84 Chapter 4
surgeries, because of the malformations they might have difficulty articulating and receiving
sensory information. However, with therapy, this would prob ably not be a major deterrent to nor-
mal articulation. The clinician explained that the surgeries were most impor tant to the children’s
ultimate ability to speak with proper air pressure and nasality. With good surgical results and
therapy, they would likely achieve normal or near- normal speech. Also, according to the clinician,
studies show that some children with orofacial anomalies have delayed language development.
The delay is prob ably related to the surgeries, the postsurgical discomfort, and the fact that speech
communication is not as rewarding for children with these defects as it is for other children. The
clinician concluded by stating that the twins’ chances of achieving normal or near- normal com-
munication were very good.
The medical social worker concluded the meeting by discussing the financial costs of the
lengthy habilitation pro cess. Few families could pay these costs for even one child, let alone two.
The children’s hospital was funded by several grants and agencies, and most of the costs would
be covered by them and by the parents’ insurance. The medical social worker explained that she
would be a resource for the parents, helping them navigate through the complex habilitation pro-
cess that would last for many years.
As predicted during the first meeting, Kyle and Jarod underwent several surgeries to repair
their clefts. Their palatal shelves, dental pro cesses, and nasal pro cesses were surgically recon-
structed, and eventually they appeared normal except for some scarring. Their hearing was regu-
larly tested, and small tubes were placed in their ears. They received speech, voice, and language
therapy as hospital outpatients, and they took part in the special education program in elementary
school. By the time Kyle and Jarod entered middle school, they were remarkably similar to the
other boys in appearance and speech, due largely to the work of the cleft palate team.
Case Study 4-7: Total Laryngectomy in a 66- Year- Old Man With
Impeccable Esophageal Speech in Three Sessions
I know that patients with total laryngectomies have contracted laryngeal cancer and have suf-
fered terribly disfiguring surgeries. I appreciate the stress, anxiety, and pain they endure. I have
empathy and sympathy for them, but I must confess that I enjoy teaching esophageal speech. For
me, there is something rewarding about teaching a patient to shape a belch into speech. Esophageal
speech training is challenging, and when you have a patient like Alvin, the product is an amazing
communication art form.
For 30 years, Alvin Sharp worked as a janitor in a small school district. He confessed to me that
being a janitor was a very rewarding job. He got to work around young people, the hours were rea-
sonable, the pay was acceptable, and most of the time there was no one to boss him around. Alvin
knew that being a janitor was not a prestigious position, but for him, that was unimportant; there
were many rewarding jobs with little prestige. It didn’t take long for me to realize that Alvin was
very intelligent. According to a study of persons with high intelligence quotients, many of them
take jobs with low stress and great freedom but with low prestige. They prefer to avoid the stress
and anxiety of high- pressure jobs in business, education, and industry. It struck me that people like
Alvin may be smarter than we think.
Alvin came to my speech and hearing clinic at a time when I was questioning my own stress
level and rewards. My professional corporation had grown into a large business with several pro-
fessional employees and office staff, many contracts, and two downtown clinics. My days were
spent juggling schedules, reviewing Medicare forms, negotiating contracts, borrowing from indi-
vidual retirement accounts to make payrolls, and dealing with unpleasant issues. Overall, the busi-
ness was successful, but financially it seemed to be a case of “feast or famine.” There was usually
too much to do and too little time to do it. When I saw the appointment for a laryngectomy patient,