- Recommended Reading
- Esophageal Speech
- Hands-Free Devices
- Text to Speech Apps
- Alternative Communications
- Speech Difficulties
- State TEDPA Programs
TEP/Prosthesis Speech Samples
Tracheoesophageal Puncture and Prosthesis:
In this case, a doctor makes a small hole in the rear of your stoma leading to the esophagus. Once this puncture heals, a prosthesis is fitted and inserted into the opening. To speak, you occlude (cover) the stoma with your thumb or finger and simply force air through the prosthesis into the esophagus. This air movement vibrates the walls of the esophagus and you can create sounds and words normally with your lips, teeth, and tongue, etc. The prosthesis has a one-way valve in it to prevent swallowed food and liquids from entering your stoma. Additionally, your stoma can be covered with a special valve, called a Hands-Free) that closes when you wish to speak, thus forcing air into the prosthesis. With this valve in place, you no longer need to occlude the stoma with your thumb/finger ... your hands are free.
(Permission to re-print provided by InHealth Technologies, Carpinteria, CA.)
Assorted TEP Prostheses
B-S Duckbill B-S
Low Pressure B-S
Indwelling Low Pressure
WHAT IS A TEP?
A TEP (tracheoesophageal puncture) is a same-day, simple, surgery, where the doctor makes a small puncture in the wall between the trachea and esophagus. This puncture will hold a prosthesis, with a valve on the esophageal end, so that lung air can again be directed through the mouth by closing off the stoma during exhalation. Closing the stoma can be done with finger, thumb or hands free valve (see illustration above). This redirected column of air will pick up vibrations as it passes through a narrowed section of the esophagus, so talking is again possible for most people.
Videos available for viewing to help your voice
When Atos sent the address of a video to check out for our website, I went to the site and watched a well done video explaining the use of an oral adapter on the electrolarynx. Then I noticed there were 60 of these videos. You can put them on autoplay or just have them in numerical order and chose the one you wish to see. They are varying lengths from 1 minute to double digits. Some are made for clinicians, instructional videos with professionals demonstrating how they solve problems. Many others, titled "Life as a Laryngectomy" simply tell who they are and a bit of their story. All are interesting and informative.
This link takes you to #1 of 60, from which you can play them straight through. This one relates to body posture to counter hypotonicity (air coming through, little sound) with the patient using a TE prosthesis:
Another sample, showing #14 of 60 is Bobby Noe, demonstating use of :
Provox® Vega™ and XtraHME™
#21 is a part of the 'Life as a Laryngectomee' series, an interview with John Aquilar:
LEARNING TO TALK
Work on getting your breathing rhythmic and practice, practice. Read out loud. Let the air flow be soft, don't blow it. Don't strain. It takes very little air to speak, so concentrate on speaking clearly and quietly. Don't worry about volume.
If you have difficulty getting air to come through, check the trouble shooting article at the bottom of this page.
TRAINING YOURSELF TO IMPROVE YOUR VOICE
When I was a boy, in the early 50s, I took voice lessons from an old maid named Elizabeth Otwell. my parents did not want me to grow up talking like a redneck sharecropper, so I went to voice lessons once a week for a couple of years. I thought it was a real waste of time. However, after my laryngectomy, and when I started with the TEP, I realized how beneficial all that training was. It is somewhat the same way with regard to the many football coaches I had from the time I was 12 until I was 21, and finally retired thanks to a bad knee. I never really understood the concept of "paying the price", and "overachieving" until I had a laryngectomy.
I have spent quite a bit of time standing in front of a mirror and talking to myself. I have done it in English, Spanish, French, some German, and a little bit of Thai. I have done it using the hands-free valve, various fingers to occlude with, and using esophageal speech. I did a limited amount of time with it on the one time I had a Cooper-Rand device, and once when I had a Servox. I did not have either one of the electronic devices long enough to get very proficient.
When I practice, I speak slowly. I try to enunciate each syllable. I use my tongue and my lips. I watch myself to see how I form the words. I try different sounds. I speak from my diaphragm, as opposed to my mouth. I work to control my breathing. I want to project my voice even when I speak softly, which is one of the things I learned I should do from Jim Shanks and Dan Kelly. The bane of the hands-free valve is to lose the seal. The length of time one can maintain a seal is directly related to the amount of back pressure placed on the seal. If you put on the valve, never talk, never sweat, and never get any mucus on the glue, then the seal should last forever. The less back pressure used in talking, the longer the seal will last.
