The term alaryngeal designates an anatomical state, physiological condition, or communicative modality characterized by the complete absence or surgical excision of the biological larynx. Primarily arising as an irreversible consequence of a total laryngectomy performed for advanced laryngeal malignancy or severe trauma, the alaryngeal condition fundamentally alters pulmonary aerodynamics, upper airway protection, and phonatory mechanics. Understanding the anatomical, acoustic, and psychosocial dimensions of alaryngeal communication is central to modern speech-language pathology, otolaryngology, and head and neck oncology.
Alaryngeal
1. Concise Definition
Alaryngeal (adjective) refers to an anatomical or physiological state lacking a larynx, or denoting acoustic communication produced without the vocal folds of the larynx. In clinical medicine and speech-language pathology, the term describes individuals who have undergone total surgical removal of the larynx, as well as the specialized therapeutic modalities, acoustic mechanisms, and assistive devices employed to re-establish functional verbal communication.
Beyond its strict anatomical denotation, the alaryngeal state embodies a complete disruption and reconfiguration of the aerodigestive tract. Following total laryngectomy, the trachea is permanently disassociated from the pharynx and diverted to an external stoma in the anterior neck. As a consequence, normal trans-laryngeal pulmonary airflow is extinguished, demanding alternative physiological vibratory sources—such as the pharyngoesophageal segment—or external mechanical transducers to substitute for the excised vocal folds and generate voice.
2. Etymology & Linguistic Origin
The term alaryngeal is an English neologism constructed from classical Greek roots via medical Latin derivation. It combines the ancient Greek privative prefix a- (ἀ-), meaning “without,” “lacking,” or “devoid of,” with the combining form laryng-, derived from lárynx (λάρυγξ), signifying the upper trachea, windpipe, or vocal organ. The term is finalized by the standard English adjectival suffix -eal (originating from Latin -alis via Greek -aios), denoting relationship, pertaining to, or belonging to.
The linguistic emergence of the descriptor coincided with late nineteenth-century surgical advancements in otolaryngology, specifically following Christian Albert Theodor Billroth’s pioneering execution of the first successful total laryngectomy in Vienna in 1873. As surgical survival rates improved, medical scholars and early speech correctionists required a precise taxonomic term to distinguish normal laryngeal phonation from post-surgical compensatory voice production, cementing “alaryngeal speech” within academic and clinical lexicons by the early twentieth century.
3. Pronunciation & Grammatical Form
The term is phonemically transcribed in standard American English as /ˌeɪ.ləˈrɪn.dʒi.əl/ and in standard British English as /ˌeɪ.ləˈrɪn.dʒəl/ or /ˌæ.ləˈrɪn.dʒi.əl/. Primary lexical stress falls upon the third syllable (-ryn-), while secondary stress rests on the initial alpha-privative syllable (a-).
Grammatically, alaryngeal operates predominantly as a classifying adjective modifying clinical entities, anatomical structures, and communication forms. Standard syntactic collocations include alaryngeal speech, alaryngeal voice, alaryngeal phonation, alaryngeal patient, and alaryngeal rehabilitation. Less commonly, the term is used nominalized in clinical discourse as an adjective-as-noun (e.g., “the alaryngeal population”), though person-first constructions (“individuals with alaryngeal speech” or “laryngectomees”) remain preferred in contemporary academic writing.
4. Detailed Conceptual Explanation
To grasp the alaryngeal condition conceptually, one must recognize the tripartite physiological role played by the intact biological larynx: airway protection during deglutition, thoracic fixation during physical exertion, and phonation via pulmonary air-driven vocal fold vibration. When a patient undergoes a total laryngectomy, the entire hyolaryngeal complex—including the thyroid, cricoid, and arytenoid cartilages, true and false vocal folds, and epiglottis—is resected. The superior end of the transected trachea is sutured directly to the skin of the anterior lower neck, creating a permanent tracheostoma. Simultaneously, the pharyngeal defect is closed, establishing a fully separate, continuous muscular tube extending from the oral cavity into the esophagus.
This irreversible separation has radical anatomical consequences. Because the lungs are now connected solely to the ambient atmosphere through the stoma, the individual no longer breathes through the nose or mouth. Consequently, normal pulmonary airflow can no longer pass through the vocal tract to initiate phonation or generate oral articulate pressure. The alaryngeal condition represents a profound disruption of human communicative ecology: the biological power source (pulmonary exhalation) is divorced from the acoustic sound source (the vocal folds) and the acoustic filter (the supraglottic vocal tract and articulators).
