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Chapter 11:
Voice Disorders
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)ocus *uestions
+ hat is a oice disorder-
+ o" are oice disorders classi/ied-
+ hat are the de/ining characteristics o/oice disorders-
+ o" are oice disorders identi/ied-
+ o" are oice disorders treated-
.
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Introduction 1 ( rie/ istory+ 6th century 1 the laryn3 studied on hu4an
cadaers 1 did not per4it to see laryn3 at "or5
+ 600 1 /irst boo5 on laryngeal structures
+ 'th century 1 "elldeeloped understanding
ho" the ocal /olds produce the oice+ '27 1 glottiscope8 crude gli4pses o/ the
laryngeal caity
+ '&% 1 laryngoscope8 ast i4proe4ent in
technology to e3a4ine the laryn3+ 9oday, adanced technology :endoscopy,
stroboscopy ; allo" e3a4ination o/ the ocal/olds lie in action
.2
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Case Study *uestions
+ hat co44unity actiities 4ight be
possible /or >r. Aitchell no" that she uses
her oice-
+ o" 4ight >r. Aitchell be inoled "ith
her pro/ession in the /uture as a
@uadriplegic-
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Case Study 28 (nton+ 6'year old eteran diagnosed "ith
laryngeal cancer si3 years ago
+ ad his laryn3 re4oed t"o years ago,
tried unsuccess/ully to learn esophageal
speech, no" uses an arti/icial laryn3
+ Is interested in helping other
laryngecto4ees
+ Is interested in possibility o/ a laryngeal
transplant
.6
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Case Study 2 *uestions
+ Gien that (nton already has a "ay to
produce speech ia the arti/icial laryn3,
"hy "ould he desire a laryngeal
transplant-+ (nton?s hobby a/ter his laryngecto4y "as
to counsel other laryngecto4ees. In "hat
"ays 4ight (nton?s counseling be superiorto that o/ a clinical pro/essional, li5e a
psychologist-
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Case Study B8 As. Chin+ %2year old teleision personality :co
anchor o/ ne"s sho";
+ E3periencing inter4ittent proble4s "ith
her oice in "hich it see4s to start and
stop and /eels strangled
+ ent to otolaryngologist, "ho gae her a
preli4inary diagnosis o/ spas4odic
dysphonia
+ As. Chin?s producer suggested she ta5e
disability leae until her oice is resoled
.'
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Case Study B *uestions
+ >o you agree "ith As. Chin?s producerthat she should be Ho// the air until heroice proble4s are resoled-
+ As. Chin has an appoint4ent soon "ith anSFP "ho 4ay not be s5illed in treatingspas4odic dysphonia. o" i4portant is it
to see a clinician "ho has "or5ed "ith thiscondition be/ore-
+ hat other pro/essionals should beinoled "ith As. Chin?s oice treat4ent-
.7
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I. hat is =oice-+ =ocal /old ibration that proides sound source
/or spo5en language
+ Phonation8 hu4ans set their ocal /olds into a
ibratory pattern :say Hoooo;
1 =ocal /olds are adducted :closed;, air is e3haledup"ards and blo"s apart the ocal /olds setting
the4 into a rapid ibratory pattern
+ =oice is /urther 4odi/ied by the processes o/resonation and articulation
+ 9hree ocal characteristics8 frequency,
intensity, and phonatory quality
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)re@uency+ Rate o/ ocal /old ibration :pitch;
+ )unda4ental /re@uency :)0; 1 basic
ibratory rate o/ the ocal /olds :in Hertz ;
1 Dindergarten girls and boys J 2&0 K
1 (dult "o4en J '0 1 220 K
1 (dult 4en J 20 1 %0 K
+ )0 relates to three characteristics8
1 =ocal /old length, 4ass, and tension
+ )unda4ental /re@uency changes as "e
age, especially bet"een birth and puberty
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Intensity+ Sound pressure reported in decibels
:loudness;
+ Relates to t"o /eatures o/ ocal production8
1 (4ount o/ air/lo" /ro4 the lungs
1 (4ount o/ resistance to the air/lo" by the ocal
/olds :"hich contributes to their e3cursion, or