It would be very good, for you to speak into a recorder, then play it back. Then do it again, and see if you're improving. I have watched videos of myself, and used them for what to do and to "not" do. When you speak, speak from the bottom of your stomach, project your voice, speak softly, enunciate each syllable, speak distinctly and precisely. (Philip Clemmons)
WAYS TO OCCLUDE LARGE STOMA
1. I occlude my stoma to speak (or to swim..see Keep Active) with a hand exercise ball manufactured by Theraband. The company manufactures these balls in three different colors but I recommend the yellow which is the softest and molds around the stoma. I have been using these balls to occlude the stoma for speech as I have a very large stoma and there is no way I can use a stoma adhesive and HME or a freehand valve. I have been using the Provox 2 prostheses for the last four years. Call The Hygenic Corporation for a Dealer near you. In the U.S. or Canada, call: (800) 321-2135 (Jose Cruz)
2. Use ping-pong ball (which can be washed).
3. A rubber thumb. The office supply covering that is worn on the thumb when you are sorting through files and papers. That would make the thumb larger.
4. Look at the grocery or drug store for a bottle, maybe shampoo, that has a large round top on it. I took one of those and glued it onto a dowel so I could hold it in my fist when I talk a lot. Helps when arthritis sets in the fingers.
I brought home some sample size bottles of shampoo and conditioner from a hotel. The little plastic bottle is very light and the round top is about an inch in diameter. Works great for a small stoma and, maybe, for a large one...but I have seen several in the Dollar store with a larger top. (Pat Sanders)
5. Try making a fist and using the big knuckle at the top of the forefinger.
6. Almost any of these can work quite well if you don't try to push the air out. Unless you exhale in an easy manner, the air wil often escape around whatever you are using to occlude
CLEANING A PROSTHESIS IN PLACE
1. There are little brushes, 2 or 3 to a package, found where you would buy toothbrushes and floss. The brushes are straight or tapered and are the perfect size to insert "gently" into the prosthesis to clean out any mucous that might have it stopped up. Take care and don't push the brush in far enough to hit the esophagus. I store or clean my brush in a medicine cup of peroxide. (Pat Sanders)
2. I use the Provox brush, which is expensive but well worth it. I bought a dozen for $54.00. Each will last about six months, but I like to keep one in each bathroom, both vehicles, and in my Dopp kit so that I will not forget it if I go on a trip on short notice. I keep the new curved tube irrigation bulbs in the same places. along with a pair of blunt, straight tip tweezers, the kind with finger holes in the handle. That way, I'm always prepared to clean anywhere. I also carry a flashlight that looks like a ball point pen. Big help in poorly lit bathrooms---and that's nearly all of them. (Roger Jordan)
3. I found one of the small t-handle insertion tools for a TEP prosthesis works real well for a quick cleaning. It even has a built in stop, I carry one in my wallet for those times I suddenly can’t talk. If you have one in a size that matches your prosthesis, give a try. (Bill Parks)
When to replace Indwelling prosthesis
It is not possible to be specific as to when an indwelling prosthesis should be changed. For most people, I suspect the determinant is when leakage becomes a problem. But one should always try to make certain that the leakage is not just a temporary occurrence caused by insufficient or careless brushing before taking the more drastic step of replacing the TEP.
This advice is especially important for those who are still in the early months (or years) after surgery. It is very important too to make sure you are measured from time to time for the correct size of prostheses as the puncture can (and frequently does) change over time. Even a completely new TEP will leak if it is not a proper fit. In my own case I have had very different intervals between changes - ranging from just two months (in one case) to a more satisfactory nine to twelve months which is my norm in more recent times.
The state of health of the individual, issues relating to diet and medication are other factors that come into play.
michael mac mahon
I wear the Blom-Singer patient-changeable and have the same issue with the tab. Because of the way the Blom-Singer is installed, there is a very small hole in the tab itself that is used for the installation tool. Prior to installing the prosthetic, I tie a piece of nylon thread into a loop that passes through the installation hole. When I put on a base plate, I hold the thread and tab up at the 12 o'clock position and then put on the base plate as usual. The thread is thin enough not to interfere with the seal of the base plate. The string is trapped in position between skin and base plate which holds the tab in the right position, plus the adhesive of the base plate helps secure the string and tab as well.
