Auditory-perceptual speech outcomes and quality of life after total laryngectomy

Anxiety, depression and quality of life in patients with head and neck cancer undergoing laryngectomy: A long-term prospective evaluation

BACKGROUND

This study aimed to assess anxiety, depression and quality of life (QoL) in patients with head and neck cancer undergoing laryngectomy using comprehensive self-reported questionnaires for a period of up to 5 years.

METHODS

This prospective observational study enrolled 150 consecutive patients with locally advanced head and neck cancer who underwent laryngectomy at Nagoya University Hospital between 2007 and 2020. Anxiety, depression and QoL were assessed at baseline (preoperative) and at 3, 6, 12, 24, 36, 48 and 60 months after surgery using two brief self-reported questionnaires, such as the eight-item Short Form Health Survey (SF-8) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The surgical procedures were total laryngectomy, pharyngo-laryngectomy and pharyngo-laryngo-oesophagectomy in 97 (65%), 41 (27%) and 12 (8%) patients, respectively. All eight items of the SF-8 were significantly worse than those of the normal population at baseline and at 3 months after surgery. However, general health, vitality, mental health and bodily pain improved to normal levels within 1 year after surgery and were maintained for 5 years. In this study, 35% of patients were categorised as potential cases of depression, and 35% were potential cases of anxiety. During the follow-up period, the proportion of patients with anxiety gradually decreased after surgery. Further analysis revealed that the SF-8 and HADS scores and trends in 89 patients without tumour recurrence were similar to those in the total enrolled 150 patients.

CONCLUSION

Anxiety, depression and QoL in laryngectomised patients improved at 1 year after surgery and were maintained for up to 5 years.

WHAT THIS PAPER ADDS

What is already known on the subject Laryngectomy is associated with prolonged functional and psychological effects and has a major impact on patient quality of life (QoL). Several prospective studies evaluating the QoL in laryngectomised patients have been reported, in which significant deterioration in social functioning was found even 1 year after surgery. What this paper adds to existing knowledge One year is not a sufficient period for laryngectomised patients to return to normal life and spend their time in a social community. A recent review showed that most studies on QoL in laryngectomised patients were conducted under 1 year after the procedure, and there were not enough studies of sufficient quality. This is the first long-term prospective observational study of Japanese patients with head and neck cancer who underwent laryngectomy up to 5 years after surgery. What are the potential or actual clinical implications of this work? Our long-term observational study showed that the scores for anxiety, depression and QoL in laryngectomised patients improved at 1 year after surgery and were maintained for up to 5 years. Clinicians should recognize the importance of psychosocial risk factors in their QoL and multidisciplinary management, including social and psychological support, is essential for long-term laryngectomised survivors.

Source and Filter Acoustic Measures of Young, Middle-Aged and Elderly Adults for Application in Vowel Synthesis

INTRODUCTION

The output sound has important changes throughout life due to anatomical and physiological modifications in the larynx and vocal tract. Understanding the young adult to the elderly speech acoustic characteristics may assist in the synthesis of representative voices of men and women of different age groups.

OBJECTIVE

To obtain the fundamental frequency (f0), formant frequencies (F1, F2, F3, F4), and bandwidth (B1, B2, B3, B4) values extracted from the sustained vowel /a/ of young, middle-aged, and elderly adults who are Brazilian Portuguese speakers; to present the application of these parameters in vowel synthesis.

STUDY DESIGN

Prospective study.

METHODS

The acoustic analysis of tokens of the 162 sustained vowel /a/ produced by vocally healthy adults, men, and women, between 18 and 80 years old, was performed. The adults were divided into three groups: young adults (18 to 44 years old); middle-aged adults (45 to 59 years old) and, elderly adults (60 to 80 years old). The f0, F1, F2, F3, F4, B1, B2, B3, B4 were extracted from the audio signals. Their average values were applied to a source-filter mathematical model to perform vowel synthesis in each age group both men and woman.

RESULTS

Young women had higher f0 than middle-aged and elderly women. Elderly women had lower F1 than middle-aged women. Young women had higher F2 than elderly women. For the men's output sound, the source-filter acoustic measures were statistically equivalent among the age groups. Average values of the f0, F1, F2, F3, F4, B1, and B2 were higher in women. The sound waves distance in signals, the position of formant frequencies and the dimension of the bandwidths visible in spectra of the synthesized sounds represent the average values extracted from the volunteers' emissions for the sustained vowel /a/ in Brazilian Portuguese.

CONCLUSION

Sustained vowel /a/ produced by women presented different values of f0,F1 and F2 between age groups, which was not observed for men. In addition to the f0 and the formant frequencies, the bandwidths were also different between women and men. The synthetic vowels available represent the acoustic changes found for each sex as a function of age.

