factors predictive of success or failure in acquisition of esophageal speech

~ ~ ~~

Speech Rehabilitation Following Laryngectomy Workshop

FACTORS PREDICTIVE OF SUCCESS OR FAILURE IN ACQUlSlTlON ESOPHAGEAL SPEECH

Shirley J. Salmon, PhD

This article discusses negative and positive predictors for acquiring esophageal speech. These indicators are grouped under two broad categories: anatomidphysiologic and psychological/ social. The success and failure rates and advantages and disadvantages of esophageal speech are also presented. Consid- eration of all factors will enable professionals to counsel patients realistically about their potential for successful acquisition of this method of alaryngeal speech. HEAD & NECK SURGERY 10:S105-S109,1988

T h e literature is replete with clinical impres- sions, findings from investigative studies, and results of questionnaire surveys suggesting factors that impact negatively or positively on a laryngectomized individual’s ability to acquire esophageal speech. Before professionals can counsel patients adequately about the advantages or disadvantages of this mode of communication, they must be aware of these factors and be willing to weigh them against succesdfailure rates.

Presented at the Speech Rehabilitation Following Laryngectomy Work- shop, Baltimore, June 4, 1988. From Audiology and Speech Pathology, VA Medical Center, Kansas City, Missouri. Address reprint requests to Dr. Salmon, Speech Pathologist, Audiology and Speech Pathology (126), VA Medical Center, 4801 Linwood Blvd., Kansas City, MO 64128. Accepted for publication August 9, 1988.

@ 1988 John Wiley & Sons, inc 0148-6403’1 OOS/SlOS $04.00/5

OF

POSITIVE INDICATORS

Positive indicators are those factors conducive to success in the acquisition of esophageal speech. They are grouped under two broad categories: (1) anatomicallphysiological and (2) psychologicall social. Both categories are considered important when predicting success. Subfactors of the anatomic/physiologic category will be discussed first.

(a) Adequate functioning of oral-pharyngeal- esophageal structures is a prerequisite for production of esophageal speech. Esophageal speakers who use an injection method of air intake must have adequate lip, tongue, and velopharyngeal function to seal air within the oral-pharyngeal cavity, to decrease the size or shape of it, and to create enough compressed air to overcome pharyngeal- esophageal (PE) segment resistance from above.’-4 Speakers who use the inhalation method of air intake must have the ability to voluntarily relax the PE segment for air to enter the e~ophagus.’’~’~

The esophagus must have the capability to serve as an air reservoir. Both the upper and lower sphincters must remain closed immedi- ately before air is expelled for esophageal voice. If the cardiac (distal) sphincter yields to air pressure from above, air will enter the stomach. Al- though the air eventually might escape from the stomach and pass through the PE segment where tone can be produced, the eructation is considered involuntary and, thus, differs from the process associated with esophageal speech.2

Acceptable voicing will occur only when the

Esophageal Speech Acquisition HEAD & NECK SURGERY Supplement 11: 1988 S105

tonicity of the PE segment remains supple.536 And, of course, intelligible speech requires adequate functioning of the oral mechanism, including velopharyngeal sufficiency and intact denti- tion.

(b) Sufficient pulmonary support and coordina- tion of respiratory musculature are also critical to esophageal speech production. In order to expel esophageal air, the natural elasticity of the esophageal wall must function with both intrathoracic and abdominal muscles to build up enough air pressure from below to overcome resistance of the PE ~egment."'",~

(c) Satisfactory hearing acuity is required of patients attempting to learn esophageal speech. Pa- tients need to understand speech instruction. Also, they must be able to auditorily monitor their speech output to improve intelligibility and decrease audible di~tractors.6'~'~

(d) Generally, good health is considered an at- tribute for anyone trying to learn a new motor skill. Physical strength and freedom from distraction of complicating medical problems are necessary to at- tend and participate in treatment sessions.6"0'11

( e ) Typically, age is related to acquisition of new skills, and esophageal speech is no exception (mean age of those undergoing laryngectomy is 60). Though somewhat controversial, it is generally agreed that for whatever associated reasons (flexi- bility, alertness, persistence, muscle tone, etc.), people in their mid-sixties or younger are better candidates for esophageal speech."s'2-'5

(f) Several investigators have reported that patients who are able to swallow rapidly and without pain are more likely to be successful esophageal

For these reasons, ease in swallowing is considered to be a positive contributing factor.

(g) One investigative group has reported that patients able to sustain phonation of /a/ for an average of 14 seconds are better candidates for esophageal speech than are those with phonation dura- tions of 9 seconds or less." Preoperative ability to sustain phonation is easy to measure and may prove a reliable predictor.

The following are considered positive indicators under the psychological/social category. They are more difficult t o investigate, but may be more significant in terms of the speech rehabilitation process.8

(a) Patients must demonstrate that they will take time to acquire esophageal speech and that they are accepting of the esophageal sound as well as the flatus or stomach rumblings associated with

Therefore, their willingness to practice it.10,15,17,18

and accept minor physical inconveniences is considered imperative.

