The Birth of a Voice

Bit by bit, Dr. Murad Lala scraped the yellowish tissue, detaching it from the skin and the pink muscle. He was assisted by his colleague at Hinduja Hospital, Mumbai, Dr. Gauri Mankekar. The flap of the skin was turned up and held down by a curved steel instrument. The cold operation theatre, the silent observers, contrasted with the light film songs that spewed from a radio in a corner. The trachea was cut. The windpipe and its twin, the foodpipe, were detached forever. Carefully, all the glands on both sides of the neck were removed, barring the carotid (the main artery that takes blood to the head) and the jugular vein (which drains the blood from the head into the heart). He then turned his attention to the larynx. The nerves that control the voice, which otherwise are carefully avoided and preserved in any other surgery, were identified and snipped. The surgeons wielded the scalpels and forceps precisely. The hyoid bone was cut and removed, along with all its intrinsic muscles and membranes, and the upper two rings of the trachea. Bit by tiny bit, the nodes were removed. The trachea was then tilted forward, brought out and attached to the surface of the skin in external neck region, just above the notch of the sternum.

The patient, A.D. Sharma, would not hear his voice again. Neither would anyone else. Dr. Lala next created a fistula, a special connection, between the windpipe and the throat. Into that, using a pipe-like instrument, he implanted a one-way valve that would serve Sharma as a ‘voice box’. The opening, (or tracheostoma) near the base of the neck, would serve as an entrance to the lungs. He would be able to breathe through the nose, but no longer would it be needed for respiration. The air would enter and exit the lungs from this hole. A small price to pay for conserving his lifespan.

Other than the hoarseness, there was no other indication that A. D. Sharma (name changed) was ill. Unknown to him, this 75-year-old bachelor, an air-conditioning specialist who loved his cigarettes, had developed a malignancy. He went to an E.N.T. surgeon because the hoarseness, now six months old, had become a nuisance. He was startled when, after a laryngoscopy, he was told about the cancer. He was not afraid, even through it was in the third stage.

“It was the doctor’s assurance that I would recover from the surgery and be able to lead a normal life,” he says in his low but distinct voice, “that carried me through.” He was advised radiation, too, which he declined to take.

For three weeks post-surgery, he communicated through notes to family and friends. He could walk around, so he didn’t feel ‘ill’. The only problem was that he couldn’t talk to his five year old Labrador, who adored him, and who was his constant companion. This phase lasted for three weeks. Then, with a little effort in the beginning, he began to talk. Painlessly, though comfortably, right from the beginning. However, the removal of the larynx came with other problems.

“The secretions kept coming out through the hole in my neck, and I had to learn to remove them with a suction instrument. They still do and now the task of cleaning them is mechanical. I have to do it standing in front of a mirror, a couple of times per day. Whilst taking a shower, I was extremely worried in the beginning. For any particle of water or dust, could directly go into the lungs and cause trouble. Now, I manage quite well.”

Today, although he can sneeze, it sounds different, and it is difficult, because the pressure from the lungs is released through the vocal cords, normally; whereas now, it must come out through the stoma, that hole at the base of his neck. He can’t cough. He can’t strain whilst passing stools. What is known as the Valsalva manouvre is not possible. (That means, in females, the pressing down during delivery can’t be done.) He can’t swim or sing. The sounds of laughter and crying are absent. He can’t lift weights, for that requires filling up and sudden exhalation of the lungs.

“None of that bothers me,” he says. “What does, is when I can’t get a word out when the valve suddenly sticks. It gets ok in a moment, but that’s the time I miss the real thing.”

Like another patient, Mr. K. Abdul, a driver, who was a tobacco chewer, he can’t hiccup like normal persons. Abdul, 48, had given up tobacco a couple of years before he experienced a swallowing problem which led to his being diagnosed with cancer. “Something was always sticking inside the throat,” he remembers.
The E.N.T. surgeon in Sharjah, where he was working as a driver, advised a biopsy. The report: malignant. The mucosa which was affected by the tobacco would have taken upto ten years to recover from its ill effects, explains Dr. Murad Lala, for the damage was already done. Abdul’s voice, also routed through a prosthesis, is so clear, even over the phone, that people don’t realize he doesn’t have a natural voice box until they notice that he’s wearing a cover over his neck and has to raise a finger to close the stoma each time he talks. What’s more, in Abdul’s case, the valve (made of lightweight plastic and silicon and presently costing about Rs.14000) had got clogged by secretions and the growth of normal bacteria and fungi, so had to be changed after three and a half years. Changing the valve doesn’t require hospitalization, it can be done in the OPD, through the tracheostoma, and has to be done whenever there is an air leak explained Dr. Gauri, or when it gets clogged.