Surviving cancer following total laryngectomy: a phenomenological study

PURPOSE

Total laryngectomy followed by radiotherapy is a life-preserving treatment for patients with locally advanced laryngeal cancer. This study explored how persons who had undergone total laryngectomy perceived themselves as cancer survivors in the follow-up phase.

METHODS

A descriptive phenomenological approach was adopted. We employed a purposive sampling strategy to collect data through interviews at the otorhinolaryngology outpatient clinics of two research hospitals in northern Italy. The interviews were transcribed verbatim and analysed, following the seven analytical steps of Colaizzi's descriptive analysis.

RESULTS

The final sample included 19 patients. The following main themes were identified: (i) accepting a life with the "without" to survive; (ii) feeling unpleasant emotions; (iii) getting the hang of communication again; and (iv) reclaiming one's role. Together, they highlight the lived experiences of laryngectomised patients during the follow-up phase and how they perceived themselves as cancer survivors.

CONCLUSION

Laryngectomised patients are a uniquely vulnerable population. This study provides insights into how surgical procedures change and affect their lives over time to improve care models, patient education, and support systems. Survivors must be adequately prepared to transition from treatment and return to the community. This preparation should begin before treatment is started. Functional education, accurate information, and psychological support must be arranged and provided before surgery. Regarding the post-treatment phase, it is essential to support voice rehabilitation and peer support, and improve the family network, to ensure these patients' reintegration into society and social recognition.

Auditory-Perceptual and Pupillometric Evaluation of Vocal Roughness and Listening Effort in Tracheoesophageal Speech

OBJECTIVES

This study evaluated auditory-perceptual judgments of perceived vocal roughness (VR) and listening effort (LE) along with pupillometric responses in response to speech samples produced by tracheoesophageal (TE) talkers.

METHODS

Twenty normal-hearing, naive young adults (eight men and twelve women) served as listeners. Listeners were divided into two groups: (1) a with-anchor (WA) group (four men and six women) and (2) a no-anchor (NA) group (four men and six women). All were presented with speech samples produced by twenty TE talkers; listeners evaluated two auditory-perceptual dimensions-VR and LE-using visual analog scales. Anchors were provided to the WA group as an external referent for their ratings. In addition, during the auditory-perceptual task, each listener's pupil reactions also were recorded with peak pupil dilation (PPD) measures extracted as a physiologic indicator associated with the listening task.

RESULTS

High interrater reliability was obtained for both the WA and NA groups. High correlations also were observed between auditory-perceptual ratings of roughness and LE, and between PPD values and ratings of both dimensions for the WA group. The inclusion of an anchor during the auditory-perceptual task improved interrater reliability ratings, but it also imposed an increased demand on listeners.

CONCLUSIONS

Data obtained offer insights into the relationship between subjective indices of voice quality (ie, auditory-perceptual evaluation) and physiologic responses (PPD) to the abnormal voice quality that characterizes TE talkers. Furthermore, these data provide information on the inclusion/exclusion of audio anchors and potential increases in listener demand in response to abnormal voice quality.

Subjective Perception and Psychoacoustic Aspects of the Laryngectomee Voice: The Impact on Quality of Life

Purpose: A retrospective study is presented to correlate the inter-judge consistency for the different psycho-perceptual parameters of the recently proposed Impression Noise Fluency Voicing (INFVo) perceptual rating scale for substitution voices, and the vocal function as perceived by the patient. Methods: The scale Voice-Related Quality of Life (V-RQoL) and the Self Evaluation of Communication Experiences After Laryngectomy scale (SECEL)—a self-evaluation questionnaire of communicative experience after laryngectomy surgery—were administered to 89 total laryngectomees, subdivided in four groups depending on their type of alaryngeal voice (i.e., tracheoesophageal and esophageal speakers, electro larynx users, voiceless patients), in order to evaluate the impact of the impairment of the phonatory function on the quality of life. Results: No significant differences exist among the various groups on their perception of QoL using subjective questionnaires, whereas the INFVo scale has proven to be a useful tool for the description and analysis of the psychoacoustic characteristics of the vocal signal and a reliable instrument to correctly classify the patients. It is also notable that the judgement of the patients on their own voice and those of the referees are highly significant. Conclusion: Although speech rehabilitation for the acquisition of a substitution voice offers a new way of communication for the laryngectomized patients, nonetheless, their QoL is not significantly related to the type of substitution voice. Therefore, improving the patient’s adaptation to the new phonatory condition is mandatory.

