EsophagealSpeech

Descr
ipt
ion:

Esophagealspeech i nvolvest he product i

on ofa voi ce sour ce
wi t
hint heesophagususi ngairsuppl iedbyt hepat i
ent .Theesophagusi sa
muscul artubethatbegi nsjustbehindt helarynx.Themosti nferiorpor tion
oft heinferiorconstr
ictormuscl e,calledt hecricophar yngeus,ext endsf rom
thecr icoidcarti
lagetoi nsertonpor tionsoft hephar yngealpost eri
orlyand
intot heesophagus.Sur geonsat temptt oleavet hismuscl ei ntactdur ingl
laryngealso i tcan be used t o const rictthe esophagus and per mi tt he
trapping of ai rinferi
or l
y.When t he ai ri s expel l
ed t hrough a neuon
const rict
ionint heesophaguser ectedbyt hecr icophar yngeusmuscl e,t he
neuewed segment( the pharyngeal–esophagealorpat i
entsegment ).Wi l
l
vibrate,pr oducing sound.The pat ienthas t he capabi l
ity ofpr oduci ng
per i
odicsoundatt hebegi nni
ngoft hevoi dtractsi milartot hatpr oducedi n
nor malspeech.Esophagealspeech i s based on t he technique in which t he
pati
entt ransportsasmal lamount( ±75ml )ofairintot heesophagus.Probably
duet oani ncreasedt hor
acicpr essure,theairisforcedbackpastt hephar yngo-
esophageal( PE)segmentt oi nduce r esonance.
Thisr esonance i
st he sound
sourcet hatall
owsspeech.Rapi dr epeti
tionoftheaf or
ement i
onedairtransport
canpr oduceunder st
andabl espeech.

Thephar
yngo-
esophagalsegment

•Thi
sist
hear
eawhi
chsepar
atest
hephar
yngealandEsophagalcavi
ties.

•Itl
iesatapproximat
elythesamecer
vicalver
tebr
all
evelast
hel
arynx
usedto(i
.e.between(C4-
C6).

•TheP.
Esegmenti
sofl
engt
h0.
8-1i
nches.

I
tcont
ains3gr
oupsofmuscl
es.

Att
het
op;f
iber
sfr
om t
hei
nfer
iorconst
rict
or.

Thelowestfiber
softheinfer
iorconstr
ict
orfor
m abandcal
ledt
he
cri
copharyngeusmuscle,andAcircul
arfi
berfr
om t
hemouthoftheupper
esophagus.
•Compressi
ng airi
ntothe esophagus t
hen r
eleasi
ng t
he ai
r,causi
ng t
he P-
E
segmenttovibr
ateandproduci
ngesophagalt
oneusedforspeech.

•
Gener
all
yther
ear
e3-
4met
hodsusedt
oteachesophagalspeech.

•
Allmet
hodsr
elyupont
hepr
inci
plet
hat

•Ifthetwochamber sar
econnected( i
.e.
,iftheP-Esegmentisopen),t
henai
rof
greaterpressurei
nonechamber( i.e.
,oralcavit
y)flowsint
othechamberwi t
h
lesspressure(t
heesophagus)andcanber ever
sedandusedforspeech.

•
Regardlessofthemet hodused,thegoalsaref ort
hepatienttobeabletorapi
dly
i
mpound airintothe esophagus,expelairf r
om the esophagusin a cont
rol
led
manner,andproducefluentEsophagalspeech.

•Normaltoni
cit
yofPE segmenti
sessent
ialf
ort
heacqui
sit
ion ofesophageal
speechorTEPspeech.
Candi
dacy:
Candi
dacy for esophageal or TEP speech can be det
ermi
ned by
admi
nist
eri
ngtheAirI
nsuffl
ati
onTest.

AI
RINSUFFLATI
ONTEST:

GivenbyTaubandBugner(1973) .Acat
heterispassedt
hroughthepat
ient
’s
noseintotheesophagustothelevelofthetracheost
oma,andairisthengent
ly
blownint
ot hecat
heterbyt
heexami ner
.

Astheairexitsthecatheter
,itshouldcausetheP-Esegmentt ovibr
ate,thus
causinganesophagealt onetobeemi ttedfrom t
heoralcavit
y.Theairshouldflow
easil
yt hrough the cat
heterand t he esophagealtone thatresul
ts should be
suff
icientforspeakingpurposes.

I
ftheesophagealt
oneproducedduri
ngtheairi
nsuf
flat
iontesti
sveryweak
orabsentitmayindi
cat
ethatthepat
ienthasmuscul
arweaknessinther
egionof
theP-Esegment.