Alaryngeal rehabilitation constitutes the scientific and clinical effort to bypass this anatomical barrier. Because the supraglottic articulators—the tongue, lips, teeth, alveolar ridge, hard palate, and velum—remain anatomically intact and fully functional, the primary clinical objective is to introduce a substitute sound generator (vibratory source). The resultant acoustic signal can then be modulated by these intact articulators into recognizable phonemes, syllables, and words.
Three primary acoustic substitutes have emerged in clinical medicine: the electrolarynx (an external electromechanical vibrator), esophageal speech (compression and controlled release of swallowed or injected air through the pharyngoesophageal segment), and tracheoesophageal speech (diversion of pulmonary air through a surgically created fistula and prosthetic one-way valve into the esophagus). Each modality presents unique physiological, acoustic, aerodynamic, and neurological demands, rendering alaryngeal communication a complex multidisciplinary domain combining biomechanics, neuroscience, surgery, and behavioral therapy.
5. Historical Development
The history of the alaryngeal state is intimately tied to surgical oncology and the evolution of prosthetic engineering. In December 1873, the Austrian surgeon Theodor Billroth performed the first human total laryngectomy on a 36-year-old male suffering from laryngeal carcinoma. While the surgical extirpation was technically successful, the patient was rendered instantly aphonic. Recognizing the acute psychological burden of voicelessness, Billroth’s assistant, Carl Gussenbauer, designed the first primitive artificial larynx in 1874—a bifurcated cannula connecting the tracheal stoma to the pharynx with an integrated vibrating metal reed, marking the birth of alaryngeal voice restoration.
Throughout the late nineteenth and early twentieth centuries, surgical techniques evolved to lower mortality rates associated with pharyngocutaneous fistulae and aspiration pneumonia. During this era, spontaneous or taught esophageal speech was documented by European clinicians, notably Julius Wolff and Arthur Hartmann, who observed that some laryngectomized individuals could learn to swallow air and produce a pseudo-voice by releasing it upward through the esophagus. By the 1920s and 1930s, structured rehabilitation protocols emerged, championed by speech pathologists such as Nathaniel Levin in the United States and specialized voice therapists across Europe.
Parallel advancements occurred in electroacoustic technology. Western Electric introduced the first commercial mechanical electrolarynx in the late 1920s, followed by trans-oral and neck-type electronic vibrators such as the Aurex and Servox devices in the mid-twentieth century. These units offered rapid, non-invasive voice recovery, although their characteristic robotic timbre and mechanical pitch provoked ongoing clinical dissatisfaction.
A transformative paradigm shift occurred in 1979 and 1980 when American otolaryngologists Mark Singer and Eric Blom, along with subsequent innovations by Frans Hilgers in Europe, introduced the tracheoesophageal puncture (TEP). By creating a controlled puncture between the posterior tracheal wall and anterior esophageal wall and inserting an indwelling one-way silicone voice prosthesis, Singer and Blom enabled pulmonary air to directly drive vibrations of the pharyngoesophageal segment. The TEP revolution elevated alaryngeal voice restoration to an unprecedented level of acoustic volume, fluency, and conversational naturalness, establishing the gold-standard surgical protocol utilized worldwide today.
6. Theoretical Foundations
The understanding of alaryngeal speech production rests firmly upon the Acoustic Source-Filter Theory of Voice Production, formulated by Gunnar Fant in 1960. In normal phonation, the respiratory system serves as the energy power supply (providing subglottic pressure), the vibrating true vocal folds act as the acoustic source (generating a complex periodic sound wave rich in harmonics), and the supraglottic vocal tract acts as an acoustic filter (resonating or damping specific harmonic frequencies to yield format frequencies characteristic of distinct vowels and consonants).
In the alaryngeal paradigm, Fant’s source-filter model is radically reconfigured rather than abandoned. The alaryngeal filter remains structurally preserved (comprising the pharynx, oral cavity, and nasal cavity), but the natural sound source is entirely eliminated, and the biological power source is redirected. In esophageal speech, the air reservoir is restricted to the cervical esophagus (approximately 40 to 80 milliliters, compared to normal vital pulmonary capacities exceeding 3 to 4 liters), and the vibratory source becomes the pharyngoesophageal segment (PE segment), specifically the cricopharyngeus muscle and adjacent inferior pharyngeal constrictors.
