Provoxweb

  • General Introduction
  • Voice Rehabilitation
    • 1. The Provox System>
      • Provox1 Voice Prosthesis
        • Provox2 Voice Prosthesis
          • Provox Vega & SmartInserter
            • Provox ActiValve
              • Provox Sizer
                • Provox Dilator
                  • Provox XtraFlange
                    • Provox Brush-Flush-Plug
                      • Provox HME
                        • Provox FreeHands HME
                          • Provox LaryTube
                            • Provox LaryButton
                              • Provox Surgical Set
                              • 2. Surgery>
                                • Primary Prosthetic Voice Rehabilitation>
                                  • Total laryngectomy
                                    • Surgical technique primary TEP
                                      • Primary tonicity control PE-segment
                                        • Tracheostoma construction
                                        • Secondary prosthetic voice rehabilitation>
                                          • Indications
                                            • Preoperative screening
                                              • Surgical technique secondary TEP
                                                • Alternative technique secondary TEP
                                                • Secondary treatment PE segment hypertonicity>
                                                  • Introduction
                                                    • Hypertonicity treatment with Botox
                                                      • References
                                                        • Surgical constrictor pharyngeus myotomy
                                                        • Fistula closure>
                                                          • Indications
                                                            • Surgical technique
                                                            • Stoma revision>
                                                              • Introduction
                                                                • Surgical techniques of tracheostoma reconstruction
                                                                  • Comments
                                                                    • Conclusions
                                                                      • References
                                                                      • Pharynx reconstruction and voice rehabilitation>
                                                                        • References
                                                                      • 3. Replacement>
                                                                        • Indications
                                                                          • Replacement procedures>
                                                                            • Choosing the right prosthesis length
                                                                              • Provox Vega & Smart Inserter
                                                                                • Provox2 voice prosthesis
                                                                                  • Provox1 voice prosthesis
                                                                                    • Replacement of other voice prostheses by Provox
                                                                                    • Additional remarks on prosthesis replacement
                                                                                    • 4. Troubleshooting>
                                                                                      • Introduction
                                                                                        • Device-related replacement issues>
                                                                                          • Leakage through the prosthesis
                                                                                            • Candida overgrowth
                                                                                              • Very frequent replacement due to leakage
                                                                                              • Fistula-related issues and problems>
                                                                                                • Leakage around the prosthesis and the prosthesis is too long
                                                                                                  • Insertion of a Provox voice prosthesis during TEP leading to leakage around the device
                                                                                                    • Leakage around the prosthesis even with the shortest length (4.5 mm)
                                                                                                      • Local infection, prosthesis seems to be OK
                                                                                                        • Local infection, prosthesis displaced
                                                                                                          • Prosthesis extruding from the fistula tract
                                                                                                            • Granulation tissue interfering with the prosthesis
                                                                                                              • Interfering hypertrophic tissue in the TEP area
                                                                                                                • Voicing increasingly difficult, not improved after replacement
                                                                                                                  • Anterograde insertion is difficult due to local infection
                                                                                                                    • Voice sounds strenuous and speaking requires to much effort
                                                                                                                      • There seems to be a 'separation of the party wall'
                                                                                                                        • Voicing is blocked by finger pressure on the stoma/voice prosthesis
                                                                                                                          • Elevated intra-tracheal pressure and effort for voicing
                                                                                                                            • Some bleeding during and after removal of the prosthesis
                                                                                                                              • Prosthesis has disappeared and seems to be ingested
                                                                                                                                • Prosthesis had disappeared and seems to be aspirated
                                                                                                                                  • TE fistula too wide to hold a voice prosthesis, surgery not an option
                                                                                                                                    • Stenosis of the neopharynx
                                                                                                                                      • Anterograde replacement is difficult due to a small stoma
                                                                                                                                        • Deep stoma interfering with application of peristomal devices
                                                                                                                                          • TE fistula deep down in trachea, making replacement troublesome
                                                                                                                                            • TE fistula migrated upwards outside the trachea, voicing problematic
                                                                                                                                              • During retrograde insertion the guide wire gets stuck in the neoglottis
                                                                                                                                                • How much to downsize in case of shortening of the fistula tract
                                                                                                                                                  • Is it possible to remove the prosthesis by pushing the device into the esophagus
                                                                                                                                                  • Voicing problems
                                                                                                                                                    • Algorithm for troubleshooting>
                                                                                                                                                      • Main complaint: Leakage
                                                                                                                                                        • Main complaint: Increased voicing effort
                                                                                                                                                      • 5. Speech Therapy>
                                                                                                                                                        • Introduction
                                                                                                                                                          • Preoperative counseling
                                                                                                                                                            • Outline of voice therapy
                                                                                                                                                              • Important basic principles in voice rehabilitation in prosthetic speech
                                                                                                                                                                • Some points of attention for the 'finishing touch'
                                                                                                                                                                  • General aspects of patient instruction
                                                                                                                                                                    • Problem solving
                                                                                                                                                                      • Conclusion
                                                                                                                                                                      • 6. Hands-free Speech>
                                                                                                                                                                        • Introduction
                                                                                                                                                                          • Provox FreeHands HME automatic speaking valve
                                                                                                                                                                            • Attachment of the valve>
                                                                                                                                                                              • Peristomal attachment
                                                                                                                                                                                • Intratracheal fixation
                                                                                                                                                                                • Assembling and disassembling the HME
                                                                                                                                                                                  • Choosing the membrane
                                                                                                                                                                                    • Proper adjustment of the cough-relief valve
                                                                                                                                                                                      • Using the walk and talk position
                                                                                                                                                                                        • Use of the cleaning container
                                                                                                                                                                                          • Speech therapy. What to practice to optimize hands-free speech>
                                                                                                                                                                                            • Closure of the membrane
                                                                                                                                                                                              • Breath-support/breath-voice coordination
                                                                                                                                                                                                • Phrase length, speech rate, maximum phonation time
