"My Voice"

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Eating, swallowing, esophageal dilatation, smelling, basic skills and esophageal speech after laryngectomy

Eating, swallowing, and smelling are not the same after laryngectomy ( also called laryngectomie, laryngektomie, laringectomia, laryngektomii, laringektomija, laringektomiya, and larenjektomi). This is because radiation and surgery create permanent lifelong changes. Radiation therapy can cause fibrosis of the muscles of mastication which can lead to one's inability to open the mouth (trismus or lockjaw), making eating more difficult. 

During laryngectomy, certain structures in the throat important in the natural act of swallowing are removed. Physically, swallowing is very different, since reconstruction can limit movement of the tongue base, important in driving food downward towards the esophagus. Additionally, with the removal of the vocal cords and the diverting of the trachea, subglottic pressure to drive food down the esophagus no longer exists, so the throat muscles have to handle more of the work.

Eating and swallowing difficulties can also be generated by a decrease in the production of saliva, and a narrowing of the neopharynx (new pharynx) and esophagus, plus the lack of peristalsis in those with flap reconstruction. Swallowing difficulties and painful swallowing can lead to accumulation of saliva and oral secretion in the mouth. Smelling is affected because inhaled air bypasses the nose. 

This section describes the manifestations and treatment of the eating and smelling challenges faced by laryngectomees. These include swallowing problem, food reflux, esophageal strictures, and smelling difficulties. 

Maintaining adequate nutrition and liquid consumption in a laryngectomee

Eating may be a lifelong challenge for laryngectomees. This is because of swallowing difficulties, decreased production of saliva (which lubricates food and eases mastication), and an alteration in one's ability to smell.

The need to consume large quantities of fluid while eating can make it difficult to ingest large meals. This is because when liquids fill the stomach there is little room left for food. Because liquids are absorbed within a relatively short period of time, laryngectomees end up having multiple small meals rather than fewer large ones. The consumption of large quantities of liquid makes them urinate very frequently throughout the day and night. This can interfere with one's sleep pattern and can cause tiredness and irritability. Those who suffer from heart problems (e.g., congestive heart failure) may experience problems due to overloading their bodies with excess fluid.

Consuming food that stays longer in the stomach (e.g., proteins such as white cheese, meat, nuts) can reduce the number of daily meals, thus reducing the need to drink liquids.

It is important learn how to eat without ingesting excessive amounts of liquid. Relieving swallowing difficulties can reduce the need to consume fluids, while consuming less liquids prior to bedtime can improve sleeping pattern.

Nutrition can be improved by:

        Ingesting adequate but not too much liquid
        Drinking less liquid in the evening
        Consuming “healthy” food
        Consuming a low carbohydrate and high protein diet (high sugar enhances yeast colonization)
        Requesting dietitian assistance 

It is essential to make sure a laryngectomee follows an adequate and balanced nutrition plan that contains the correct ingredients, despite difficulties with their eating. A low carbohydrate and high protein diet that includes vitamins and minerals supplements is important. The assistance of nutritionists, speech and language pathologist (SLP), and physicians in ensuring that one maintains adequate weight is very helpful.

How to remove (or swallow) food stuck in the throat or the esophagus

Some laryngectomees experience recurrent episodes of food becoming stuck in the back of their throat or esophagus and preventing them from swallowing. 

Clearing the stuck food can be accomplished using these methods:  

1. First do not panic. I remember that you cannot suffocate because as a laryngectomee, your esophagus is completely separate from your trachea.

2. Try to drink some liquid (preferably warm) and attempt to force the food down by increasing the pressure in your mouth. Sometimes changing the position of the head while swallowing to the right or left allows the stuck food to be move down into the stomach . If this does not work -

3. If you speak through a tracheo-esophageal voice prosthesis try to speak. This way, the air you blow through the voice prosthesis may push the food above it into the back of your throat, relieving the obstruction. Try this first standing up and if it does not work bend over a sink and try to speak.  If this does not work -

4. Bend forward (over a sink or hold a tissue or cup over your mouth), lowering your mouth below the chest and applying pressure over your abdomen with your hand. This forces the contents of the stomach upward and may clear the obstruction.

