Klaske van Sluis

124 7.5. Conclusion For future research, it should be considered to test EMST in a group of TL participants without plugging the voice prosthesis prior to the training. If this also results in improvements, users can be spared the hassle of plugging. Next to this, special attention should be given towards exhaling technique used during the training. It is recommended to assess effectiveness of the training in a large group of participants which includes patients who explicitly report pulmonary problems, less fit elderly participants, and women. Finally, there are still unan- swered questions about the association between patients characteristics (e.g. time since TL, flap reconstruction, neck dissection etc.) and effectiveness of EMST. 7.5 Conclusion This pilot feasibility study indicates that an EMST program is generally safe and feasible in individuals following TL, although it requires adjustments of the device and skills of the participants to perform the training. Compliance to the training program was high. The EMST leads to an increase MEP, no evident changes in PEF outcomes were found. An increase in dynamic range in dB was seen, but this did not result in less reported voice handicap measured with VHI-10. No effects were found in the voice parameters MPT and vocal range in Hz, and ventilatory efficiency during exercise. For this relatively fit group of TL participants, clinical relevant benefits measured with self-reported clinical outcomes could not be determined. It is recommended to assess EMST in a less fit TL population who specifically report pulmonary problems to further investigate potential clinical benefit. 7.6 Acknowledgements The authors acknowledge Atos medical (Malmö, Sweden) for their research grant, which contributes to the existing infrastructure for quality of life re- search of the Department of Head and Neck Oncology and Surgery. The au- thors acknowledge Aspire Products for providing EMST training devices free of charge to study participants. FJM Hilgers emeritus professor and emeritus head and neck surgeon at the Netherlands Cancer Institute and University of Amsterdam is greatly acknowledged for his innovative idea, enthusiasm, and support to test EMST in total laryngectomy patients. References [1] K. E. van Sluis, L. van der Molen, R. J. van Son, F. J. Hilgers, P. A. Bhairosing, and M. W. van den Brekel, “Objective and subjective voice out- comes after total laryngectomy: a systematic review,” European Archives of Oto-Rhino-Laryngology , vol. 275, no. 1, pp. 11–26, 2018.