Hayes Martin, M.D.

Although there still may be somedifference of opinion as to the relativeindications for radiation and surgeryrespectively in the treatment of larynxcancer, nevertheless, there can be noquestion but that, in certain cases, totallaryngectomy is the only solution. Arecent survey has shown that in 1947this operation was performed at least846 times in the United States,1 and itis probable that the number is steadilyincreasing.

When total laryngectomy is advised,the family doctor will often be presentat the consultation, and the patient mayhesitate to consent to the procedurewithout the approval of his personalphysician. Following the operation, thefamily doctor can play a significant rolein the rehabilitation period, both inkeeping up the patient's morale forlearning a new method of speech andin the social and occupational readjustments that may be necessary under newand somewhat altered conditions oflife. The purpose of this communication is to discuss both the surgical andpsychological aspects of total laryngectomy from the standpoint of the patientand his family doctor.

Preoperative Preparation

When, after adequate preliminaryexamination, a surgeon has recommended complete removal of thelarynx, he usually first seeks the approval of the referring physician (family doctor) and responsible membersof the family. If the procedure is accepted by them, it next becomes necessary to obtain the consent of the patient, and, in so doing, the questionoften arises as to how bluntly and directly the patient should be apprised ofwhat he actually faces. Many laymen

are sufficiently intelligent, well informed, and emotionally stable to understand the merits of the proposition.In this connection, it must not be assumed that common sense, intelligence, and emotional stability are synonymous with a high degree of education, social position, or financial success. Bluntly stated, the facts are as follows: the disease is cancer; the larynxmust be removed; following the operation the windpipe will open into theneck; breathing will no longer becarried out through the mouth andnose; normal speech will be permanently lost, and artificial speech must belearned by one of several methods. Onthe encouraging side are the facts thatthe operative mortality is small (ito 2per cent), the hospital stay about tento fourteen days, and lastly, that thepatient can regain the faculty ofspeech. Even with well-balanced patients it is probable that little is to begained by too elaborate discussion ofall the morbid details.

The surgeon, the family, and thefamily doctor may decide that the reaction to any blunt statement of thefacts would be distinctly unfavorablein the case of the less intelligent, poorly integrated, senile, or indecisive patient. In these cases, some or even mostof the morbid details may be justifiablywithheld, and the patient need only betold that in order to obtain relief hemust have an operation, followingwhich his speech will be lost for a time,but that with practice he can learn tospeak again. The welfare of many patients faced with the ordeal of totallaryngectomy is undoubtedly betterserved if, with the approval of responsible members of the family, they canbe induced to accept the operation withless than full knowledge of the details.

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Rehabilitation of the Laryngectomee

In the medical literature on larynxcancer one frequently finds referenceto patients who have “¿�refusedlaryngectomy.― To a surgeon experiencedin the handling of cancer patients, itwill be obvious that, in many instancesof patients who are alleged to have“¿�refused―necessary operations, the psychological management was inept,blunt, and therefore ineffective. Inclinics, where this problem frequentlyarises and where due consideration isgiven to the vagaries and frailties ofhuman nature, it is uncommon that apatient refuses a necessary operation.Many patients facing total laryngectomy are much encouraged by meetingwith a patient who has already undergone the procedure and who haslearned to speak again. Others are entirely incapable of an objective appraisal of the situation, and such anencounter before the operation wouldonly cause increased anxiety.

The ImmediatePostoperative Period

Despite excellent preoperative psychological preparation, there will sometimes be considerable anxiety and depression when the patient, on awakening from the anesthetic, finds himselfbreathing through the tracheostomy,rather than through the mouth andnose, and unable to speak. This emotional state may last for several days,and much can be done to counteractit through skilful handling of the problem by the nurse, the family, and thesurgeon and his associates. If the totalspeech disability is accepted by all concerned as a natural consequence of thetreatment rather than as an overwhelming tragedy of a permanent nature, andif, whenever the question is raised, fullconfidence is expressed that speech willsoon be regained, much can be accomplished to lessen the grimness of thisphase of the experience.

The family will need to be assuredthat a significant part of the mental depression is apparent, rather than real,

and that the silence on the part of thepatient is actually a physical disability,rather than a mental reaction. If possible, arrangements should be madewithin a few days after operation for aspeech instructor (himself a laryngectomee) to visit the patient and discussthe plans for future instruction. Muchis gained if the patient is confident that,as soon as wound healing permits, hemay begin instruction to regain hisspeech.