These methods work for most people. However, everyone is different and one needs to experiment and find the methods that work best for them. Swallowing does, however, get better in many laryngectomees over time.

Some laryngectomees report success in removing the obstruction by gently massaging their throat, walking for a few minutes, jumping up on their feet, sitting and standing several times, hitting their chest or the back, using a suction machine with the catheter paced in the back of their throat, or just waiting for a while until the food is able to descend into the stomach on its own.

If nothing works and the food is still stuck in the back of the throat it may be necessary to be seen by an otolaryngologist or go to an emergency room to have the obstruction removed. 

How to swallow and avoid food from getting stuck in the esophagus or throat

Swallowing as a laryngectomee requires patience and care. Following an episode of food obstruction in the upper esophagus swallowing may be difficult for a day or two. This is probably because of the local swelling in the back of the throat; normally, this will disappear with time.

Ways to avoid such episodes:
  • Eating slowly and patiently
  • Taking small bites of food and chewing very well before swallowing
  • Swallowing a small amount of food at a time and always mixing it with liquid in the mouth before swallowing. Warm liquid makes it easier to swallow.
  • Moisten dry/crumbly foods with sauces, gravies
  • Flushing the food with more liquids as needed. (Warm liquids may work better for some individuals in flushing down the food) 
  • Sit upright while eating/drinking, and stay upright for at least 30-45 minutes after mealtime
  • Avoiding food that is sticky or hard to chew. 
One needs to find out for him/her self what food is easier to ingest. Some foods are easy to swallow (e.g., toasted or dry bread, yogurt, and bananas) and others tend to be sticky ( e.g., unpeeled apples, lettuce and other leafy vegetables, and steak).

Swallowing tablets and capsules

Ingestion of large pills and capsules may be difficult for laryngectomees. Over time, laryngectomees generally learn the maximal size of pills and capsules that they can swallow.

Tips to take medications include:
  • Some medications are available in several dosages which may be manufactured in smaller size pills or capsules. It is therefore possible to swallow the desired dose by taking several small pills or capsules.
  • The size of pills of some generic medications may vary depending on their manufacturers. If this is the case it may be possible to find a smaller size pill produced by a different manufacturer.
  • Some medications are also available as a suspension. It is best to check with one’s physician and pharmacy if a commercially available suspension is available, or can be prepared by one's pharmacy. 
  • Pills can be crushed and dissolved in room temperature liquids, or broken down to small pieces prior to ingestion. However, slow release medications may lose their time delay action when crushed. Ingestion of large gel capsules may not be possible.
  • Capsules can be opened and their content swallowed. However, this exposes some medication to the stomach acidity that may inactivate and reduce their potency.
  • Some crushed medications or capsule contents may be irritating to the mouth and/or esophagus and stomach.
  • It is best to check with one’s physician and/or pharmacist if dissolving a pill or capsule’s contents is an option.
  • When oral ingestion is not an option other routes of drug administration may be possible. These include intramuscular and intravenous injection, aerosols, and rectal or vaginal suppositories.
  • When the size of a tablet or capsule is too large the physician may select a similar medication (from the same class or with similar effects) that is available in smaller size pill or capsule.

Gastroesophageal  reflux

Most laryngectomees are prone or develop gastroesophageal reflux disease (GERD). 

There are two muscular bands or sphincters in the esophagus that prevent reflux. One is located where the esophagus enters the stomach and the other is behind the larynx at the beginning of the esophagus in the neck. The lower esophageal sphincter often becomes compromised when there is a hiatal hernia which may occur in more than 3/4 of people over 70. During laryngectomy the sphincter in the upper esophageal sphincter ( the cricopharyngeus ) which normally prevents food from returning to the mouth is removed. This leaves the upper part of the esophagus flaccid and always open which may result in the reflux of stomach contents up into the throat and mouth. Therefore, regurgitation of stomach acid and food, especially in the first hour or so after eating, can occur when bending forward or lying down. This can also occur after forceful exhalation when those who use a TEP try to speak.

Taking medications that reduce stomach acidity, such as antacids and proton pump inhibitors (PPI), can alleviate some of the side effects of reflux, such as throat irritation, damage to the gums and bad taste. Not lying down after eating or drinking also helps prevent reflux. Eating small amounts of food multiple times causes less food reflux than eating large meals.

