Radiol Oncol 2001; 35(4): 249-54. 

Communication after laryngectomy 

Irena Hočevar-Boltežar and Miha Žargi 

Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Center, 
Ljubljana, Slovenia 


Background. Laryngectomy is the mode of treatment of the patients with advanced laryngeal and hypopharyngeal 
cancer. It affects many important functions, including speech. 
Patients and methods. Various alaryngeal speech modes are available so that no laryngectomee should be 
left without a means of communication. 
Results. There is a variety of artificial devices, including electronic ones that produce their own battery driven 
sound. Alternatively, the patient can learn a new form of voicing using a muscular segment of the upper 
esophagus as a source of sound (esophageal speech). A puncture can be created surgically through the 
esophageal wall and a prosthesis placed in it to divert pulmonary air into the esophagus and through the 
same muscular segment to produce sound. 
Conclusions. Many factors influence the choice of an alternative to be used with a particular patient. In 
Slovenia, esophageal speech is the most frequently used alaryngeal speech mode. 

Key words: laryngeal neoplasms; laryngectomy; speech, alaryngeal; speech, esophageal 

Epidemiology and etiology of laryngeal and 
hypopharyngeal cancer 

Laryngeal and hypopharyngeal cancers are 
quite common in Slovenia. In 1995 they represented 
1.9 % of all new malignant diseases 
in Slovenia. The incidence of laryngeal cancer 
was 9.1/100.000 inhabitants in men, and 
0.5/100.000 inhabitants in women. The incidence 
of hypopharyngeal cancer was 
4.5/100.000 inhabitants in men, and 
0.3/100.000 inhabitants in women. In 55 % of 
patients with laryngeal cancer and only 12 % 
of patients with hypopharyngeal cancer, the 

Received 15 October 2001 
Accepted 10 November 2001 

disease was discovered in a localized stage. In 
all other patients, the malignant disease was 
in an advanced stage and required more aggressive 
treatment.1 

Laryngeal and hypopharyngeal cancers 
usually occur in men aged 50-65 years with a 
long history of tobacco consumption frequently 
associated with alcohol abuse. The alcohol-
related nutritional deficiencies could be 
involved in the etiology of these cancers.1,2 As 
a result, the patients often present with notable 
co-morbidities. In addition, the socio-

Correspondence to: Irena Hočevar-Boltežar, MD, PhD, 
Department of Otorhinolaryngology and Cervicofacial 
Surgery, Zaloška 2, SI-1000 Ljubljana, Slovenia. 
Phone: +386 1 522 24 65; Fax: +386 1 52 24 815; E-mail: 
irena.hocevar-boltezar@guest.arnes.si 


Hočevar-Boltežar I and Žargi M /Communication after laryngectomy 

cultural level is rather poor in the majority of 
cases. This particular characteristic of laryngeal 
and hypopharyngeal cancer patients explains 
the delay in diagnosis and the problems 
linked to treatment compliance. 

Laryngectomy and its consequences 

Laryngectomy is a surgical procedure usually 
reserved for patients with advanced laryngeal 
or hypopharyngeal carcinoma or patients 
who fail radiation treatment.3 Loosing the larynx 
means adapting to a living without some 
basics that characterize us as human. 
Respiration and speech are altered for ever; 
swallowing needs to be re-learned; smell and 
taste are attenuated; lifting, straining and 
coughing (all of which are dependent on a 
closed glottis) are compromised. Although 
there are numerous potential problems (emotional, 
psychological, physical, economic, social, 
surgical, and communicative), the inability 
to speak is considered the greatest of the 
difficulties the patient is faced by.4 

Voice restoration after laryngectomy 

After the removal of the larynx, the patient no 
longer has a source of sound for speaking. 
Currently, there are two categories of sound 
restoration: alternative “natural” sound sources 
and mechanical speech aids. The former 
category utilizes esophageal and tracheoesophageal 
speech, whereas the latter an electronic 
artificial larynx.5 