A little experimentation will show the proper length of string for you. I like to keep a half-inch or so sticking beyond the edge of the base plate in order to pull the tab up should it wiggle down during the course of the working day.
I do not know if the Provox prosthetic has a similar hole in the tab, so this may not work for that brand. (But I would guess a sewing needle should be able to punch a hole in the soft plastic, if needed. The hole only needs to be large enough to pass one width of the thread, so it isn't a large hole.)
Just my way of dealing with the tab - your mileage may vary :)
Huntsville, AL (work)
Evansville, IN (home)
IF THERE IS A LEAK
1. If you swallow and a drop or two leaks through the prosthesis, first you cough, than try this! Occasionally, food gets at the edge of the valve of the prosthesis and holds it open just enough that taking a drink will allow liquid to run into the trachea. This can cause spasms of coughing so you want to get it fixed as soon as possible. To check to see if this is the problem, I lean over so the water doesn't run down my trachea, use a light and mirror and sip a little water. Then I watch to see if it is dripping through the middle of the prosthesis. If it is, then a good flushing or cleaning should remove the food that has it blocked. I would clean with a brush (see hint above) and flush with the syringe/pipet. Drink some water and check it again. That should correct it, but, if you still have a leak, repeat the cleaning and flushing.
2. I had continous central leakage of my TEP which would not last more than 1-2 weeks. This frustrating problem stopped once I began to flush my TEP with very warm or hot water and not use room temperature water. I heat water and make sure it is not too hot by sipping. If I can drink it, I can use it for flushing with a bulb. The warm water is probably more effective because it flushes away mucus, debris and perhaps even fungus to keep the inner canal open. One potential advantage is that the heat may be deleterious to the viability of Candida and therefore impede its growth inside the TEP. My prosthesis will last now for a month or more rather than days. It is so simple that it is worth while for anyone to try.
(Dribrook, Washington DC)
3. If you can't stop a leak coming through the prosthesis when you eat or drink, there are now plugs to use to stop up the passage through the prosthesis on a temporary basis untill you can get to your SLP for a change.
Some laryngectomees who did not have a plug available have used a cotton swab while they eat or drink to temporarily block leakage but do not use the type where the cotton may be loose and could fall into the trachea or a cut off one, or even the short handled Q-tip. The only safe one would be the long handled one that you can hold onto.
For those who insert their own prosthesis, the original insertion tool can make a temporary stop to the drip. It is the right size and has a lip on it so you can't insert it too far into the prosthesis and it has a handle so it can't be dropped down the trachea.
LEAK - NEWLY INSTALLED PROSTHESIS
1. I have been using indwelling prostheses for just over a year now. Every one that my SLP has inserted has leaked liquid thru the middle when I do the swallow test. I live about an hour from the SLP and I just leave the TEP in and go home. By the time I get home the prosthesis has stopped leaking and I have no further problems. I am of the opinion that the process of folding the flange, inserting it in a gel cap, etc.. causes the TEP to be warped out of shape a little. It also takes some time for all of the gel cap to dissolve and disappear and also any KY jelly or other lubricant that was used during insertion.
My point is that both patients and SLPs should be patient and give the prosthesis some time to settle in. I always have the SLP leave the insertion/safety tab on my TEP just in case I would have to return and have it taken out/re-inserted. I've had 4 indwelling TEPs inserted and every one of them has had this "temporary" leakage problem. So just because it leaks when you take that first drink or two after the SLP puts it in, DOES NOT mean it is a faulty TEP. Give it some time to settle in, and see what happens.
Cheers, C. Bruce "Buck" Martin
2. I use the patient changeable prosthesis and I will often have a small leak that doesn't last long. I find sipping a hot liquid or using very warm water in a flusher to warm the prosthesis helps. It may very well be the flange that has not settled into place or it can be the flap that is not opening and closing properly. In either case, it usually adjusts.
I also make sure the flap works before insertion.
BULB TYPE IRRIGATION SYRINGE
From Wal-Mart or your local drug store, buy a bulb type irrigation syringe and an eye dropper (the kind with the black bulb on the end.) Take the little bulb off the dropper and insert syringe tip into glass tube...Voila!!!...if you press the bulb in, using a lubricant like KY jelly, it will slip on, lodge securely, and when the carrier (water) evaporates the bulb will never come out... well not without a LOT of pulling and pushing and twisting. No cutting or taping or gluing...great if you’re traveling and forgot to bring one. And, because the end of the tube is tapered, it fits perfectly into any prosthesis.