Food reflux from the stomach to the esophagus

Symptoms and treatment of gastroesophageal reflux 

Acid reflux occurs when the acid that is normally in the stomach backs up into the esophagus. This condition is also called GERD.

The symptoms of acid reflux include:

  • Burning in the chest (heartburn)
  • Burning or acid taste in the throat
  • Stomach or chest pain
  • Difficulty in swallowing
  • A raspy voice or a sore throat
  • Unexplained cough (not in laryngectomees, unless their voice prosthesis leaks)
  • In laryngectomees: granulation tissue forms around the voice prosthesis, voice prosthesis device life is shortened, voice problems

Measures to reduce and prevent acid reflux include:

  • Losing weight (in those who are overweight)
  • Reducing stress and practicing relaxation techniques
  • Avoiding foods that worsen symptoms (e.g., coffee, chocolate, alcohol, peppermint, and fatty foods)
  • Stopping smoking and passive exposure to smoke
  • Eating small amounts of food several times a day rather than large meals
  • Siting when eating and staying upright 30-60 minutes later
  • Avoiding lying down for 2-3 hours after a meal
  • Elevating the beds' head side by 6-8 inches (by putting blocks of wood under 2 legs of the bed or a wedge under the mattress) or by using pillows to elevate the upper portion of the body by at least about 45 degrees
  • Taking a medication that reduces the production of stomach acids, as prescribed by one's physician
  • When bending down, bending the knees rather than bending the upper body 

                                                            Acid reflux pillow

    Medications for the treatment of gastroesophageal acid reflux

    There are three major types of medication that can help reduce acid reflux symptoms: antacids, histamine H2-receptor antagonists (also known as H2 blockers), and proton pump inhibitors. These drug classes work in different ways by reducing or blocking stomach acid.

    Liquid antacids are generally more active than tablets, and are generally more active if taken after a meal or before going to bed, but they work only for a short time. H2 blockers (e.g., Pepcid, Tagamet, Zantac) work by reducing the amount of acid produced by the stomach. They last longer than antacids and can relieve mild symptoms. Most H2 blockers can be bought without a prescription.

    Proton pump inhibitors (e.g., Prilosec, Nexium, Prevacid, Aciphex) are the most effective medicines in treating GERD and stopping the production of stomach acid. Some of these medicines are sold without a prescriptionThey may reduce the absorption of calcium. Monitoring the serum calcium levels is important; individuals taking these agents and those with low calcium levels may need to take calcium supplements. 

    It is advisable to see a physician if the GERD symptoms are severe or last a long time and are difficult to control.

    Speaking when eating after laryngectomy

    Laryngectomees who speak through a tracheo-esophageal voice prosthesis may have difficulties in speaking when they swallow. This is especially challenging during the time it takes the food or liquids to pass by the esophageal voice prosthesis site. Speaking during that time is either impossible or sounds "bubbly". This is because the air introduced into the esophagus through the voice prosthesis has to travel through the food or liquids. Unfortunately it takes the food much longer to go through the esophagus, especially in someone who had had a flap to replace the pharynx. This is because that flap has no peristalsis (contraction and relaxation) and the food goes down mainly due to gravity.

    It is therefore important to eat slowly, mix the food with liquids while chewing and allow the food to pass through the voice prosthesis area before trying to speak. Over time, laryngectomees can learn how much time is needed for food to pass through the esophagus to allow speaking. It is helpful drink before attempting to speak after eating.

    There are eating and swallowing exercises that a SLP can teach a laryngectomee that may assist them in relearning how to swallow without difficulties.

    Swallowing difficulties

    Laryngectomees are usually not allowed to swallow food immediately after surgery and must be fed through a feeding tube for 2-3 weeks. The tube is inserted into the stomach through the nose, mouth or the tracheo-esophageal puncture and liquid nourishment is supplied through the tube. This practice, however, is slowly changing; there is increasing evidence that in standard surgeries, oral intake can start with clear liquids as soon as 24 hours after surgery. This may also help with swallowing as the muscles involved with continue to be used.