Esophageal speech (ES) 

ES traditionally has been the dominant approach 
to laryngeal speech rehabilitation. 
Some retrospective studies demonstrated a 
range of success from 12 % to 97 %.6-11 In 
1982, Gates et al. published the results from 
the first prospective investigation of ES ac-

Radiol Oncol 2001; 35(4): 249-54. 

quisition, which showed that 26 % of their laryngectomy 
study group were able to acquire 
ES.6 In a more recent prospective study, 
Hillman et al. found that only 6 % of their patients 
developed usable ES.12 

ES is produced by compressing the air into 
the esophagus; the released air vibrates the 
pharyngeal-esophageal segment and produces 
the esophageal tone used for speech. 
The sound produced enters the oral cavity 
where it is articulated and shaped into words. 

Generally, there are three primary methods 
used to teach esophageal speech: consonant 
injection, glossopharyngeal press, and 
inhalation. Regardless the method used, the 
goals are for the patient to be able to impound 
rapidly the air into the esophagus, expel 
it from there in a controlled manner, and 
produce fluent ES. Esophageal speakers have 
a much lower air reservoir (less than 100 cm3) 
than is available to laryngeal speakers from 
the lungs (even > 5 litres). The small air supply 
will limit the esophageal speaker’s ability 
to produce long utterances on a single charge 
of air. 

The advantages of the ES are: 

• 
The sound of ES is more natural and closer 
to the laryngeal voice. 
• 
ES requires no dependence on mechanical 
instrument. 
• 
The patient is able to achieve some measure 
of pitch and loudness control, and 
good esophageal speakers are able to vary 
these dynamically during speech. 
• 
Both hands are free during speech. 
ES has also some disadvantages: 

• 
ES must be learnt and may take a long 
time to master it. Some patients may never 
learn to produce functional ES even after 
much effort. 
• 
A person’s ability to articulate clearly must 
be good, otherwise the intelligibility of ES 
may be poor. 
• 
The patient may have difficulty being 
heard above back-ground noise.5 

Hočevar-Boltežar I and Žargi M /Communication after laryngectomy 

Tracheoesophageal speech (TES) 

The tracheoesophageal puncture method, coupled 
with the use of the voice prosthesis, was 
introduced by Singer and Bloom in 1980.13 The 
surgery may be performed at the time of the laryngectomy 
(primary procedure), or it may be 
performed at a later date (secondary procedure). 
Early studies, focused on carefully selected 
groups of patients who underwent the 
insertion of a prosthesis as a secondary procedure, 
reported success rates ranging from 56% 
to 93 %.14-16 More recent studies, which have 
focused on the insertion of a prosthesis as a 
primary procedure, have reported acquisition 
rates ranging from 30 % to 93 %.17-19 

In this approach, a small, silicone, valved 
prosthesis is inserted into a surgically created 
midline tracheoesophageal fistula. The uni-directional 
valved prosthesis is designed to 
maintain tract patency and protect against aspiration. 
The patient can divert pulmonary air 
from the trachea (by occluding the tracheostoma 
with a finger) through the prosthesis, 
thereby creating a sound in the pharyngoesophageal 
segment. The air pressures 
required to force open the slit of the valve 
range between 2 and 25 cm H2O and depend 
on the rate of airflow from the lungs and the 
type of the device used.20 Some patients may 
have considerable difficulty producing the 
pressures. In these cases, a lower resistance 
prosthesis is suitable. Special valves are available 
to avoid manual occlusion of the stoma. 
These valves close automatically when greater 
than normal thoracic pressures are present as 
when the patient wishes to produce speech. 

There are still contraindications in the selection 
of patients for the prosthesis insertion: 
inability to care for the stoma, poor manual 
dexterity, a stenotic stoma, poor eyesight, 
esophageal stenosis, and poor patient’s motivation. 


