1. proper placement
2. use of slowed rate of speech
3.  "over-articulation" to assure articulatory precision
4. synchrony in manipulating on-off control
5. attention to non-verbal behavior

during course of therapy may develop other secondary or intermediate goals:

1. loudness variability
2. pitch variability
3. voiced/voiceless distinctions

• proper placement involves finding the best spot on the neck and using the right amount of coupling (pressure or contact with surface tissues)- determines the quality of the voice
• face plate must be in complete contact with surface - demonstrate on hand as pt may lack sensitivity in neck area
• other problems affecting efficient coupling include radiation-induced fibrosis which reduces the supple nature of the neck and therefor reduces the ability of tissue to transmit external source through the vocal tract
• scar tissue around incision as well as swelling in post-surgical pt. - may be compounded in pt receiving radiation therapy
• should assure that client can quickly and consistently get good quality voice
• mark "sweet spot" on the neck with marker or distance tube extends from lips into oral cavity with sticky tape
• carry out target practice with single vowels or phrases until accurate placement is achieved with 95% consistency
• for intra-oral device must also find suitable placement in the oral cavity - usually lateral region along one side of the tongue
• insert only 1-2 inches of tubing with upward or downward orientation
• problems include saliva blockage - can be remedied by using saliva tip or cut tubing at 45 degree angle
• practice speaking around the tube - don't hold it with lips, tongue or teeth
• practice with problem consonants, rate, coordination of sound with movement of mouth, improving nonverbal behaviors i.e. eye contact, not blocking the mouth with the hand etc.

Goal 2 Articulatory proficiency/precision

• consonant production of fricatives, affricates and stops are the most difficult for listeners to perceive
• initial and medial sounds easier than final sounds
• VOICED SOUNDS BETTER PERCEIVED THAN VOICELESS
• start with easier sounds and then move to more difficult
• to teach have the pt produce plosives, fricatives and affricate in isolation without the artificial larynx, then use in words with the electrolarynx on
• most difficult contrast is often in voiced-voiceless distinction
• deactivate the device and use enough intraoral pressure for plosion or frication to be perceived
• articulate voiceless obstruent slightly before activation of the "on" control
• continue activation of device while producing enough intraoral pressure to override the sound of the instrument
• compensate for the glottal fricative /h/
• encourage careful articulation of all sounds using mirror practice
• use oral-motor exercises to regain strength and precision of movement

• common problems include
• activating the "on" control before speaking
• beginning to speak before activating the "on" control
• deactivating the "on" control before finishing speaking
• continuing to activate the "on" control after finishing speaking
• must also learn to coordinate the activation of the electrolarynx with the beginning of the articulatory gesture and terminate with conclusion of speech
• SLP should demonstrate error for client and model correct behavior
• use tape recorder to provide feedback to client of attempts

• optimum is to get natural rate and appropriate pauses
• must guard against motor mouth - no pausing at all- as well as too many pauses that do not add to meaning of message
• pauses immediately before a word will help emphasize or stress that word

• understand and use natural mannerisms complementary to speaking such as
• using interjections such as "um" "hm"
• appropriate head nodding
• facial expressions
• hand gestures
• eye contact
• eliminate distracting behaviors such as
• stoma noise
• call attention to stoma noise as soon as it occurs
• can hold breath while talking
• facial grimaces, head bobbing, loss of eye contact
• excessive muscle tension

• Pitch and loudness variability
• worked on in final stages of therapy
• both can be set and varied by controls on the artificial larynx device itself
• pitch adjustments clumsy and cumbersome - however experienced speakers find ways to modify pitch without changing the controls
• make changes in coupling pressure, slight alterations in usual placement location, changing resonating cavity by extending or flexing the neck, thinking high or low to increase tenseness or laxness of oral-pharyngeal musculature