Tony Totolini and his wife were very happy; they were going to take an ocean-going vessel from their home in Rome, Italy to New York City where they would see and live with their son.  They had looked forward to this for some time; the ocean trip would be beautiful and healthful.  However, there were some problems; for one thing Tony and his wife did not speak English, thus they would be relying on their son and his family to help them understand what was going on.  Further, Tony had just had surgery for the removal of his larynx.  After his total laryngectomy he was without voice.   Without voice and without an English language for speech Tony did face some obstacles.

     Fortunately, when he arrived in New York Tony was able to make connections with an Anamilo club which provided a person, a ?lary? (laryngectomee), who would be able to help him learn to produce esophageal voice and, hopefully, to learn English.  The man in question was named Ed Sweeney.  This man used esophageal voice, had an Irish background, with a good command of English.  Over time Tony would try to learn not only to use a substitute voice but also to learn the language of this, his adopted country.  There were problems but they were not insurmountable.

     Language comes in different forms, it may be received or it may be expressed.  If received it is through the eye or through the ear.   Through the eye it is perceived as reading.  Through the ear we call it listening as opposed to hearing as such.  We express language by writing or speaking.  If I say, ?ich mache das fenster auf? I am saying (in German) ?I open the window?.  Whether one says it in German or in English, opening the window is the gist of the message, allowing communication with language.  For our purposes we will be focusing primarily on the expression of language through speaking.

     Only two things are required to produce sound i.e. a source of energy + something to vibrate = sound.

     What is needed in order to speak?  Here, we need four elements:

(1) a source of energy or power,
(2) a noisemaker or vibrator,
(3) a resonance chamber or resonator and,
(4) the ability to shape the sound, referred to as articulation.
   
     The articulators which are used to shape the various sounds of language are the tongue, teeth, lips, jaw, hard/soft palates, pharynx etc. Articulators are used to shape sounds into meaningful words, phrases, sentences. Therefore, a source of energy + a vibratory source + resonance + articulation = speech. For the non-laryngectomized speaker, exhaled air from the lungs (energy source) sets the vocal folds (vibratory source) into vibration to make sound which is introduced into the pharynx, nasal, and oral cavities (resonators) and is then shaped into various sounds by the articulators (articulation) to produce speech. It is important to understand that this is a dynamic system in which sound is carried along with the exhaled air flow to the resonators and that exhaled air flow is involved in the production of many sounds of speech.

     During laryngectomy the vocal folds (vibratory source) are removed, the airway abbreviated and turned to the outside through a stoma in the neck from which the laryngectomee now breathes. Exhaled air no longer reaches the pharynx, nasal and oral cavities.  The resonators and articulators are essentially unchanged although the vocal track is shortened. For the sake of simplicity, one could say that following laryngectomy the energy source (respiration) is present but is no longer connected to the resonators. The vibratory source is no longer present. But the resonators and articulators are unchanged. However we cannot have speech without all four elements of speech in some way interacting together.

     The key element to re-establishing speech following laryngectomy is developing a substitute vibratory source to produce sound. Secondly, to introduce the substitute source of vibration into the modified vocal track so that the resonators and articulators can be employed to produce serviceable speech. The laryngectomee has three choices, each of which can provide a substitute source of voicing on which to base his speech.  The choices of voice are: standard esophageal voice (SEV), artificial larynx (AL), and tracheoesophageal puncture (TEP).

     That means Tony now has to have a new voice maker because his larynx, which included the vocal cords, has been removed surgically. 

     Tony has opted to try to use esophageal voice.  For esophageal voice, air is stored in a substitute lung, the esophagus.  This tube holds only 100 cc of air, in contrast to 4000-5000cc in the lung.  That is like driving a big car with a gas tank holding only a cup of gas.  Tony will have to learn how to get the air into the esophagus. The esophagus can function if it has some vibrating mechanism against which to push the air.  The top of the esophagus, the place where the esophagus and the inferior constrictor muscle meets, is called the pharyngo-esophageal segment (P-E Segment), a substitute voice box or vibrator.  Air can be pulled or pushed into the esophagus.  That air can be expelled as lung air is expelled.

     Had Tony chosen Tracheoesophageal (TEP) voice his surgeon would have created an opening (track) between his airway and esophagus. Once fitted with a voice prosthesis Tony would be able to make a substitute sound for speech by covering his stoma and exhaling.  The exhaled air passes through the prosthesis causing the upper end of the esophagus (P-E Segment) to vibrate. This site of vibration or substitute voice is the same as that for esophageal voice. Basically the difference between esophageal and tracheoesophageal sound is merely in the source of energy for voice/speech.

     If Tony had chosen to use an artificial larynx he would have two fundamental types to chose from - pneumatic and electromechanical.  With a pneumatic type artificial larynx the exhaled air from the lungs sets a diaphragm (usually rubber) into vibration when the device is placed over the stoma. Sound is then introduced into the oral cavity via a small tube. In the case of an electromechanical device the energy source is a battery.  The vibrator is a metal or plastic disc which is set into vibration by an energized striker. The electromechanical artificial larynx utilizes a basic physics of sound principle called ?sounding board effect? to produce sound. The electromechanical artificial larynx provides both an energy source as well as a vibratory or sound source for speech.  The laryngectomee must lean to effective couple the device to the vocal tract or resonators to produce speech.