Speech Re-education

Some laryngectomees acquire esophageal speech automatically without anyoutside instruction by accidentally discovering first that they can produce thesound of an ordinary belch, and, then,that they can articulate this sound toproduce words. Not long after the firstlaryngectomy was performed by Billroth about seventy-five years ago, thephenomenon of esophageal speech wasdiscovered by a patient and reportedby his surgeon in the medical literature. In the case of most patients, organized instruction is advisable; otherwise the new facility of speech by oneor the other method may be long delayed or sometimes never acquired.Such training of the laryngectomee isbest obtained from someone who himself has gone through a similar experience and preferably carried out by thegroup method of teaching, rather thanby individual instruction. In most largecities where laryngectomies are performed in fair numbers, there are organized classes in nonprofit institutions where such instruction is given.After the operation, the laryngectomeeshould register with such a group assoon as possible. If the physician doesnot know of any organized group forspeech training, he may get such information by calling the nearest office ofthe American Cancer Society or bywriting the Professional Service Section, Medical and Scientific Division,American Cancer Society, 47 BeaverSt., New York 4, N. Y.

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I

Figure 1. G.H., aged 46, had a total laryngectomy on July 5, 1950. He acquiredesophageal speech within a few weeks after his operation and returned to his formerposition in a brokerage office. He has carried on successfully at his work even thoughmuch of his business is transacted over the telephone. Note that the shirt collar isbuttoned up so as to conceal the tracheostomy opening.

Methods of Artificial Speech

There are at least three practicalmethods of artificial speech followinglaryngectomy, which vary relatively inthe degree of their functional desirability and usefulness to the individual. Noone single method can fairly be advanced as the complete solution for allpatients. Each one of these respectivemethods has been found to be the bestsolution in the case of certain individuals, some of whom use more than onemethod, depending upon the requirements of the immediate environment.All methods of artificial speech dependupon the production of a sound and itsconduction to the mouth where, by theuse of the tongue, lips, and teeth, it isarticulated into speech.

Esophageal Speech. This method is

undoubtedly the most useful and bestsuited to the majority, but it can be acquired to a satisfactory degree by onlyabout 80 per cent of all laryngectomees.(Fig. 1.) The sound is produced bydrawing air into the esophagus (rarelyas far down as the stomach) and expelling or eructing this air so as to produce a vibration of the soft tissues surrounding a relatively narrow apertureat about the level of the cricopharyngeus muscle, or, in some cases, at ahigher level in the hypopharynx. Whenthese tissues vibrate, a sound is produced identical with the belch in a normal person. If the laryngectomee canbelch, he can articulate the sound intospeech. Conversely, if he cannot learnto belch, he cannot acquire this methodof speech. The popular fiction thatsome laryngectomees learn “¿�tospeak

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with the stomach muscles―is, of course,pure nonsense.

It should be emphasized that themechanism of esophageal speech isneither complicated nor difficult. Certain individuals whose motives may notalways be entirely unselfish claim tohave invented a new method of artificial speech (as for example, “¿�buccopharyngeal―) and advance complicateddiscussions of its mechanism and ofthe methods of re-education. All such

producing sound for artificial speechby a vibrating membrane or reed. Atany rate, many of these devices havebeen made by isolated mechanics, butthere was no standardization untilabout twenty-five years ago when alaryngectomee patient of the late JohnE.Mackentyarousedtheinterestofanofficial of the Western Electric Company, a subsidiary of the AmericanTelephone and Telegraph Company.As a result, since 1926, a standardized

a

Figure 2. The reed larynx consists essentially of a metal chamber with a vibratingreed.

Figure 3. G.H. demonstrating the use of the reed larynx. One end of the deviceis held against the tracheal stoma and air is led to a metal chamber containing areed and thence the sound is conducted to the mouth where it is articulated intospeech. Some patients find this device unsightly and, therefore, unacceptable.

claims are a perversion of the truth andtherefore unfortunate.

Occasionally, a laryngectomee isable to produce a belch, and thereforeto speak, within a few days after theoperation. Others require months ofeffort. In some of the more radical operations, portions of the pharyngealwall and upper esophagus are removedwith the larynx, and, since the pharyngeal constrictors are lost in these patients, no narrowed point is left in thegullet past which air can be expelled toproduce vibration and a sound. Mostof such individuals can never acquireesophageal speech.

