Background: Patients with complex airways such as a tracheostomy or a laryngectomy stoma have unique communication barriers. Consequently, patients may feel isolated, or clinicians may underestimate their communication and cognitive capabilities (especially immediately after the complex airway is established) (1).  Therefore, complex airways can negatively impact a patient’s ability to participate in serious illness conversations (1). This Fast Fact offers information on vocalization options and expert advice to clinicians when communicating with seriously ill patients with complex airways (1).

Relevant specialists: Speech-language pathologists (SLPs) are common in inpatient and outpatient settings and are instrumental in helping patients with complex airways communicate. Their services may not always be reimbursable for patients receiving hospice care.  They often collaborate with occupational therapists (OTs) and otolaryngologists. Clinicians must have basic awareness of complex airways to advocate for those with less routine access to these specialty services.

Voice and speech physiology: Voicing occurs when air is forced past opposing vibratory tissues (usually the vocal folds) to produce sound. Speech further requires modulating the tension of these vibratory tissues, altering the shape of the resonant cavities of the airway, and coordinating the tongue, lips, and other oral muscles (2). Patients with complex airways primarily have problems with voicing, however, depending on the patient’s condition, speech may be impaired as well. For patients with a tracheostomy, disease pathology or features of the artificial airway, such as the tube size or the presence of a balloon cuff, can block airflow to the vocal folds and impair voicing. In contrast, patients with a laryngectomy have had their vocal folds surgically removed and breathe through a permanent stoma in the neck, where the trachea has been completely separated from the mouth, throat, and esophagus. These patients each require different voice rehabilitation strategies to mimic the physiologic vibratory function of the larynx. See Fast Fact #250 and Fast Fact #281 for more information.

Voice rehabilitation: Achieving a usable voice is a major care goal for many patients with complex airways and they will be willing to engage in dedicated rehabilitative work with SLPs, OTs, and other specialists. Other patients will not want to pursue speaking as their primary means of communication and will be satisfied with other communication strategies (e.g., communication boards, nodding yes/no). Clinicians should work with patients to optimize whichever method of communication the patient prefers. 

Tracheostomies: Voicing primarily involves occluding the tracheostomy tube during exhalation so that air is forced up through the vocal folds, thus vibrating them (3). Patients must tolerate a cuffless tracheostomy or intermittent balloon deflation to accomplish voice rehabilitation successfully. Those with complete upper airway obstruction (e.g., stenosis, tumor) will not be able to rehabilitate their voice. 

• The simplest technique to assess readiness for voice rehabilitation for tracheostomy patients is finger occlusion of the tube. The clinician covers the opening of the tracheostomy tube during exhalation to assess for tolerance and voicing ability. Patients who cannot tolerate finger occlusion will appear uncomfortable and unable to voice. These patients are NOT yet safe for voice rehabilitation.
• Patients who safely tolerate finger occlusion can be trialed on a one-way speaking valve (also called a Passy-Muir valve). These devices allow inhalation through the tracheostomy tube and exhalation through the anatomic upper airway to voice.
• Patients who are almost ready for decannulation (removal of the tracheostomy tube) may be able to use a cap over the tracheostomy tube. The patient just breathes through their nose or mouth.

Laryngectomies: Patients with a laryngectomy must replicate the function of the vocal folds by vibrating the tissues in their surgically reconstructed pharynx (neo-pharynx) to produce sound. The main way to do this is via esophageal speech. Anyone can produce esophageal speech by speaking while belching. 

• The most common way for patients to produce esophageal speech is with a tracheoesophageal prosthesis (TEP), a small one-way valve placed between the back wall of the trachea and the esophagus (4). Patients inhale through their laryngectomy stoma, occlude the stoma on exhalation, and voice by forcing air into the esophagus and up through the throat and mouth.
• Some patients produce this same esophageal speech without the TEP, by trapping air in the throat and forcing it through the neo-pharynx using their swallowing muscles, not exhalation.
• For patients who cannot tolerate a TEP or learn esophageal speech, an electrolarynx is an external device that vibrates the neo-pharynx, allowing patients to speak with a robotic sounding voice.

Tips for communicating with patients who are unable to voice: Patients may use a variety of techniques to communicate including mouthing words, signing, gesturing, writing, or typing.  

• Ensure access to assistive devices including paper, markers, or reusable writing tablets. Involve OTs and SLPs to find the correct device (5).
• Follow the patient’s lead about how they want to communicate, recognizing it takes patience, compromise, and negotiation to find what works. Allow for extra time each encounter.
• Attend to the emotions one encounters. Express appreciation for their effort.
• Offer modifications to standard processes to accommodate alternative communication needs. For example, in advance of a serious illness conversation, a guide could be provided prior to the visit to allow the patient time to reflect and respond in writing.
• Avoid open ended questions if possible. Use yes/no questions instead until communication improves.
• Avoid finishing written or typed sentences for patients as this often interrupts thought and expression.
• Involve an in person or video interpreter as appropriate.

References 

1. Rose L, Sutt A-L, Amaral AC, et al. Interventions to enable communication for adult patients requiring an artificial airway with or without mechanical ventilator support. Cochrane Database of Systematic Reviews. 2021;10. doi: 10.1002/14651858.CD013379.pub2.
2. Sataloff RT, Heman-Ackah YD, Hawkshaw MJ. Clinical Anatomy and Physiology of the Voice. Otolaryngologic Clinics of North America. 2007;40(5):909-929. doi:10.1016/j.otc.2007.05.002.
3. Hess DR. Facilitating Speech in the Patient With a Tracheostomy. Respiratory Care. 2005;50(4):519-525. doi:10.4187/respcare.05500519.
4. Tang CG, Sinclair CF. Voice Restoration After Total Laryngectomy. Otolaryngologic Clinics of North America. 2015;48(4):687-702. doi:10.1016/j.otc.2015.04.013.
5. Hanson EK, Beukelman DR, Yorkston KM. Communication support through multimodal supplementation: a scoping review. Augment Altern Commun. 2013;29(4):310-321. doi:10.3109/07434618.2013.848934.

Authors’ Affiliations: Icahn School of Medicine at The Mount Sinai Hospital, New York City, NY; Memorial Sloan Kettering Cancer Center, New York City, NY.  
Conflicts of Interest: None.
Version History: First electronically published in January 2026; originally edited by Sean Marks MD.