Combined Vocal Exercises for Rehabilitation After Supracricoid Laryngectomy: Evaluation of Different Execution Times *Hevely Saray Lima Silveira, *Marcia Simões-Zenari, †Marco Aurélio Kulcsar, †Claudio Roberto Cernea, and *Kátia Nemr, *†São Paulo, Brazil Summary: Introduction. The supracricoid partial laryngectomy allows the preservation of laryngeal functions with good local cancer control. Objective. To assess laryngeal configuration and voice analysis data following the performance of a combination of two vocal exercises: the prolonged /b/vocal exercise combined with the vowel /e/ using chest and arm pushing with different durations among individuals who have undergone supracricoid laryngectomy. Methods. Eleven patients undergoing partial laryngectomy supracricoid with cricohyoidoepiglottopexy (CHEP) were evaluated using voice recording. Four judges performed separately a perceptive-vocal analysis of hearing voices, with random samples. For the analysis of intrajudge reliability, repetitions of 70% of the voices were done. Intraclass cor- relation coefficient was used to analyze the reliability of the judges. For an analysis of each judge to the comparison between zero time (time point 0), after the first series of exercises (time point 1), after the second series (time point 2), after the third series (time point 3), after the fourth series (time point 4), and after the fifth and final series (time point 5), the Friedman test was used with a significance level of 5%. The data relative to the configuration of the larynx were subjected to a descriptive analysis. Results. In the evaluation, were considered the judge results 1 which have greater reliability. There was an improve- ment in the general level of vocal, roughness, and breathiness deviations from time point 4 [T4]. Conclusion. The prolonged /b/vocal exercise, combined with the vowel /e/ using chest- and arm-pushing exercises, was associated with an improvement in the overall grade of vocal deviation, roughness, and breathiness starting at minute 4 among patients who had undergone supracricoid laryngectomy with CHEP reconstruction. Key Words: Laryngectomy–Voice–Voice disorders–Speech therapy–Vocal quality. INTRODUCTION According to American statistics, in 2017, laryngeal cancer will account for 0.8% of all cases of cancers diagnosed in the United States. This type of cancer affects men more than women (5.4 to 1.1), predominantly starting in the fifth decade of life. 1,2 The Brazilian National Cancer Institute reports similar statistics, clas- sifying laryngeal cancer in 2% of all malignancies. 3 One option for laryngeal cancer treatment is surgery consist- ing of total or partial resection. To avoid total laryngectomy and the resulting need for permanent tracheostomy and irreversible loss of the laryngeal voice, Majer and Rieder 4 developed the supracricoid partial laryngectomy technique, a subtotal laryn- gectomy that preserves the cricoid cartilage and hyoid bone. With improvements in the technique for the treatment of transglottic tumors—which are characterized by the involve- ment of the glottis with little extension to the subglottis—nearly the entire larynx is removed, while the hyoid bone, cricoid car- tilage, and at least one of the arytenoids are preserved, allowing the reconstruction of the organ. The choice to reconstruct via cricohyoidoepiglottopexy (CHEP) or cricohyoidoplexy (CHP) depends on whether the epiglottic cartilage is preserved or removed, respectively. 4–6 Despite improvements in the technique, individuals who undergo supracricoid laryngectomy exhibit deglutition and voice abnormalities. Speech therapy can address deglutition prob- lems by adapting food consistencies, thus allowing for the recovery of an exclusively oral diet. 7,8 However, while dyspha- gia improves with speech therapy, patients usually experience ongoing moderate to severe dysphonia. 6,7,9–11 Due to the aperiodic vibration of the remaining structures and incomplete glottic closure, the voice may exhibit roughness, breathiness, and reduced intensity. 12 A study that employed the grade, roughness, breathiness, asthenia, strain scale found ab- normalities in all parameters, with a predominance of grade 2 roughness and breathiness and grade 3 overall vocal deviation. 10 Another study found moderate to severe abnormities for overall vocal deviation and roughness. 11 Tension may increase due to the difficult vibration of the remaining laryngeal tissues, which increases phonatory effort and accounts for laryngopharyngeal resonance and acute pitch. 7,13 The prolonged /b/ is among the vocal exercises that may be indicated in such cases. According to Laukkanen 14 and Laukkanen et al, 15 in 1964, Kaarlo Marjanen, a respected Finnish teacher of oral interpretation, regarded the prolonged production of voiced bilabial fricative /b/ as an especially effective vocal exercise. The literature describes this exercise as part of the phona- tory competence method, which is usually used in voice therapy to address muscle tension dysphonia and dysphonia with laryn- geal and glottal gap elevation. This exercise changes the vertical Accepted for publication September 12, 2017. From the *Faculdade de Medicina—Universidade de São Paulo, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, São Paulo, SP, Brazil; and the †Faculdade de Medicina—Universidade de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil. Address correspondence and reprint requests to Kátia Nemr, University of São Paulo, Rua Cipotânea, 51, São Paulo, SP, Brazil, CEP 05360-160. E-mail: knemr@usp.br Journal ofVoice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2017.09.009 ARTICLE IN PRESS