November 2004


 

 

Name Of Column Author Title Article Type
VoicePoints Farrell, Dietrich-Burns, Messing Part II:  Intra-Oral Artificial Larynx Education-Med
Musings From The President Pat Sanders Recovering From Surgery. Experiences
News, Views, & Plain Talk Pat Sanders Lary Reflux Experiences
Bits, Buts, & Bytes Dutch Computer Tips News & Events
Welcome New Members Listing Welcome News & Events

 


 VoicePoints [ ©  2004 Dan H. Kelly, Ph.D. ]
  
  coordinated by   Dr. Dan Kelly, Retired Associate Professor ( dy_kelly@msn.com )
                                Department of Otolaryngology, Head & Neck Surgery
                                7700 University Court, Suite 3900, West Chester, OH  45069

© October 2004 Stephanie Farrell, M.A., CCC-SLP,
Katie Dietrich-Burns, M.S., CCC-SLP,
Barbara P. Messing, M.A., CCC-SLP

Second in a Three Part Series:  

Foundation Skills for the Artificial Larynx Part II:  Intra-oral Artificial Larynx
 
Stephanie Farrell, M.A., CCC-SLP, Katie Dietrich-Burns, M.S., CCC-SLP, Barbara P. Messing, M.A., CCC-SLP.  All authors are affiliated with the  Milton J. Dance Head and Neck Rehabilitation Center  at the Greater Baltimore Medical Center, Baltimore, Maryland  

This article is the second in a three part series intended to provide information on the various types of artificial larynges and the foundation skills necessary for optimal use.  There are three distinct categories of artificial larynges; the transcervical (neck-type), intra-oral, and pneumatic.  The most common artificial larynx in the United States is the transcervical type.  Transcervical artificial larynges are devices that conduct a battery powered, electromechanical sound from an external device through the tissues of the neck and into the oropharynx.  The sound is then shaped into speech through movements of the lips, teeth, tongue and jaw.  This type of artificial larynx will be discussed in the third article of this series. 

In the first article, the pneumatic artificial larynx was introduced.  As Messing et al describe, the pneumatic artificial larynx is a unique intra-oral device in that it is the only lung powered artificial larynx.  Indeed, the vast majority of intra-oral artificial larynges is not lung powered, but rather are electromechanical.  This article will focus on foundation skills for use of electromechanical, battery-powered artificial larynges which are designed specifically for or can be adapted for intra-oral use.  This category of artificial larynges encompasses a wide variety of devices through the years.  The Cooper-Rand is the most widely recognized intra-oral artificial larynx, but clinical ingenuity has allowed for many of the transcervical type electrolarynges such as the Servox Inton, Servox Digital, Trutone, and NuVois to be adapted for intra-oral use. As stated by Messing et al in the first article of this series, a model outlined by Salmon (1983) was chosen as a protocol for directing training in the use of an artificial larynx.  Using the mnemonic I PAT PAL, Dr. Salmon describes the important elements and hierarchy of teaching patients how to use an artificial larynx with the intent of maximizing speech intelligibility (see Figure 1).

Figure 1. Instructional Method for Teaching Use of an Artificial Larynx I = Information.  The patient is informed on benefits of artificial larynges and selection of the proper device.  Influential factors:  purchase price and upkeep, availability, possible modifications, expediency, post-operative complications, patient preference. P = Placement of the device to achieve.  For example, with certain artificial larynges, the sweet spot

is the place in at the best clarity of sound and resonance is achieved.  With intra-oral devices appropriate placement of the intra-oral tubing is discussed. A = Articulation.   Shaping sounds into speech using the articulators for precise sound production.  Overarticulation or exaggerated movements of the articulators is often recommended to increase speech intelligibility level.  Placement of the artificial larynx should favor lip reading. T = Timing.  On-off timing consistent with syllable initiating and releasing positions of phonemes in words and phrases results in optimum sound production and greater speech intelligibility level.   PAL = Pitch and loudness.  Modify pitch to more closely resemble gender appropriate pitch level.  Loudness ? volume should be adequate for the communication setting.   Changes in one will usually show changes in the other.