Supporting Patient Autonomy in Shared Decision Making for Individuals With Head and Neck Cancer

PURPOSE

Management of head and neck cancer (HNC) can result in substantial long-term, multifaceted disability, leading to significant deficits in one's functioning and quality of life (QoL). Consequently, treatment selection is a challenging component of care for patients with HNC. Clinical care guided by shared decision making (SDM) can help address these decisional challenges and allow for a more individualized approach to treatment. However, due in part to the dominance of biomedically oriented philosophies in clinical care, engaging in SDM that reflects the individual patient's needs may be difficult.

CONCLUSIONS

In this clinical focus article, we propose that health care decisions made in the context of biopsychosocial-framed care-one that contrasts to decision making directed solely by the biomedical model-will promote patient autonomy and permit the subjective personal values, beliefs, and preferences of individuals to be considered and incorporated into treatment-related decisions. Consequently, clinical efforts that are directed toward biopsychosocial-framed SDM hold the potential to positively affect QoL and well-being for individuals with HNC.

Primary Total Laryngectomy versus Organ Preservation for Locally Advanced T3/T4a Laryngeal Cancer

OBJECTIVE

Organ preservation (OP) treatment for advanced laryngeal cancer has increased compared to primary total laryngectomy. Our study compares oncologic and functional outcomes between these approaches.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary care institution.

METHODS

Retrospective review of patients receiving primary total laryngectomy or OP for laryngeal cancer between 1/1/2000 and 12/31/2018.

RESULTS

A total of 118 patients received primary total laryngectomy and 119 received OP. Overall survival was similar between total laryngectomy and OP. When stratified by T stage, disease-free survival was worse among T3 patients receiving OP versus total laryngectomy. In T3 patients, 28 OP patients experienced local recurrence (28.9%) compared to 3 total laryngectomy patients (7.1%; p < 0.01). In total, 20 OP patients with local recurrence received salvage surgery. These patients had similar overall survival to patients who underwent initial total laryngectomy (TL). About 14 OP patients with local recurrence did not receive salvage surgery. About 89 (75.4%) TL patients achieved normal diet as compared to 64 (53.8%) OP patients (p < 0.001). In TL patients, 106 (89.8%) received primary or secondary tracheoesophageal-prosthesis, 82 (77.4%) of whom achieved completely understandable speech.

CONCLUSIONS

There was no difference in survival by treatment in T4 patients, possibly because of strict patient selection. However, disease-free survival was worse in T3 patients receiving OP, likely due to a high local recurrence rate. Approximately 40% of patients with local recurrence were not eligible for salvage laryngectomy. TL patients had comparable swallowing and speech outcomes with OP patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Quality of Life with Voice Prosthesis after Total Laryngectomy

Introduction

The loss of voice after total laryngectomy is one of the main impairments in personal and social life. In order to prevent potential psycho-social consequences in the patient and his family, the restoration of phonatory function is the main objective of post-laryngectomy rehabilitation. The aim of this study was to assess quality of life in patients who received prosthetic voice after total laryngectomy.

Materials and Methods

Over a one-year period, 51 patients with voice prostheses after total laryngectomy were recruited. 32 patients (62.74%) were administered radiation therapy and 9 patients (17.64%) underwent to surgical reconstruction with flaps. Each patient was administered the VHI-10 and V-RQOL self-assessment questionnaires.

Results

The study showed that vocal restoration with voice prosthesis allows patients to recover a significant degree of quality of life after total laryngectomy. The average score on the V-RQOL questionnaire was 75.9 and on the VHI-10 questionnaire was 13.5. It has not been shown a statistically significant correlation between quality of life after tracheoesophageal prosthesis and radiation therapy, chemotherapy or reconstruction flaps. Younger patients showed, on average, a higher score at V-RQOL. These results allow to state that, after prosthetic rehabilitation, at least 75% of patients experienced an increase in quality of life. Moreover, the prosthetic technique (primary vs secondary) does not affect the long-term outcome and radiotherapy, chemotherapy or reconstruction flaps are not absolute contraindications to rehabilitation with voice prosthesis.

Conclusion

After total laryngectomy, rehabilitation with tracheoesophageal prosthesis is a satisfactory choice to restore the patient's ability to communicate verbally.

Listener impressions of alaryngeal communication modalities

Purpose: Following a total laryngectomy in which the larynx is completely removed, individuals in the USA have three primary options for alaryngeal verbal communication including tracheoesophageal speech (TES), oesophageal speech (ES) and electrolarynx (EL). Using a large sample of participants from across the USA, this study investigated listener impressions of each primary type of alaryngeal communication. As these are the individuals more likely to be participating in social interactions and in positions of hiring for employment, the general public's impressions of TES, ES and EL may be a vital consideration during the treatment process.Method: A total of 381 individuals rated eight speech samples, including samples from speakers of each alaryngeal communication modality as well samples from age and sex matched laryngeal speakers, with regards to three outcome measures: intelligence, likability and employability.Result: Listener impressions of alaryngeal speech samples were modulated by the type of communication mode. Further, the patterns of results differed by speaker sex, with ES speech rated consistently more favourable for female speakers across all outcome measures and TES rated consistently more favourable for male speakers across all outcome measures.Conclusion: An overall preference for laryngeal speech was noted, particularly with male speakers. The female ES stimuli, interestingly, was the highest rated alaryngeal communication modality. Regardless of speaker sex, all alaryngeal modes greatly affected impressions of employability relative to impressions of likeability and intelligence.