Had the two undergone their surgeries in the eighties, they’d have had a high-pressure valve. That would have required more air and more force to produce a voice. Those valves needed to be removed manually from the opening in the neck three or four times daily, for cleaning. That often resulted in a larger hole and leakage of air that rendered them useless. Until the nineties, there wasn’t much change in the prosthesis, so these voice restoration surgeries weren’t in vogue. Then, research improved the products. Now, in the year 2005, patients have low-pressure, in-dwelling prostheses which make it easier for them to ‘talk’ as normally as possible.

Says Dr. Lala, “The first time a voice prosthesis is implanted, it’s known as the primary puncture, and insertion is easy. Each time it is replaced, there is a change in the tissues, and the placement gets loose, so a bigger diameter valve has to be used. Whichever valve is used, it has to be brushed gently a couple of times a day with a specially made brush that is put through the stoma into the valve and twirled around. I don’t know whether it is the climate or the kind of food we eat, or just economics, but the valves in our patients don’t have to be replaced as often as those of patients abroad. ”

Explains Dr. Mankekar, “Both Sharma and Abdul, have also lost their sense of smell for that involves the nose, which is now no longer involved with their breathing. Therefore, aromas and fragrances are but memories. When they get a respiratory tract infection, the phlegm comes out through the stoma, and has to be sucked out often. And of course, the nose drips outside quite a lot, for the liquid can’t be sucked in naturally.”

Whilst Sharma takes a shower, Abdul prefers the bucket and mug combination for his bath: both are very, very careful not to let even a drop of water get into their lungs. A bib or gauze strip must always be worn around the neck, day and night, to prevent anything from entering the stoma.

The finger that must close the stoma to create the voice goes up instinctively due to habit. There are ‘covers’ available that can close the hole by sealing it in place with a gel. But in India’s tropical weather, the sweat doesn’t allow the seal to be complete, and the ‘cover’ is rendered useless. Science has come a long way since laryngectomees (those whose larynxes have been removed because of malignant growths on or around them) had to suffer in silence. Literally. Today, within weeks of the surgery they can get back to work. The manner of sound production is different, and women, specially, have to get used to a much lower, hoarse, masculine sounding pitch. Patients have to get used to lesser usage of air in the lungs. Total laryngectomy is considered to be an adequate oncological (oncology=the study of cancer) operation for quite some time and those who have undergone it have a good chance of survival.

In order to be able to speak, it is necessary to have an outward airflow, a sound source and a cavity in which the sound will be transformed into understandable speech sounds. The exhaled air causes vibrations in and between the two folds in the voice box. That’s the sound source. This sound is transformed into understandable sounds in the mouth, nose and throat cavities by articulation (mainly by the movements of the tongue). Resonance happens in the nose and the sinuses. The entire group of muscles involved form the speech canal, which doesn’t change with laryngectomy. What goes is the sound source, the voice box. The airway and throat are disconnected, so the lungs are not directly available to deliver the necessary airflow. So, there has to be a new air source and sound source.

There is a method of inducing oesophagal speech without the use of a valve. A potential air source can be air trapped in the oesophagus and/or the stomach, and by expelling this air it appears to be possible to set the mucosa in the oesophagus-throat area into vibration, which acts as the sound source. This sound can be formed into understandable speech, and is known as oesophageal speech. However, relatively little air is available in this method, mostly not more than roughly 80 ml, in contrast to the litres of air in the lungs available before the operation. So the phonation time is short, about 1 to 2 seconds. Normally, it is more than 20 seconds. This technique is difficult to acquire and rehabilitation often takes a long time. Less than 10 percent develops a really good voice. This speech is caused by a kind of controlled belching, and can’t be done when a person is eating.

Another method of alaryngeal speech (speech without a larynx) is by using a tone generator, an electrically driven instrument, also called an ‘electrolarynx’. This device generates vibrations which are passed through the skin towards the throat. Thr sound is transformed in the speech canal into understandable, but monotonous sounding, robot-like speech.

For those in India who are functionally illiterate, speech is the only means of quick communication.

Abdul didn’t find anything wrong with changing his career. From driving cars, he switched over to providing meals (tiffins) from his home, as he found that more practical. Sharma, who had retired after forty years of working on airconditioners, finds the main disadvantage of his new status is that he can’t wear ties to formal occasions!!!

A life of involuntary silence might have been a huge penalty. It no longer need be so.


NOTES:

1. Dr. Murad Lala is an oncology-surgeon at the P.D. Hinduja Hospital and MRC, Mahim, Mumbai.

2. Dr. Gauri Mankekar is an E.N.T. surgeon at the P.D. Hinduja Hospital and MRC, Mahim, Mumbai.

3. Names of patients have been changed.

Reference: From Astonishing to Predictable Speech by Frans J.M. Hilgers.