(S.J. Salmon, Ph.D., 1983)

A battery-powered, intra-oral artificial larynx is designed to introduce an electronic tone from a hand-held external device, through a plastic tube, directly into the oral cavity. The sound is transferred from the tone generator via the external tubing into the oral cavity.  The laryngectomee must then shape the sound into intelligible speech.  The presence of the plastic tubing may impede functional articulation because speech is formed through the coordinated, sequential movements of the lips, teeth, tongue, and jaw.  These fine, coordinated movements can become clumsy and imprecise when they must occur in the region of the oral tubing.  Two types of tubing can be used with the intra-oral artificial larynx; soft, open plastic tubing, and saliva ejector tubing.  In general, when placed into the mouth, the soft open tubing is smaller in diameter, allowing the articulators to negotiate the presence of the tube more freely (Lennox, 2002).  Tubing can be easily cut to a specific length to accommodate the unique needs of the individual.  A laryngectomee may elect (to use a shorter tube to increase the loudness of transmitted sound.  A shorter tube effectively reduces the distance between the electromechanical sound output and the oral cavity, resulting in less sound dampening and a louder sound.  Conversely, laryngectomees with restricted range of motion in their hands and arms may choose to use a longer tube to allow for a lower, more natural hand and arm position (Lennox, 2002).  Laryngectomees who have excessive saliva may find that the open tubing clogs frequently.  When the open end of the tube is blocked against the cheek or tongue or becomes obstructed with saliva, sound transmission is dampened.  If such unintentional blockage is a problem, the laryngectomee may be more successful using a saliva ejector or "capped" tube (Blom, 1978).  The saliva ejector tube is the type used by dentists to clear saliva from the mouth, similarly it helps to prevent saliva from collecting in the tubing of the electrolarynx (Salmon, 1997).  In general, saliva ejector tubes are larger in diameter and firmer because they contain a stiffing wire which allows contouring the tube as desired.  Presence of a larger diameter tube may make precise articulation more difficult.  An advantage of the saliva ejector tube is that the enclosed wire can be bent to facilitate a more optimal placement in the oral cavity (see Figure 2)

Intra-Oral Connector Shown
w/ Saliva Ejector Tubing


Reprinted w/ Permission:
Bruce Medical Supply

By retaining the desired shape, the saliva ejector tubing may improve consistency of optimal oral placement and consequently improve intra-oral resonance.Both types of tubing are available for purchase in different lengths (e.g., 4", 6", 8" etc), or can be easily cut to a specific length to meet each laryngectomee's unique communication needs.  Devices such as the Cooper-Rand also offer options such as a puff switch, (see Figure, 3) forehead switch, or motion attachment to eliminate the use of hands to activate the tone generator and allow the patient to hold the device intra-orally (Peters & Dichtel, 1995).