The Mandarin Voice Handicap Index for Laryngectomees With Pneumatic Artificial Laryngeal and Esophageal Speech

Purpose The Voice Handicap Index (VHI) questionnaire assesses the impact of total laryngectomy on voice-related quality of life. This study evaluates the Mandarin VHI, including its internal consistency, test-retest reliability, content validity, and differences in scores for Mandarin alaryngeal patients with pneumatic artificial laryngeal (PA) and esophageal (ES) speech. Method Translation and validation of the VHI questionnaire was performed through the forward-backward translation technique. This study used a sample of 78 PA and 23 ES participants from Taiwan who completed the Mandarin VHI. Forty-two of the alaryngeal participants completed the Mandarin VHI twice over a period of 7-63 days. Results The measurement of the internal consistency of the Mandarin VHI showed a high Cronbach's alpha coefficient for the total score (.975) and the functional (.930), physical (.939), and emotional (.938) subscales. Based on the results of the intraclass correlation coefficients, good test-retest reliability for the total and domain scores was found (intraclass correlation coefficient = .827-.863). Conclusion The Mandarin VHI was validated as an instrument with proper internal consistency and reliability, which supports the Mandarin VHI as a valid instrument for the self-evaluation of handicaps related to voice problems in PA and ES speakers.

Surface Electromyography-Based Recognition, Synthesis, and Perception of Prosodic Subvocal Speech

Purpose This study aimed to evaluate a novel communication system designed to translate surface electromyographic (sEMG) signals from articulatory muscles into speech using a personalized, digital voice. The system was evaluated for word recognition, prosodic classification, and listener perception of synthesized speech. Method sEMG signals were recorded from the face and neck as speakers with (n = 4) and without (n = 4) laryngectomy subvocally recited (silently mouthed) a speech corpus comprising 750 phrases (150 phrases with variable phrase-level stress). Corpus tokens were then translated into speech via personalized voice synthesis (n = 8 synthetic voices) and compared against phrases produced by each speaker when using their typical mode of communication (n = 4 natural voices, n = 4 electrolaryngeal [EL] voices). Naïve listeners (n = 12) evaluated synthetic, natural, and EL speech for acceptability and intelligibility in a visual sort-and-rate task, as well as phrasal stress discriminability via a classification mechanism. Results Recorded sEMG signals were processed to translate sEMG muscle activity into lexical content and categorize variations in phrase-level stress, achieving a mean accuracy of 96.3% (SD = 3.10%) and 91.2% (SD = 4.46%), respectively. Synthetic speech was significantly higher in acceptability and intelligibility than EL speech, also leading to greater phrasal stress classification accuracy, whereas natural speech was rated as the most acceptable and intelligible, with the greatest phrasal stress classification accuracy. Conclusion This proof-of-concept study establishes the feasibility of using subvocal sEMG-based alternative communication not only for lexical recognition but also for prosodic communication in healthy individuals, as well as those living with vocal impairments and residual articulatory function. Supplemental Material https://doi.org/10.23641/asha.14558481.

Health-Related Quality of Life Following Total Laryngectomy: A Systematic Review

OBJECTIVE

Treatment of advanced laryngeal and hypopharyngeal cancer has shifted from total laryngectomy (TL) toward laryngeal-preserving therapies due to a general perception that TL has a significantly negative impact on the individual's life. However, whether the physical impairments related to TL translate to a reduced health-related quality of life (HRQoL) has not yet been determined. Therefore, the objective of this systematic review was to determine how HRQoL is affected following TL.

METHODS

Systematic searches were conducted in PubMed, Embase, and Cochrane. Inclusion criteria were original studies describing quality of life following TL after larynx/hypopharynx cancer using a formally developed patient-reported questionnaire. Study quality assessment was carried out with the tool developed by the National Heart, Lung, and Blood Institute.

RESULTS

Forty-six studies using 12 different questionnaires were included. The majority were cross-sectional (85%), and study quality was rated poor in 30%, fair in 30%, and good in 39% of studies. When comparing results from the four most frequently used questionnaires with normative data, we found that in more than 60% of studies, differences to the reference population were of clinical importance, with only few exceptions.

