Instruction on the use of a neck-type artificial larynx using the ?I PAT PAL? method:

I = Information.  The patient is informed on benefits of the transcervical artificial larynx as well as other artificial larynges.  This discussion should include:  device costs, availability, model options, design differences between models and purchasing information.  The purpose of the artificial larynx must be discussed. Is this device to serve as the patient's primary mode of communication, or will it be a "back-up" device for use when esophageal voice or tracheoesophageal voice are not optimal.  The Speech Pathologist ideally will have an assortment of devices available for demonstration, trial and purchase. Once a model has been decided upon and dispensed specific care and use instructions should be provided.

P = Placement.  Optimal and consistent positioning of the device is necessary for appropriate sound transmission.  Correct placement varies with individual users and may vary over time and treatment.  Optimal placement is determined by examination of the patient's neck and oral structures and direct experimentation.  If the neck is edematous or fibrotic sound waves will not be adequately transmitted through the tissue.  Alternatively, neck-type artificial larynges may be placed on the apple of the cheek, at the midline junction between the neck and floor of mouth or the anterolateral aspect of the neck (Keith, 1994).  The point of optimal sound transmission is termed the ?sweet spot?.  It is paramount that the entire circumference of the vibrating head be placed firmly and directly on the sweet spot. Incomplete contact of the vibrating head will generate a distracting buzz, which results in a poor signal-to-noise-ratio and reduces speech intelligibility.  If placed too firmly against the tissue, sound transmission may be dampened (Graham, 1997).  If the unit is placed correctly the sound will be perceived by the listener as emanating from the mouth.  Some clinicians find it useful to mark the "sweet spot" with a piece of tape or skin marker. This allows the patient to locate the sweet spot easily while practicing optimal placement in front of a mirror. Practice should continue until consistent placement has been established. (Graham,1997).  Ideally, the laryngectomee would hold his artificial larynx in his non-dominant hand, while placing the unit on the ipsilateral side of the neck. This frees the dominant for writing, gesturing, hand shaking or holding a telephone receiver.  Non-dominant hand use cannot, always be achieved without compromising patient comfort. Arthritis or upper extremity weakness may make use of the non-dominant hand impractical.   If the laryngectomee has a unilateral hearing aid, it is recommended that the patient place the artificial larynx on the contralateral side of the neck. This placement increases the distance between the artificial larynx and the hearing aid which reduces ambient noise, generated by the electrolarynx, from entering the aided ear. Improved signal-to-noise ratio in the aided ear may help the laryngectomee monitor his voice out-put.    

A = Articulation.    The lips, teeth and tongue and mandible position are responsible for shaping the tone produced by the artificial larynx.  An oral-peripheral examination it is recommended prior to embarking upon direct treatment of articulation skills.  This examination should identify fit of dentures, movement of oral structures and strength. If problems are noted, an oral-motor treatment program should be instituted. The oral-peripheral examination should be repeated periodically if the laryngectomee patient is undergoing radiation therapy, as changes in oral and neck tissue status, such as mucositis and lymphedema may restrict oral movement or transmission of sound waves through the soft tissue of the neck. This may result in changes to the sweet spot. Unlike intra-oral or pneumatic devices, transcervical artificial larynges do not have tubing that might obstruct movement.  However, slight exaggeration of lingual and labial contacts is often necessary to improve speech intelligibility for all patients using electromechanical speech. A natural or slightly reduced rate of speech should be encouraged. Firm articulatory contacts increase intraoral-pharyngeal air pressure, which may contribute to accurate production of voiceless consonants (Graham, 1997). Voiceless consonants are the most difficult phoneme class for electrolarynx users to produce. Electrolarynges transmit sound, or voice, continuously if the tone button is depressed.  Laryngeal speakers start and stop voicing intermittently throughout words depending upon the phonemes in that word. For example, the vocal folds vibrate, for the voiced phoneme /g/ but not for the voiceless phoneme /k/. Electrolarynges transmit sound, or voice, continuously if the tone button is depressed.   Therefore, voiced phonemes will be substituted for voiceless sounds (e.g. /g/ for /k/). Voiceless phonemes with no voiced cognate, such as /h/ cannot be produced by an electrolarynx.  To produce a voiceless phoneme such as a /k/ in the word car, the speaker must articulate the /k/ a split second prior to turning to activating the electrolarynx. It is important to educate the laryngectomee and his family about articulation problems relating to voiced- voiceless sound substitutions and to teach compensation strategies for these errors as soon as possible. Simple, short-term solutions may include, spelling out words that are not understood by family and staff or using alternative words.   

