title: Effectiveness of voice rehabilitation on vocalisation in postlaryngectomy patients: a systematic review.
abstract: BACKGROUND
  Laryngeal cancer is one of the most common malignant neoplasia of the head and neck. Its incidence has been increasing steadily all over the world. Many patients will undergo total laryngectomy with or without radical neck dissection after being diagnosed. After this surgery, normal speech is lost, and a permanent stoma in the middle of the neck is left. Therefore, voice rehabilitation is one of the most difficult challenges that these patients must overcome. In order to support the patients, otolaryngologists, nursing specialists and speech pathologists have explored several different methods for voice rehabilitation. Variations exist on the approaches of rehabilitation and indicators selected to measure the effectiveness. There is a need to undertake a systematic review to provide a plan of care and ascertain the effectiveness regarding different voice rehabilitation programs for postlaryngectomy patients. REVIEW OBJECTIVE: To critically analyse the literature and present the best available evidence related to the effectiveness of voice rehabilitation program on postlaryngectomy patients.
  
  
  METHODS
  A three-step search strategy was utilised. An initial limited search of MEDLINE and CINAHL databases was undertaken followed by an analysis of the text words contained in the title and abstract to identify the optimal index terms. A second extensive search using all identified key words and index terms was then undertaken. Third, the reference list and bibliographies of all identified reports and articles were searched for additional studies. The measurement index included voice intelligibility, volume, clarity, quality of voice, patients' satisfaction, quality of life, etc. The search included reports in English and Chinese.
  
  
  METHODS
  The review considered any randomised controlled trials that addressed voice rehabilitation methods in postlaryngectomy patients. In the absence of randomised controlled trials, other quantitative research designs, such as non-randomised controlled trials, cohort studies and case-controlled studies, were considered for inclusion.
  
  
  METHODS
  Full copies of articles considered to meet the inclusion criteria were obtained for critical appraisal by two reviewers using the CASP (Critical Appraisal Skills Program) and McMaster scales. We utilised the 60% fulfilling of the evaluation scale items as the cut-off point and articles with a quality score less than 60% were excluded. Details of eligible trials were extracted and summarised by two reviewers independently using standardised data extraction tools developed by the Joanna Briggs Institute.
  
  
  RESULTS
  Twenty-two articles were included in the review (Appendix I). Different voice rehabilitation methods for laryngectomees were investigated in the included studies including oesophageal voice, electrolarynx voice and surgical voice restoration. One cohort studies, five prospective studies, five retrospective studies and 11 descriptive studies were included. Because of the heterogeneity of included studies, meta-analysis was not possible. Therefore, the results were presented in narrative summary. The following main findings were identified: 1 At present, oesophageal speech, electrolarynx and tracheoesophageal were the commonly used voice rehabilitation methods with total laryngectomy patients. 2 Among these three methods, the success rate of electrolarynx and tracheoesophageal is much higher than oesophageal speech. 3 The intelligibility and speech quality of electrolarynx was lower than tracheoesophageal. 4 Patient satisfaction and self-assessed quality of life was better in tracheoesophageal group. 5 The objective index was similar between excellent tracheoesophageal and oesophageal speech patients. Conclusion  1 Electrolarynx is the easiest vocal rehabilitation method for total laryngectomy patients to use as it requires little training and does not limit the patients. But patients' satisfaction was lower because of the mechanical voice and noise. 2 Oesophageal speech is the hardest vocal rehabilitation method to learn. It needs a long period of time to practise and requires the patient to be in good physical condition and to be relatively young. The success rate was relatively lower; however, it is the most commonly used rehabilitation method in developing countries because of low cost. 3 Tracheoesophageal is the most commonly used voice rehabilitation method in developed countries. It is a surgical method that could be performed as either a primary procedure or secondary procedure. Reported patient quality of life and satisfaction following tracheoesophageal were the best; however, there are complications and the frequent replacement of the prostheses is an important problem yet to be solved. Implication for practice  1 Voice rehabilitation after total laryngectomy is an immediate and long-term problem that patients and health worker must face. 2 Healthcare workers should understand the advantages and disadvantages of each voice rehabilitation method in detail to assist people with total laryngectomy to make the most appropriate decision in regard to rehabilitation method taking into consideration their age, sex, physical condition, job, economic status and other context factors. Implication for research  1 Further high-quality studies comparing the effectiveness of oesophageal speech, electrolarynx and tracheoesophageal vocal rehabilitation methods are needed, especially with the subjective and objective outcome index concurrently. 2 Further investigation is required to identify strategies to decrease the complications of tracheoesophageal and reduce frequency of required tracheoesophageal replacement. 3 More research is needed in the context of developing countries where healthcare resources may be limited.
authors.affiliation: Eye & ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai, P.R. China. shuxinxi71@126.com
authors.forename: Shuxin
authors.initials: S
authors.lastname: Xi
mesh_terms: D004947:Esophagus / Q000601:surgery; D055317:Evidence-Based Practice; D006801:Humans; D007822:Laryngeal Neoplasms / Q000601:surgery; D007825:Laryngectomy / Q000534:rehabilitation*; D007831:Larynx, Artificial; D017060:Patient Satisfaction; D016032:Randomized Controlled Trials as Topic; D013065:Speech Intelligibility; D013072:Speech, Esophageal / Q000379:methods*; D014132:Trachea / Q000601:surgery; D014833:Voice Quality; D014834:Voice Training