     It is not the intent of this article to describe the many nuances of learning to use the various means of substitute voice available for the laryngectomee.  They are described here only as a basis for understanding the differences in energy and vibratory source for the various methods of substitute voice available to the laryngectomee. Furthermore, it is imperative that one understands that the production of many speech sounds used in English, as well as other languages, depend on exhaled air flowing from the lung through the vocal track and exiting at the lips. For the esophageal and artificial larynx speaker this is not possible. There is no connection from the lungs to the vocal track as the result of surgery to remove the larynx. The tracheoesophageal speaker presents a different set of problems. Although the TEP and voice prosthesis provide a conduit for air to flow from the lungs to the vocal track there is no way to produce that airflow without sound.

     As discussed above, there are three means of re-establishing voice following laryngectomee: standard esophageal voice, artificial larynx, and tracheoesophageal puncture.   How do you measure the success of any substitute voice?  The term ?FIT? can represent the basic characteristics of voice.  F = frequency (which you and I call pitch), I = intensity (which you and I call loudness) and T = time (which can be measured in a wide variety of ways.)  When a person speaks we ask the question ?is the voice FIT??  Finally, when that is done we ask about quality - is it a voice quality that sounds more musical or noisy.

     Now we can measure esophageal voice or any voice for that matter by assessing the ?FIT?.  Instead of a frequency (F) range of 2-3 octaves for laryngeal voice the person using esophageal voice has less than one octave.  But he does not need to speak in a monotone, as ?Johnny-one-note.?  His intensity or loudness (I) may be ten percent less than he had with his voice box. The measure of time (T), can include such things as how long does it take to get the air in, how long does it take to get the voice out, how many syllables or words can be said in a unit of time, overall how fast can he speak as expressed in words per minute.  We are satisfied if the goal is something in the neighborhood of two-thirds the rate one spoke before the laryngectomy.  So we have a lower, softer and slower form of communication.

     The artificial larynx may provide change of loudness and it may be as rapid or more rapid than speech before the laryngectomy.  With an electro larynx pitch tends to be more monotonous.

     In contrast, TEP offers a more nearly normal voice pattern, using lung air (4000cc - 5000cc) in order to activate a vibrator, which, like esophageal voice, is at the very top of the esophagus.  We can say that TEP is a form of esophageal voice!  TEP is better than SEV as to pitch, loudness, rate and variety.  Voice quality should be comparable to esophageal voice.  In contrast, the artificial larynx should provide some reasonable expression of pitch, loudness and time, particularly if the AL is pneumatic (air-driven) rather than battery powered.

     Before leaving the matter of loudness of esophageal speech, we should note that frequently the person, aware of a softer voice, tries to talk more loudly (presumably to be better understood).  We have noted that SEV air parallels lung air, so trying to talk louder should involve sending lung air out faster.  However, there is a price to be paid.  More lung air coming from the stoma means more noise to mask or interfere with speech!  It is as though every time a person starts to talk, a huge fan also goes on.  Strange as it may seem, the better, clearer, more intelligible esophageal speech is achieved by reducing noise, and talking softer!  This is a hard lesson for some, especially those older persons who also are more apt to have some hearing loss, thus less apt to hear the stoma noise!  The esophageal speaker should decide if he prefers to be heard, or understood.  Remember that being heard does not guarantee being understood.

     Humming a tune or a nursery rhyme, even with a ?FIT? voice, is melody without words, i.e., prosody.  Two things are now needed to get speech.  The sound must resonate through the throat, nose and mouth.  After you pluck or bow the string of a violin, resonance happens.  Sound does not just come from the string; it goes into the chamber or belly of the instrument, be it a violin or cello.  The resonance gives tone its quality.  For the laryngectomee resonance is crucial to turn noise into speech.

     The last step in turning the sound into speech is articulation. As used by a dentist, articulation refers to the joining or meeting of the teeth.  In speaking, articulation may involve any of the structures in the mouth: jaw, lips, teeth, tongue, or palate. Articulation is a process by which varying degrees of obstruction are placed on the out going air stream and the size and the shape of the resonating cavities are modified. The articulators shape the sounds used to produce speech.

     At this point we are ready to attempt to test a speaker?s ability to produce the varied vowel and consonant articulations that are necessary for the production of English. I have devised a simple set of words and phrases to accomplish this task (see Table 1).

Table 1: Uncle Jim?s speech test

     In these 24 phrases one can test how well one speaks; although the vowels are scattered throughout, the consonants are our target in order to determine how well we speak.  We say that vowels carry the power of speech but consonants carry the understandability or intelligibility of speech.  You and /or someone close to you can listen to the way in which you speak these various phrases and find out if any do not measure up to the level that is expected.  It is always better to have someone else listen, but if that is not possible try recording your utterance and then listen to your recording.

    Suppose you had x-ray vision and took a side view of the mouth and throat of a person speaking.  As the speaker says different vowel sounds the jaw may go up or down a bit, and the lips may pucker or spread in a smile.  But the most striking movement is made by the tongue, which can go up and down as well as back and forward.  The key is how the mouth-throat tube varies to change the size and shape of these two cavities!  Vowel sounds, therefore:
(1) always are voiced,
(2) can be described by position of the tongue in the mouth (high/low, front/back),
(3) never involve complete blockage between two structures and
(4) change mouth/throat configuration, (like resonance).