    Most laryngectomees experience problems with swallowing (dysphagia) immediately after their surgery. Because swallowing involves the coordination between more than 20 muscles and several nerves, damage to any part of the system by surgery or radiation can produce swallowing difficultiesThe majority of laryngectomees relearn how to swallow with minimal problems. Some may only need to make minor adjustments in eating such as taking smaller bites, chewing more thoroughly, and drinking more liquids while eating. Some experience significant swallowing difficulties and may require assistance in learning how to improve their ability to swallow by working with an SLP who specializes in swallowing disorders. Swallowing dysfunction, due to fibrosis often requires a change in diet, pharyngeal strengthening, or swallow retraining especially in those who have had surgery and/or chemotherapy. Swallowing exercises are increasingly used as a preventing measure.

    Swallowing function change after a laryngectomy and can be further complicated by radiation and chemotherapy. The incidence of swallowing difficulty and food obstruction can be as high as 50% of patients and, if not addressed, can lead to malnutrition. Most difficulties with swallowing are noticed after discharge from the hospital. They can occur when attempting to eat too fast and not chewing well. They can also happen after trauma to the upper esophagus by ingesting a sharp piece of food or drinking very hot liquid. These can cause swelling which may last a day or two. (I describe my experiences with eating in my book a in Chapter 20 entitled Eating.)

    Patients experience difficulties in swallowing (dysphagia) as a result of:

    • Abnormal function of the pharyngeal muscles (dysmotility)
    • Cricopharyngeal dysfunction of the the cricoid cartilage and the pharynx
    • Reduced strength of the movements of the base of the tongue
    • Development of a fold of mucous membrane or scar tissue at the tongue base called "pseudoepiglottis". Food can collect between the pseudoepiglottis and the tongue base
    • Difficulty with tongue movements, chewing, and food propulsion in the pharynx because of removal of the hyoid bone and other structural changes
    • A stricture within the pharynx or esophagus may decrease food passage leading to its collection
    • Development of a pouch (diverticulum) in the pharyngoesophageal wall that can collect fluid and food resulting in the complaint of food "sticking" in the upper esophagus

    The free flap that is sometimes used to replace the larynx has no peristalsis, making swallowing even more difficult. After surgery in such cases food descends to the stomach mostly by gravity. The time for the food to reach the stomach varies between individuals and ranges from 5 to 10 seconds. 

    Chewing the food well and mixing it with liquid in the mouth prior to swallowing is helpful, as is swallowing only small amounts of food each time and waiting for it to go down. Drinking liquids between solid foods is helpful in flushing down the food. Eating takes longer; one must learn to be patient and take all the time needed to finish the meal.

    The swelling that develops after surgery tends to decrease over time, which reduces the narrowing of the esophagus and ultimately makes swallowing easier. This is good to remember because there is always hope that swallowing will improve within the first few months after surgery. However, if this does not occur dilatation of the esophagus is one therapeutic option.

    Swallowing problems may improve over time. However, dilatation of the esophagus may be needed if the narrowing is permanent. The extent of the narrowing can be evaluated by a swallow test. Dilatation is usually done by an otolaryngologist or gastroenterologist (see below in the Dilatation of the esophagus section). Increasing experience suggested that temporary placement of nonmetal expandable stents can be effective for managing refractory benign strictures

    In most cases, dilation is successful, and patients can stabilize in as soon as six weeks but up to eight months. A small number of patients, however, continue to have severe dysphagia; that's when pharyngeal reconstruction is needed. This can be accomplished by obtaining a flap of non-radiated tissue (i.e., forearm) to create a wider throat.

    Tests used for the evaluation of swallowing difficulty

    There are five major tests that can be used for the evaluation of swallowing difficulties: 

    • Barium swallow radiography
    • Videofluoroscopy (motion X-ray study) 
    • Upper endoscopic evaluation of swallowing
    • Fiberoptic nasopharyngeal laryngoscopy 
    • Esophageal manometry (measures esophagus muscle contractions) 

    The specific test is chosen according to the clinical condition.