ho" /ar apart the ocal /olds 4oe and co4e
bac5 together;+ Eery person has a baseline intensity leel
that characteriKes hisLher conersational
speech
.2
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Phonatory *uality
+ o" "ell the t"o ocal /olds "or5 togetherduring the ibratory cycle
1 I/ ocal /olds "or5 sy44etrically and
har4oniously, oice is pleasant and clear
1 I/ co4pro4ised in so4e "ay :e.g., gro"th on
one o/ the /olds;, phonatory @uality is a//ected
+ (lso in/luenced by the resonation o/ the
oice into the oral and nasal caities :e.g.,nasal oice @uality;
.B
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hat is a =oice >isorder-
+ Pitch, loudness, or phonatory @ualitydi//ers signi/icantly /ro4 persons o/ a
si4ilar age, gender, cultural bac5ground,
and racial andLor ethnic group, and+ =ocal @uality detracts /ro4 the ability to
/unction and achiee in society
.%
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>escribing =oice *uality
+ >ysphonia8 u4brella ter4 /or a oice thatis disordered in so4e "ay
+ (phonia8 total loss or lac5 o/ oice
+ Aany other, 4ostly subectie ter4sM 1 Pitch and /re@uency8 jitter or diplophonic
1 Foudness and intensity8 pressed or strident
1 Resonance8 nasal or ringing 1 Phonatory @uality8 flutter or crea
.&
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>escribing =ocal )old )unctioning+ Hypofunction8 ocal /olds are under
/unctioning and hae inade@uate tension,
so air escapes through
1 reathiness or hoarseness, or no oice at all
+ Hyperfunction8 ocal /olds are oerly tense
and co4press too tightly together
1 9oo loud, too high, andLor too strained
1 So4eti4es spasticity o/ the oice
+ Diplophonia8 ocal /olds produce t"o
di//erent pitches si4ultaneously
.6
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=oice "ithout a Faryn3
+ !aryngectomy 8 surgically re4oing thelaryn3
+ 9"o pri4ary reasons8
1 laryngeal cancer8 re4oed to stop spreading 1 laryngeal trau4a8 re4oed i/ too da4aged to
protect respiratory syste4 or i4pede
breathing
+ Alaryngeal communication8 an alternatie
"ay to produce speech
.$
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Prealence and Incidence8
=oice >isorders in (dults+ Prealence J 27N, Incidence J 6N
+ igher prealence /or "o4en, pea5 ages o/ %0
60 years
+ igher prealence a4ong people "ith /re@uentallergies, asth4a, colds, and sinus in/ections
+ igher prealence a4ong pro/essions reliant on
oice+ Co44on causes8 ocal nodules,
ede4aLs"elling, polyps, carcino4a, and ocal
/old paralysis
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Prealence and Incidence8
=oice >isorders in Children+ 2&N o/ children e3hibit signi/icant ocal
proble4s, "ith %0N o/ these cases
ongoing, not transient, proble4s
+ )or so4e it is a congenital proble4, but
4ost cases result /ro4 oeruse or 4isuse
o/ oice
+ Aost co44on cause8 "ocal nodules that
i4pede s4ooth 4eeting o/ /olds, resulting
in breathy or hoarse oice
.7
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Prealence and 9reat4ent
+ Rate o/ oice disorders /or both childrenand adults is relatiely high, but 4anycases go undiagnosed andLor untreated
+ Seeral reasons /or this8
1 #reatment access8 e.g., disorder notconsidered to i4pact educationalper/or4ance in school
1 $no%ledge8 e.g., person 4ay beliee that
oice proble4 "ill disappear spontaneously 1 Social perception8 e.g., the disordered oice
:e.g., a breathy, hoarse oice; brings positiesocial attention
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II. o" are =oice >isorders
Classi/ied-
+ =oice disorders are grouped based on
their cause, an etiological classi/ication
+ )our di//erent categories8 (. =ocal abuse
. !eurogenic disorders
C. Psychogenic disorders>. (laryngeal co44unication
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(. =ocal (buse+ Chronic or inter4ittent oeruse or 4isuse
o/ the ocal apparatus+ =ocally abusie behaiors8
1 9al5ing in noisy eniron4ents
