What’s a voice box? It can be removed? Briefly learn about voicing and laryngectomy from an undergraduate Speech and Language Pathology student learning about it herself! Maybe you’ll find it interesting. If not, you’ll at least acquire some knowledge that could enable you to act in a more compassionate manner toward people with abnormal voices. The more empathy, the better. Enjoy!
The Voice Box—Crash Course
Despite its name, the structure in which phonation, or voicing, occurs is not at all shaped like a box. It does, however, consist of multiple sturdy, yet flexible structures that create the space and tools we need to voice! The larynx is a small structure, only about the size of your thumb, that contains the vocal folds. This structure sits right about your trachea, which is the route taken by your air once it is breathed in through your nose and/or mouth to get to your lungs. When we exhale, air comes up from the lungs, out through the trachea, and into the larynx that sits above it. The vocal folds in the larynx comfortably sit open and separated during inspiration (breathing in) so the air can flow up and out of the oral or nasal cavity. When we want to speak, we use muscles of our larynx to bring the vocal folds together during an exhale. When the air, coming up from a tube to a confined area, interacts with the elastic pieces that are our vocal folds, the air pressure pushes them open. Due to their elasticity and sturdiness, the vocal folds will close naturally afterwards, causing vibration. A physics concept known as the Bernoulli effect makes it so that, when we continue to supply air pressure to the adducted vocal folds, they will very quickly open and close, causing vibration that allows for sustained phonation. Producing sounds rely on three bodily systems: the phonation system of our larynx and vocal folds, the respiratory system that supplies the energy that is made acoustic when the vocal folds vibrate, and the resonance system, which consists of the various spaces or cavities in our upper body that are used to create pressure and shape air.
Carcinoma and Laryngectomy
Often times when carcinoma (cancer) develops in the larynx, it’s on the vocal folds, first on the outermost, epithelial layer, and then in the muscle. To save patients’ lives, surgeons will remove part or all of the larynx in a procedure known as a laryngectomy. When the larynx, with its hyoid bone, various cartilages, and many muscles, including the vocal folds, is removed completely from a patient, they have lost not only the system that produces sound, but also the structure that serves as protection for their trachea and respiratory tract. Simply removing the larynx without redirecting the trachea would leave it, the windpipe, sitting open and uncovered, extremely vulnerable to aspiration. Therefore, part of a laryngectomy includes attaching the trachea to a stoma, or hole made in the neck. This small hole is made around where one’s Adam’s apple would sit if they had their laryngeal cartilage. The patient will breathe in and out via this hole, allowing air to access their trachea and respiratory system.
Post-surgery life for patients is demanding, as many adaptations need to be made to daily life. Communication, and more specifically speaking, is one of the processes that will need to be undergone differently. Directly following surgery, the neck is very tender and sore. During these first few weeks, patients speak with the use of an electronic larynx. This is a small, handheld machine that produces a vibrating noise. It is put to the skin of the neck or face so that its vibrating sound can serve as a voice for the patient who, at the time, is manipulating their oral cavity the way they would if they were speaking. Watch the video at the end of the article to see this in action—it’s really quite amazing!
After the first few months, the pharynx has recovered and patients are often ready to undergo a secondary surgery in which a space is made for a voice prosthesis valve. This small tube connects the trachea to the esophagus, which is made of muscle that is able to stretch, bend, and expand with the body’s movements. For patients with this structure, air that enters through their stoma will go to their lungs. During an exhale, when air is brought upward through the trachea, it will be interjected and taken into the esophagus if the stoma is covered. The air will then be manipulated by the space and tension of the esophagus to produce sound. Because the esophagus is not made of the same spaces and structures that the larynx and vocal fold are, the voice produced sounds quite different to that of someone with their normal structures. It is still often seen as an optimal choice amongst the patients’ options, as it allows them to produce speech without a vibration machine that produces a “robotic” sound and must be carried with the person. It’s important for patients to keep in mind that the valve will need to be removed and cleaned often. It is not a permanent surgical insertion, but a prosthetic piece.
This is how people who do not have voice boxes — larynxes — produce speech, despite the larynx being a system heavily relied on for speech production. I hope you enjoyed this article! There’s so much information out there on this subject, so if this caught your interest, I encourage you to look further into it. I think it’s important that all people, regardless of interest in speech or medical procedures, learn of things like this. The more we know, the more compassionate we tend to be. Next time you hear someone with a “robotic” sounding voice, know that they may have just undergone surgery to remove an intense and painful cancer.
Sources:
Gillam, Ronald Bradley, and Thomas P. Marquardt. Communication Sciences and Disorders. Jones & Bartlett Publishers, 2016.