Thist ypeofweaknesswoul dmostl ikelydisqual i

fyt hepatientfortheTEP
procedureduet oinsuffi
cientP-
Esegmentt ensi
onf orvoicingpurposes.Select
ive
myotomy- SingerandBl om (1981)haveshownt hatphar yngoesophagealspasm
can be r esponsible for approxi
mat el
y 12 per cent of f ail
ures to achieve
sati
sfactoryspeechaf t
erTEPsur gery.

Tr
eat
mentf
orpat
ient
swhof
ailt
hei
nsuf
flat
iont
est
:

Secondar
yphar
yngealconst
rict
orandcr
icophar
yngeusmyot
omy.

-Si
ngerandBl
om (
1981)

Phar
yngealPl
exusNeur
oct
omy

-Si
nger
,Bl
om andHamaker(
1985)
Ty
pesofai
rint
akepr
ocedur
es:

I
NHALATI
ON:

Askthepati
enttotrytov er
yquickl
ysnif
fthr
oughthenose.Event
houghnoair
canact ual
l
ybesniff
edintot henosebecauseofthealt
eredai
rway,t
hesuddenchest
expansionthati
sassociatedwiththemuscularmovementofsnif
fi
ngisoft
ensuffi
cient
toreduceesophagealairpressureandall
owtheentryofai
r.

•Next
,askt
hepati
enttoexhal
eandt
ryt
ophonat
e/a/
.Ift
hisi
sunsuccessf
ul,
askt
he
pati
entt
otr
yitonceagai
n.

•
Negati
vepressur
eint
heesophaguscanbei
ncr
easedi
fthest
omai
squi
ckl
ycov
ered
midwaythr
ougharapi
dinhal
ati
on.

•Si
milar
ly,
occl
udingt
hestomaduri
ngexhalat
ionwil
lai
dincompr
essi
onoft
he
esophagusandthusf
aci
li
tat
etheexpul
sionofair
.
•I
fthepatientissuccessfuli
nproduci
ngan/ a/wi
ththi
stechnique,askthepat
ientt
otr
y
toproducet hesy l
l
ables/pa/
,/t
a/,
and/ ka/usi
ngasnif
finhalat
ionbefor
eeach
att
empt edpr oducti
on.Conti
nuepract
icingwit
hmonosyll
abicwords.

•Whenthepati
enti
sabl
etopr
oducemonosyll
abicwordswit
hsomecont r
ol,hav
ethe
pat
ientt
ryonceagai
ntouset
heconsonant
-i
nject
ionorgl
ossophar
yngealpr
ess
methods.

Ai
rInj
ect
ionMet
hod:

•Her
eai
risi
nject
edf
rom t
hemout
hint
otheesophagusv
iat
het
ongueandphar
ynx.

•Thet
ongueact
sli
keapist
ontoforceai
rbacki
ntot
hephar
ynxandt
heesophagus.
Thisi
scal
ledt
ongue-
pumpinj
ect
ion.

•Theindiv
idual
closest
heoutl
etsot
hatt
heai
rshoul
dnotescapei
not
herway
s.So,
he
closesthemouthandnosophary
nx.

•
Her
eai
risi
nject
edf
rom t
hemout
hint
otheesophagusv
iat
het
ongueandphar
ynx.

•Thet
ongueact
sli
keapist
ontoforceai
rbacki
ntot
hephar
ynxandt
heesophagus.
Thisi
scal
ledt
ongue-
pumpinj
ect
ion.

•Theindiv
idual
closest
heoutl
etsot
hatt
heai
rshoul
dnotescapei
not
herway
s.So,
he
closesthemouthandnosophary
nx.

ConsonantI
nject
ionMet
hod:

•
Apl
osi
veoraf
fri
cat
eisusedt
oinj
ectai
rint
otheesophagus

•Thepartoft
heairi
spushedbacki
ntot
heesophagusandt
her
emai
ningpar
tisusedt
o
producethesound.

•
Whenhelear
nstoproducetheconsonantdist
inct
lyandheisaheadtopr
oduce4-
5
t
imes,
whenhedoesitsomeamountofai risaccumulatedi
nEsophagust
henisasked
t
ocomeoutwithsound|pa|
.

•
/p/
,/t
/,/
k/,
/s/
,/∫
/and/
t∫/ar
ether
ecommendedphonemes(
Diedr
ich&Youngst
rom,
1966;
Mool
enaar
-Bi
j
l,1953;
Stet
son,
1937)

•Thengradual
l
yincr
easefrom si
ngl
ewor
dli
ke|
pop|
|top|
etc.
,andsmal
lphr
asest
hat
haveplosi
vesandconsonant
s.

•Anadvantageoft
hismet
hodist
hatt
hereissi
mult
aneousairinj
ect
ionaswel
lasai
r
expul
sion.Whereasinot
hermet
hodsiti
sasequenti
alact
ivi
ty.