1 )re@uent coughing or clearing o/ the throat 1 Using ca//eine products
1 Oelling, screa4ing, and cheering
1 Giing speeches or lectures 1 Spending ti4e in s4o5y eniron4ents
+ 9"o co44on conditions8 "ocal nodules and contact ulcers and granuloma
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=ocal !odules
+ S4all bilateral protuberances or callousedgro"ths on the inner edge o/ the ocal/olds
+ Acute nodules are si4ilar to bruises on theocal /olds, but these can harden andthic5en oer ti4e, "hich beco4es achronic condition
+ Aost prealent in children and adults "hoengage in ocal 4isuse and abuse
+ (dditional /actors8 te4pera4ent and
general health
.2B
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Contact Ulcers and Granulo4a
+ Contact ulcers8 in/la4ed lesions thatdeelop on the cartilage in the laryn3
+ Granulo4a8 a 4ass o/ tissue generated by
the body?s healing process at the site o/the contact ulcer
+ Aostly results /ro4 ocal abuse, but also
/ro4 acidic irritation due to chronic re/lu3or tubal intubation :during surgery;
+ Fo", breathy oice @uality
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. !eurogenic >isorders+ Result /ro4 illness, da4age, or disease to
the neurological syste4s associated "ithoice production
+
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=agus !ere Fesions+ Can occur due to surgical da4age, trau4a,
and iral in/ections+ Aost serious outco4e8 ocal /old paralysis
+ Aostly unilateral paralysis8
1 Abduction paralysis8 one o/ the ocal /olds cannotopen, oice is not usually a//ected, but breathing4ay be di//icult
1 Adduction paralysis8 one o/ the ocal /olds cannotclose, so they cannot 4eet together, causinghoarse or breathy oice @uality
+ Co4plete paralysis8 both ocal /oldsparalyKed, co4pletely bloc5ing air"ay 1
tracheosto4y is necessary
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Spas4odic >ysphonia
+ (//ects 4otor control o/ laryn3, results in
inter4ittent oice stoppages
+ #er5y, grunting, s@ueeKed, groaning, and
stutteringli5e oice @uality
+ Ranges /ro4 4ild to seere
+ (dductor type8 4ost co44on, oice is
strangled, strained, and s@ueeKing
+ (bductor type8 less co44on, oice is
breathy and open
.2$
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(4yotrophic Fateral Sclerosis
+ (lso called Fou Gehrig?s >isease 1progressie, degeneratie, neuro4usculardisease
+ Cause is un5no"n, i4pact is signi/icant, and
4ost surie less than 0 year a/terdiagnosis
+ =oice is so/t, breathy, lo" in pitch and
loudness, li4ited ariability, and hypernasal+ >i//iculty clearly articulating speech soundsbecause cannot strongly coordinate 4otorprocesses
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Par5inson?s >isease
+ Progressie, degeneratie neurologicaldisease caused by depletion o/ dopa4ine
+ Unable to produce a strong oice because
o/ a "ea5ened respiratory syste4
+ Rigid 4uscular tone restricting 4oe4ents
o/ laryn3 produces hoarseness and a
4onotonic pitch
+ !ee Sil"erman &oice #reatment program 1
e//ectie /or i4proing oices o/ persons
"ith Par5inson?s
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C. Psychogenic >isorders
+ !onorganic disorders, resulting /ro4
e4otional or psychological characteristics
+
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Psychological or E4otional
9riggers
+ (/ter so4eone recoers /ro4 a ocal
inury because o/ oeruse or 4isuse o/ the
oice, 4ay e3perience a sense o/
ulnerability and an3iety about using oice
+
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Psychopathology
'( Stress, An)iety, and Depression+ (cute stress disorder8 "ithin one 4onth o/
haing a trau4atic e3perience,
e3aggerated startle responses, 4otorrestlessness can be re/lected in the oice
+ GeneraliKed an3iety and an3iety disorder8
4uscle tension, tre4bling, t"itching 4aylead to ocal tre4ors and oice brea5ages
.B2
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*( Con"ersion Disorder
+ Physical sy4pto4s or de/icits result /ro4