The Reed Larynx. It is difficult to establish who first conceived the idea of

form of reed larynx (Figs. 2, 3) hasbeen constructed by that company andsold at the cost of production. Thereis little or no cost in maintenance, andthe patient usually learns to reservicethe instrument himself. The devicemay be obtained for $19.60 by anylaryngectomee who presents a letterfrom his doctor at the New York Telephone Company offices, 140 WestStreet, New York City. The instrumentis also distributed through the branchesof the Bell Telephone Companythroughout the United States, and, inany community, information may beobtained from the local Bell Systemcompany.

In this mechanism, the column of

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air from the tracheal stoma is conducted to a metal chamber containinga metal reed that vibrates to producea sound. The sound is then led througha rubber tube into the mouth where itis articulated to form speech.

This method can be learned by anylaryngectomee in about a half-hour'stime, although many find it unacceptable since a noticeable and somewhat unsightly piece of apparatus is held in thepatient's hand, one end is pressed

against the tracheal stoma and theother, ending in a rubber tube, leadsto the mouth. The volume of sound isconsiderable, and many patients whoacquire esophageal speech of only lowintensity suitable for ordinary purposesemploy the reed larynx when a highervolume of sound is necessary in noisyenvironments (trains, busy streets,noisy stores, etc.).

The Elect rolarynx. This device, powered by a pocket battery, consists essentially of a buzzing mechanism, whichwhen pressed against the side of theneck produces a sound that is transmitted through the soft tissues into thepharynx and oral cavity, there to bearticulated into speech (Figs. 4, 5).When used, it produces a continuousbuzzing sound that is objectionable to

many. The method is probably aboutthird in its acceptability to the averagepatient, but nevertheless, there are individuals unable to acquire esophagealspeech who prefer the electrolarynx tothe reed larynx. Like this, its use canbe learned in about a half-hour.

One of the greatest objections to thedevice is that it is somewhat expensive,prohibitively so to many. Each instrument costs $100, and, since repair andservicing is required after a few months'

use, more than one instrument is necessary. In addition, battery cost will varyfrom $15 to $25 a year, and there is acharge for reservicing. It may be obtained from the Aurex Corporation,511 Fifth Avenue, New York City.

The Family Doctor and theProblem of the Laryngectomee

Provided that he concurs in the surgeon's opinion, the family doctor canplay a prominent role in encouragingthe patient to accept a necessary operation without delay. He may assist inpointing out to the patient and the family that, under certain conditions, thepreservation of life itself is the firstconsideration and that to such an endthe loss of the larynx may be a reason

Figure 4. The electrolarynx consists essentially of a battery-powered buzzer thatis held against the side of the throat.

Figure 5. G.H. demonstrating the electrolarynx. The battery is carried in thepocket and the cord-connected buzzer is held against the side of the neck.

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able price to pay. Furthermore, he canbe of assistance during the immediatepostoperative period following laryngectomy by assuming a confident attitude toward the future so as to reassure the patient that he will not onlylearn to speak again but also to resumea fairly normal mode of life.

In the intermediate postoperativeperiod he can be of assistance in encouraging the patient to seek instruction for speech training. He should usehis influence to see that the patientfinally accepts and perfects himself inone or other of the available methodsof artificial speech. The patient shouldnot be misled by overenthusiastic proponents of a single method, who mayerroneously insist that one alone andin particular is worth while. As a matterof fact, if the patient acquires artificialspeech and is satisfied, it makes littledifference which method he chooses asbeing suitable to his own case. At anyrate, it is the responsibility of the surgeon and the family doctor and/or ofthe social-service facilities to assist andco-operate in the rehabilitation.

A patient was recently found to havebeen occupying a bed in a New York

City institution for terminal care ofcancer six years after total laryngectomy. The ostensible reason for thiscontinuous hospital stay was that hecould not speak, and it was thereforeassumed that he could not work and,consequently, that he was a candidatefor continuous custodial care. Investigation revealed that no one had everquestioned the totality of his disabilityor his right to custodial care for as longas he lived.

In brief, the patient requiring totallaryngectomy needs and deserves sympathetic understanding and carefulhandling from the time the operationis proposed throughout his hospitalstay and in the rehabilitation periodwhen he learns artificial speech and readjusts himself to altered conditions.In this problem the family doctor canplay a prominent role, and he shouldjoin with the surgeon in providing thenecessary encouragement and counselso that the patient may avail himselfof all possible facilities that will assist in his rehabilitation.

Reference1. Martimm,H.: The immcidemmceof total laryngec

tomy. Ann. Otol., Riminol. & Laryngol. 59: 359.363, 1950.

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