To fill: simply immerse in tepid water, squeeze the bulb, then let go. It really cleans well because it has the volume or pressure to do the job. You can vary the nozzle pressure by squeezing harder or lighter. To clean it all you have to do is simply flush the unit with hydrogen peroxide and then warm water. Total cost not much more than $3 -- even less if you steal the parts. Note: this is a little bit of YANKEE know-how. (Paul Galioni)
"SOME COMMENTS ON THE ESCALATION OF TRACHEOESOPHAGEAL VOICE PROSTHESIS DIMENSIONS"
Dr. Eric D. Blom, PhD, of Head and Neck Surgery Associates in Indianapolis, IN, had a Letter to the Editor published in Otolaryngology - Head & Neck Surgery on the above subject. The original letter from Volume 129 April 2003 is in the archives of the Journal of American Medical Association. An Adobe Acrobat (.pdf) format copy of a reprint is available for those who would care to read it in its entirety (to include its charts). Dr. Blom notes in his conclusion, based upon numerous independent clinical observations, that, "Although it is not irrefutably established that leakage around a tracheoesophageal voice prosthesis is predictably related to increased dimensional characteristics or the dilating effects of insertion, an awareness of a possible relationship seems warranted." One of the studies cited by Dr. Blom in his letter was "Downsizing of Voice Prosthesis Diameter in Patients with Laryngectomy", by Drs. Eerenstein, Grolman, & Schouwenburg, 2002. An Adobe Acrobat (.pdf) format copy of an AMA reprint of this study is also available, should you be interested in reading it.
hints from members
TWO WAYS TO CUT TUBES FOR WEARING WITH PROSTHESIS
1. I use a modified trach tube to hold the Provox HME filter. Other brands of tubes could be modified this way also. I cut it off to an inserted length of about 3/8", then cut a U at the back of the stem to clear my prosthesis. I use silicon adhesive on the front and sides of the tapered flange. I let it dry for 15 minutes before inserting in my stoma. This prevents the transfer of the adhesive to my skin. It remains tacky and sticks to the skin around my stoma, but when I remove it (to cough or whatever) it pulls away gently. I pop it back in and it stays in place. It sort of acts like Velcro.
During the day, if I get mucus on it, which can ruin the adhesion, I rinse thoroughly in hot water, dry and pop it back into place. Each night before going to bed I give it the hot water rinse, so it will stay in through the night. The next morning, hot water rinse, add another coat of silicon adhesive. After about a week the adhesive build-up gets too thick so I remove the build-up with silicon adhesive thinner, using a 2x2 gauze pad, wash with soap and water and start another weeks cycle.
I hated the adhesive patch HME holders. Unless you are using a hands-free valve the procedure, the above works great and is much less expensive. (Kent Smith)
2. I use a trach button for holding my stoma open and to make it easier to occlude (This was the Bivona-Colorado template that they started selling to use as a button. Bivona has been bought out by Portex). The button is light weight, will fold and roll for easy insertion and comes with a small hole in it. By enlarging that hole to uncover the area where my prosthesis is, I am able to have the air flow into the button and into the prosthesis when I occlude. The small ridge at the back holds it in for me. (Pat Wertz Sanders)
While I have an Indwelling TEP that is changed by the SLP, I always have a couple of the low pressure prostheses at home and carry a couple with me when traveling. I have been using the Indwelling for about 8 years, and once accidentally pulled it out with my tweezers when cleaning it. I replaced it with a low pressure that held fine until I got a new Indwelling installed the next day. I believe in being prepared. All of us should. (Roger Jordan)
Those little mustard or Jelly jars in the Hickory Farms type gifts? They make real good containers for soaking the prosthesis in and they don't leak so can be used in a travel kit. They are thick enough so it would take a lot of banging around to break one. Par Stratton
A LESSON FOR TEP USERS
I have been using TEP speech for approximately 12 years and have never had occur what happened to me today. I exchanged my prosthesis this morning for one that was ready to be reinserted and shortly thereafter mucous started coming from the stoma in copious amounts. I thought that somehow I had caught a severe cold. After putting up with this stream of mucous for about 20-30 minutes, I decided to investigate. The suddenness and the constant output puzzled me. It turned out the mucous wasn't coming from the inner stoma, but leaking out of the middle of the prosthesis. After inserting a brand new prosthesis everything magically cleared up. Lesson: A prosthesis doesn't last forever - sometimes you should change to a new prosthesis and discard the old one! (Irwin Title)
PROSTHESIS SIZING & FITTING - troubleshooting
GETTING VOICE (No Air coming through)
Here is the way we problem-solve, step by step:
Step 1. Determine whether the problem with getting voice is a problem with the prosthesis, or with the patient's anatomy & physiology. To do this, we usually remove the prosthesis from the puncture and have the pt try to voice "open tract" on a prolonged 'ahhhhhh'. Don't swallow when there is nothing in the puncture or you will get saliva leaking through the puncture into your trachea. If the voice is good, the problem is with the prosthesis and you go to Step 2. If the voice is not improved, the problem is with the pt. Skip Step 2, and Go to Step 3.