seere an3iety or stress+ Can result in a loss or disordered oice as
one ariety o/ conersion disorder
+( &ocal tics and #ourettes Disorder
+ =ocal tics produce sudden, rapid,
recurrent ocaliKations
+ 9ourette?s8 ocal tics occuring
si4ultaneously "ith other 4otor tics
a//ecting the head, torso, and e3tre4ities
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Autational )alsetto and
#uenile =oice
+ =ocal characteristics are not consistent"ith age and gender
+ -utational falsetto8 4ale child oradolescent e3hibits inappropriately highoice 1 =oice therapy and 4edical treat4ent are
e//ectie+ .u"enile "oice8 /e4ale co4panion to
4utational /alsetto, "o4en 4aintain achildli5e oice into adulthood
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>. (laryngeal Co44unication
+ Producing oice "ithout a laryn3
+ 9"o 4ost co44on reasons8
1 Faryn3 is not aailable because o/ atracheosto4y
1 Faryn3 has been co4pletely re4oed in a
larnygecto4y
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9rachesto4y
+ hen respiratory syste4 is co4pro4ised,4echanical entilation and respiration isneeded 1 tracheosto4y tube is inserted through the
nec5 to direct air into the lungs+ Unable to tal5 because air is not going
oer ocal /olds
+ PassyAuir 9racheosto4y Spea5ing=ale8 allo"s adults and children to spea5een "hile entilated
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Faryngecto4y+ /tiology: Faryngeal cancer is lin5ed to tobacco
and alcohol use, nutritional inade@uacies andoccupational e3posures a//ects (/rican(4erican
older 4ales at the highest rates
+ Symptoms: 4ost consistent sy4pto4 ishoarseness
1 (ny person e3hibiting hoarseness should see5 4edical
attention i/ persists /or 4ore than t"o "ee5s
+ #reatment 8 Rid the body o/ the 4alignancy 1 4ost oncologists use conseration approaches, and
pre/er to only re4oe part o/ the laryn3 i/ possible
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III. >e/ining Characteristics o/
=oice >isorders+ =oice disorders i4pact one or 4ore o/ the/ollo"ing perceptual characteristics o/
oice8
(. Resonance
. Foudness and pitch
C. Phonatory @uality
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(. Resonance
+ &elopharyngeal port controls the e3tent to
"hich e3haled air enters the nasal andoral caities
+ 9he port typically rests in an open
position, but "hen "e spea5, it is al4ostal"ays closed :air/lo" channeled into the
oral caity;
+ =oice disorders o/ resonance result /ro4proble4s "ith control o/ port, called
"elopharyngeal inadequacy Justice
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=elopharyngeal Inade@uacy+ Co44on causes8
1 Cle/t palate and cranio/acial abnor4alities 1 Iatrogenic :proble4s resulting /ro4 surgery;
1 (llergies
1 !euro4uscular i4pair4ent+ Results in either8
1 Hypernasality 8 port re4ains open to allo" too
4uch resonance and nasal e4issions duringspeech
1 Hyponasality 8 too little nasal resonance, oice
4ay sound stu//y and congestedJustice
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. Pitch and Foudness
+ Pitch8 /re@uency+ Foudness8 intensity
+ 9oo 4uch or too little tension in oice
production can cause abnor4al pitch orloudness
+
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Pitch
+ I4portant concepts8
1 abitual pitch8 pitch one uses nor4ally
1 isordered pitch8
1 abitual pitch di//ers signi/icantly /ro4 opti4al
1 E3tre4ely li4ited ocal rangeJustice
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Foudness
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C. Phonatory *uality
+ hen ocal /olds do not "or5har4oniously, i4pair4ent in general
@uality o/ the oice
+ Co44on types o/ i4paired phonation8 1 ard glottal attac5
1 Glottal /ry
1 reathy phonation 1 Spasticity
1 oarseness
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I=. o" are =oice >isorders
Identi/ied-
(. 9he =oice Care 9ea4
+ Close collaboration o/ a ariety o/
pro/essionals