Puff-Switch for Cooper-Rand

Reprinted w/ Permission:
Luminaud, Inc., Mentor, OH

Such devices may be particularly helpful for patients who have restricted dexterity and range of motion in their arms and hands, or who simply prefer to communicate hands-free. Instruction on the use of an intra-oral artificial larynx using the I PAT PAL method:I = Information.  The patient is informed on benefits of an intra-oral artificial larynx as well as other artificial larynges.  It is also important to introduce both the conventional plastic mouth-tubes and the saliva-ejector tubes, and to discuss the benefits and drawbacks to each type of tubing.  The patient is then able to make an informed decision on proper device and equipment selections.  The discussion should include:  device costs, availability, model options (Cooper-Rand, Servox digital with adaptor, etc.), design differences between models and purchasing information.  Ideally, the Speech Pathologist will have an assortment of devices and tubing available for demonstration as well as for purchase.P = Placement.  Optimal positioning of the device is necessary for appropriate sound transmission.  The speech-language pathologist should demonstrate the intra-oral artificial larynx with and without proper placement.  The open or capped end of the tubing should be placed approximately 11/2 -2 inches into the oral cavity with the tube above the plane of the tongue.  It is also important to instruct the patient to direct the tube toward the middle of the palate for optimum resonance.  The external device should be held laterally with the distal end of the tubing towards the side of the mouth.  This positioning facilitates lip reading and natural articulation.  By determining the proper intra-oral placement of the device the patient will locate their "sweet spot", that is, the place where they achieve optimal sound resonation, intelligibility and volume. The patient will then work to acquire consistent placement by taking the tubing in and out of the mouth (Salmon, 1983).A = Articulation.   Articulation is significantly impacted by proper placement of the intra-oral tubing.  The lips, teeth and tongue should freely negotiate the intra-oral tubing without blocking the tube.  Other considerations for improved speech intelligibility would be to check for appropriate fit of dentures and assess the patient's oral motor skills with respect to strength and range of motion of articulators.  Saliva will naturally collect in the tubing.  During natural pausing, suck or shake saliva from the tube to improve intelligibility (Salmon, 1997).  Biting the tubing or blocking the tubing with the tongue tip should be minimized as this behavior will reduce intelligibility.Overarticulation or exaggerated movements of the articulators is often recommended to increase speech intelligibility level (Salmon, 1983).  Articulatory precision is accomplished through structured exercises targeting voiced-voiceless cognates at the word, sentence, paragraph and conversational speech levels.  Exaggerating articulatory movements is often necessary to improve speech intelligibility.  A slow, yet natural rate of speech should be emphasized.  T = Timing.  Battery-operated artificial larynges are designed with an on-off switch.  By depressing the switch, an electromechanical sound is generated.  The patient may sustain the generated tone by maintaining pressure on the button or switch.  As pressure is released, the tone will cease.   Instruction with on/off timing for an intra-oral device should include:  coordinating the timing of speech onset and offset with manipulation of the button on the external sound source.  Natural pausing and speech phrasing should be emphasized.PAL = Pitch and loudness. Modification of pitch is completed at the time of initial artificial larynx set-up.  Pitch adjustments should be made to most appropriately match the patient's gender. After the patient establishes proficiency with the elements of placement, articulation, and timing, they can be taught to modulate pitch for more natural speech by manipulating the pitch buttons on the external device.  Loudness ? volume should be adequate for the communication setting (Salmon, 1983).  The volume can be altered by adjusting the settings on the external sound device.  The laryngectomee must master volume adjustments appropriate to both quiet and noisy settings.Historical Perspective of the Intra-oral Artificial LarynxArtificial larynges have undergone tremendous evolution over the centuries.  In 1942, Wright introduced the first electrolarynx.  It was held against the neck and was connected to a battery pack via an electrical cord.  In 1957 Dr. Herbert Cooper and the Rand Development Corporation introduced the world to the first intra-oral electrolarynx (Henslee). Nearly 50 years later, the Cooper-Rand (see Figure 4) remains the most widely known intra-oral artificial larynx on the market (Salmon, 1978).

Cooper-Rand Intra-Oral Electrolarynx

Reprinted w/ Permission:
Luminaud, Inc., Mentor, OH

How much do intra-oral artificial larynges cost? The Cooper-Rand costs approximately $460.00 and includes both the soft open tubing and the saliva ejector cap.  Most of the electro-mechanical artificial larynges commercially available presently offer intra-oral adaptor caps and tubing.  Artificial larynges which can be adapted for intra-oral use range from $375.00 to $700.00.  Additional replacement tubing can be purchased in packs of 10 for approximately $3.00-$5.00.  All electro-mechanical models require some type of battery to power the sound generator. The cost of a 9-volt battery varies greatly.  Many 9-volt batteries can be purchased for $1.00-$2.00 however rechargeable 9-volt batteries may run as high as $10.00-$15.00.  Other models, such as the Servox digital, use a rechargeable battery that range in cost from $26-$40 (See Figure 5).

Servox Battery Shown w/ Charger

Reprinted w/ Permission:
Bruce Medical Supply

Advantages and Disadvantages of Intra-oral Artificial LaryngesThe advantages of intra-oral devices are as follows: - voice restoration following surgery is nearly immediate- durable- relatively easy to learn- provides communication during periods of high stress and tension *other methods of speech such as standard esophageal voicing and tracheoesophageal voicing may be compromised by heightened tension at the level of the esophageal opening during periods of high stress* (Peters & Dichtel, 1995).- can be used to conduct sound even if the neck tissue is compromised by fibrosis or edema

- relatively inexpensive compared with other voice rehabilitation options

- 9-Volt batteries are readily available

The disadvantages of intra-oral devices are:

- highly visible

- an initial period of practice is required to learn to use the device as with all communication options available to the patient

- saliva will frequently clog the air tube

- most require one or two hands to work the device.  In general, the patient must hold or don the external portion of the device

- can have a mechanical, robotic sound quality.

