You have to breathe to live. But what happens when a progressive disease like muscular dystrophy or amyotrophic lateral sclerosis (Lou Gherig's disease) moves from attacking arms and legs to attacking breathing (respiratory) muscles? Or what happens when a car accident survivor is left with a head injury and swelling that slows down the response of the brain's respiratory center? And what about children born with lung disease or deformities of the chest wall and spine that interfere with breathing? These patients will have to breathe. How do they do it?

Tracheostomy

A surgical opening is made in the windpipe (trachea) by cutting the neck below the Adam's apple, below the vocal cords. A tube is placed in the opening, and air is inhaled and exhaled through the tube rather than through the mouth and nose. For some, a tracheostomy is a short-term measure. For others, it is long-lasting or permanent.

Such life support does have a price. As a result of tracheostomy and the new route of air travel, structures of the upper airway that warm and moisten air, filter air-borne debris, and facilitate coughing, sneezing, smelling, tasting, and swallowing play a reduced or non-existent role. The extra debris, without the normal means of clearing it, can cause a buildup of fluids and secretions in the lungs that need to be cleared by suctioning through the tracheostomy tube. Reduced smell, taste, and swallowing can reduce appetite and food intake to the point, in the most severe cases, of threatening life once again. Food and secretions can be misdirected (aspirated) into the lungs and potentially cause pneumonia and even asphyxiation.

Lack of Speech

If these were not enough potential problems, air flow as a result of the tracheostomy by-passes the vocal cords that allow for the production of sound and speech. Air takes the path of least resistance, with most of it going out the tracheostomy tube. Some air may leak up to the vocal cords, but it may not be forceful enough to drive the vocal cords into vibration, or it may only allow enough force for very short utterances.

Caretakers and family members become frustrated because they do not know the needs and wants of the patient. The patient feels isolated and alone at a time when his or her life is undergoing dramatic change.

Young children are deprived of the vocal explorations and social interactions that are critical to the development of language skills. The situation is made worse because caretakers tend to talk less to children who cannot communicate. These children are then robbed of the rich models they need to hear so they can figure out what language is all about. What can be done?

Speech With Tracheostomy

There are a number of options for speaking with a tracheostomy. Tracheostomy tubes can consist of plain tubes or can come with inflatable cuffs that, when pumped up, provide a greater seal against the neck than plain tubes. This increased seal can provide greater air supply to the lungs, but may not allow enough air leakage to power the vocal cords.

Patients with a cuffless tube or patients who may only need the cuff inflated at certain times, for example during eating or sleeping, may get enough air leakage for speech, or they may be able to produce speech by blocking or occluding the tube with their fingers or hand. Then the patient will breathe through the mouth and nose and vibrate the vocal cords as they did before surgery.

These methods do not work for all patients for a variety of reasons. Covering the tube may cause an increased resistance to breathing that is intolerable to some patients. Contaminants from the hand or fingers may introduce infection into the body, a particularly critical situation for patients with aspiration problems. Some patients may not get enough air for speech without blocking the tube, but may not have the awareness, muscle movement, or muscle tone to make a good occlusion.

Talking Valves

As an alternative, a variety of valves are available that can be attached to the tracheostomy tube. These valves allow air to enter via the tube, but leave by way of the mouth and nose. Use of certain valves is also reported to have secondary benefits of reducing secretions, increasing the sense of smell, reducing aspiration, facilitating tube removal in patients for whom tracheostomy is not permanent, and perhaps even increasing oxygenation of blood in the arteries. Because all valves do not produce the same quality of speech or the same secondary benefits, a valve for a specific patient should be selected based on the scientific and clinical results.

Ventilator Users

For some patients, a tracheostomy tube alone may not be enough. The tube may need to be connected to a breathing machine (ventilator) that provides a mixture of gases for life support. Patients on ventilators can speak as long as the tracheostomy tube allows flow through the larynx and vocal cords. However, the speech patterns of ventilator users present particular problems.

Because of the design of the ventilator, speech occurs during the expiratory cycle of the ventilator. Then there is a long silence until the next cycle of the ventilator. During this silence, the patient may lose his or her turn to talk as conversation partners fill the silence with their own speech. Listeners may also find it hard to follow the patient's communication message because the normal rhythm of conversational give-and-take is disrupted.

Spoken phrases may have sudden bursts of loudness, reduced loudness at the end of phrases, and changes in voice quality because pressure in the trachea from the ventilator gases is not as stable as this pressure is in typical speech production. Recent research has indicated that the speech of patients on ventilators may be improved by making simple adjustments to ventilator settings, particularly if no other problems exist besides breathing insufficiency. There is also at least one speaking valve available that can be used with a ventilator.

Speech-Language Pathologist and the Rehabilitation Team

The multiple and interrelated decisions that need to be made for patients with tracheostomies or ventilators cannot be made by one professional. Physicians, nurses, respiratory therapists, dietitians, speech-language pathologists, and others must all work together to choose the options that best meet the patient's total health needs. The speech-language pathologist assesses the patient's cognitive and language abilities to determine communication potential, evaluates oral-motor and swallowing functions, and assesses the patient's ability to produce voice in different situations that may include using a speaking valve. Whatever mode of communication is recommended for the patient in the context of his or her other needs, the speech-language pathologist plays a central role in ensuring that patients and caretakers know how maximum communication can be achieved. Speech-language pathologists also treat problems of swallowing when indicated.

Tracheostomy and ventilator use is life sustaining. Speech for patients with tracheostomies or ventilators is life enriching.

Find a speech-language pathologist near you who is certified by the American Speech-Language-Hearing Association.

Vocal Fold Nodules and Polyps

What are vocal fold nodules and polyps?