GLOSSOPHAYNGEALPRESSMETHOD(Gat
eley71

Thefir
ststepinteachi
ngapat i
enttousethegl
ossophar
yngealpr
essmet hodisto
havehim orherclosetheli
ps,pl
acethetipoft
hetongueagai
nsttheal
veolarr
idge,and
bri
ngthemi ddl
epor t
ionofthetongueInt
ocontactwi
ththehardandsoftpal
ates.

•Thepati
entshouldt
henbeinstr
uct
edt o“pump”t
het
onguebymovingtheposteri
or
port
ionofthetonguebackwar
dunti
litapproxi
mat
esorcont
act
sthepharyngealwall
.

•Thepati
entshouldbeadvisedthatthet
ipoft
het onguemaybesqueezedagai
nstt
he
alveol
arr
idge,whi
chcanser veasananchorpointagainstwhi
cht
herocki
ng-
li
ke
mov ementsoftherestoft
het onguecanbeperformed.

•Lauder(
1978)hassuggest
edthatt
hepati
entbet
oldtoi
magi
nethatthemouthisl
ikea
papersackful
lofai
randthatt
hetongueshoul
dbeusedt
opushallofthi
sai
rbackward
anddownt hethr
oat
.

•Si
mi l
arl
y,t
hesamei magecanbeusedwhi l
ethepati
enti
sinst
ructedtosealthel
ips
ti
ghtl
yandt ocompressthecheekstoassisti
npumpingtheairastheanteri
orporti
on
ofthetongueremainssqueezedthealv
eolarri
dgeandtheposter
iorport
ionofthe
tonguemov esbackwardtowardtheposter
iorphar
yngeal
wall.

Fact
orsAf
fect
ingAcqui
sit
ionofEsophagalSpeech:

•
Radiat
ionTherapy
:Theyexper
iencedr
ynessi
nthr
oatandmout
h,
f
ati
gue,swell
i
ngetc.

•
Excessi
veTensi
on:
Leadst
olackofmout
hopeni
ngandt
onguei
shel
din
backofmout
h.

•
Lackofmuscl
eact
ivi
tyt
oexpel
air

•
Hypot
oni
cP.Esegment:Resul
tisweaksoundcl
i
nici
anshoul
dexpl
ore
i
mprov
ementondigi
tal
pressur
eonneck.

SPEECHCHARACTERI
STI
CS:
•
Rel
iabl
ephonat
ionondemand.

•
4-9syl
labl
esperai
rchar
ge.

•
2-3secsofvoi
cedur
ati
onperai
rint
ake.

Goodspeech i
• ntel
li
gibi
li
ty.

•
Fundament
alf
requencyofnearnor
mal
.

I
•nt
ensi
tynearnor
malwi
thavar
iat
ionof5-
7dbf
rom nor
mal
s.

Shor
• tlat
encybet
weenai
rint
akeandphonat
ion.

•
Soundi
smor
enat
ural
.

•
Pat
ient
sachi
evesomeamountofl
oudnessandpi
tchcont
rol
.

•
Lowpi
tchedv
oice.

Compl
icat
ions:
Voicechangei sthemostcommoncompl i
cati
on, occur
ringinupto50%of
cases.20Voi ceproblemsincl
udehoarseness,
weakv oice,ordecreasedpit
ch.Thevoice
dysfunctionmaybecausedbyi nj
urytotheext
ernalbranchoft hesuperi
orlar
yngeal
nerve,decreasedcricothy
roi
dmuscl econtr
act
il
it
y,ormechani calobstr
ucti
onrel
atedto
narr
owi ngoft heanteri
orpart
softhethyroi
dandcricoidcarti
l
ages.
 Long-t
erm complicati
onsincl
udetrachealandsubglott
icstenosis(especi
all
yin
thepresenceofpreexi
stinglar
yngealt
raumaori nfecti
on),
aspir
ation,swall
owing
dysf
unction,t
ubeobstructi
on,tr
acheal
-esophageal f
ist
ula,
andv oicechanges.St
eep
l
earni
ngcurve(5-
25%successr
ate)
.Reducedl
engt
hofut
ter
ance;
“inj
ect
ion”i
nter
rupt
s
f
low.Soundcanbeweak.
Lowpitchvoi
ce.

Cont
rai
ndi
cat
ions:

•
Rel
ati
vecont
rai
ndi
cat
ionsi udemuscul
ncl arweaknessinther egi
onoftheP-E
segment.
Thistypeofweaknesswoul
dmostl
ikel
ydisqual
ifyt
hepati
entfort
he
TEPpr
ocedur
eduet
oinsuf
fici
entP-
Esegmentt
ensi
onf
orvoi
cingpur
poses.

•
phar
yngoesophagealspasm canber
esponsi
blef
orappr
oxi
mat
ely12per
centof
f
ail
urest
oachi
evesat
isf
act
oryspeechaf
terTEPsur
ger
y.