- rechargeable, device specific, batteries are required for certain models.  These may be more expensive than a standard 9-volt battery and must be routinely charged.

Conclusion

The intra-oral artificial larynx provides a simple, effective means of oral communication.  It is relatively simple to learn, and can be used nearly immediately because neck edema does not impact sound transmission.  The device can be customized for a patient?s individual needs by offering various tubing lengths, and stiffness.  Historically, intra-oral electrolarynx users were limited to a choice of one or two devices.  Today however, innovation and advancing technology have made virtually all electromechanical artificial larynges easily adaptable for intra-oral use.  Forty-eight years after the first electromechanical artificial larynx was introduced, it remains an excellent choice for voice restoration.

Part Three of this three part series will discuss transcervical artificial larynges.
************
References:

1.  Blom, E.D. (1978) The Artificial Larynx:  Past and Present.  In Salmon, S.J. & Goldstein, L.P. (Ed.) The Artificial Larynx Handbook.
     New York, New York.  Grune & Stratton.
2.  Graham, M.S. (1997).  The Clinician?s Guide to Alaryngeal Speech Therapy,
3.  Newton, MA, Butterworth-Heinemann.
4.  Henslee, J.,
History of the Artificial Larynx,  http://www.larynxlink.com/Library/Laryngectomee/history.htm
5.  Keith, R., Darley, L., Frederic. L., (Eds.). (1994).  Laryngectomee Rehabilitation. Austin, Texas. Pro-Ed, 3rd ed.
6.  Lennox, D (2002, November). Oral Adapters.  In Saunders, P. (Ed.). (2002). Headlines:  Kirklin Clinic Head & Neck Cancer Support Group.  p. 1.
7.  Messing, B.P., Dietrich Burns, K., & Farrell, S. (2004, October) Foundation Skills for the Artificial Larynx-Part I: 
     Pneumatic Artificial Larynx.  VoicePoints: Web Whispers Journal.
8.  Peters, P.M. & Dichtel, W.J. (1995).  The Source for Laryngectomy.  East Moline, Illinois.  Linguisystems, Inc.
9. Salmon, S. J.  (1983). Using the Artificial Larynx:  A Presentation on Instruction. In R.E. Stone & K.A. Stone (Ed.),
    Post-Laryngectomy Rehabilitation. Help Employ Laryngectomized Persons:  H.E.L.P., Unit 7, Indiana University
    School of Medicine, Medical Educational Resources Program.
10. Salmon, S.J. (1997). Using an Artificial Larynx.  In Lauder, E. (Ed.). (1997). Self Help for the Laryngectomee.  Chapt. 3.

 

                Murray's Mumbles ... Musings from the President
 
     We miss Murray who is busy having physical therapy and recovering from surgery. He'll be back to his column as soon as it becomes easy for him to type again.  He sends his regards and is following the list messages.

     A little history: Murray became WebWhispers President in the year 2000.  He was serving as VP when our President, Carter Cooper, died from a sudden massive heart attack.  This was just weeks prior to the IAL convention where there was to be a WW dinner and several meetings had been scheduled to determine important decisions for the direction that WW would be taking.  Murray moved into the Presidency immediately and asked if I would accept the VP position. I was already chairing a committee and working with the officers.  Our Treasurer Terry Duga and Dutch Helms, our founder and WebMaster,  were also making plans for the improvement and running of WW and were attending the IAL. The four of us worked together to make a smooth transition.

     At that time, we had yearly elections for all elected officers and just after the convention,  we scheduled the elections and asked Bob Hodge, whom we had finally met face-to-face at the convention after knowing him through our WW list, if he would run for the Secretary slot which was open. Libby Fitzgerald was a blessing who joined us later when we lost Bob Hodge to a recurrence of his cancer.

     Murray is a great leader for us and we miss the daily touching bases, but he will be back on board full time soon. We'll welcome that day.

Pat Sanders, WebWhispers VP - Web Information


 News, Views, & Plain Talk
  
                           by Pat Wertz Sanders, WebWhispers VP - Web Information
                                           

LPR

Laryngopharyngeal Reflux

     After my laryngectomy, I asked a lot of questions about laryngeal cancer causes other than smoking or drinking.  I wanted to know if breathing in acids or alkalis were a problem since I had been in a lot of contact with chemicals.  I asked if stomach acid could be a cause and was told that it was a known cause of esophageal cancer but not of laryngeal cancer.