In tracheoesophageal speech, the source-filter model is reconstructed with remarkable fidelity to natural human biology. The pulmonary system is reintegrated as the energetic power source via the tracheoesophageal shunt valve, delivering abundant pulmonary volumes and pressures to the PE segment. The PE segment vibrates under aerodynamic shear stresses, functioning as a neoglottis that produces a fundamental frequency (F0) typically between 60 and 100 Hertz—significantly lower and more variable than normal male (100–130 Hz) or female (200–230 Hz) vocal folds, yet acoustically sufficient to drive the upper vocal tract resonators.
In electrolarynx speech, the source-filter relationship operates via transcutaneous acoustic transmission. The electromechanical piston vibrates against the soft tissue of the submandibular region or lateral neck, transmitting an externally generated acoustic wave through the pharyngeal wall directly into the oral tract. The patient then shapes this mechanical fundamental frequency into phonemes exclusively through precise articulatory positioning. Consequently, motor speech theories emphasizing neuro-articulatory compensation play a critical role, as alaryngeal speakers must deliberately augment intraoral pressure, enhance articulatory contact, and adjust timing mechanisms to overcome the acoustic constraints of the surrogate source.
7. Key Components, Types & Dimensions
Alaryngeal rehabilitation encompasses three primary communicative modalities, along with distinct physiological and prosthetic components:
- Tracheoesophageal Speech (TEP): Widely regarded as the functional standard of care, this modality utilizes a surgical fistula between the trachea and esophagus. A silicone one-way prosthetic valve (e.g., Blom-Singer or Provox) prevents digestive aspiration while allowing expired air, diverted by digital occlusion or a heat-and-moisture exchanger (HME) tracheostoma valve, to vibrate the PE segment.
- Esophageal Speech: An entirely unassisted modality in which the individual learns behavioral air-insufflation techniques (air-injection or air-inhalation methods) to compress ambient oral air down into the upper esophagus and selectively release it upward to vibrate the cricopharyngeal sphincter.
- Electrolarynx (Artificial Larynx) Communication: An external, battery-powered electronic device that produces an acoustic vibration. It is categorized into:
- Neck-type devices: Pressed firmly against the skin of the neck, submandibular space, or cheek, conducting acoustic energy through soft tissue.
- Intra-oral devices: Transmitting acoustic vibrations directly into the oral cavity via a small plastic tube inserted through the corner of the lips, indicated when neck tissues are excessively fibrotic or indurated from radiation therapy.
- The Pharyngoesophageal (PE) Segment: The biological neoglottis in both TEP and esophageal speech, consisting of the cricopharyngeus muscle and inferior pharyngeal constrictor fibers, which must exhibit adequate compliance without excessive hypertonicity (spasm) or severe hypotonicity.
- Pulmonary Conditioning Infrastructure: Specialized medical equipment, including baseplates, hands-free tracheostoma valves, and heat and moisture exchangers (HMEs), designed to preserve bronchial hygiene, humidify inspired air, and facilitate speech aerodynamics.
8. Examples & Illustrative Cases
The practical realities of the alaryngeal condition can be illustrated through distinct clinical scenarios demonstrating varying rehabilitative trajectories:
Case 1: Primary Tracheoesophageal Voice Restoration. A 62-year-old male with T3N0M0 squamous cell carcinoma of the larynx undergoes total laryngectomy with primary tracheoesophageal puncture and placement of an indwelling 20-French voice prosthesis. Following surgical wound healing and clearance of the pharyngeal suture line via a barium swallow study, an outpatient speech-language pathologist initiates voice training on postoperative day 14. By digitally occluding his stoma, the patient redirects pulmonary air through the prosthesis into the esophagus, engaging the PE segment. Within three therapeutic sessions, he produces continuous phrases of 6 to 10 syllables on a single exhalation, achieving a fundamental frequency of 88 Hz and a conversational speech intelligibility score above 90% in quiet environments.