Step 2. If the problem is with the prosthesis (voice is good open tract), the puncture should be dilated a sufficient length of time, and then the puncture tract length is carefully measured (not just a guess!). The prosthesis is inserted. Wait a few minutes if a gel cap insertion is used, so the capsule will completely dissolve. If the prosthesis is the correct length and properly inserted, it should rotate freely in the tract while it is still attached to the insertion tool. And if it is correctly inserted, you should feel resistance to gently trying to pull it back out while still attached to the inserter, because the esophageal flange is fully deployed in the esophagus. In many laryngectomees, you can see the esophageal flange of the prosthesis by passing a flexible endoscope through the nose and down into the upper esophagus. If the prosthesis is seen, you know that you have the correct size and that it is fully inserted into the puncture. It can be hard to see it sometimes because of secretions, the way healing occurs after surgery, and the absence of the usual landmarks that are there before surgery. Some tricks to get a good view: the scope is advanced slightly below the prosthesis. The examiner can tell where the scope is because the light of the scope will shine through the tissue allowing you to see it on the outside of the neck. You should occlude the stoma and try to voice on a long 'ahhhh' or 'eeeee' as the examiner very slowly removes the scope, and usually the prosthesis will be seen for a brief instant. It helps to record the exam and play it back because sometimes you think that you see the prosthesis but aren't sure. If the prosthesis isn't visualized with the scope, it may still be correctly inserted, just not easily visible. If the voice is worse with the prosthesis inserted in the puncture compared to open tract voicing, the prosthesis may be the wrong length or not correctly inserted, or you may need a prosthesis that has a lower resistance to the flow of air. The different types of prostheses have different levels of resistance.
Step 3. If the problem is with the anatomy/physiology (voice isn't good even with an open tract), first check that the puncture is still completely open all the way through to the esophagus. You should be able to insert adilator/stent/catheter, lubricated with water-soluable lubricant like K-Y jelly, into the puncture. If you can't get it in, the puncture may have closed on the esophageal side --- think of the puncture like a tunnel, and the back end of the tunnel has collapsed. Verify whether it is closed by taking a small, very small sip of water and looking at the puncture with a bright light. If the water doesn't seep through the puncture, it is closed and you need a repuncture. If you see water seeping through, the puncture is still open. Go to Step 4.
Step 4. The puncture needs to be fully open to a diameter that is slightly larger in diameter than the prosthesis (eg, 22 French for a 20 French prosthesis) to have an easy insertion. Start with a dilator/stent/catheter that is slightly smaller in diameter than the puncture - it should slide easily in and out of the puncture with a lubricant. Move to successively larger diameter stents/catheters until thedilator that is slightly larger than the diameter of the prosthesis (eg, 22 French for a 20 French prosthesis) slides easily in and out of the puncture tract. That can take hours sometimes, even overnight, but don't rush it. Once it is fully dilated, check that the open tract voicing is good. If it is, the puncture tract length is measured and the correct prosthesis is inserted. If the open tract voice is still not good after you know that the puncture is fully dilated, go to Step 5.
Step 5. Check that the stoma occlusion isn't interfering with the flow of air or the vibration of the pharyngoesophagus when trying to voice open tract. (you may need to periodically replace the dilator so that you can swallow saliva, and so that the puncture stays fully dilated.) If using finger occlusion, do not exert inward pressure which might "pinch" the esophagus. Gently but completely cover the stoma with the finger. As you start to voice, the stoma usually will move forward to meet your finger. Also make sure that your finger doesn't block the prosthesis. If that doesn't solve the problem, go to Step 6.