     This never made sense to me since I knew I had awakened at night with a rush of acid coming up into my throat and sometimes even up behind and out of my nose.  The next day, that whole area would burn, I would be hoarse, having to clear my throat and cough to clear the mucus.  This area was a much more tender area than the esophagus. After the surgery, we raised the head of my bed and I took medication so it has been better.

     I learned to talk and played with my new computer, installed the day I came in from the hospital, but I did not have a service provider until 6 months later.  Even after I got Compuserve (with a limit of 5 hours a month!), there was no big Internet with a Google search engine in 1995.  I learned to chase down information on the fairly new World Wide Web, in which you had to find a site that related to what you were looking for and from there try a connected (linked) site.  I ran into a lot of dead ends in my searches and particularly so in my search for what happens when stomach acid hits the throat and vocal cords.

     During all this time, I had been calling on patients at UAB Hospital and, in addition to teaching them to talk or showing them equipment and answering questions, I would always ask if they had been bothered by heartburn.  Almost before I could get the question out, the caregiver would jump in to say, ?Oh, Boy, does he ever!  He ate TUMS all the time.?  I would always tell them to be sure the doctor knew about that because there were some one-a-day medicines that could help a lot and they did not want to start having acid come up into their new throat.

      Finally, I found the Voice Center at Wake Forest University where there was a great deal of research and their conclusion was: there was a different kind of reflux, one that usually did not cause heartburn, and it did cause throat cancers.

      The other day, I saw a brochure, put out by the drug company AstraZeneca with information developed by The Center For Voice Disorders of Wake Forest University and the Department of Otolaryngology, Bowman Gray School of Medicine.  I rejoiced that the word was out.  This is one of the first articles I found and it is still on their site:

http://www.thevoicecenter.org/reflux_cancer.html

     Let?s take a look at some of what is on these sites now, through Google and the Internet. From the American Academy of Otolaryngology ? Head and Neck Surgery site, http://www.entnet.org/healthinfo/topics/GERD.cfm , you can read this section on GERD and LPR. However for those who would like a synopsis, I?ll include some high points.

What is GERD?

Gastroesophageal reflux, often referred to as GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from "refluxing" or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid to move up the esophagus.

When stomach acid touches the sensitive tissue lining the esophagus and throat, it causes a reaction similar to squirting lemon juice in your eye. This is why GERD is often characterized by the burning sensation known as heartburn.

In some cases, reflux can be SILENT, with no symptoms until a problem arises. Almost all individuals have experienced reflux (GER), but the disease (GERD) occurs when reflux happens on a frequent basis often over a long period of time.

What is LPR?

During gastroesophageal reflux, the acidic stomach contents may reflux all the way up the esophagus, beyond the upper esophageal sphincter (a ring of muscle at the top of the esophagus), and into the back of the throat and possibly the back of the nasal airway. This is known as laryngopharyngeal reflux (LPR), which can affect anyone. Adults with LPR often complain that the back of their throat has a bitter taste, a sensation of burning, or something "stuck." Some may have difficulty breathing if the voice box is affected.

     Symptoms can be the burning in the throat, a hoarseness, feeling of a band tightening in the throat (likely caused by the swelling from the burn of the reflux), possibly swallowing difficulty, clearing of the throat and a nagging hacky cough from the irritation, probably more mucus and you may have heartburn.

http://www.thevoicecenter.org/LPR_and_voice_disorders.html 

Some of the sub-headings are:

HOW AND WHY ARE ORL PATIENTS WITH LPR  DIFFERENT THAN GI PATIENTS WITH GERD?

Back to Wake Forest Voice Center, this is an article that is well worth reading in full:

CLINICAL MANIFESTATIONS OF LPR

Reflux and Functional ("Non-Organic")Voice Disorders
Granulomas
Paroxysmal Laryngospasm
Polypoid Degeneration (Reinke's Edema)
Laryngeal Stenosis
Carcinoma of the Larynx

DIAGNOSIS

TREATMENT

I am copying the section that I think you will be particularly interested in:

Carcinoma of the Larynx
      The most important risk factors for the development of laryngeal carcinoma are tobacco and alcohol; however, LPR also appears to be an important cofactor, especially in non-smokers. 23,24 The senior author reported 31 consecutive cases of laryngeal carcinoma in which LPR was documented in 84%, but only 58% were active smokers.2 The exact relationship between LPR and malignant degeneration remains to be proved, but the available pH-metry data suggest that most patients who develop laryngeal malignancy both smoke and have LPR.24 In addition, leukoplakia and other premalignant appearing lesions may resolve with antireflux therapy. 2
    
     Tobacco and alcohol adversely influence almost all of the body's antireflux mechanisms -- they delay gastric emptying, decrease lower esophageal sphincter pressure and esophageal motility, decrease mucosal resistance, and increase gastric acid secretion2 -- and thus, strongly predispose one to reflux. pH-metry, followed by rigorous antireflux treatment, is recommended for all patients with laryngeal neoplasia, with or without other risk factors.



                          Dutch's Bits, Buts, & Bytes
 

(
1) Q: Is there an alternative to Spybot Search and Destroy?

WW Member Craig Smith over at "Computer Coaches" sent me the following note: "I have found a new program that is great for getting the spyware/mailware genre of infections off the computer.  It is called SpySweeper and is well worth the money ($29.00).  Right now it is on sale with a $10 rebate from Best Buy.  This works better than SpyBot."   You can check SpySweeper out at their web site at:  http://www.spysweeper.com/
 
(2) Q: Is there a decent online language translation service?
 
A.  A popular translation Web site is Babelfish.  Named for the alien fish used for intergalactic translation in Douglas Adams' book The Hitchhiker's Guide to the Galaxy, the Web site is http://www.babelfish.altavista.com and offers text translation from a variety of languages. Keep in mind that no translation is perfect.  The rules for languages vary quite a bit, and these solutions will not get it exactly right.  When I use these utilities, I like to convert the translation to English just to see how close it gets.  If the translation is close enough, I will use it.
 
(3) Q: How often, if ever, should I open my computer and blow out any dust?  What types of problems arise from not cleaning the computer?
 
A: The answer to the first part of your question really depends on the cleanliness of your home or office.  If you notice a lot of dust buildup when you clean, you need to consider that the same type of buildup could be occurring inside your PC.

Another factor to consider is that your PC has a cooling fan on the power supply that pulls in air to the computer.  This sucks dust right in, which allows faster buildup there than on your your bookshelves or tabletops.

In his time as a PC tech working on home computers, my friend has found all kinds of horrors when he opened a computer case.  There have been spiders, cockroaches and a variety of unidentified gooey substances.  Computers owned by those who smoke may have a thick layer of brown tar coating the inside and outside.

A clean computer is a happy computer.  Any contamination of a conductive nature, such as tar from cigarettes or insect carcasses, can cause a short circuit.  Even dust can contain moisture and cause a computer to fry.  Dust buildup can also cause computers to overheat by blocking the air from the cooling fans.

My advice is to turn off your PC and unplug it.  Carefully open the case and use a can of compressed air to blow out the inside of the PC.  Check semi-frequently to get an idea of how fast the dust is building up.  I clean my computer once every six months.  I know of others that have to do it weekly.

If you have an insect problem or you smoke, that will be harder to clean.  I suggest using a computer in as clean and smoke-free an environment as possible.

(4) 
Q: Whenever I send a digital picture to a friend or family member it opens so big that it will not fit on their screen and they cannot see the whole image. How can I fix this?

A: Whenever you take a picture with your digital camera, it is creating an image of very high resolution.  When viewed at full size it can be quite large, not just in screen size but also in file size.  When sending an image via e-mail, you don't need to send a high-resolution picture.

Let me give you an example.  My default settings for my digital camera shoot at 2,560 x 1,920 pixels.  This is great for having prints made but way too big for e-mail.

I open the picture with Microsoft Photo Editor, which is included with Windows, and select the menu choice Image and then Resize.  I change the units to pixels and then change the width to 640, and the height automatically changes to the correct number of pixels to maintain the aspect ratio.  Then I select Save As and choose a new name for the file.  This makes the file size go from about 2 megabytes (MB) to 75 kilobytes (KB) and allows the whole image to show up on the screen when it is maximized.

I still have my original high-resolution image, and I have a smaller copy to send via e-mail.  You can experiment with the size settings until you get images to the size you like.  This is also good for posting images to the Web.