    Videofluoroscopy which is usually the first test done to most patients, records swallowing during fluoroscopy. It allows accurate visualization and study of the sequence of events which make up a swallow; it is limited to the cervical esophagus. The video, taken from both the front and the side, can be viewed at much slower speeds to enable accurate study. This helps identify abnormal movement of food, such as aspiration, pooling, movement of anatomic structures, muscle activities, and exact oral and pharyngeal transit times. The effects of various barium consistencies and positions can be tested. Thick or solid food boluses can be used for patients who complain of solid food dysphagia.

    Esophageal videofluoroscopy (arrow shows stricture)

    Narrowing (strictures) of the neopharynx and esophagus

    A stricture of the esophagus is a narrowing along the pharyngo-esophagus that blocks or inhibits the ease of food passage, resulting in the esophagus having an hour-glass configuration.  

    Strictures after laryngectomy can be due be related to the effects of radiation as well as the tightness of the surgical closure and can also gradually as scarring develops. Interventions that can help the patient include:

    • Dietary or postural changes 
    • Myotomy (cutting the muscle) 
    • Dilatation (see below)
    • Placement of self-expanding plastic stents (see below)

    Alternatives to these procedures include nasal enteric tubes, gastrostomy tubes, and jejunostomy tubes. Total parenteral nutrition can also be used in patients who are not candidates for stent placement.

    Esophageal stents

    An esophageal stent is a flexible mesh tube, approximately 2cm (3/4 inch) wide, and is placed through the constricted area of the esophagus to allow food and beverages to pass from your mouth to the stomach. The stent is not as wide or as flexible as a normal esophagus and care must be taken not to block it while eating. 

    Stent placement usually requires both endoscopic and fluoroscopic guidance, but can be done with either modality safely. In general, dilation of a stricture before placing the stent is not required. Most stents are placed distally and across the gastroesophageal junction, but proximal stent placement (which requires more precise placement) can also be performed. Complications include bleeding and perforation (which are rare) as well as migration, tumor overgrowth, and tumor ingrowth (which are more common).

                                                     Esophageal stent in place                                     

    Dilatation of the neopharynx and esophagus
    Narrowing of the neopharynx (The surgically reconstructed new pharynx) and esophagus is a very common consequence of radiation treatment as well as laryngectomy; and dilatation of the esophagus is often needed to reopen it. The procedure usually needs to be repeated and the frequency of this procedure varies among individuals. In some people this is a lifelong requirement and in others the neopharynx and esophagus may stay open after a few dilatations. The procedure requires sedation or anesthesia because it is painful. A series of dilators with greater diameter are introduced into the esophagus to dilate it slowly. While the process breaks down the fibrosis, the condition may return after a while.

    Sometimes a balloon rather than a long dilator is used to dilate a local stricture. Another method that may help is the use of topical and or injectable steroids to the esophagus. Although dilation is done by an otolaryngologist or a gastroenterologist, in some cases it can be accomplished by the patient at home by performing self-dilations at-home device. In difficult cases, surgery may be needed to remove the stricture or replace the narrow section with a graft (tissue flap).

    Because dilation breaks down fibrosis, the pain generated by the procedure may last for a while. Taking pain medication can ease the discomfort.


    Wire Guided Balloons used for esophageal dilatation

    Use of Botox®

    Botox® is a pharmaceutical preparation of toxin A which is produced by Clostridium botulinum, an anaerobic bacteria that causes botulism, a muscle paralysis illness. The botulinum toxin causes partial paralysis of muscles by acting on their presynaptic cholinergic nerve fibers through the prevention of the release of acetylcholine at the neuromuscular junction. In small quantities it can be used to temporarily paralyze muscles for 3-4 months. It is used to control muscle spasms, excessive blinking, and for cosmetic treatment of wrinkles. Infrequent side effects are generalized muscle weakness and rarely even death.  Botox® injection has become the treatment of choice for selected individuals to improve swallowing and tracheo-esophageal speech after laryngectomy. 

    For laryngectomees, Botox® has been used to reduce the hypertonicity and spasm of the vibrating segment, resulting in an esophageal or tracheoesophageal voice that requires less effort to produce. However, it is only effective for overactive muscles and may require the injection of relatively large doses into the spastic muscles. It can be used to relax muscle tightness in the lower jaw when one experience difficulties in swallowing. It cannot help conditions that are not due to muscle spasms, such as esophageal diverticula, strictures due to fibrosis after radiation, and scars and narrowing after surgery.

