Klaske van Sluis

8 1.5. Speech rehabilitation after total laryngectomy limited invasion a primary closure of the pharynx can be performed, but in more extensive resections, reconstruction of the lost tissue is necessary by reinforcing tissue from another part of the body, e.g. a pectoralis major flap, radial forearm flap or gastric pull-up. For the patient to be able to breathe, a tracheal stoma is made by bringing the trachea to the skin in the inferior anterior area of the neck. When possible, a primary insertion of voice prosthesis is performed allowing early vocal rehabilitation with tracheoesophageal speech. 1.5 Speech rehabilitation after total laryngectomy Due to the removal of the larynx, one of the immediate consequences is that the patient loses his ability to generate voice; the patient will need a substitute voice. Substitute voicing is defined as ‘voicing without the true vocal folds’. After total laryngectomy the three most used options for creating a substitute- voice are tracheoesophageal speech, artificial larynx, and esophageal speech. 1.5.1 Tracheoesophageal speech The majority of this thesis is focused on outcomes in tracheoesophageal speech, which is considered the preferred speech rehabilitation option in the Western world. A fistula is created between the trachea and esophagus, in which a valve (voice prosthesis) is placed. This re-establishes the connection between the lungs and the mouth. When the stoma is occluded, air from the lungs enters the esophagus, which results in vibrations in the pharyngo-esophageal segment. The pharyngoesophageal segment (PE-segment), also referred to as the neoglottis, serves as the new vibratory voicing source in tracheoesophageal speech. In contrast to the quasi-symmetrical vocal folds, the vibrating neoglot- tis consists of amorphic vibrating elements. The whole vibrating segment is larger since it has more mass and therefore its vibrations are typically less reg- ular compared to laryngeal speech. Tracheoesophageal speech is generalized by a lower fundamental frequency, a rougher voice quality, reduced voicing dis- tinctions in consonants and abnormal prosody. Tracheoesophageal speech can be perceptually hoarse or breathy, it can be noisy, caused by air seeping from the stoma during speech or the gargling noise of saliva or mucus flowing down the throat [15, 16]. The general speaking rate is reduced with fewer words and syllables per minute and longer or greater number of pauses [16–18]. In speech production, problems occur in producing voiced and voiceless consonants, voic- ing vowels, maintaining pitch, and producing specific phonemes [19]. In Figure 1.2 a schematic drawing of tracheoesophageal speech is visualized. 1.5.2 Esophageal speech Esophageal speech is performed by administering air into the esophagus, which is subsequently expelled, causing mucosal vibrations in the PE-segment. Prior