The effectiveness of voice rehabilitation on vocalization in post-laryngectomy patients: a systematic review.

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 ascertain the effectiveness regarding different voice rehabilitation programs for post-laryngectomy patients.

Review Objective: To critically analyse the literature and present the best available evidence related to the effectiveness of voice rehabilitation program on post-laryngectomy patients.

Search Strategy: 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 keywords and index terms was then undertaken. Thirdly, 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.

Selection Criteria: The review considered any randomised controlled trials (RCT) that addressed voice rehabilitation methods in post-laryngectomy patients. In the absence of RCTs, other quantitative research designs, such as non-randomized controlled trials, cohort studies, and case-controlled studies were considered for inclusion.

Data Collection And Analysis: 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: Two hundred and four papers in English and 11 papers in Chinese were initially selected and reviewed for inclusion through the titles and abstracts. Sixty-nine full reports of these papers were then retrieved. Twenty-two articles were included for the critical appraisal. Different voice rehabilitation methods for laryngectomees were investigated in the included studies including esophageal voice, electrolaryngx voice and surgical voice restoration. One cohort study, 5 prospective studies, 5 retrospective studies and 11 descriptive studies were included. Due to the heterogeneity of included studies, meta-analysis was not possible. Therefore, the results were presented in narrative summary. The following main findings were identified:˙ At present, ES (esophageal speech), EL (electrolarynx), and TEP (tracheoesophageal) were the commonly used voice rehabilitation methods with TL (total laryngectomy) patients.˙ Among these three methods, the success rate of EL and TEP is much higher than ES.˙ The intelligibility and speech quality of EL was lower than TEP.˙ Patient satisfaction and self-assessed quality of life was better in TEP group.˙ The objective index was similar between excellent TEP and ES patients.

Conclusion: EL is the easiest vocal rehabilitation method for TL patients to use as it requires little training and does not limit the patients. But patients' satisfaction was lower, due to the mechanical voice and noise. ES is the hardest vocal rehabilitation method to learn. It needs a long period of time to practice and requires the patient to be in good physical condition and to be relative young. The success rate was relatively lower, however it is the most commonly used rehabilitation method in developing countries due to low cost. TEP 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 TEP 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: The health care workers should understand the advantages, disadvantages and impact of each voice rehabilitation method in detail. So that they are able to help laryngectomees decide on the most appropriate method according to their age, sex, physical condition, job, economic status, and so on.

Implication For Research: Further high quality comparative studies of the effectiveness among ES, EL and TEP vocal rehabilitation methods are needed, especially when used concurrently with the subjective and objective outcome indexes. Decreasing the complications of TEP and how to improve the life-duration of TEP requires further investigation. More research should be conducted into patients living in developing countries where health care resources may be limited.