                                                                                                                                                                                                  • Pitch, loudness, intonation
                                                                                                                                                                                                    • Shouting
                                                                                                                                                                                                      • Decrease backpressure
                                                                                                                                                                                                        • Hypertonicity/spasm of the neoglottis
                                                                                                                                                                                                          • Hypotonicity of the neoglottis
                                                                                                                                                                                                            • Confusing hands-free TE-speech with esophageal speech
                                                                                                                                                                                                            • Conclusion
                                                                                                                                                                                                              • Troubleshooting>
                                                                                                                                                                                                                • No voice sound
                                                                                                                                                                                                                  • Weak/whisper/aphonic voice
                                                                                                                                                                                                                    • Air leakage under membrane>
                                                                                                                                                                                                                      • Air escaping underneath cough-relief valve
                                                                                                                                                                                                                        • Shortness of breath
                                                                                                                                                                                                                          • Cough-relief valve opens when patient is speaking loud
                                                                                                                                                                                                                            • Seal of the adhesive does not last long
                                                                                                                                                                                                                              • Problems with intratracheal fixation
                                                                                                                                                                                                                                • Too much noise of cough-relief valve when coughing
                                                                                                                                                                                                                                • References
                                                                                                                                                                                                                              • 7. Voice Research>
                                                                                                                                                                                                                                • Introduction
                                                                                                                                                                                                                                  • Perceptual evaluations
                                                                                                                                                                                                                                    • Acoustic analyses
                                                                                                                                                                                                                                      • Maximum phonation time
                                                                                                                                                                                                                                        • Videofluoroscopy
                                                                                                                                                                                                                                          • Summary
                                                                                                                                                                                                                                            • References
                                                                                                                                                                                                                                          • Pulmonary Rehabilitation
                                                                                                                                                                                                                                            • Introduction
                                                                                                                                                                                                                                              • Heat and Moisture Exchangers (HME's)>
                                                                                                                                                                                                                                                • Treatment aspects
                                                                                                                                                                                                                                                  • Prevention aspects
                                                                                                                                                                                                                                                  • Provox HME>
                                                                                                                                                                                                                                                    • Compliance aspects
                                                                                                                                                                                                                                                      • Improvements in compliance
                                                                                                                                                                                                                                                        • Improvements in voicing
                                                                                                                                                                                                                                                          • Early post-operative pulmonary hygiene
                                                                                                                                                                                                                                                            • Breathing resistance
                                                                                                                                                                                                                                                              • Newest Provox HMEs
                                                                                                                                                                                                                                                              • Treatment with inhalation medication
                                                                                                                                                                                                                                                                • Conclusions
                                                                                                                                                                                                                                                                  • References
                                                                                                                                                                                                                                                                  • Olfaction Rehabilitation
                                                                                                                                                                                                                                                                    • Introduction
                                                                                                                                                                                                                                                                      • Clinical research on postlaryngectomy olfaction
                                                                                                                                                                                                                                                                        • Clinical research on olfaction rehabilitation
                                                                                                                                                                                                                                                                          • Considerations on postlaryngectomy olfaction rehabilitation
                                                                                                                                                                                                                                                                            • References
                                                                                                                                                                                                                                                                            • Media etc.
                                                                                                                                                                                                                                                                              • References
                                                                                                                                                                                                                                                                                • Copyright information
                                                                                                                                                                                                                                                                                  • Media-downloads>
                                                                                                                                                                                                                                                                                    • Animations
                                                                                                                                                                                                                                                                                      • Video clips
                                                                                                                                                                                                                                                                                        • Sounds
                                                                                                                                                                                                                                                                                          • PDF
                                                                                                                                                                                                                                                                                        Program for TE voice quality assessment and acoustic signal typing according to van As et al. (van As CJ, van Beinum FL, Pols LCW, Hilgers FJM. Acoustic signal typing for evaluation of voice quality in tracheoesophageal speech. J Voice 2006; 20: 355-368), an application in the phonetic analysis program PRAAT (see: www.praat.org).

