INTRODUCTION

Since the first total laryngectomy, performed by Billroth1, in 1873, many techniques of rehabilitation have been developed aiming at suppressing the main sequel left behind by the surgical removal of the larynx - the irreversible loss of laryngeal voice. The importance of the voice in the life and the relationships of subjects2, 3, 4 and the sequel left behind by the total removal of the larynx justify the efforts to make vocal rehabilitation feasible.

Electrolarynx 5, tracheoesophageal fistulas6-9, tracheoesophageal prosthesis10-15, and esophageal voice16-19, are alternatives for rehabilitation in such cases. Considering the impossibility to have tracheoesophageal prostheses, esophageal voice seems to be the best alternative since it is a natural adaptation of the body to sound production. However, one of the most limiting aspects of the development of this voice is learning it, in addition to needing a long time, which are not guarantees of final success2, 3, 16-21.

Some factors for the absence of frequent satisfactory results are synthesized in the answers to the question posed by Mahieu16: “Why do some patients fail in developing esophageal voice whereas others seem to produce it with little effort? Obviously, some do not wan to learn, but others are not capable of learning, despite their motivation and intelligence, among other factors...”. It seems to be an intriguing question faced by most therapists when analyzing their patients that develop or not esophageal voice.

However, what is the basis for this lack of skills?

In 1992, we studied the determining factors for vocal rehabilitation of laryngectomees assessing 64 patients concerning the statistical significance of 21 variables (personal data, lesion and treatment) and acquisition of esophageal voice. We observed a positive correlation between level of education, pre-surgical speech therapy (with prognostic value in the rehabilitation) and inverted correlation with presence of metastases, recurrence or second lesion (Nemr17).

Another possibility to explain the lack of skill could be the inability to develop or improve the cognition related to the perception of laryngeal loss and the process of vocal rehabilitation. The knowledge and the understanding of factors related to laryngeal surgery and esophageal voice recovery could enable the assimilation of a new corporal image providing conditions for “making” the action, that is, to produce the esophageal sound and later to understand the mechanism, abstracting and making the new voice automatic, based on the difference between make and understand22. Thus, the patient would be capable of using the esophageal voice in any communication situation.

The attempt to make this learning feasible and the definition of objectivity in the prognostic criteria of rehabilitation of these patients lead to the study of an aspect not described in the literature - the cognitive conditions of laryngectomized patients, consolidated on the Piaget’s Model of Knowledge, the Genetic Epistemology22, 23.

OBJECTIVE

The purpose of the present study was to develop a new approach of speech therapy for the development of esophageal voice based on the Genetic Epistemology by Jean Piaget, transforming in a therapeutic success a group of patients considered absolute failures, that is, those who had not produced esophageal emissions after at least 10 speech and voice therapy sessions.

According to the hypothesis created for the present study, if the patient develops the pre and post-surgery understanding of vocal production and breathing, based on dynamic images, we will stimulate the cognition (be it to develop or improve it), enhancing the chances of developing esophageal voice. If these patients develop esophageal voice, we will be able to demonstrate a new therapeutic approach, facilitating the learning.

MATERIAL AND METHOD

Material: We formed a group of six patients who had been seen by the Service of Speech and Voice Therapy and the Department of Head and Neck Surgery and Otorhinolaryngology at Hospital Heliópolis, since 1987, after total laryngectomy or pharyngolaryngectomy and who were classified as therapeutic failures. The group consisted of a number of patients corresponding to the mean number of patients frequently seen at the speech therapy sessions in group at the institution.

Inclusion Criteria: patients had been seen in the first speech therapy session at Hospital Heliópolis, in group and with the same therapist (the speech therapist author of the present study); they should have been through at least 10 speech therapy sessions; no esophageal sound should have been uttered. We accepted cases of total laryngectomy and pharyngolaryngectomy, regardless of age, gender, education, profession, date and type of surgery, reconstruction, neck dissection and radiotherapy.

Many patients were contacted and the group consisted of the six first patients who responded and met the inclusion criteria, having accepted to participate in the study.

Table 1 shows the identification data (gender, age, education and profession), surgery and radiotherapy (type of surgery and year), and speech therapy follow-up of patients selected to the study.
All patients had been smokers up to the surgery, ranging from 1 to 4 packets of cigarettes smoked a day. Except for P6, the other patients had been alcohol users in varied doses of distilled and/or fermented drinks before surgery. All patients ate well, had no swallowing complaints regardless of consistencies and no other abnormalities of the upper digestive tract (such as pain, reflux, or others). Complementary assessment showed normal endoscopy and neurological tests.

Method: The patients were submitted to a protocol of therapy during one year with weekly sessions, seen by the same therapist, under the same conditions and using the stimulation of the same techniques of esophageal air introduction: method of air swallowing24, and air injection (or Dutch method)25 with two variations: air injection by glosso-pharyngeal pressure and consonantal emission (or plosive phonemes).