CONCLUSIONS

In general, we found that people who received TL have a worse HRQoL than the male normative reference population. However, even though TL patients experience a clinically important difference in many domains when compared with normative data, their burden of symptoms is generally mild. The current review also makes it evident that despite the relatively large number of studies conducted, the strength of evidence remains weak. Laryngoscope, 131:820-831, 2021.

The Effects of Contextual Priming and Alaryngeal Speech Mode on Auditory-Perceptual Ratings of Listener Comfort

BACKGROUND

The effectiveness of postlaryngectomy communication methods (esophageal, tracheoesophageal, and electrolaryngeal speech) has been primarily evaluated using functional outcomes. This evaluation neglects the importance of listeners and their influence on communicative effectiveness. Listener comfort (LC), or the ease with which a listener interacts with alaryngeal speakers, may provide an important index of communicative effectiveness. The present study investigated the use of LC in the auditory-perceptual evaluation of alaryngeal speech modes, as well as evaluating the influence of contextual cues used to elicit ratings on listener judgments of all three alaryngeal modes.

METHODS

Thirty-three naïve listeners provided independent ratings of LC for 39 alaryngeal speech samples using a visual analogue scaling procedure. Each group of listeners rated alaryngeal speech in three imagined listening conditions (Telephone Conversation, Social Situation, and a non-specified Control Condition). To analyze LC ratings obtained, a 3 × 3 mixed factor analysis of variance was conducted.

RESULTS

A significant interaction effect between alaryngeal speech mode and listening condition (P = 0.04) was identified. Overall, pairwise comparisons of alaryngeal speech mode indicated that listeners were more comfortable when presented with tracheoesophageal speech samples compared to those of esophageal and electrolaryn geal speakers.

CONCLUSIONS

Our data suggest that LC ratings are influenced by alaryngeal speech mode. Tracheoesophagea speech was perceived to have the most favorable LC ratings compared to the other alaryngeal speech modes in all listening conditions. Contextual cues (i.e., social condition and telephone condition) did not have an effect on LC ratings.

Verbal performance of total laryngectomized patients rehabilitated with esophageal speech and tracheoesophageal speech: impacts on patient quality of life

Introduction

Total laryngectomy has important psychophysical and social consequences for patients’ quality of life because of the functional changes resulting from the removal of the larynx. Voice deprivation is perhaps the most relevant limiting factor in social relationships, increasing feelings of solitude and tending to drive individuals into social isolation. Multiple voice rehabilitation methods after total laryngectomy are available. This study aimed to determine the acoustic quality of the rehabilitated voice achieved with esophageal speech (ES) and tracheoesophageal speech (TES), and acoustic quality impacts on patients’ perceptions of their quality of life.

Materials and methods

The patient inclusion criterion was the completion of a speech rehabilitation course with ES or TES at least 6 months after total laryngectomy. The voice acoustic analysis was carried out automatically by using the Multidimensional Voice Program. The following parameters were extracted: fundamental frequency (F0), Jitter% (Jitt), Shimmer% (Shim), and noise-to-harmonic ratio (NHR). Subjective voice evaluation was performed by using the following questionnaires: Voice Handicap Index (VHI), Voice-related Quality of Life (V-RQOL), and Voice Performance Questionnaire (VPQ).

Results

The acoustic analysis showed a difference between ES and TES patients on all acoustic parameters; this difference was significant for F0 (133.09±2.4 and 119±3.3, respectively; p<0.001), NHR (0.43±0.21 and 0.31±0.14, respectively; p=0.02), and maximum phonation time (2.02±038 s and 10.64±0.28 s, respectively; p=0.01. Regarding patient-related outcomes, TES correlated with better total scores compared with ES; however, the differences in the total scores on the VHI (p=0.09), V-RQOL (p=0.39), and VPQ (p=0.52) were not statistically significant.

Conclusion

The rehabilitation of laryngectomized patients must be addressed by a multidisciplinary team that considers the personalities, personal needs, and relational conditions of individual patients in order to determine and apply the phonatory rehabilitation method most suitable for achieving a better quality of life.

Quality of life after total laryngectomy: evaluating the effect of socioeconomic status

OBJECTIVE

Total laryngectomy is considered the primary treatment modality for advanced laryngeal carcinoma. This study assessed the quality of life in patients after total laryngectomy, and ascertained whether quality of life is affected by socioeconomic status.

METHOD

Forty-seven patients (20 state- and 27 private-sector) who underwent total laryngectomy between 1998 and 2014 responded to the University of Washington Quality of Life Questionnaire, the Voice-Related Quality of Life Questionnaire and the Brief Illness Perception Questionnaire.

