**3.4. Rehabilitation: educational process of learning the esophageal speech**

The rehabilitation and education process starts with an individual preoperative counseling and patient preparation for a postoperative rehabilitation. A duration of the preoperative patient preparation varies depending on the individual's needs. During this period, the patient is given education on all the consequences of tracheotomy and total laryngectomy, pulmonary and speech aids for laryngectomized persons and modalities of speech-language rehabilitation. In addition, an oncological team of experts together with the patient decides on a single rehabilitation method.

The onset of postoperative speech-language therapy depends on a number of factors, such as further oncological treatment (primarily the need for radiotherapy), general health condition, psychological condition, and neuromotor capabilities of the patient. The optimal time to start postoperative rehabilitation is considered 40 days (approximately 6 weeks after surgery) unless postoperative radiotherapy is indicated [26]. However, Remacle and Demard state that rehabilitation can be started earlier, immediately after cicatrization, usually 3 weeks after the operation [17]. If postoperative radiotherapy is indicated, rehabilitation is delayed as long as acute consequences of radiation that hamper the process of rehabilitation are present. Of course, rehabilitation should begin within 6 months of surgery [26]. The total duration of rehabilitation is different and individual.

Early postoperative rehabilitation phase lasts 1 month from the onset of therapy, and primary focus of the therapy is on relaxation techniques and respiratory - rehabilitation operators in physiological breathing onto a tracheostoma to avoid, initially always present, tracheal noise at later phonation.

At this stage, the patient is also educated on how to achieve a ructus. Achieving a ructus is taught by two basic principles in one of three available methods. The first principle is based on the correct technique of injecting speech air into the esophagus, and the other is based on the proper technique of eructation of speech air. **Figure 1** shows the scheme of esophageal voice production.

There are several different methods of introducing speech air into the esophagus used in clinical speech therapy, namely: deglutition, inhalation, injection, blocking, Portman's, Tartapan's, and their combinations [5, 17, 22].

In 1900, Gottstein created and described the deglutition/swallowing method, and Gutzmann supplemented and propagated it. The method requires inserting the required air for the alaryngeal phonation according to the principle of swallowing or air ingestion as a bolus which causes eructation. This is considered the initial method because it allows a volitional ructus, but it affects the rhythm of speech and substantially slows it down, which is its disadvantage. As air swallowing, that is, "dry swallowing" is limited, it is recommended to consume the fluid during therapy [17].

In 1922, Seeman described the inhalation method, also referred to as aspirational or suctioning method. It requires a few swift inhalations that cause a sudden drop in intraoral pressure, which allows aspiration of air from the oral cavity into pharynx, and into the esophagus and relaxation of the pharyngoesophageal segment. When the pressures get equal, the air suction is stopped, the aspirated air is eructated and sounded through the pharyngoesophageal segment. Initially, the vocals are articulated, followed by the syllables made of a combination of gutural/h/ and vocals. Sometimes, the use of the method is followed by hyperventilation. There are several modifications of this method in the world.

The injectable or occlusive method was formed by collecting the experiences of patients who noticed that the easiest way for them to loudly articulate occlusives and syllables combined from occlusives and vocals is alaryngeally. The method requires sufficient pressure of the tongue which causes air compression in the oral cavity and pharynx and is injected into the

**Figure 1.** Esophageal voice production.

voice, is reduced, the frequency range is reduced, and the acoustic parameters determining the timbre of the voice also differ significantly from the regular laryngeal voice [5, 23, 24]. Such values of acoustic parameters form a rough and breathy voice, subjectively experienced. In addition, the time for turning on the voice is prolonged and the maximum time of the phoning is significantly reduced. According to prosodic features, the melody of the esophageal voice is more uniform and variable, lexical stress is not realized or is partially realized, frequent undesirable respiratory pauses are often present and the tempo of speaking is slower [5].

Sociofunctional features of the esophageal voice, which also make the advantage of this rehabilitation modality are: both hands free during speech and being less noticeable to the environment during speech, spontaneous and natural way of alaryngeal speech without additional surgery and insertion of foreign bodies, independence of prosthetic aids, the ability to speak without high consumption of material resources. On the other hand, the features that make up its shortcomings are: long periods of rehabilitation, lack of regular and continuous attendance at rehabilitation, discontinuous speech and additional undesirable noise during speech, especially tracheal noise during inspiration, which interfere with the intelligibility of

The rehabilitation and education process starts with an individual preoperative counseling and patient preparation for a postoperative rehabilitation. A duration of the preoperative patient preparation varies depending on the individual's needs. During this period, the patient is given education on all the consequences of tracheotomy and total laryngectomy, pulmonary and speech aids for laryngectomized persons and modalities of speech-language rehabilitation. In addition, an oncological team of experts together with the patient decides on

The onset of postoperative speech-language therapy depends on a number of factors, such as further oncological treatment (primarily the need for radiotherapy), general health condition, psychological condition, and neuromotor capabilities of the patient. The optimal time to start postoperative rehabilitation is considered 40 days (approximately 6 weeks after surgery) unless postoperative radiotherapy is indicated [26]. However, Remacle and Demard state that rehabilitation can be started earlier, immediately after cicatrization, usually 3 weeks after the operation [17]. If postoperative radiotherapy is indicated, rehabilitation is delayed as long as acute consequences of radiation that hamper the process of rehabilitation are present. Of course, rehabilitation should begin within 6 months of surgery [26]. The total duration of

Early postoperative rehabilitation phase lasts 1 month from the onset of therapy, and primary focus of the therapy is on relaxation techniques and respiratory - rehabilitation operators in physiological breathing onto a tracheostoma to avoid, initially always present, tracheal noise

At this stage, the patient is also educated on how to achieve a ructus. Achieving a ructus is taught by two basic principles in one of three available methods. The first principle is based

**3.4. Rehabilitation: educational process of learning the esophageal speech**

the pronounced words [25].

72 Esophageal Cancer and Beyond

a single rehabilitation method.

rehabilitation is different and individual.

at later phonation.

esophagus, and in the articulation of the labial, alveolar and guttural occlusive the air is liberated and affects the achievement of a satisfactory tonus of the pharyngoesophageal segment. In 1966, Diedrich and Youngstrom created a variation of this method by introducing certain modifications [17].

The blocking method was accomplished by performing several procedures of injectable method followed by specific articulator's movements and by changing the head position. The method involves injecting air from the oral cavity to the esophagus by lip occlusion causing anterior blockage with simultaneous posterior repositioning of the base of the tongue and inferior mandibular repositioning.

By combining several specific procedures from the deglutition and inhalation method, a new method was created by Portman, and was named after him as Portman's method. It requires a few fast-paced air inspirations that are followed by "edacious" deglutition of the air bolus to make speech air flow into the esophagus [22].

In addition, there is Tartapan's method, which is seldom used in clinical speech therapy practice, as well as other possible combinations of existing standard methods that are not specifically described.
