. L. van Gogh, MD,1 I. M. Verdonck-de Leeuw, PhD,1 J. M. Festen, PhD,1 G. J. Verkerke, PhD,2 H. F. Mahieu, PhD1 1 Department of Otolaryngology/Head & Neck Surgery, Vrije Universiteit Medical Center, P. O. Box 7057, 1007 MB Amsterdam, The Netherlands. E-mail: [email protected] 2 Department of Biomedical Engineering, University of Groningen, Groningen, The Netherlands Accepted 23 August 2005 Published online 9 February 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20355 Keywords: laryngectomy; artificial larynx; voice prosthesis; Abstract: Background. A pneumatic artificial sound source alaryngeal speech; voice 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-pro- Total laryngectomy, as surgical treatment for ducing voice prosthesis (SPVP) is evaluated for a brief period and compared with their regular tracheoesophageal shunt locally advanced laryngeal tumors, interferes speech. with all functions of the larynx (ie, phonation, res- Results. Perceptual voice evaluation by an expert listener piration, deglutition, and indirectly olfaction). and acoustical analysis demonstrate a uniform rise of vocal pitch The most persistent problems of patients with lar- when using the SPVP. Female laryngectomees with an atonic yngectomies are related to the loss of voice.1,2 It is pharyngoesophageal segment gain vocal strength with the SPVP. Exerted tracheal pressure and airflow rate are equivalent generally acknowledged that rapid and effective to those required for regular tracheoesophageal shunt valves. voice restoration is critical to the successful reduc- However, communicative suitability and speech intelligibility tion of psychological, social, and economic set- deteriorate by the SPVP for most patients. Tracheal phlegm backs induced by postlaryngectomy aphonia.3,4 clogging the SPVP is a hindrance for most patients. Since laryngectomy has been performed, numer- Conclusions. The SPVP raises vocal pitch. Female laryngec- tomees with an atonic or severely hypotonic pharyngoesopha- ous attempts have been made with varying suc- geal segment can benefit from a stronger voice with the SPVP. cess to obtain or improve the postlaryngectomy VC 2006 Wiley Periodicals, Inc. Head Neck 28: 400–412, 2006 voice by creating a pneumatic artificial source of voice production.5 Esophageal injection voice and electrolarynx devices, however, formed the stand- Correspondence to: H. F. Mahieu ard approaches to alaryngeal voice rehabilitation Contract grant sponsor: This study was supported by grant GGN until tracheoesophageal (TE) puncture incorpo- 55.3712 from the Dutch Technology Foundation STW. rating a silicone shunt valve prosthesis6 evolved VC 2006 Wiley Periodicals, Inc. worldwide as an established technique for post- 400 Sound-producing Voice Prosthesis HEAD & NECK—DOI 10.1002/hed May 2006 Table 1. Clinical data for the study group; female and male, in order of pharyngoesophageal segment tonicity. Months PE segment Patient Age Sex postoperative Myotomy Postoperative RT tonus F1 52 F 54 Yes Yes Atonic F2 65 F 31 Yes Yes Atonic F3 68 F 46 None Yes Atonic F4 76 F 47 Yes Yes Atonic F5 69 F 102 Yes None Severely hypotonic F6 77 F 91 None None Slightly hypotonic F7 53 F 38 Yes Yes Slightly hypertonic F8 76 F 49 Yes None Severely hypertonic F9 79 F 114 None None Severely hypertonic M1 52 M 32 Yes None Slightly hypotonic M2 69 M 31 Yes None Slightly hypotonic M3 71 M 115 Yes None Slightly hypotonic M4 74 M 41 Yes None Slightly hypotonic M5 76 M 31 None None Slightly hypotonic M6 56 M 52 Yes None Normotonic M7 63 M 20 None Yes Normotonic M8 76 M 29 Yes None Slightly hypertonic M9 77 M 65 Yes Yes Severely hypertonic M10 78 M 44 Yes Yes Severely hypertonic M11 64 M 14 Yes None Spasmodic Abbreviations: RT, radiotherapy; PE, pharyngoesophageal; F, female; M, male. laryngectomy voice restoration. The advantages pneumatic sound source to be incorporated in a of this method over esophageal injection voice are regular TE shunt valve was designed.16 Preceding louder phonation and better intelligibility7;in in vivo studies17,18 proved the feasibility of this addition, it usually enables quick and trouble-free voice production and provided us with directions voice acquisition, higher speech rate, and more for the development of an updated series of sound- sustained phrasing because of a larger available producing voice prostheses (SPVPs). These were air reservoir.8,9 evaluated in vitro by aero-acoustic measurements The term ‘‘voice prosthesis’’ is widely used in and detailed high-speed photographic sequences the literature when referring to TE shunt valves, to establish the most promising sound source con- although these devices do not actually produce figuration for clinical use.19 This article describes sound. In both esophageal injection voice and TE the results with the selected SPVP group of 20 shunt voice, the passage of air through the pha- laryngectomized