    A constrictor muscle hypertonicity or pharyngoesophageal spasm (PES) is a common cause for tracheo-esophageal speech failure following laryngectomy.  Constrictor muscle hypertonicity can increase peak intra-esophageal pressure during speaking, thus interfering with fluent speech. It may also disturb swallowing by interfering with the pharyngeal transit of food and liquids.

    Botox® injection can be carried out by otolaryngologists in the clinic. The injection can be done percutaneously or through an esophago-gastro-duodeno-scope. The percutaneous injection into the pharyngeal constrictor muscles along one side of the newly formed pharynx (neopharynx) is done just above and to the side of the stoma and is managed.

    An injection through an esophago-gastro-duodeno-scope can be performed whenever a percutaneous injection is not feasible. This method is used in patients with severe post-radiation fibrosis, disruption of the cervical anatomy, and anxiety or inability to withstand 
    a percutaneous injection. This method allows direct visualization and greater precision. The injection into the PES segment is often done by a gastroenterologist and is followed by gentle expansion by balloon massage to facilitate uniform distribution of the Botox®.

    Botox® injection

    Pharyngo-cutaneous fistula

    A pharyngo-cutaneous fistula is an abnormal connection between the pharyngeal mucosa to the skin. Typically a salivary leak develops from the pharyngeal area to the skin, indicating a breakdown of the pharyngeal surgical suture line. It is the most common complication after laryngectomy and usually occurs 7-10 days after the operation. The main causes leading to development of fistula is poor wound healing. Things such as too much tension on the wound, a wound infection after surgery, poor nutrition, continued use of alcohol and tobacco, and prior radiation are the usual things that lead to problems with wound healing and the formation of a fistula.

    Most fistulae will heal on their own without additional surgery. Until that occurs external drainage may need to be established to keep secretions out of the stoma and an alternative method of feeding such as a percutaneous endoscopic gastrostomy (PEG) is used. Surgical repair is reserved for those fistulae which do not close on their own and those that pose some danger particularly to the stoma and the lungs.

    The closure of the fistula can be evaluated by a dye test (such as ingestion of methylene blue which appears in the skin if the fistula is unobstructed) and/or by radiographic contrast studies.

    Pharyngo-cutaneous fistula

    Smelling after laryngectomy

    Laryngectomees may experience difficulties with their sense of smell. This is despite the fact that regular laryngectomy surgery, does not involve nerves related to smell and the sense of smell or olfaction, remains intact. What has changed, however, is the pathway of airflow during respiration. Before a laryngectomy, air flows into the lungs through the nose and mouth. This movement of air through the nose allows for scents to be detected as they come in contact with the nerve endings in the nose responsible for the sense of smell.

    After a laryngectomy, however, there is no longer an active air flow through the nose. This can be perceived as a loss of smell. Patients, however, can relearn how to smell, by closing their mouths and swallowing to create a vacuum that introduces air into the nose.

    The “polite yawn technique” can also help laryngectomees regain their capacity to smell. This method is known as the “polite yawn technique” because the movements involved are similar to those used when one attempts to yawn with a closed mouth. Swift, downward movement of the lower jaw and tongue, while keeping the lips closed, will create a subtle vacuum, drawing air into the nasal passages and enabling the detection of any scent through the new airflow. With practice, it is possible to achieve the same vacuum using more subtle (but effective) tongue movements.

    How to avoid unpleasant smells

    One “advantage” of being a laryngectomee is the ability to avoid unpleasant smells or odors such as cigarette smoke. This is because all our air intake is through the stoma, while smelling is done through our nostrils. This can be achieved by preventing the noxious smell from reaching the nose by:
    • Squeezing the nostrils with the fingers
    • Placing a cotton ball in each nostril
    • Wearing a surgical mask over the nose with or without a fitted piece of plastic     

        Wearing a surgical mask

    Squeezing the nostrils

    Basic skills for laryngectomees by Elizabeth Finchem

    Here are a few basic skills our newest laryngectomees can work on at home. They include a few topics that may help to discover how you can compensate for what some may think they have lost after laryngectomy.  Recently a laryngectomee stated that he still can’t smell, taste, blow, or talk hands free prompted me to write about how to correct this perception with basic information.  