The therapeutic proposal of this protocol aimed at stimulating the understanding of the relations of meanings of the vocal process before the surgery and after it, through images with visual aids such as dynamic figures and slides, for the patients to assimilate and incorporate in their body the new significance of the vocal mechanics. The theoretical assumption for the study was based on the conceptual differentiation that Piaget makes of make and understand22: based on assimilation of the new corporal image (anatomical), the patient would develop conditions to “make” the action (that is, the esophageal voice), and later, to understand the esophageal voice mechanism, abstracting and having an automatic new voice (that is, to use the esophageal voice fluently).

During the weekly sessions in group (mean duration of one hour), we presented images through drawings and figures that showed normal breathing, feeding and phonation. Next, we presented figures of the laryngeal location, the tumor, the removal of the larynx, the anatomical-physiological changes caused by the surgery and the mechanisms of feeding with and without nasogastric tubes after the surgery. We also presented the schemes concerning breathing and esophageal voice production with the techniques of esophageal air introduction, already described.

Sessions were divided into 3 parts: figures were shown at the beginning of the sessions and repeated, according to the interest and the need of the group. In the second part, we conducted the training of esophageal voice with stimulation of the three techniques and/or the one that the patient felt more comfortable with. The last part was reserved for questions about the technique or any other topic that interested the group (such as smoking and alcohol use) and considerations about learning the voice (difficulties and facilities of each one). All participants were encouraged to keep on practicing the exercises at home.

Data were recorded at the end of each session concerning performance of each patient: if they had understood the images shown, which were their questions, if they have asked for repetition, if they had produced esophageal sounds or fluent esophageal voice (gradually, the evolution of one syllable words, two and three-syllable words; short sentences and long sentences with non-systematic and systematic fluency) and the most relevant observations presented by patients concerning the issues related to communication and cognition.

Illiterate patients, during the periods in which they had no voice, were understood by the therapist by lip reading and signs, always reinforced by the need to have good articulation to facilitate message understanding. The message was always repeated verbally by the therapist to ensure the correct understanding.

The research project and Free Informed Consent Term had been approved by the Research Ethics Committee of the Hospital Complex Heliópolis.

RESULTS

We conducted 45 sessions in one year.

All patients managed to produce some esophageal sound up to the 9th session.

The three literate patients (P1, P3 and P5) managed to have fluent esophageal voice before they had completed six months of therapy, managing to understand the process and realize the causal relations within the voice production system.

Two illiterate patients (P2 and P4) took one year to define the causal relations necessary to learn it. The cognitive learning was slow and gradual; as of the 30th session, they managed to produce sound by the three methods and at the end of the protocol, they had managed to produce sentences with non-systematic fluency.

The third illiterate patient (P6) did not develop esophageal voice. At the end of the protocol, he remained with non-systematic utterances of esophageal sounds by air injection method (using the plosive phoneme /p/). During the 45 sessions, P6 did not manage to establish the necessary causal inferences, keeping the significance of the automatic pattern of laryngeal voice production and showing cognitive inability to establish a new significance of the vocal production mechanism and assimilate a new corporal image.





DISCUSSION

The fact that all patients managed to produce esophageal sounds up to the 9th session confirms the standardization of 10 sessions on average to produce esophageal sounds, as described by the authors before17. However, sound production proved to be necessary but not enough to develop fluent voice.

The three literate patients that reached fluency before 6 months of therapy managed to understand the process and realize the causal relations within the vocal production system. By the 9th session, these patients had managed to understand and make the new mechanism of vocal production, as advocated by Piaget22. The correlation between esophageal voice and level of education had already been highlighted, and it has been considered one of the determining factors for statistically significant differences in rehabilitation of the laryngectomized voice (Nemr17). Since literacy is only possible based on visual representation of the word, implying that the subject has been through the endogenous and exogenous development stages, literate patients proved to have covered this cognitive path.

The first therapeutic approach which was based on verbal stimulation and used of static images, with presentation of basic anatomical aspects before and after the surgery, did not provide enough information for the successful development of esophageal voice and the patients did not manage to produce it and were classified as therapeutic failures.

In the present study, the use of dynamic images provided to five patients the conditions to develop cognition, understanding the anatomical conditions modified by the surgery and the mechanisms for feeding, breathing, speaking and producing voice before and after the laryngeal removal. This approach proved to be efficient and essential for patients to acquire awareness, pre-requisite for the understanding of the new vocal mechanism.

We should point out, however, the difference observed between literate and illiterate patients. The three literate patients took a shorter period of time (less than 6 months) to understand and perform the procedures proposed when compared to the illiterate subjects, which took almost one year to define the causal relations necessary to learn.

The performance of exercises at home, always practiced by the patients who improved the best (P1, P3 and P5), was essential because the repetition of the action helps its understanding and enables repetition of the action in the form of thoughts (understanding and action abstraction). Conversely, two of the patients that had difficulties (P2 and P4) reported that they rarely repeated anything at home.

