Getting Your Voice Back After Laryngeal Cancer Surgery

From body language and sign language to written messages and speech, we communicate with each other in a variety of ways. When it comes to speaking, your voice is much like your fingerprint or your DNA. It’s unique to you and your respiratory system.

Not everyone who goes through treatment for advanced laryngeal cancer will need to have extensive surgery. But if you have a laryngectomy to remove part or all of your larynx (voice box), your voice will change.

Fortunately, there are ways to rehabilitate and adjust to a new voice and communication with the help of a speech-language pathologist and the latest technological advances in speaking prostheses. Together, these can help you learn new ways to communicate.

“With some of the newer speaking prostheses, a lot of people can still communicate with a human-sounding voice — it’s just deeper, raspier and a little more guttural sounding,” shares otolaryngologist Paul Bryson, MD. “These devices are called tracheoesophageal prostheses (TEPs).”

Understanding larynx cancer

Typically, there are three things needed to create verbal speech:

1. Your voice is powered by air that’s forced up from your lungs through your trachea (windpipe).
2. That air flows through and vibrates your vocal cords in your larynx to create sound.
3. That sound is then shaped and folded into speech by your mouth, nose and throat.

Whenever any of these three processes are disrupted, your voice can be directly affected in terms of tone, volume and even pitch. This is why you experience hoarseness in your voice if you have a respiratory infection, for example.

More specifically, when it comes to your larynx and laryngeal cancer, there are three distinct parts of your larynx that can be affected:

• Supraglottis: The upper part above your vocal cords.
• Glottis: Your vocal cords.
• Subglottis: The part below your vocal cords, right above the trachea.

“Treatment options, rehabilitation and prognosis will vary based on the size, extent and remaining function of the larynx at the time of diagnosis,” says Dr. Bryson. “There are always two goals with treatment for laryngeal cancer: To eradicate the cancer and preserve as much of the function of the larynx as possible.”

A total laryngectomy removes the entire voice box and is reserved for the most advanced voice box cancers. Earlier-stage cancers can often be treated with surgery, targeted radiation therapy or a combination of both. Some advanced cancers may be treated with a combination of chemotherapy and radiation.

How a laryngectomy affects your voice

A total laryngectomy severs the connection between your windpipe and esophagus (food pipe). These surgeries directly affect breathing and speech because your airway is rerouted to the front of your neck, bypassing your mouth and nose.

To ensure proper airflow, a surgeon creates a permanent opening at the base of your neck, called a stoma. With the stoma, you’ll no longer pass air through your mouth and nose when you breathe in. This new, safe and stable airway helps you breathe and speak with the help of specific techniques and technological devices like a TEP or voice prosthesis.

After surgery, you’ll also use a device called a heat and moisture exchanger (HME). This device helps humidify the air you breathe by capturing warmth and moisture from your exhaled breath and returning it to the air you inhale. This is essential for keeping your airways comfortable, reducing mucus and making breathing easier by maintaining thin, manageable secretions.

“I think many people don’t realize the important role the nose plays in keeping our lungs healthy,” says speech-language pathologist Michelle York, MA, CCC-SLP. “The HME is a small but powerful device that takes over the function your nose performed before surgery.”

In some cases, your surgeon may also perform a primary TEP at the time of the total laryngectomy. This sets the stage for training your new voice after surgery sooner. This primary voice puncture becomes a pathway between your windpipe and esophagus with the help of a small, one-way valve (TEP). But this decision is based on a variety of factors, like whether you’ve had prior radiation, your ability to swallow, whether you have a history of reflux and your manual dexterity.

“All these aspects play a role in determining if someone is suitable for TEP, particularly for a primary puncture,” adds York. “In some cases, even one complicating factor might lead us to defer the TEP and discuss revisiting it as a secondary option in the future.”

Aside from the surgeon, you’ll also meet with a specialized speech-language pathologist to become acquainted with these options for alaryngeal speech.

Ways to recover your voice

Early in your recovery, you may need to rely on written communication to express yourself until you’re fully healed. As you recover in the hospital and at home, you’ll stay in close contact with your care team. A speech-language pathologist who specializes in post-laryngectomy rehabilitation will work with you to adapt or learn one or more of the following ways to communicate.

Voice prosthesis

If you had a primary puncture placed at the time of your total laryngectomy, or placed as a secondary puncture months after the initial total laryngectomy surgery, you’ll be able to learn tracheoesophageal speech using the TEP, which is most commonly preferred.

When you cover your stoma with your finger as you exhale, air is redirected through the valve and into your esophagus. The exhaled air causes the top of the esophagus to vibrate, where the sound is then shaped by your mouth to produce tracheoesophageal speech. There are also newer, hands-free prostheses available so you may not have to cover the stoma while you speak, too.

Some kinds of prostheses need to be taken out and cleaned regularly. Others are designed to only be removed by medical professionals and need to be changed every couple of months. Replacing these valves is quick and relatively uncomplicated.

Artificial larynx

Also called an electrolarynx, these are battery-operated, long-standing handheld devices. When you hold it up against your neck or cheek, or use an intra-oral aid in the corner of your mouth, it produces painless vibrations that are then shaped by the tongue, lips and teeth, in a similar fashion to TEP speech.

Although the sound of your voice while using these devices will have a monotone, electric quality to it, the latest technology will sometimes preserve regional accents. This device is less common than a TEP but is well-established as a form of communication after total laryngectomy.

Esophageal speech

This method of speech is used less often than others, partially because it’s a more difficult method. This form of speaking requires you to move air down into your esophagus and release it in a controlled way to create sound, similar to burping. This method can be more time-consuming and exhausting as you can only get so many words out before you have to repeat the process.

Finding your voice again

When you lose your larynx, it may take time to find your new voice — but it is possible. Your voice will sound different from what you’re used to hearing. But over time, as you develop these skills and learn about the process with the help of your speech-language pathologist, care team, friends and family, your voice will continue to be a unique factor in what makes you who you are today.

“I think the people who do the best are the ones that are motivated to regain communication, and have supporting family and friend networks that help them make their appointments and help them make the transition,” Dr. Bryson says. “Voice rehabilitation is a critical part of the laryngeal cancer survivorship journey.”