Case 2: Post-Radiation Fibrosis and Electrolarynx Adaptation. A 55-year-old female undergoes salvage total laryngectomy following failed definitive concurrent chemoradiotherapy. Postoperative tissues exhibit profound brawny edema, fibrosis, and delayed healing, precluding safe initial puncture due to high fistula risk. The clinician introduces a digital neck-type electrolarynx equipped with adjustable pitch and volume controls. Because dense radiation fibrosis in the submandibular region attenuates transcutaneous sound transmission, the clinician identifies an alternative acoustic “sweet spot” on the lateral cheek. With focused instruction on exaggerating lingual and labial articulatory movements, suppressing extraneous stoma noise, and synchronizing the power button with phrase onsets, the patient achieves functional conversational intelligibility for domestic and social interactions.
Case 3: Unassisted Esophageal Phonation. A 70-year-old rural patient undergoes total laryngectomy in an area lacking access to prosthetic maintenance specialists. Assisted by a specialized speech therapist, the patient masters the glossopharyngeal press injection method, using the tongue to pump small boluses of intraoral air past the upper esophageal sphincter. By systematically releasing this trapped air, the patient produces reliable, unassisted 3-to-4-syllable bursts. While vocal intensity is lower (approximately 55–60 dB SPL) and phrase length is restricted, the patient achieves absolute communicative independence without prosthetic failure risks or battery reliance.
9. Measurement & Assessment
Comprehensive assessment of the alaryngeal speaker requires multidimensional diagnostic protocols spanning acoustic, aerodynamic, perceptual, and health-related quality-of-life evaluations:
Acoustic Analysis: Standard computerized vocal assessment software is employed to quantify parameters such as mean fundamental frequency (F0), sound pressure level (SPL), jitter (frequency perturbation), shimmer (amplitude perturbation), and signal-to-noise ratio (harmonic-to-noise ratio). Due to the inherent irregularity and elevated aperiodicity of the vibrating PE segment, traditional autocorrelation algorithms frequently fail; clinicians therefore rely on spectral analysis, narrow-band spectrograms, and Cepstral Peak Prominence (CPP) to measure voice quality objectively.
Aerodynamic Evaluation: Specialized aerophone instruments measure trans-stomal pressure, mean airflow rates (milliliters per second), and aerodynamic airway resistance across the voice prosthesis and PE segment. Optimal tracheoesophageal voice requires an intra-tracheal phonation pressure between 25 and 45 cm H2O; pressures exceeding this range indicate hypertonicity or stricture of the PE segment, whereas significantly lower pressures suggest poor stomal seal or valve incompetence.
Perceptual and Intelligibility Scales: Standardized diagnostic reading passages (e.g., the “Rainbow Passage” or “Grandfather Passage”) are administered to evaluate conversational words-per-minute (WPM), speech intelligibility percentages in quiet versus noisy environments, and communicative strain. Visual analog scales and the GRBAS/CAPE-V auditory-perceptual frameworks are adapted specifically for the alaryngeal voice profile.
Patient-Reported Outcome Measures (PROMs): Because objective acoustic performance does not always correlate linearly with personal communicative satisfaction, clinicians utilize validated instruments such as the Voice Handicap Index (VHI), the Voice-Related Quality of Life (V-RQOL), and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire – Head and Neck Module (EORTC QLQ-H&N35) to quantify psychosocial impact.
10. Applications & Practical Significance
The alaryngeal concept is profoundly significant across surgical, rehabilitative, educational, and public health domains. In surgical oncology, modern oncologic decision-making involves calculating whether organ-preservation protocols (chemoradiation) or definitive surgical resection (laryngectomy) will deliver superior survival alongside functional alaryngeal survivorship. The widespread availability of successful alaryngeal rehabilitative techniques empowers oncologists to recommend life-saving surgical intervention without resigning the patient to permanent aphonia.
In speech-language pathology, alaryngeal rehabilitation represents one of the most advanced technical clinical specialties. Therapists must master surgical anatomy, manage prosthetic complications (such as trans-prosthetic and peri-prosthetic leakage caused by Candida albicans biofilm degradation), and coordinate aerodynamic fitting protocols. Furthermore, clinicians oversee total airway pulmonary rehabilitation, teaching patients stoma care, mucus clearance techniques, and the optimal use of pulmonary filtration devices to compensate for the lost humidification capacity of the upper nasal airways.