patients. Our objective was to ryngoesophageal (PE) segment sets the closely determine for which group of laryngectomees an approximated mucosal surfaces of this structure SPVP might be beneficial, in particular with into vibration, producing a low-pitched sound, respect to the patient’s PE segment tonicity and which can be used as a substitute voice. If, how- sex. ever, the tonus of the PE segment is too low to attain sufficient mucosal approximation, the resulting voice will be weak and breathy or merely MATERIALS AND METHODS a coarse whisper.10,11 With sufficient approxima- tion, the vibrating mass is often fairly large, which Patients. The patients were nine women and 11 yields a low fundamental frequency (f0). Female men, with a mean age of 69 years (range, 52–79 laryngectomees in particular often have severe years). All underwent total laryngectomy with TE problems accepting their low-pitched alaryngeal 14 to 115 months before this study (mean, 52 12,13 voice. The mean speaking f0 of laryngeal months). Eight patients received radiotherapy af- female voices is 211 Hz (SD, 2.7 semitones),14 ter laryngectomy, nine subjects underwent unilat- which decreases after laryngectomy and current eral or bilateral neck dissections, six patients voice rehabilitation to an unnaturally low mean f0 required pedicled or free flap reconstructions, and of 108 Hz (SD, 28 Hz).15 To improve voice quality 15 patients underwent a primary pharyngeal my- for these two groups of laryngectomees (women otomy. Clinical data are summarized in Table 1. and those with a hypotonic PE segment), a small All patients received a new Groningen ultra-low- Sound-producing Voice Prosthesis HEAD & NECK—DOI 10.1002/hed May 2006 401 FIGURE 1. Blueprint of the sound-producing module with bent silicone lip in gray (dimensions in millimeters). resistance (ULR) shunt valve before the tests. Spoken and written informed consent was ob- tained from all patients in this study. The medical ethics committee of the Vrije Universiteit Medical Center, Amsterdam approved the research pro- tocol. Sound-producing Voice Prosthesis. The new sound source consists of a single bent tapered silicone lip (11.0 3 3.3 mm), which performs self-sustaining oscillations driven by the expired pulmonary air that flows along the outward-striking lip20 FIGURE 2. Prototype of the sound-producing module in a Gro- through the TE shunt valve. The resulting fre- ningen ULR shunt valve. quency of oscillation and sound intensity can be modified by altering the airflow along the lip.16 For female voice frequencies, the optimal lip Procedure and Speech Recordings. Before being thickness is 0.5 mm at the base and 0.3 mm at the recorded with the new sound-producing module free tip; for male voice frequencies, lip thickness is inserted in their TE shunt valve, patients were 0.35 mm at the base and 0.25 mm at the free tip. encouraged to experience and practice this new These lip configurations were selected by in vitro mechanism of alaryngeal voice for approximately benchmarking using two criteria: favorable sound 1 hour. Two block-randomized groups of patients 19 quality and most natural f0 range for each sex. (block size 2) were formed for this crossover trial. To allow easy placement and removal of the One group started all of the described vocal tests sound source for speech evaluation purposes in with their own Groningen ULR shunt valve, our experimental setting, the bent silicone lip was whereas the other group first performed all mea- fitted in a small stainless steel container (Figure surements with the SPVP. All subjects’ voices 1), that can be partly inserted in a patient’s Gro- were recorded in a sound-treated room, using a ningen ULR shunt valve (Figure 2). Thus, the microphone (MKE 212-3, Sennheiser, Germany) SPVP could be evaluated without the need of and a DAT-recorder (DA-7, Casio Computers, Ja- repeatedly replacing the entire shunt valve. The pan). Subjects were asked to read the first para- intention is to eventually integrate the bent sili- graphs of the Dutch prose ‘‘De Vijvervrouw’’ in a cone lip in the design of a regular TE shunt valve. normal conversational manner. Digital recordings 402 Sound-producing Voice Prosthesis HEAD & NECK—DOI 10.1002/hed May 2006 of approximately 90 seconds were made for each scales, developed by Nieboer22 and later modi- laryngectomee with both types of voice prosthesis. fied,23,24 was adapted for our purpose. This subset These recordings were used for the communica- included the five scales ‘‘high pitch– low pitch’’, tive suitability judgments, the perceptual voice ‘‘weak–powerful’’, ‘‘tense–nontense’’, ‘‘gurgling– evaluation, and to establish speech rate deter- nongurgling’’ and ‘‘melodious–monotonous.’’ The mined as the number of syllables per minute 40 digital recordings were presented in random (spm).
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