RESULTS

Significant differences were found in socioeconomic status between state- and private-sector patients (p &lt; 0.001). There was no significant difference in overall quality of life between groups (p = 0.210). State-sector patients scored significantly higher Voice-Related Quality of Life Questionnaire scores (p = 0.043). Perception of illness did not differ significantly between groups.

CONCLUSION

Overall quality of life after total laryngectomy appears to be similar in patients from different socioeconomic backgrounds. However, patients from lower socioeconomic circumstances have better voice-related quality of life. The results illustrate the importance of including socioeconomic status when reporting voice outcomes in total laryngectomy patients.

Integrated rehabilitation after total laryngectomy: a pilot trial study

BACKGROUND

Acquisition and acceptance of the alaryngeal voice, psychological state, and Quality of Life (QoL) of laryngectomized patients.

METHODS

Thirty-two patients who underwent total laryngectomy were included in the study; 17 of them were treated by a psychologist and a speech therapist (experimental group); 15 performed only speech therapy (control group).

RESULTS

The experimental group showed a significant improvement in all parameters of the INFVo scale, in the score of the Environment subscale and in the total score of the I-SECEL (Self-Evaluation of Communication Experiences after Laryngeal Cancer); in the Depression, Obsession-Compulsion and Paranoia areas of the SCL-90-R (Symptom Check List-90-Revised); and in the Social area (REL) of the WHOQOL-B (World Health Organization Quality of Life Scale-Brief).

CONCLUSIONS

An integrated rehabilitative approach to laryngectomized patients improves emotional state and psychosocial aspects and promotes acceptance and use of the new voice and recovery of a better quality of life.

The relationship between acoustical and perceptual measures of vocal effort

Excessive vocal effort is a common clinical voice symptom, yet the acoustical manifestation of vocal effort and how that is perceived by speakers and listeners has not been fully elucidated. Here, 26 vocally healthy adults increased vocal effort during the production of the utterance /ifi/, followed by self-ratings of effort on a 100 mm visual analog scale. Twenty inexperienced listeners assessed the speakers' vocal effort using the visual sort-and-rate method. Previously proposed acoustical correlates of vocal effort were calculated, including: mean sound pressure level (SPL), mean fundamental frequency (f o), relative fundamental frequency (RFF) offset cycle 10 and onset cycle 1, harmonics-to-noise ratio (HNR), cepstral peak prominence and its standard deviation (SD), and low-to-high (L/H) spectral ratio and its SD. Two separate mixed-effects regression models yielded mean SPL, L/H ratio, and HNR as significant predictors of both speaker and listener ratings of vocal effort. RFF offset cycle 10 and mean f o were significant predictors of listener ratings only. Therefore, speakers and listeners attended to similar acoustical cues when making judgments of vocal effort, but listeners also used additional time-based information. Further work is needed to determine how vocal effort manifests in the speech signal in speakers with voice disorders.

Validating the Changes to Self-identity After Total Laryngectomy

BACKGROUND

A total laryngectomy often prolongs life but results in long-term disablement, disfigurement, and complex care needs. Current clinical practice addresses the surgical options, procedures, and immediate recovery. Less support is available longer-term despite significant changes to aspects of personhood and ongoing medical needs.

OBJECTIVE

The aim of this study was to explore the experience of living with and/or supporting individuals with a laryngectomy at least 1 year after surgery.

METHODS

Constructivist grounded theory methods and symbolic interactionism were used to guide collection and analysis of interview data from 28 participants (12 individuals with a laryngectomy, 9 primary supporters, and 7 health professionals).

RESULTS

The phenomena of "validating the altered self after total laryngectomy" highlighted how individuals, postlaryngectomy, navigate and negotiate interactions due to the disruption of their self-expression, related competencies, and roles. Several reframing patterns representing validation of the self emerged from the narratives. They were as follows: destabilized, resigned, resolute, and transformed. The data describe the influence of the processes of developing competence and building resilience, combined with contextual factors, for example, timing and turning points; being supported; and personal factors on these reframing patterns.

CONCLUSION

The findings further our understanding of the long-term subjective experience of identity change after laryngectomy and call attention to the persisting need for psychosocial support.

IMPLICATIONS FOR PRACTICE

This research provides important evidence for evaluating and strengthening the continuum of services (specialist to community) and supporting social participation, regardless of communication method, and for competency training for all involved to optimize person-centered practices.

Objective and subjective voice outcomes after total laryngectomy: a systematic review

Background

Esophageal speech (ES), tracheoesophageal speech (TES) and/or electrolarynx speech (ELS) are three speech rehabilitation methods which are commonly provided after total laryngectomy (TL).

Methods

A systematic review of the literature was conducted to evaluate comparative acoustic, perceptual, and patient-reported outcomes for ES, TES, ELS and healthy speakers.