In emergency medicine and public health, the alaryngeal state demands immediate clinical recognition. Individuals who are total neck-breathers will asphyxiate if oxygen masks are placed over their nose and mouth during cardiopulmonary resuscitation; emergency protocols strictly mandate direct ventilation via the cervical stoma. Medic-alert bracelets, emergency stoma resuscitation masks, and specialized community education initiatives are vital safeguards for the alaryngeal population.
11. Research & Empirical Evidence
Decades of empirical literature have delineated the comparative efficacy, aerodynamic profiles, and psychosocial outcomes of alaryngeal voice restoration modalities. Foundational investigations by Blom, Singer, and Hilgers demonstrated that tracheoesophageal speech achieves functional communication outcomes far superior to traditional esophageal speech, with TEP success rates consistently reported between 75% and 90% in compliant patient cohorts, whereas successful esophageal speech mastery rarely exceeds 20% to 30%.
Comparative acoustic investigations conducted by researchers such as Bressmann, Robbins, and colleagues have shown that TEP speech closely mimics normal laryngeal aerodynamics in terms of maximum phonation duration (MPD) and conversational fluency. Whereas esophageal speakers achieve an average MPD of only 2 to 4 seconds due to minimal esophageal air storage, TEP speakers regularly achieve MPDs ranging from 8 to 15 seconds, supported by sustained pulmonary lung volumes. Furthermore, studies by Eadie and Doyle highlighted that while listener evaluations consistently judge all alaryngeal modalities as displaying abnormal vocal roughness and diminished pitch range, TEP voice is rated significantly higher in communicative intelligibility, pleasantness, and acceptability than electrolaryngeal or esophageal speech.
Recent empirical inquiries focus on biofilm degradation of silicone voice prostheses. Research spearheaded by Busscher, van der Mei, and Hilgers established that oral flora, particularly Candida species and Streptococcus bacteria, colonize the prosthetic silicone flapper valve within an average operational lifespan of 3 to 6 months, causing micro-leakage and necessitating valve replacement. Contemporary clinical research investigates silver-oxide coatings, fluoroplastic compounds, and micro-engineered materials designed to mitigate fungal bio-fouling and extend prosthesis longevity.
12. Cultural & Cross-Cultural Considerations
The experience of living as an alaryngeal speaker is profoundly shaped by linguistic, geographical, cultural, and socio-economic variables. Linguistically, the impact of alaryngeal speech varies depending on whether an individual speaks a non-tonal language (such as English, Spanish, or French) or a tonal language (such as Mandarin Chinese, Cantonese, Thai, or Vietnamese). In tonal languages, where variations in lexical pitch determine word meaning, alaryngeal speech presents steep functional hurdles. Conventional electrolarynxes and rudimentary TEP voices possess restricted dynamic pitch variation, often stripping words of lexical pitch contours and severely depressing speech intelligibility. Consequently, researchers in Asia have pioneered pitch-controllable electrolarynxes (using pressure-sensitive switches or optical tracking) to facilitate accurate tonal inflections.
Geographically and socio-economically, access to post-laryngectomy technology varies globally. While high-income countries feature universal access to TEP prostheses, routine outpatient valve replacements, and high-performance HME systems, low- and middle-income regions face prohibitive prosthetic costs and a scarcity of specialized speech-language pathologists. In these resource-constrained settings, esophageal speech and durable, mechanically robust electrolarynxes remain essential rehabilitative lifelines.
Culturally, the cosmetic and acoustic visibility of the alaryngeal condition carries significant stigma. The presence of an open anterior cervical stoma, the sound of wet stomal secretions, and the deep, rough, or mechanical vocal quality of alaryngeal speech can trigger profound social anxiety, isolation, and withdrawal. In collectivist cultures or regions where open neck stomas are viewed with apprehension, concealable stoma covers, hands-free speech valves, and community-based support clubs (such as the International Association of Laryngectomees) provide vital psychosocial buffers against social disenfranchisement.
13. Criticisms, Debates & Limitations
The alaryngeal rehabilitative landscape is marked by contentious clinical debates and procedural trade-offs:
Primary versus Secondary TEP Placement: A major surgical debate centers on whether tracheoesophageal puncture should be executed simultaneously with total laryngectomy (primary) or weeks to months later following full tissue cicatrization and oncologic radiotherapy (secondary). Advocates of primary puncture cite immediate vocal access and evasion of a second surgical procedure; opponents emphasize heightened rates of intraoperative complications, tissue tear, and persistent pharyngocutaneous fistulae, particularly in heavily pre-radiated tissue fields.
