Losing your voice and learning to speak again

Losing your voice is certainly going to have a huge impact on your life, if you have had your larynx completely removed (a total laryngectomy).

After the operation, you will have your windpipe (trachea) separated from your mouth and food pipe (oesophagus) during the operation. You will have a hole in your neck, called a stoma, that you will use for breathing. You can no longer use air coming from your lungs through your mouth to speak, and you will have to learn new manners of communicating.

A speech therapist will visit you before your operation to discuss the possible ways you can communicate after your surgery. You may be able to meet other people who have had similar surgery or see videos and other materials of people communicating after their laryngectomy. The type of communication you will be able to use will depend on your individual condition, the type and amount of surgery you undergo, and on your personal preferences and level of comfort.

There are three main ways to help you make sound and learn to speak again. These are

· Voice prosthesis or tracheo oesophageal puncture (TEP)

· Oesophageal speech

· Electrolarynx

The main goal will be to try and maintain your life as close to normal as possible. This means helping you to feel confident speaking with people in everyday situations, including using the telephone.

Voice prosthesis (Tracheo oesophageal puncture – TEP)

Tracheo oesophageal puncture (TEP) is the most common way to restore speech after laryngectomy, but it is not suitable for everyone. Patients usually undergo TEP as part of the operation to have their larynx removed, or they can go back for a minor operation to have it done later. This is usually at least 8 weeks after you have had surgery to remove your larynx.

In TEP surgery, the operating doctor makes a tiny hole, called a fistula, at the back of your stoma. The hole creates an additional opening between your windpipe and food pipe (oesophagus). Your surgeon may put a catheter into the fistula to keep it open. Or they may put a small valve (voice prosthesis) into the hole during the operation. If you don't have a catheter into the hole, you will need to have a feeding tube, laid through your nose (nasogastric tube) for some time.

If you have a catheter into the opening, you may be able to receive liquid food down the tube. But once the area has healed and you are eating and drinking, the doctor takes the catheter out and they put a small, one-way valve into the hole.

If you have the tracheo oesophageal puncture some time after your laryngectomy, the catheter will only need to be in place for a few days, or you may have the valve (voice prosthesis) put in straight away.

The voice prosthesis is a valve that lets you produce sounds by thrusting air from your lungs through the valve and up into your mouth. You need to cover your stoma with your fingers so that the air goes through the valve and not out of the stoma. As soon as you learn to use this type of voice prosthesis, you may also be able to use other types of valve which are hands free. They automatically shut the stoma closed when you are using your speaking valve. So you won't have to put your hand up to cover the hole when you want to say anything. But hands free valves are not suitable for everyone.

It takes practice to learn how to use a voice prosthesis. After a while, the muscles deep in your throat will get stronger and will start vibrating easier as the air passes through. Your speech therapist will help you. When you have got used to it, you may be surprised at how well you can be understood.

The 3 main types of valves are:

· Blom-Singer valve

· Provox valve

· Groningen valve

Blom-Singer valves and some Provox valves are external valves. This means that they are designed to be taken out for cleaning and many people will look after these themselves. Your valve must be kept as clean as possible. If it gets blocked, air can't pass through it easily and you won't be able to speak. Your nurse or your GP will show you how to take out the valve, clean it and put it back in place. You will be able to practice this until you are confident enough to do it on your own.

Groningen and some types of Provox valve are internal valves. You leave them in place until they need changing – about every 6 months, or sooner if they are leaking. A specially trained therapist, doctor or nurse must change them. They can do this at one of your follow up appointments.

Sometimes you may have to switch from using one type of valve to another if your unit needs to be changed.

Your medical team will instruct you on what to do if your valve falls out and that you know who to contact for advice.

Occasionally, people find it difficult to speak with a speech valve installed. This is usually because the muscles in their pharynx get a spasm. Your speech and language therapist will help you to try and overcome the spasm. Your surgeon may also suggest a treatment to inject some botulinis toxin (Botox) into the muscle to relax it. Sometimes the problem with speech is caused by swelling of the area around the valve caused by acid indigestion. Your doctor or specialist nurse can prescribe anti indigestion medicines if you have acid indigestion.

Oesophageal speech (swallowing air)

This used to be the most common way that people learned to speak after a laryngectomy. To speak in this way, you move air down into your food pipe (oesophagus). The air passes through the muscles in your throat and causes vibrations. You learn to use these vibrations and turn them into speech by moving your mouth and lips as you would when speaking normally.

If you use this method, your speech therapist will begin teaching you after you recover from your operation. Some people cope with that more quickly than others. Sometimes it may seem that you will never be able to get it right. But keep trying, and you should eventually be able to do it. The biggest difficulty is moving down enough air to be able to produce continuous speech. About 1 in 3 people manage this very well. Some people can even go back to work – even to jobs that need a lot of talking. Your speech and language therapist can be a great support during this time. They will understand that you need a lot of practice.

Nowadays, many people find it easier to use a voice prosthesis than oesophageal speech, but oesophageal speech has the advantage of not needing any equipment. This may be better for you than valve speech if you have difficulty with fiddly things. Or better than an electrolarynx if you think it might be difficult for you to hold something to your throat every time you need to speak.

Electrolarynx

An electronic larynx (electrolarynx), is a battery operated machine that produces sound for you to create a voice. There are many different makes and types, but they are usually about the size of a small electric razor. You hold the machine against your neck, or fit a small tube into the corner of your mouth. When you press the button on the machine, it makes sound. If you move your tongue and mouth you can form the sounds into words. This method of speech after laryngectomy may be best for you if

· You are not able to have a voice prosthesis (TEP) for medical reasons

· You did not have a voice prosthesis put in at the time of your laryngectomy but are waiting to have one put in later

Example of an electrolarynx

To be able to use this method you need training from a speech and language therapist and plenty of practice. The speech has a mechanical sound to it but most people can make themselves understood. One patient told us

"Don't be afraid to use the telephone. Start a telephone conversation with "I have a speech problem, can you understand me? and then it will go as normal. Difficulties can arise
with numbers and it pays to ask the recipient to repeat them back to you"

Some of the machines have buttons to vary the pitch or tone of the sound made by the electronic larynx. This will make your voice sound more varied. Your speech and language therapist will advise you on the best type for your situation and can arrange for you to have an electrolarynx on loan. You can look at the laryngeal cancer organisations page for companies that supply these machines.

Writing things down

You may find it useful to carry a small notebook and pen so that you can always write notes to people if you need to. Laptop computers, tiny typewriters, electronic notebooks or electronic keyboards are other ways you can communicate. A number of small portable machines are available. Your speech and language therapist can advise you on which may suit you best. It may help you to speak to someone who uses the same type of voice restoration that you have chosen. The National Association of Laryngectomee Clubs is an organisation that offers support before and after surgery to the larynx. For further details on how to get in touch with them, go to our laryngeal cancer organisations page.