T = Timing.  Once the "sweet spot" has been established the patient's next voicing goal will be to obtain consistent, coordinated on and off timing. All transcervical electrolarynges currently available are battery-operated and switch activated.  Sound is generated when the switch is depressed and ceases when it is released. Individuals new to artificial larynges may activate the on-control prior to speaking or conversely start moving the articulators before turning on the device. Others may release the button before they have finished speaking. Frequently, laryngectomees new to the artificial larynx may fail to turn the device off immediately after speaking. This adds a schwa at the end of each mistimed utterance. For example, instead of "one",   "one-/ә/" is produced.  Other timing problems include: turning the unit off between every syllable within a word, creating a distracting, staccato-like effect or conversely, not turning the unit off between phrases, creating run-on utterances.  The patient should be encouraged to mentally think of his sentences in phrase units and pause slightly (off voicing) between those phrases and to refrain from deactivating the unit after every word or syllable. For example, the sentence "We speak in thought units, not in parts of speech" is best understood by the listener if delivered with a slight pause at the comma, dividing the two phrases.

Timing errors, whether in the on or off aspect, can impact intelligibility as much as poor articulation. Fortunately, these timing errors are easily corrected with guided practice. Timing errors often become clear to the patient if the speech pathologist demonstrates both the error and the correct target in succession. The first goal of timing instruction and practice is coordination of external sound source activation/deactivation with purposeful speech movements.  Advanced timing skills facilitate articulation of voiceless consonants. For example, articulating voiceless consonants just prior to activating the on control. Natural pausing and speech phrasing should be reinforced, from the start of electrolarynx training.

PAL = Pitch and loudness. The pitch of the electrolarynx is set by the speech pathologist during the initial artificial larynx treatment session. Pitch should be adjusted to a level that is appropriate to patient's age and gender. Volume should be set so that the patient can hear himself clearly.  After the patient establishes proficiency with the elements of placement, articulation, and timing, they can be taught to modulate pitch for more natural intonation patterns by manipulating the pitch buttons on the external device.  The laryngectomee should be instructed on basic volume adjustments specific to his or her device within the first few treatment sessions.

Distracting Behaviors- Distracting non-verbal behaviors are not part of the standard I PAT PAL pneumonic. However, Archer (2002) suggests that nonverbal communication is more powerful in message decoding than words alone.  Therefore, nonverbal behaviors must be considered a fundamental skill, no less important than placement or articulation, for effective communication. Distracting behaviors may appear within the first treatment session. Behaviors, such as stoma blast, facial grimaces, & head contortion, call attention to communication delivery at the expense of content.  Prolonged exhalation naturally occurs during laryngeal voice production. To project the voice, the laryngeal speaker forces air over the vocal folds. Electromechanical voicing allows for continuous voicing at any point, regardless of inhalation-exhalation cycle (Graham, 1997). Forced exhalation will not create a volume gain in the laryngectomee. Strong exhalatory force creates turbulence at the stoma which produces an audible sound referred to as "stoma blast".  Stoma blast calls attention to its self, is distracting to listeners, and if forceful enough may mask or override the signals of speech with noise.  Negative practice, contrasting controlled exhalation with forceful exhalation is useful in eliminating stoma blast, and improving intelligibility. Facial grimaces or atypical head and arm postures often resolve once the patient?s attention has been called to them. Videotaping or practicing conversational skills at a laryngectomy patient group may also be useful in eliminating these unwanted behaviors.  

Historical Perspective of the Transcervical Artificial Larynx

In 1942, Wright introduced the first electrolarynx, the Sonovox (Keith, 1994).  This unit was produced by Aurex in 1945, and set the design foundation of the modern transcervical artificial larynx. In 1959, the transistorized Electrolarynx was developed by Bell Laboratories (Keith, 1994). The Bell or Western Electric was produced in two models 5A and 5B, which incorporated internal preset frequency ranges for males and females respectively. This preset pitch range could be adjusted to meet individual preference.  The laryngectomee could additionally modify the pitch with an external tone activation switch.  The Western Electric 5A and 5B do not have an external intensity or volume adjustment.  The Western Electric was powered by a carbon-zinc battery. However, physical adjustments to the battery compartment as reported by Eric Blom in 1978, allowed the unit to accommodate standard 9-Volt battery (Keith, 1994). The patient and clinician were advised to exercise care during these adjustments, because damage incurred during this change nullified the manufacturer?s warranty.