Step 6. Make certain that you aren't tensing up when youtry to voice open tract. The jaw should drop freely when you prolong 'ahhhhh', and the shoulders should be low and relaxed. Take some slow deep breaths to make certain that all is relaxed, and then try to voice without
tightening up. If the open tract voice still isn't better, go to Step 7.
Step 7. The clinician can try to do an air insufflation test by placing a red rubber catheter a small distance into the puncture so that the fenestration is inside the esophagus. The other end of the catheter is connected to an air supply, and a very low 'flow rate' introduced into the esophgus as you try to say 'ahhhhhh' - don't need to occlude the stoma since the air isn't
coming from your lungs. If you get good sound, then the problem is either with your respiratory support or the way you are occluding the stoma. If you still don't get good voicing, go to Step 8.
Step 8. The physician can perform a "lidocaine block" which is an injection of a topical anesthetic into the neck. If the muscles of the throat have too much tone, or are going into spasm, the block will release them temporarily and free the voice. It can take a good 20-30 minutes after the injection for the voice to loosen up, and it will wear off after ~ an hour. If the voice is good during the block, it might suggest that Botox would be helpful.
When I worked with Mark Singer, MD, who developed the TEPmethod with Eric Blom, SLP, he always reminded me that the TEP method is simple, but that doesn't mean it is always easy. When a person fails to develop TE speech, it requires careful problem-solving to determine the cause of the problem, and that can be time consuming. Too often, we clincians are in a hurry and don't think it through. Instead we try this and try that, without fully understanding what might be the real issue.
I've seen too many pts where a surgeon reached for the Botox right off the bat, which didn't work, because the real problem was the way the stoma was occluded, or an improperly fit prosthesis, or the pt's excess tension. If a clinician is stumped by a pt, they can always contact some of the "master clinicians" who are willing to offer suggestions. Both InHealth and ATOS have knowledgeable SLPs on staff who can also assist with problem-solving.
Carla DeLassus Gress, ScD, CCC-SLPCharlottesville, VA .
removing the TEP and allowing puncture to heal
If it doesn't work for you?
Some people have difficulty with keeping a TEP from leaking, staying in or working the way it should (and does for most.) For some of those, the simplest way is for the doctor or SLP to be aware and help you plan for just simply removing the prosthesis, check it over ... and let the puncture close. For some, there will be further problems.
Question: I have asked for advice from those who know about this process to tell us something of what to expect. I put this question in the list for feedback.
I was just in the WW FaceBook Group and someone was asking how long it takes a puncture to heal. I never had to do that and I wonder, too. I also wonder if it takes longer for the 20fr size puncture to close than it does the 16fr?
There is more to it than that but if you have had the wrong size prosthesis and it pistons in place, I think it make a wound longer to heal... it could be like scar tissue. Please help me to get together some ideas for the Information Library.
1. A puncture healing is dependent on the overall health of the person. As we always say, "we are all different." Our medical issues, age, nutrition, etc. will cause the differences in length of time for the puncture to heal. If the puncture is in tissue which was used in reconstruction of the area, it might require a different solution. I had to have mine surgically closed; it wouldn't heal because it was skin from my forearm. Rita B.
2. This is an issue that will be different for everyone. I have known of people that have taken out the prosthesis and the puncture site closed in 8 hours. I have also known people that it never closes on it's own. A lot depends on how much radiation the patient has had and how healthy the tissue around the puncture site is. As to the size of the puncture site I would think that it may take a little longer for a 20fr site to close than a 16fr site.
3. It happens pretty quick depending on the person, your antibodies, health etc.. In just a matter of a couple days, it can heal to the point of not being usable to hold a prosthesis.
4. When the tissue was not good enough to start with, the puncture is more likely to fail... and more likely to not regain health and close if you remove the prosthesis.
Pat W S
WHISPERS ON THE WEB READING FOR TEP advice
Esophageal Voice: Regarding the Voices of Female Tracheo-esophageal Speakers
http://webwhispers.org/news/dec2005.htm Dr. Jeff Searl
In our Medicare section, scroll down to:
PROBLEMS WITH PROTHESIS REIMBURSEMENT
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