                                                                                                                                                                                                                                                                                        Instructions for use; Tutorial (HTML); Tutorial (PDF); Trial voice samples

                                                                                                                                                                                                                                                                                        Acoustic analyses

                                                                                                                                                                                                                                                                                        Acoustic analyses is an instrument that is often used for objective evaluation of voice quality. The parameters used for the evaluation of voice quality often consist of fundamental frequency, perturbation and noise measures. There are numerous software programs available for acoustic analyses. Performing acoustic analyses in tracheoesophageal speech is more difficult in tracheoesophageal voice than in normal voice. The problems are caused by the irregularity of the voice. These irregularities are sometimes very severe and cause errors in the pitch-extraction (see figure 1. below). It is therefore important to check the results of pitch-extraction by means of visual inspection of the pitch markers placed by the program.
                                                                                                                                                                                                                                                                                        Picture
                                                                                                                                                                                                                                                                                        Figure 1. pitch-extraction results of a sustained /a/ of a tracheoesophageal speaker using the Computerized Speech Lab with CSL software (bottom) and the Multi Dimensional Voice Program software (top). The pitch-markers (see arrows at the right hand side) are correctly placed with MDVP and not with CSL.

                                                                                                                                                                                                                                                                                            In order to obtain a first impression of voice quality, provide information to other clinicians, and prepare for further acoustic analyses, acoustic signal typing is a useful instrument. These acoustic signal types are based on a narrow-band spectrogram displaying the harmonics in the voice signal. Van As et al. describe an acoustic signal typing system that can be used to group voice samples of tracheoesophageal speech can be categorized into four different signal types. (Van As 2001). In figure 2, these four signal types and the criteria for their use are shown, and a typical sound sample for each signal type can be played. Research shows that these signal types are related to the overall judgment of voice quality as good, as reasonable, or poor, which makes them useful as an adjunct to perceptual evaluation. Apart from these signal types, also objective acoustic measures can be calculated. The following 6 measures have shown to be relevant in relation to voice quality: fundamental frequency, standard deviation of fundamental frequency, percentage of voiced, harmonics-to-noise ratio, glottal-to-noise ratio, and band energy difference. For a detailed description of these parameters see Van As (Van As 2001).

                                                                                                                                                                                                                                                                                        Figure 2. Categorization of tracheoesophageal voice quality into 4 different signal types, based on the narrow-band spectrogram. For clarification each figure shows the entire 2 seconds at the top, followed by a 0.1 s selection from the middle of the vowel, the curve of pitch extraction, the narrow-band (100 ms) spectrogram, and the long-term average spectrum.

                                                                                                                                                                                                                                                                                        Samples of the 4 signal types also can be downloaded from the "Media etc." page,
                                                                                                                                                                                                                                                                                        and/or listened to below.

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                                                                                                                                                                                                                                                                                        Type 1. Stable and harmonic.    

                                                                                                                                                                                                                                                                                          Type 2. Stable and at least 1 harmonic.

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                                                                                                                                                                                                                                                                                        Type 3. Unstable or partly harmonic.     

                                                                                                                                                                                                                                                                                         Type 4. Barely harmonic.

                                                                                                                                                                                                                                                                                        © The Netherlands Cancer Institute - 2003-11; ISBN 90-75575-05-X