Parallel to the issue of doing exercises at home, we can also mention that illiterates needed repetition of information at the sessions. The two illiterate patients requested the instructions and the dynamic pictures to be repeated more than once, normally in the same session. The need for repetition of information, which had been clearly seen by the patients, seems to reinforce Bertelli’s quote19: “To learn how to talk through the esophagus is a habit, a conditioning”.

Another important aspect was how slow some illiterate patients were to assimilate and accommodate new knowledge. They adapted the new knowledge gradually with the mean time of 8 session for each new advance. This slow but gradual improve is justified by Piaget22 in the process of awareness and in the effects resulting from conceptualization of action.

The difficulties presented by the illiterate patients could be explained, based on the Genetic Epistemology by Jean Piaget, by the impoverishment of endogenous cognitive development. The subjects that do not carry on with real representations beyond spoken language and are not stimulated to the written representation of words, do not have their signification systems enriched. The same patients, at the end of the protocol, presented sentence emissions with non-systematic fluency.

This difficulty to incorporate a new corporal image significance after surgery and to become aware of the new vocal mechanism, assimilating and accommodating it, can be similarly compared to the reeducation of a child in which the work should be initially started by concrete actions, based on objects, toys, etc., and then followed by images. Abstraction, verbal and written conceptualization are later steps that require more preparation and cognitive development. Similarly, we can state that laryngectomized patients need to be stimulated by images (reinforcing the concrete, palpable aspect) so that possibilities are opened for a new corporal image significance.

The third illiterate patient (P6) did not manage to establish the necessary causal inferences and kept the same significance of automatic pattern of laryngeal voice production, showing cognitive inability to establish a new significance of the vocal production mechanism. The patient was confused at the end of the protocol (he was the only patient who had an accompanying person, because it seemed that he did not know how to take the bus alone). In addition, his background could partially explain his inability - he had never worked, did not get married and never studied. It was observed that even though the patient had had appropriate conditions for endogenous aspects, the exogenous aspect was limited and did not allow enough development of mental structures23. Throughout the protocol, the patient did not behave like the other two illiterate patients, who had a slow but gradual progression; he rather had a clear limitation in understanding the situations of the dynamic figures used during learning. He continued, at the end, to produce esophageal sounds only by one method (air injection by plosive phonemes). It is worth mentioning that the patient had the best organic conditions provided - a simple total laryngectomy without radiotherapy. Referring back to Mahieu’s 16 quotation, it seems that this patient, despite the motivation and the wish to develop the voice, was not capable, since he lacked cognition to understand the process. He managed to conduct the action, but did not incorporate the action into an acquired and automated knowledge. The necessary causal inference did not establish and the patient remained one causal level before, and he stated in the last session: “If people speak with no hole on their necks and I have a hole, then I can not speak.”

We should bear in mind an important issue: the study of cognitive conditions of subjects can explain most therapeutic failures, without excluding the participation of physiological and anatomical, psychological and social aspects. We should consider that problems related to physiological and anatomical aspects, when present, can clearly explain the therapeutic failure or even prevent any rehabilitation of esophageal voice from succeeding, such as the presence of esophageal sphincter or pharyngoesophageal segment abnormalities, which prevents the introduction of air through the esophagus or the return of voice. Conversely, psychological, emotional and/or social abnormalities can contribute to hinder rehabilitation, but do not explain the phenomenon, they only interpret the situation the patient has.

New studies should be performed for this cognitive issue to be better analyzed, enabling the definition of the prognosis of vocal rehabilitation before the surgery and supporting the team and the patient about the best options. To respect the bioethical principles, trying to find new ways that guarantee the benefits, no harm, autonomy and justice, is the full purpose of vocal rehabilitation of the laryngectomized patients.

CONCLUSIONS

Based on the results obtained by the present study, we concluded that:

1. Therapeutic approach based on images, providing the establishment of a new corporal signification for total laryngectomized patients was efficient for five out of six studied patients;
2. All subjects managed to produce esophageal sounds up to the 9th session;
3. The production of esophageal sounds proved to be necessary but not sufficient for the development of fluent esophageal voice;
4. Literacy proved to be of great importance in the vocal rehabilitation of laryngectomized patients.

ACKNOWLEDGMENTS

We would like to thank professors Abrão Rapoport, Ph.D., Josias de Andrade Sobrinho, Ph.D. and Odilon Vitor Porto Denardin, Ph.D., for their support in the conduction of the present study.

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1 Speech and Voice Pathologist, Ph.D. in Social Psychology, University of São Paulo, Professor of the
Post-Graduation course on Head and Neck Surgery, Hospital Heliópolis – HOSPHEL.
2 Full Professor, Institute of Psychology, University of São Paulo.
Service of Speech and Voice Therapy, Department of Head and Neck Surgery and Otorhinolaryngology, Hospital Heliópolis – HOSPHEL – São Paulo – SP – Brazil.
Address correspondence to: Katia Nemr Rua Cincinato Braga, 463 ap. 82 São Paulo SP – 01333-011
Tel. 55 11 9996.7233 – E-mail: knemr@uol.com.br
Article submitted on March 12, 2002. Article accepted on September 10, 2002