(b) Personality traits such as hard-working, en- ergetic, determined, independenudependent, and self-discriminating frequently are associated with the term "motivation." Motivation is acknowledged as indispensable for learning this method of communication. 'OJ 'J 5~19 Also, those who remain gainfully employed, particularly females, more often achieve esophageal speech.'*

(c) Other traits attributed to successful esophageal speakers include an extroverted personality with regard to talking and relating to others, a fa- vorable self-concept, a good body image, and lower levels of anxiety.'o'20-22 Patients must exhibit enough self-confidence to use their newly acquired esophageal speech in public.

(d) The greater the level of involvement by family members and other laryngectomees, the greater the likelihood of esophageal speech acquisition.' 1~15,23 Individual testimonies from patients indicate the importance of being challenged or encouraged by others to practice, use, and accept their new voice.

(el The quality of esophageal speech rehabilitation is enriched by speech pathologist experienced in teaching alaryngeal speech and familiar with learning principles that include ways to enhance motivation.' ' p Z 2 - 24 A team of professionals working within a planned program of management to help patients achieve success is also beneficial?'

Some patients do not acquire esophageal speech, despite the fact that they exhibit all or a majority of these positive indicators. Others seem to defy all predictions and learn to use this method of speech proficiently. Many approach their initial esophageal lessons with optimism and enthusiasm. They look forward to the chal- lenge of learning a new task and they fantasize about mastering the new skill. Some realize their dreams. Many do not.

NEQATIVE INDICATORS

Factors most commonly described as interfering with esophageal speech acquisition are grouped under the same two broad categories: anatomic/ physiologic and psychological/social. Consider- ation of these negative indicators may prevent patients from persisting in months of speech therapy when little or no progress is apparent. Again, the anatomic/physiologic factors will be considered first.

(a) The combination of radiotherapy and exten- sive surgery used for more advanced lesions causes

S106 Esophageal Speech Acquisition HEAD & NECK SURGERY Supplement II: 1988

muscle atrophy and fibrosis, which interfere with swallowing and movement of the neck.26 In addition, postoperative radiotherapy causes sore throat, discomfort when swallowing, and dryness of the mouth.” Many patients discontinue esophageal speech lessons during radiotherapy and may not re- turn because of prolonged after-effects.

(b) Extended operations that involve removing major portions of structures within the oral-pharyngeal-esophageal tracts may completely preclude acquisition of esophageal speech.” Such operations include jejunal pull-ups, removal of the pharynx, soft palate, or large sections of the tongue.

(c) Patients with dysphagia who have difficulty swallowing solid foods such as hamburger, vegeta- bles, and small pieces of steak are considered poor candidates. One proponent of this theory believed that dysphagia was a sign of poor muscle tone and actually refused to accept patients for esophageal speech training until they could eat a normal meal and really enjoy itY7

(d) Although velopharyngeal (VP) incompetence or palatal paresis precludes use of injection for in- sufflation of the esophagus, the inhalation method of air intake can be used as an alternative. Never- theless, patients with VP insufficiency exhibit additional problems. Their ability to impound air in the oral cavity for production of plosive or fricative consonants is impaired so that intelligibility of esophageal speech is adversely affected!” Im- paired tongue movements or tongue strength can also affect both method of air intake and

In addition, pouches or diverticuli that cause the anterior pharyngeal wall to bulge require the patient to work harder to achieve the necessary build-up of oral-pharyngeal pressure. Also, they alter characteristics of the resonator and collect additional secretions so that esophageal voice quality is less acceptable and may sound wet or b~bbley.~’

(e) In an effort to i n sda te the esophagus, some patients contract the inferior constrictor muscles of the pharynx and the entrance to the esophagus instead of voluntarily relaxing them. The re- sult is that air becomes trapped in the hypopharynx and the pharyngeal mucosa are forced into vibra- tion. Occasionally, a mild stenosis of the entrance to the esophagus causes the same effect. Under ei- ther circumstance, pharyngal voice/speech is produced. This type of voice is unsatisfactory due to its peculiar quality, h@ frequency, short duration, and reduced intensity?’ Although a few methods have been suggested for altering or overcoming this

type of speech, it is difficult to change once it has been established.

Hypotonicity of the PE segment can prevent air from entering or exiting the e ~ o p h a g u s . ~ . ~ ~ Hypertonicity of the PE segment can cause in- consistent v o i ~ i n g . ~ l - ~ ~ Both conditions are significant reasons for failure to develop esophageal voice. Myotomies performed to correct these problems sometimes cause fistula or swallowing problems that persist indefinitely.