The Organ Preservation Paradox: The widespread adoption of chemoradiation organ-preservation protocols (e.g., following the historic VA Laryngeal Cancer Study Group trial) was intended to save the larynx and avoid the alaryngeal state. However, long-term survivorship data reveal a complex dilemma: many patients whose biological larynx is anatomically preserved suffer from intractable dysphagia, laryngeal necrosis, severe radiation-induced aspiration, and an aphonic, non-functional voice—often culminating in a “dysfunctional larynx” that yields a quality of life worse than that of an adjusted alaryngeal patient functioning successfully with a TEP.
Electrolarynx Stigmatization vs. Accessibility: Despite being non-invasive, instantly deployable, and computationally reliable, the electrolarynx remains deeply stigmatized due to its overt robotic acoustic signature. Patients frequently resist its long-term use, preferring to remain mute until mastering alternative methods, while speech clinicians debate whether immediate reliance on an electrolarynx undermines a patient’s motivation to learn more challenging esophageal or TEP modalities.
14. Related Terms & Distinctions
- Total Laryngectomy: The surgical extirpation of the entire cartilaginous and muscular laryngeal complex; it is the operative etiology that results in an alaryngeal state.
- Partial Laryngectomy: Surgical resection of a sub-portion of the larynx (e.g., hemilaryngectomy, supraglottic laryngectomy) wherein residual vocal fold tissue is preserved; this results in a dysphonic laryngeal voice, not an alaryngeal state.
- Aphonia: The total loss or absence of vocal sound, which can be functional, psychogenic, neurological, or surgical; an alaryngeal individual is aphonic until trained in an alaryngeal speech modality.
- Dysphonia: Any impairment of voice production characterized by altered pitch, loudness, or quality stemming from diseased or structurally impaired vocal folds within an anatomically intact larynx.
- Tracheostomy: A surgical incision into the anterior trachea to secure a patent airway, leaving the biological larynx anatomically intact above it; distinctly different from a laryngectomy stoma, which is permanent and anatomically isolates the upper vocal tract entirely.
- Pharyngoesophageal (PE) Segment: The specific neuromuscular vibratory band composed of the cricopharyngeus and pharyngeal constrictors that replaces the vocal folds as the sound generator during alaryngeal esophageal and TEP speech.
15. Summary & Key Takeaways
The term alaryngeal encapsulates the anatomical absence of the biological larynx and defines the physiological, biomechanical, and behavioral methods developed to restore functional communication. Brought on most commonly by total laryngectomy for head and neck malignancies, the condition completely decouples the pulmonary tract from the upper oral resonators. Through the framework of Fant’s source-filter theory, clinical medicine overcomes this disruption via three primary sound-generating pathways: external electronic vibration (electrolarynx), biological air injection (esophageal speech), and pulmonary-driven prosthetic diversion (tracheoesophageal puncture).
While tracheoesophageal speech represents the modern clinical standard for acoustic fluency and volume, each rehabilitative path presents distinctive engineering, aerodynamic, and psychosocial considerations. Achieving long-term alaryngeal communicative autonomy demands vigilant multi-professional care, rigorous pulmonary conditioning with heat-and-moisture exchangers, proactive prosthesis management, and dedicated auditory-verbal speech therapy designed to restore human connection and agency.
References
- Blom, E. D., & Singer, M. I. (1979). An approach to voice restoration following total laryngectomy. Annals of Otology, Rhinology & Laryngology, 88(4), 533–537.
- Fant, G. (1960). Acoustic Theory of Speech Production. Mouton & Co.
- Hilgers, F. J., & Schouwenburg, P. F. (1990). A new low-resistance, self-retaining prosthesis (Provox) for voice rehabilitation after total laryngectomy. The Laryngoscope, 100(11), 1202–1207.
- Robbins, J., Fisher, H. B., Blom, E. D., & Singer, M. I. (1984). A comparative acoustic study of normal, esophageal, and tracheoesophageal speech production. Journal of Speech and Hearing Disorders, 49(2), 202–210.
- van As-Brooks, C. J., & de Maddalena, H. (2014). Voice rehabilitation after total laryngectomy: State-of-the-art and future perspectives. GMS Current Topics in Otorhinolaryngology, Head and Neck Surgery, 13, Doc05.