+ Aedical pro/essionals8 pri4ary care
physician :PCP;, otolayrngologist
+ (llied health pro/essionals8 speech
language pathologist, psychologist orpsychiatrist
+ Possibly educators or oice coaches alsoJustice
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. 9he (ssess4ent Process
+ Identi/ication o/ "arning signs
+ (ssess4ent Protocol8
1 Case history and interie"
1
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arning Signs /or =oice >isorders+ Children and adolescents8
1 =ocally abusie behaiors
1 Underlying 4edical condition
1 Psychological "ellbeing
+ (dults8 1 Change in phonatory @uality /or 4ore than t"o
"ee5s, consult physician
+ Re/errals8 PCP "ill li5ely 4a5e at least t"ore/errals8
1
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(ssess4ent Protocol
+ Speechlanguage pathologist?s goals8 1 CharacteriKe the general /eatures o/ the oice
1 Establish i/ any o/ these /eatures di//er /ro4
the nor4
1 I/ disorder is present8
+ Identi/y cause
+ Identi/y interention approach that "ill be the 4ost
bene/icial to i4proing the oice
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Case istory and Interie"
+ Interie" "ith the client to learn 4oreabout8
1 Aedical history
1 Chronological history o/ proble4
1 Sy4pto4s and possible etiology o/ proble4
1 ay in "hich client uses oice /or daily liing
actiities
1 Client?s 4otiation /or see5ing help
Justice
Communication Sciences and Disorders: An
Introduction
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Clinical
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Instru4ental
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=. o" are =oice >isorders
9reated-+ Eli4ination o/ the cause o/ the disorder :e.g.,
ocally abusie behaior;
+ Co4pensation /or a disorder :cause cannot
be eli4inated;
+ 9hree possible goals8
1 9each a ocal behaior that is absent
1 Substitute ocal behaior /or inappropriate one
1 Strengthen ocal behaiors that are "ea5 or
inconsistentJustice
Communication Sciences and Disorders: An
Introduction
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(. 9reat4ent /or =ocal (buse
Seeral options8
+ Surgery :e.g., re4oal o/ ocal nodules;
+ =ocal hygiene progra4s
+ =oice therapies
+ Co4puter progra4s
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Communication Sciences and Disorders: An
Introduction
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. 9reat4ent /or !eurogenic
>isorders
+ Co4bination o/ 4edical interentions and
oice therapies
+ Aedical interentions8
1 Phonosurgery8 i4proe4ent, alteration, or
restoration o/ the oice :e.g., thyroplasty;
1 Inections into the ocal /olds :e.g., 9e/lon,
boto3;
+ =oice therapies8
1 e.g., Fee Siler4an =oice 9reat4ent progra4Justice
Communication Sciences and Disorders: An
Introduction
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C 9reat4ent o/ Ps chogenic.&6
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C. 9reat4ent o/ Psychogenic
>isorders
+ Aultidisciplinary approach including
speechlanguage pathologist and 4ental
health pro/essionals
+ Goal8 deter4ine e4otional or psychosocial
cause o/ oice disturbance
+ 9herapy usually /ocus on reducing
tension, counseling, and eli4inating any
oice abuses or 4isuses
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Communication Sciences and Disorders: An
Introduction
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> 9reat4ent o/ (laryngeal.&$
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>. 9reat4ent o/ (laryngeal
Co44unication
+ Co44unication counseling8 e3plore allalternatie options /or producing oice 1 (rti/icial laryn38 ibrating po"er source placed
against the nec5, o/ten 4echanical soundingoice
1 Esophageal speech8 learn to trap air in theesophagus and then use that /or oice, o/ten
ery di//icult /or 4ost people 1 9racheoesophageal speech8 surgical puncture
bet"een the trachea and esophagus proidesan air source /or spea5ingJustice Copyright ©2006 by Pearson Education, Inc.