(f) A flacid lower esopahgeal sphincter (cardiac sphincter) can prevent air from being retained in or, subsequently, expelled from the esophagus. Ex- cessive air pressure in the stomach may aggravate hiatus hernia, ulcers, and other stomach disorders to the extent that patients are discouraged from using esophageal speech?6

(g) Surgery, radiotherapy, or chemotherapy for recurring cancer can cause loss of previously acquired speech. Physical after-effects including fa- tigue often prevent continued use of esophageal speech. An early sign of metastasis, frequently to the esophagus, can be a sudden regression in speech, particularly in the ability to sustain ph~nat ion?~

The following are considered negative indicators under the psychological/social category. Some of these factors are more elusive to investi- gation, but may be more significant in terms of the speech rehabilitation process.

(a) For whatever reasons (depression, nonac- ceptance, lack of time/perseverance, adverse effects, etc.), those not interested in learning esophageal speech obviously will not do s0.11,12,22935,38 Some patients are satisfied with using an artificial larynx or a vocal restoration procedure for all of their communicative needs and see no reason to at- tempt to learn “standard esophageal speech.

(b) When pain or discomfort is associated with practicing or using esophageal speech, some laryngectomees are afraid to persist in using it. Fear of recurrence causes them to resist irritating the pharyngeal or esophageal areas already weakened by ~ a n c e r . 2 ~ 1 ~ ~

(c) Laryngectomees who live alone or have no one with whom to share day-to-day events are less likely to learn esophageal speech?8 Poor environmental circumstances such as these may influence the number of times per day patients allocate far practice, which is also significantly related to successful acquisitionF2 On the other hand, attitudes of those in the immediate environment influence failure or success in achiev- ing Finally, hearing loss in those most

Esophageal Speech Acquisition HEAD 8, NECK SURGERY Supplement II: 1988 S107

closely associated with the patient may impair their ability to perceive esophageal speech so they dis- courage use of it.“

(d) As a group, head and neck cancer patients have a history of alcohol abuse. In this older patient population (average age, 55-65), there is also the possibility of dementia. The presence of these factors, in addition to mental incompetence, prevents the learning of esophageal speech as well as other means of alaryngeal voice rehabilitation!

(e) Sadness about having a life-threatening dis- ease and loss of a body part is a healthy, normal reaction. The tendency to withdraw into an isolated state for an extended period of time is not healthy. Extended depression prevents one from facing real- ity and delays rehabilitation. Patients who react in this manner are unable to accept their loss or to consider ways of coping with it. The extreme of this type reaction may be suicide?’

(f) A final factor considered worthy of mention is one originally labeled by Marshall Duguay3 as G.0.K.-God Only Knows. There are, of course, in- dividuals for whom specific reasons for failure to acquire esophageal speech cannot be ascertained. Conversely, there always are exceptions to the rule and some patients confound us all and acquire esophageal speech despite major complications.

DISCUSSION

It is difficult to determine the exact percentage of patients who are successful in acquiring esophageal speech. Reports indicate that an average of 64% of those attempting to learn are s u c c e ~ s f u 1 ~ ~ with a range from 25%26 to The variations likely are due to methodological differences among investigators, i.e., subject se- lection criteria, speech tasks, experimental conditions, definitions of success/acquisition, judges’ experience with esophagal speech, etc. Also, as one investigative group has suggested, the number of ideal candidates may be diminishing so that present successes/failure cannot be compred with those reported in older studies.26 Finally, many laryngectomees now are using two or more alternate methods of alaryngeal speech (artificial

larynx, “standard” esophageal speech, or esophageal speech via a vocal restoration procedure). In the past, success rates associated with acquisition of esophageal speech have implied sole use of this method for communication purposes. Nowadays, laryngectomees are encouraged to use the method of communication that best suits their need for the occasion. Thus, use of esophageal speech might be limited to short utter- ances, with family members, primarily in the evening. If past criteria for successful acquisition of esophageal speech were applied to such a speaker, he would likely be categorized a failure, whereas application of current standards might classify him as a success.

No matter how frequently or proficiently laryngectomees are using esophageal speech, there are certain advantages and disadvantages commonly associated with it. The quality of esophageal voice is only one disadvantage. Because it does not resemble the sound of laryngeal voice it is distracting and calls attention to the speaker. At best, those who use it often are accused of sounding as if they had severe laryngitis. There are other disadvantages. Esophageal speakers must take time to periodically i n s d a t e the esophagus. Thus, they speak at a slower rate. Also, they use a fundamental frequency approxi- mately one octave lower than adult males with laryngeal voice, and constantly combat a noisy environment because of their reduced intensity level. They frequently complain about the inability to eat and speak at the same time or inability to speak when they are feeling emotional.

On the other hand, there are advantages to using this method of alaryngeal communication. Esophageal speakers are able to talk and have both hands free. They are independent of me- chanical devices, prostheses, or any care- providers associated with these devices. They are forever grateful for having been able to acquire the essential motor skills, which have come after many hours of prolonged but necessary practice. And, they take great pride in having mastered their new esophageal voice^.^'

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factors predictive of success or failure in acquisition of esophageal speech

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