The advantages of TES are: 

• 
This technique can provide the most rapid 
restoration of nearly normal speech in 
most of the laryngectomized patients. 
• 
TES is smooth and fluent because of the 
availability of pulmonary air. 
• 
Loudness and pitch variation is possible. 
• 
The approach is feasible in most of the laryngectomized 
patients and is also reversible 
if so desired. 
The disadvantages of TES are: 

• 
The insertion of the voice prosthesis requires 
another surgical procedure if not 
done together with the laryngectomy. 
• 
Occasional aspiration due to poorly seated 
prosthesis, or poorly functioning prosthesis 
is possible. 
• 
A buildup of candida deposits requires frequent 
cleaning. 
• 
The functioning period of the prosthesis is 
limited.5,21 
Artificial larynx (AL) 

Previous reports of AL use among laryngectomy 
patients vary in many aspects. The estimates 
of AL use range from 5 % to 66 %.6,22,23 
This device uses electric power to drive a vibrator 
that provides the sound source. It generates 
a sound with approximately the same 
frequency as is the fundamental laryngeal frequency. 
One type of the device consists of a 
tube that delivers sound from the vibrator to 
the mouth. the sound is then articulated in 
the normal way. Another version consists of a 
hand held vibrator that is designed to deliver 
the sound through the skin when placed on 
the neck. Until recent years, the AL was considered 
to be the method of choice only for 
those patients who were unable to learn ES. 
Clinical experience has demonstrated that AL 
actually may be helpful in the acquisition of 
ES. AL may serve as a communication bridge 
until ES or TES training is initiated. Recent 
studies from the USA report that a majority 
of laryngectomees use AL – 55 %.12 

The advantages of AL: 

• 
It is easy to learn how to use it. 
Radiol Oncol 2001; 35(4): 249-54. 


Hočevar-Boltežar I and Žargi M /Communication after laryngectomy 

• 
AL provides adequate volume to be heard 
in noisy places. 
• 
Volume and pitch control is possible. 
• 
The speech with AL is intelligible when 
properly used. 
Speech with AL has some disadvantages: 

• 
AL has a noisy electronic sound that attracts 
attention. 
• 
The neck type device cannot be used in the 
patients with heavily scarred neck. 
• 
Moderate initial purchase cost and occasional 
additional cost for repair. 
• 
AL requires very clear articulation to assure 
intelligibility.5,21 
Characteristics of alaryngeal speech 

Fundamental frequency (F0) 

Most electronic speech aids have a manually 
adjustable F0. These are typically set to a low 
pitch for a male voice (about 100 Hz) and to a 
higher one for a female voice (about 200 Hz). 
Some have a variable frequency adjustment. 

The F0 of the ES is usually lower than the 
average laryngeal F0. The results of different 
studies range from 57 Hz to 136 Hz.24,25 The 
reasons for such a variety of the results are 
probably different measuring instruments 
used in different speech samples. 

The F0 in TES is reported to be closer to 
normal laryngeal speakers, at least for male 
speakers, and ranges from 72 Hz to 134 
Hz.24,26 Some authors measured higher F0 in 
TES than in ES.27 

Vocal intensity(VI) 

The level of VI in users of AL is typical of normal 
laryngeal speakers during normal conversation 
or reading, ranging between 75 and 
85 dB. The intensity range is somewhat reduced.
28 The intensity of the electronic vibrator 
is largely determinated by the design of 
the instrument. 

The intensity of ES is usually lower in overall 
loudness than normal. The range of VI that 
esophageal speakers are able to produce is 
much lower than the intensity range of normal 
speakers (about 10 dB vs. 30 dB).29 

The intensity of TES appears to be only 
slightly lower than the levels produced by laryngeal 
speakers. In some speakers, variation 
of intensity may be greater than normal.30 

Temporal characteristics 

There are little data on the temporal characteristics 
of speech with an AL. The few studies 
available indicate that reading rates are 
slower when using an AL compared to normal 
phonation or TES.28 We might expect 
longer reading times because of the need for 
precise articulation to maintain an acceptable 
level of intelligibility. 