Results

Twenty-six articles could be included. In most studies, methodological quality was low. It is likely that an inclusion bias exists, many studies only included exceptional speakers. Significant better outcomes are reported for TES compared to ES for the acoustic parameters, fundamental frequency, maximum phonation time and intensity. Perceptually, TES is rated with a significant better voice quality and intelligibility than ES and ELS. None of the speech rehabilitation groups reported clearly better outcomes in patient-reported outcomes.

Conclusions

Studies on speech outcomes after TL are flawed in design and represent weak levels of evidence. There is an urge for standardized measurement tools for evaluations of substitute voice speakers. TES is the favorable speech rehabilitation method according to acoustic and perceptual outcomes. All speaker groups after TL report a degree of voice handicap. Knowledge of caretakers and differences in health care and insurance systems play a role in the speech rehabilitation options that can be offered.

Electronic supplementary material

The online version of this article (doi:10.1007/s00405-017-4790-6) contains supplementary material, which is available to authorized users.

The electrolarynx: voice restoration after total laryngectomy

The ability to speak and communicate with one’s voice is a unique human characteristic and is fundamental to many activities of daily living, such as talking on the phone and speaking to loved ones. When the larynx is removed during a total laryngectomy (TL), loss of voice can lead to a devastating decrease in a patient’s quality of life, and precipitate significant frustration over their inability to communicate with others effectively. Over the past 50 years there have been many advances in techniques of voice restoration after TL. Currently, there are three main methods of voice restoration: the electrolarynx, esophageal speech, and tracheoesophageal speech through a tracheoesophageal puncture (TEP) with voice prosthesis. Although TEP voice is the current gold standard for vocal rehabilitation, a significant minority of patients cannot use or obtain TEP speech for various reasons. As such, the electrolarynx is a viable and useful alternative for these patients. This article will focus on voice restoration using an electrolarynx with the following objectives: 1) To provide an understanding of the importance of voice restoration after total laryngectomy. 2) To discuss how the electrolarynx may be used to restore voice following total laryngectomy. 3) To outline some of the current electrolarynx devices available, including their mechanism of action and limitations. 4) To compare pros and cons of electrolaryngeal speech to TEP and esophageal speech.

The Effect of Noise on Relationships Between Speech Intelligibility and Self-Reported Communication Measures in Tracheoesophageal Speakers

PURPOSE

The purpose of this study was to examine how sentence intelligibility relates to self-reported communication in tracheoesophageal speakers when speech intelligibility is measured in quiet and noise.

METHOD

Twenty-four tracheoesophageal speakers who were at least 1 year postlaryngectomy provided audio recordings of 5 sentences from the Sentence Intelligibility Test. Speakers also completed self-reported measures of communication-the Voice Handicap Index-10 and the Communicative Participation Item Bank short form. Speech recordings were presented to 2 groups of inexperienced listeners who heard sentences in quiet or noise. Listeners transcribed the sentences to yield speech intelligibility scores.

RESULTS

Very weak relationships were found between intelligibility in quiet and measures of voice handicap and communicative participation. Slightly stronger, but still weak and nonsignificant, relationships were observed between measures of intelligibility in noise and both self-reported measures. However, 12 speakers who were more than 65% intelligible in noise showed strong and statistically significant relationships with both self-reported measures (R2 = .76-.79).

CONCLUSIONS

Speech intelligibility in quiet is a weak predictor of self-reported communication measures in tracheoesophageal speakers. Speech intelligibility in noise may be a better metric of self-reported communicative function for speakers who demonstrate higher speech intelligibility in noise.

Structured review of papers reporting specific functions in patients with cancer of the head and neck: 2006 - 2013

Health-related quality of life (HRQoL) focuses on 4 core domains: physical and psychological function, social interaction, disease, and treatment-related symptoms, and is a key outcome in patients with cancer of the head and neck. We reviewed papers published between 2006 and 2013 that used validated questionnaires to report functional outcome in this group. A total of 572 papers were identified and 118 of them concerned function. Specific outcomes included anxiety, chewing, maxillectomy, mucositis, pain, shoulder function, and trismus. The specific functions most often identified were xerostomia, speech or voice, and swallowing or dysphagia. A considerable body of evidence has now accumulated on HRQoL and functional outomes although the precise role of HRQoL during the planning of treatment remains controversial. Over time, the emphasis of the studies included has tended to move away from the reporting of outcomes in general to more hypothesis-driven and group-specific work.

Salvage total laryngectomy after external-beam radiotherapy: A 20-year experience

BACKGROUND

The purpose of this study was to present our evaluation of the clinical and functional outcomes after salvage total laryngectomy (STL).

