Laryngectomees have traditionally had four communicative
alternatives. The first and least intrusive is any form of nonverbal
communication. . . writing, gesture/pantomime, or communication boards. While
effective, these methods are quite time consuming, tiring, and are only
effective for face-to-face situations.
The second alternative has been
esophageal speech. On the average less then 20% of all laryngectomee patients do
succeed in acquiring esophageal speech. Reasons for this lack of success may
include difficulty with air injection, tracheoesophageal fistulas, and
cardiopulmonary disease, resulting in decreased breath support and
endurance.
The third choice has been the electrolarynx. Devices cost
anywhere from $400 to $800. Subsequent therapy to master the use of the device
averages three to six months, twice per week, with the average cost of a session
being $120. Many patients achieve successful verbal communication in a timely
manner. Intraoral electrolarynxes are particularly useful immediately after
surgery, providing a means for verbal expression. However, intelligibility is
generally poor and hygienic concerns high secondary to the continual
introduction and removal of the straw from the oral cavity.
Neck-held
electrolarynxes also present contraindications. These include:
- post-surgical swelling, making it difficult to achieve
adequate placement for sound transmission
- post-surgical stiffness in the tissue surrounding the
incision, resulting in greatly decreased sound transmission.
- skin irritation, often caused by radiation therapy, which
is exacerbated by the continual use of the electrolarynx.
- arthritis in the hand, wrist, and/or elbow, resulting in
decreased ability or inability to sustain placement, sustain pressure on the
on/off button, or hold the prosthesis in place.
- radiation fibrosis, edema, or neck thickness, resulting
in reduced transmission of sound.
In
addition, other difficulties may prohibit the use of the electrolarynx
including.
- difficulty achieving a consistent adequate placement,
which severely reduces sound quality.
- neck pain during use of the prosthesis, as experienced by
radical neck dissection patients.
- lack of an adequate sound transmission site, as
experienced by radical neck dissection patients. Finally, many patients forego
use of an electrolarynx purely due to the robot-like sound quality and
subsequent self-consciousness.
The fourth alternative had been Tracheoesophageal
Puncture (TEP). Cost of the surgical procedure to create the puncture averages
$2000 to $3000, not including pre- and post-operative visits, medications,
supplies (prosthesis, French Catheters, saline solutions, etc.) and ensuing
speech therapy. Total cost can easily exceed $6000. Many patients have
successfully undergone this procedure since its inception. Perhaps the greatest
asset of TEP is the tremendous volume that some patients are able to achieve.
Clarity is also judged to be good to excellent, depending on the
patient.
Contraindications to TEP include:
- patient age.
- extensive neck scarring.
- radiation treatments, resulting in tightening of the
surrounding tissues and possible shrinkage of the stoma site.
- insufficient pulmonary strength due to cardiac or
pulmonary disease.
- constricted esophageal pathway.
- fistulas.
In addition,
the success of the TEP can be hindered by a patient's failure to properly care
for the prosthesis, improper fitting of the prosthesis with subsequent air
leakage and fungi build up. It is not uncommon for a patient to drop the
prosthesis into the trachea or lung creating a traumatic and painful situation
for the patient until it is removed by a doctor. Unfortunately about four people
in ten (40%) are not successful with the T.E.P. long term. This additional
surgery with a relatively low success rate can also lead to longer problems such
as infection and fistula as well as requiring admission to the emergency room
when voice prosthesis fall into the lung. As a result many laryngectomees opt
not to undergo this treatment.
A new device, UltraVoice Plus has been
developed which presents another option enabling laryngectomees to speak. This
new device consist of an oral unit which is worn inside the mouth and a
controller which transmits radio waves to the oral unit. The radio waves carry
the tone of the human voice which is reproduced in the mouth by the oral unit.
Because the sound is created within the vocal tract, it is significantly more
natural and intelligible then external units. In addition, it has been designed
to alleviate some of the contraindications associated with the other
technologies.
As the UltraVoice is worn in the oral cavity, typical
considerations such as edema, fibrosis, and placement sites are eliminated.
Worries about adequate sound transmission and skin irritation secondary to
radiation treatments are also eliminated. For arthritic patients, the control
unit can be operated with the side of the hand or wrist, or it can be equipped
with an adaptive device, i.e. built-up button, toggle switch, etc.
The
UltraVoice is worn all day like a regular denture or retainer, including for
meals. This provides the laryngectomee with the ability to eat and talk
simultaneously, a skill not attainable with esophageal speakers. It also
eliminates hygienic concerns, such as those involved with the intraoral
electrolarynxes.
In order to maximize usage of the UltraVoice, a short
course of therapy with a certified speech/language pathologist is highly
recommended. However, the laryngectomee is able to begin speaking intelligibly
with the UltraVoice from the moment it is inserted. Clarity is judged to be
excellent. Patients incorporating esophageal speech, electrolarynxes, and
sometimes TEP's are unable to achieve independent verbal communication until
further into their course of treatment.
The only contraindication for the
UltraVoice is intolerance to an intraoral prosthesis. Age, fistulas, and
cardiopulmonary status do not affect the laryngectomee's success. Conversely,
the UltraVoice is quite helpful for those patients with cardiopulmonary disease,
as the UltraVoice serves as an energy conservation device for these patients and
provides them with the ability to speak significantly longer without
fatigue.
Compared to procedures like the TEP, the UltraVoice is markedly
less expensive. While TEP cost include preoperative visits, surgery, physician's
fees, supplies, medications, post-operative visits, and a course of speech
therapy, the UltraVoice is all inclusive. The UltraVoice fee includes the cost
of the dental fittings, the denture and the actual prosthetic elements. The only
extra expenditure is a brief course of therapeutic instruction. Furthermore, the
average course of therapy for the UltraVoice is significantly shorter then that
for esophageal speakers, resulting in comparable total cost between these two
rehabilitative means. The UltraVoice is also significantly less expensive then
electronic communication boards, which average $5,000 to $6,000 not including
the cost of therapeutic instruction.
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