In general, the patients using ES read slower 
than normal laryngeal speakers. Their 
reading rates are about 60-70 % of the rate of 
a normal speaker. They spend 30-45 % of their 
reading time in silence because they need to 
recharge air supply more frequently. They 
have a much shorter phonation time, typically 
less than 6 s, which is no doubt due to a 
small volume of air in the esophagus.24,29,30 

Patients using TES also read at a slower 
rate than normal speakers but faster than 
esophageal speakers. Their slower rate may be 
due to difficulties in controlling the pharyngoesophageal 
segment and the need to articulate 
precisely. These speakers spend about 10-30 % 
of their reading time in silence. Their phonation 
time is longer than in esophageal speakers 
– about 12 s, but shorter than in normal 
speakers (in average 15-20 s).24,29,30 

Intelligibility 

Few studies have compared all three forms of 
alaryngeal speech. The intelligibility of speakers 
using AL ranges between 30 and 90 %. 
The average intelligibility is reported to be 

Radiol Oncol 2001; 35(4): 249-54. 


Hočevar-Boltežar I and Žargi M /Communication after laryngectomy 

about 60 %. The major cause of relatively low 
intelligibility is the failure to maintain the 
voicing distinction. Voiceless consonants 
tend to sound like voiced consonants. 

The intelligibility of ES varies considerably, 
but in general, it is somewhat higher 
than in AL users. The average is about 70 %. 
Most of the deficiencies committed by 
esophageal speakers were voicing errors. 
Like in users of an AL, voiceless consonants 
were perceived as voiced. 

TES also show considerable variation in intelligibility, 
but in general, they produce the 
most intelligible speech of the three forms of 
alaryngeal speech. The patients using TES do 
not have to use any structures in the vocal 
tract to insufflate the pharyngo-esophageal 
segment; therefore, they can maintain their 
normal (or develop near normal) patterns of 
articulation and more normal flow of 
speech.31-33 

Speech rehabilitation after laryngectomy in 
Slovenia 

According to a study performed in a group of 
members of an Association of laryngectomized 
subjects in Slovenia, 62 % of the subjects 
use ES, 8 % use TES, and 9 % of subjects 
use AL in every-day communication. About 
18 % of 113 subjects who answered the questionnaire 
communicate using pseudo-whisper 
or writing. Only 2 % of subjects use AL 
and ES or TES. The laryngectomees assessed 
their satisfaction with their mode of communication 
using longitudinal analogue scale – 
85 %.34 

The results differ from the studies performed 
in the USA or Australia. Hillman et al. 
report that only relatively small percentages 
of laryngectomees developed usable ES (6 %) 
or remained nonvocal (8 %), and that a majority 
of the patients ended up as users of AL 
(55 %) or TES (31 %).12 In Australia, the mode 
of communication after laryngectomy is 

about the same: 5.2 % patients use ES, 50 % 
AL, and 31.6 % TES.35 

The reason for the difference in communication 
mode is a good access to speech therapy 
in Slovenia. Patients start learning ES two 
or three weeks after the surgery. The 
Association of laryngectomized subjects organizes 
free courses for better communication 
skills twice a year. Perry and Shaw report 
on very low referral rate to speech pathology 
in Australia.35 In Slovenia, the voice prosthesis 
is inserted only in the patients who cannot 
learn ES. 

Many factors influence the choice of the 
mode of speech rehabilitation in a particular 
patient. For a successful rehabilitation, a 
team approach is necessary. A team of professionals 
(ENT surgeon, phoniatrician, 
speech therapist, psychologist) meets the patient 
before laryngectomy to explain him/her 
the possibilities of voice restoration after the 
surgery. The rehabilitation is started as soon 
as the wounds are healed and continues in 
the following years. The whole team and the 
patient are aware that only a successful 
speech rehabilitation enables a good quality 
of life after laryngectomy. 

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