    There was a time, not so long ago, when the International Association of Laryngectomees Annual Meeting program included ‘speech improvement’ breakout sessions that provided tiered training for designated groups (beginner, intermediate, or advanced speakers) to improve their skills for whichever method they chose to communicate with year after year.  Some folks referred to these sessions as “Jim’s Dog and Pony Show” since Jim Shanks, PhD, SLP, taught all of them at one point or another.  Along the way the demonstrations included how learning to smell, taste and blow related to speech techniques we could use to improve the intelligibility of our speech after laryngectomy. I also learned the finer points of fluent esophageal speech while attending these demonstrations that amounted to very practical hands on labs for learning and teaching.  I hope sharing some of these tried and true techniques will be helpful for your rehabilitation, and for those who are learning how to work with laryngectomees.

    A good place to begin is to have you put your lips together and puff out your cheeks with only the air that is in your mouth. (voice prosthesis users do not need to inhale or exhale lung air to do this task.)  Additional air will build in the mouth from your nasal passages.  Notice how you can move the air from one cheek to the other. Next, you can use this air in your mouth to blow out the match. No, you don’t need to blow with lung air from your stoma for this task either.  As you blow out the match you may find that you can smell the sulfur and the smoke if you sniff.  Next you can try blowing out a candle in the same way. This mouth air can also be directed into a balloon one mouthful at a time to fully inflate a big balloon.  You may discover that you can do things you’d assumed were no longer possible post op.

    Following the above directions probably surprised you. They proved that you do have plenty of air in your mouth when you put your lips together.  You have access to more air from your nose, which is still open and connected to your mouth.  You have enough mouth air to blow out a match or candle.  With your lips together drop your lower jaw. With these two steps you have created a bellows effect that draws air up your nasal passages so you can smell on demand as you sniff.  It may be faint at first, but you can develop this skill to increase your ability to smell.  This will also enhance you sense of taste since smell plays an important part of taste sensation.  When this skill is developed some horn players have discovered how to use this ‘circular breathing (nose to mouth) to play their beloved horns again, using lung air for breathing only.  Did you know that DIDGERIDOO players use this technique to play their tree trunk horns continuously?  Check it out on youtube.com

    It seems to me that very few SLPs, or speech instructors teach these basic steps anymore.  As I begin working with new students this material seems to be very new to them.  In fact, some seem to assume these skills are now impossible post op.  I can tell you from my decades of teaching new laryngectomees as well as SLPs who wish to learn how to work with laryngectomees these basic methods do work.  It makes me sad to read that so many are left to believe that their ability to taste, smell, or blow from the mouth or nose was taken along with their larynx.  We can compensate and learn to do these maneuvers in a new way.  They may not be as strong on the first few attempts, but they can be developed and serve the purpose very well.

    You may wonder how you can possibly sniff up your nose or blow your nose again? Try it.  Take those first few steps. Lips together and drop you lower jaw to draw air in with a sniff action, or reverse it by bringing your lower jaw back up as you use your tongue to thrust the air upward through the nose to blow one side at a time. 

    It is a pity when there are those who are left to believe that everything we did pre-operatively is gone forever.  Slowly some discover what they are able to do with what is left on their own.  Even so, few understand how it is possible, or how the body’s systems actually work.  Another case of “go home and figure it out”?  I hope not since we can learn from one another when we share information.

    The value of esophageal speech and how to master it.
    by Elizabeth Finchem

    Esophageal Speech (ES) has the following advantages:

    1.         A natural, biological source that remains post-laryngectomy.
    2.         It is fully functional when mastered.
    3.         Requires no puncture or tracheal-esophageal prosthesis.
    4.         Offers much less danger of aspiration than TE puncture voice restoration, but not electro larynx..
    5.         It has pitch and volume control; though at times somewhat limited.
    6.         Can offer speech on demand when one is proficient.
    7.         Eliminates emergency voice loss, or a need for voice prosthesis changes, or electrolarynx repairs.