METHODS

We conducted a retrospective review of 218 patients who underwent STL between 1994 and 2014.

RESULTS

Seventy percent of patients originally had T1 or T2, N0 tumors and 73% had definitive external-beam radiotherapy (EBRT) alone. A majority utilized tracheoesophageal prosthesis (77%) and were gastrostomy free (80%) at last follow-up. The 5-year disease control and overall survival (OS) rates were 65% and 57%, respectively. Patients with a disease-free interval after initial treatment <2 years were more likely to develop a recurrence (p = .001) and die of disease (p = .032) after STL. The disease-free interval after EBRT impacted disease control (p < .001), with 5-year disease control of 92% for >5-year disease-free interval and 60% for <2-year disease-free interval.

CONCLUSION

Most patients remain disease-free after STL, achieve intelligible tracheoesophageal speech, and maintain an oral diet. Delayed recurrence after initial treatment portends better survival and may indicate a distinct biological profile. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1962-E1968, 2016.

The relationship between communicative participation and postlaryngectomy speech outcomes

BACKGROUND

The purpose of this study was to examine relationships between communicative participation and postlaryngectomy speech outcomes, including listener-rated speech intelligibility and acceptability, and patient-rated speech acceptability and voice handicap.

METHODS

Thirty-six laryngectomized individuals completed the Communicative Participation Item Bank (CPIB) short form and the Voice Handicap Index-10 (VHI-10). They provided recordings from the Sentence Intelligibility Test (SIT) and a reading passage, and rated their own speech acceptability. Forty-eight inexperienced listeners transcribed the SIT sentences to derive intelligibility scores. Eighteen additional listeners judged the speech acceptability using the rating scales.

RESULTS

Listeners judged tracheoesophageal speakers as significantly more intelligible and acceptable than electrolaryngeal speakers (p < .05). Speech acceptability was significantly more acceptable to speakers than listeners (p < .05). Weak, nonsignificant relationships were found between communicative participation and listener-rated outcomes. Stronger, significant relationships were found between communicative participation and self-rated speech acceptability and voice handicap (p < .05).

CONCLUSION

Patient-reported communication outcomes are complementary to listener-rated outcomes. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1955-E1961, 2016.

Talker identification across source mechanisms: experiments with laryngeal and electrolarynx speech

PURPOSE

The purpose of this study was to determine listeners' ability to learn talker identity from speech produced with an electrolarynx, explore source and filter differentiation in talker identification, and describe acoustic-phonetic changes associated with electrolarynx use.

METHOD

Healthy adult control listeners learned to identify talkers from speech recordings produced using talkers' normal laryngeal vocal source or an electrolarynx. Listeners' abilities to identify talkers from the trained vocal source (Experiment 1) and generalize this knowledge to the untrained source (Experiment 2) were assessed. Acoustic-phonetic measurements of spectral differences between source mechanisms were performed. Additional listeners attempted to match recordings from different source mechanisms to a single talker (Experiment 3).

RESULTS

Listeners successfully learned talker identity from electrolarynx speech but less accurately than from laryngeal speech. Listeners were unable to generalize talker identity to the untrained source mechanism. Electrolarynx use resulted in vowels with higher F1 frequencies compared with laryngeal speech. Listeners matched recordings from different sources to a single talker better than chance.

CONCLUSIONS

Electrolarynx speech, although lacking individual differences in voice quality, nevertheless conveys sufficient indexical information related to the vocal filter and articulation for listeners to identify individual talkers. Psychologically, perception of talker identity arises from a "gestalt" of the vocal source and filter.

Examining the construct validity of the V-RQOL in speakers who use alaryngeal voice

PURPOSE

The construct validity of the Voice-Related Quality of Life (V-RQOL; Hogikyan & Sethuraman, 1999) measure was evaluated in a sample of 109 individuals who have undergone total laryngectomy.

METHOD

A principal components factor analysis was performed on participant responses to the 10-question V-RQOL measure.

RESULTS

Factor analysis of the V-RQOL in our alaryngeal sample confirmed the presence of two factors (physical and social-emotional), which is consistent with the identified domains in the current V-RQOL. However, the current data indicate that some of the questions proposed by the original authors of the V-RQOL (Questions 7 and 9) do not align with their proposed domains in this postlaryngectomy sample.

CONCLUSION

The results indicate that some V-RQOL questions do not align with their proposed domains. Consequently, an alternative scoring algorithm may be warranted for alaryngeal populations, and the authors make suggestions for this change that are simple and efficient. Based on the findings of the present factor analysis, use of this modified scoring procedure may serve to increase the sensitivity of the V-RQOL for those who are laryngectomized and use alaryngeal methods of voice and speech. Consequently, the value and application of the V-RQOL may be expanded in the clinical setting.