Vocal fold nodules are benign growths on both vocal folds that are caused by vocal abuse. Over time, repeated misuse of the vocal folds results in soft, swollen spots on each vocal fold that develop into harder, callus-like growths. The nodules will become larger and more stiff the longer the vocal abuse continues.

Polyps , on the other hand, can take a number of forms and are sometimes caused by vocal abuse. Polyps appear on either one or both of the vocal folds and appear as a swelling or bump (like a nodule), a stalk-like growth, or a blister-like lesion. Most polyps are larger than nodules and may be called by other names, such as polypoid degeneration or Reinke's edema.

What will my voice sound like if I have nodules or polyps?

Nodules and polyps cause similar symptoms and include:

• Hoarseness
• Breathiness
• A "rough" voice
• A "scratchy" voice
• Harshness
• Shooting pain from ear to ear
• A "lump in the throat" sensation
• Neck pain
• Decreased pitch range
• Voice and body fatigue

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What causes nodules and polyps?

Nodules are most frequently caused by vocal abuse or misuse. Polyps may be caused by prolonged vocal abuse, but may also occur after a single, traumatic event to the vocal folds, such as yelling at a concert. Long-term cigarette smoking, hypothyroidism, and gastroesophageal reflux may also cause polyp formation. Vocal abuse takes many forms and includes:

• Allergies
• Smoking
• "Type A" personality (person who is often tense or anxious)
• Singing
• Coaching
• Cheerleading
• Talking loudly
• Drinking caffeine and alcohol (dries out the throat and vocal folds)

It has been noted that, for unknown reasons, vocal nodules occur more frequently in women between the ages of 20 and 50.
 

How are nodules and polyps diagnosed?

If you have experienced a hoarse voice for more than 2 to 3 weeks, you should see a physician. A thorough voice evaluation should include a physician's examination, preferably by an otolaryngologist, who specializes in voice, a voice evaluation by a speech-language pathologist, and possibly a neurological examination. The voice team will assess vocal quality, pitch, loudness, ability to sustain voicing, and other characteristics of the voice. An instrumental examination may take place, which involves inserting an endoscope into the mouth or nose to look at the vocal folds and larynx in general. A stroboscope (flashing light) may be used to watch the vocal folds as they move.
 

What can be done to get rid of nodules and polyps?

Nodules and polyps may be treated medically, surgically, and/or behaviorally. Surgical intervention involves removing the nodule or polyp from the vocal fold. This approach only occurs when the nodules or polyps are very large or have existed for a long time and is rare for children. Contributing medical problems may be treated to reduce their impact on the vocal folds. This includes treatment for gastroesophageal reflux, allergies and thyroid problems. Medical intervention to stop smoking or to control stress is sometimes warranted.

A majority of people receive behavioral intervention, or voice therapy, from a speech-language pathologist. Voice therapy involves teaching good vocal hygiene, eliminating vocal abuses, and direct voice treatment to alter pitch, loudness, or breath support for good voicing. Stress reduction techniques and relaxation exercises are often taught, as well.
 

What causes vocal fold paralysis?

Vocal fold paralysis is caused by head and neck injuries, tumors, disease, surgery, or stroke. Nerve damage to the vagus nerve, which has branches that run from the brainstem to the larynx and regulates the movement of the vocal folds, is the specific cause of vocal fold paralysis.

What are the symptoms of vocal fold paralysis?

The severity of voice and swallowing problems depends on where the nerve damage occurs. Typical symptoms include:

• Hoarseness
• Breathy voice
• Inability to speak loudly
• Limited pitch and loudness variations
• Voicing that lasts only for a very short time (around one second)
• Choking or coughing while eating
• Possible pneumonia due to food and liquid being aspirated into the lungs (the vocal folds cannot close adequately to protect the airway while swallowing)

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Are there different types of paralysis?

Yes. Bilateral vocal fold paralysis involves both vocal folds, which become stuck halfway between open and closed (the paramedian position) and do not move either way. This condition often requires a tracheotomy (an opening made in the neck to provide an airway) to protect the airway when the person eats.

Unilateral vocal fold paralysis is more common than bilateral involvement. Only one side is paralyzed in the paramedian position or has a very limited range of motion. The paralyzed vocal fold does not move to vibrate with the other fold, but vibrates abnormally or does not vibrate at all. The individual will run out of air easily and be unable to speak clearly and with sufficient loudness to be understood.

How is vocal fold paralysis diagnosed?

The vocal folds can be examined by using an endoscope that is inserted through the nose or mouth. A light on the endoscope allows the examiner to view the folds and movement patterns during phonation (producing sound) and at rest. Swallowing problems can also be evaluated by endoscopy or fluoroscopy, a radiology procedure that allows the examiner to view the movement of food and liquid mixed with barium from the mouth to the esophagus. Typically a complete voice evaluation is conducted by a speech-language pathologist and otolaryngologist (ear, nose, and throat doctor).

How is vocal fold paralysis treated?

Bilateral paralysis is often medically treated and may require a tracheotomy to allow the person to eat safely. Surgery may be considered to bring one or both vocal folds closer to midline.

Unilateral paralysis can be treated medically and/or behaviorally. Medical treatment includes muscle-nerve transplant, medialization thyroplasty (moving the paralyzed vocal fold toward midline), or injection of a substance to increase the size of the paralyzed vocal fold.

Behavioral treatment includes voice therapy by a speech-language pathologist and may be the only treatment required for the individual. The individual will work with the SLP on pitch alteration, increasing breath support and loudness, and finding the correct position for optimal voicing (such as turning the head to one side or manipulating the thyroid cartilage). Research has shown that voice therapy is an effective intervention in the interim period between diagnosis of the paralysis and final resolution of the problem.