    Let us be clear about what ES is and is not. For example, it is not gulping air and burping up a word.  That is the way I was taught at the beginning of my speech therapy, and it sent me down the wrong track.  This method begins with too much air and quickly leads to a cricopharyngeus sphincter (sphincter used when swallowing) spasm. The only benefit from the burping concept is the feeling of the air pressure rising and timing it to say a word or two with that air.  What is more important in that action is the slight tightening of the diaphragm that keeps the air moving “north” up into the esophagus instead of forcing it into the stomach.  It is esophageal speech, not stomach speech.

    I teach ES with a different approach.  After decades of training, developing my own ES voice, and experience teaching others how to achieve ES in about 8-10 week. We begin with the basic three methods of air intake:
    1) Consonant injection,
    2) Tongue press,
    3) Inhalation. 
    Inhalation is not inhaling a breath into the lungs, but instead it is merely the opening the cricopharyngeal sphincter (which is normally contracted). This is what you do when the physician asks you to say “ah”.  You open this sphincter enough for examination of the mouth.  You should hear a little “click” sound as the wet tissue opens, and then you may have taken in enough air to say “ah”.  Note that the tongue is always up in the mouth for “tongue press”, and the tongue is always down in the mouth for “inhalation”.

    Instead of focusing on reading word lists aloud that begin with consonants to inject air into the esophagus we begin by focusing on double vowel that follows the consonant sounds to release the air charge with Pee, Tee and Kay.  These three consonants coupled with vowels like ie (as in Pie), ea (as inteach), or oo (as in took) seems to be a better balance of air in, sound out.  After a few attempts it is important to take a sip or two of water to keep the swallowing sphincter relaxed enough to let the consonant air back up without a huge burp and rush of words …only to be “out of air”.  Then what? 

    We begin again with “P” to illustrate that “Puh” (as in pup) sound can be felt on the fingers when held out away from the mouth about 6 inches.  According to Isaac Newton, “for every action there is an opposite and equal reaction”.  The same amount of air felt on the fingers is also going backward into the esophagus for the word “Pie”.  Next comes the consonant T to teach the tongue placement against the front teeth at the gum line.  “Tie” should work here.

    Working with “K” (as in “Kay”) is important because it is on the back of the tongue and may introduce too much air at first.  For several reasons K, hard C and G may need to be softened or modified a bit for the right balance of air injected.
    Note that it’s not unusual for a laryngectomee who has been over-articulating while mouthing words with hope of being heard along with lip reading, or an electro larynx user, to strike K, hard C (as in cake) and G (as in goat) harder than they need to for ES.  Only the consonants are heard unless an occasional vowel is released inadvertently.  More often there is a good deal of stoma blast that goes with the mouthing in a failed attempt to be louder.

    As soon as we can move on to multiple syllables we begin working on phrases that can be used daily.  Rather than “practice” word lists, we focus on using ES for simple questions and responses. Pet commands such as sit, stay, come, down along with the pet’s name is something that will be used often each day.  Family names and a few other phrases such as “thank you”, “car keys”, and “get gas” can be tailored for “homework” that will be used. (For conversation the electro larynx is best in the beginning when one is looking to acquire and master it.) The interrogatives (who, what, when, where, why and how) can keep a chat going while one uses their ES.  We want these simple responses to become spontaneous.  In closing it is important to be aware that expecting people to read lips is not helpful to learning ES.  The goal is to learn how to produce the vowel sounds that are now missing due to the loss of the normal sound generator: the voice box.  It is possible to learn to produce esophageal vowel sounds by injecting enough air into the esophagus to cause vibration that will become the new esophageal sound generator.  People are always surprised to learn that proficient ES speakers do not breathe when they speak.  Instead they have learned to inhale, exhale, inject and then speak. Otherwise we hear a good deal of stoma blast as they try to use lung air to speak as they did before laryngectomy that is, while exhaling.  The stoma blast sound may actually mask their ES vowel sounds as well as their consonants that distinguish one word from the next.  We aim for intelligibility as well as effortless speech.

    ES is unimaginable for some who believe there must be something that has to replace the larynx (voice box) that was removed.  The truth is the human body is adaptable enough to use what is left in a new way very affectively. Some consider this second natural voice a miracle.  I do.  Now I am sharing this gift with others as many others shared this knowledge with me.