 

   ListServ "Flame Warriors"   


                                                                               
Terms of Importance
flame

1. n.   A hostile, often unprovoked, message directed at a participant of an internet discussion forum.  The content of the message typically disparages the intelligence, sanity, behavior,  knowledge, character, or ancestry of the recipient.
2. v.   The act of sending a hostile message on the internet.

flame warrior
1. n.   One who actively flames, or willingly participates in a flame war ... (Another Example Below) ...

Rebel Without A Clue

Rebel Without a Clue's deep seated and infantile hostility to authority
motivates his random and seemingly gratuitous attacks on list owners,
moderators or anyone else who attempts to maintain a modicum of
order and civility in discussion forums.  He is unattached to any cause
other than petulance for its own sake, and will therefore seldom inspire
general insurrection.  In his frequent and ineffectual attacks on the
established order he will often cite the Bible, or the US Constitution to
support incoherent arguments.  Rebel Without a Clue NEVER reads
forum rules or courtesies, and loudly decries as fascism any enforcement
of them whatsoever.

Above courtesy of Mike Reed
See more of his work at: http://www.winternet.com/~mikelr/flame1.html 
 
 

   Welcome To Our New Members:

I would like to welcome all new laryngectomees, caregivers and professionals to WebWhispers! There is much information to be gained from the site and from suggestions submitted by our members on the Email lists.  If you have any questions or constructive criticism please contact Pat or Dutch at Editor@WebWhispers.org.

Take care and stay well!
Murray Allan, WW President

     We welcome the 31 new members who joined us during October 2004:

Barbara Beckwith - Caregiver
Henderson, NC
Dennis Bonar
Colorado Springs, CO
Robert Browna
New Castle, DE
Julie Cardani
Centerville, IA
Tom Dodson - Vendor (Romet LCC)
W. Palm Beach, FL
John Greider
St. Louis, MO
Howard Hanna
Mesquite, TX
Anna Hooper - SLP Student
Chico, CA
Philip Hopp
Cornwall on Hudson, NY
Steven Hurston
Baton Rouge, LA
Patricia Jackson
Punta Gorda, FL
Shelley Jolie, RN
New Haven, CT
Antal Kovach
Sarasota, FL
Kathleen LaGattuta - Caregiver
Woodside, NY
Myra Lasseter
Gadsden, AL
Marilyn Light
Deland, FL
Paulette Lynn - Caregiver
Sanger, TX
Megan McGuiness - SLP Student
Columbia, SC
Danielle McMahon - InHealth Rep
Carpinteria, CA
C.W. Moreland
Lee's Summit, MO
Joan Morena - Caregiver
Mountain Top, PA
Mark Peterson
Sinclair,ME
Robert Pietsch
Monument, CO
Sharon Reynolds
Wilkesboro, NC
Anna Rudolph
Kokomo, IN
Len Shacklock
Brighton, Ont., Canada
Harry Smith
Santa Fe Springs, CA
Carolyn Sprung - Caregiver
Alamonte Springs, FL
Janice Taylor - Caregiver
White Bluff, TN
John Witbeck
Bethlehem, PA
  Sarah Wood - SLP Student
Heaton,
Newcastle, UK
 



 
WebWhispers is an Internet-based laryngectomee support group.
  It is a member of the International Association of Laryngectomees.        
  The current officers are:
  Murray Allan..............................President
  Pat Sanders............V.P.-Web Information
  Terry Duga.........V.P.-Finance and Admin.
  Libby Fitzgerald.....V.P.-Member Services
  Dutch Helms...........................Webmaster
      

  WebWhispers welcomes all those diagnosed with cancer of the
  larynx or who have lost their voices for other reasons, their
  caregivers, friends and medical personnel.  For complete information
  on membership or for questions about this publication, contact
  Dutch Helms at: webmaster@webwhispers.org   

 

Disclaimer:
The information offered via the WebWhispers Nu-Voice Club and in
http://www.webwhispers.org is not intended as a substitute for professional
medical help or advice but is to be used only as an aid in
  understanding current medical knowledge.  A physician should always be   
consulted for any health problem or medical condition.



As a charitable organization, as described in IRS § 501(c)(3), the WebWhispers Nu-Voice Club
is eligible to receive tax-deductible contributions in accordance with IRS § 170.



  ? 2004 WebWhispers
Reprinting/Copying Instructions
can be found on our
WotW/Journal Page.