Laryngeal examination in thyroid and parathyroid surgery: An American Head and Neck Society consensus statement: AHNS Consensus Statement

Voice and Swallowing Dysfunction Associated With Extracorporeal Membrane Oxygenation in Pediatric Patients

OBJECTIVES

This study aims to determine the incidence of vocal fold motion impairment (VFMI) and swallowing dysfunction in pediatric patients undergoing cervical extracorporeal membrane oxygenation (ECMO) and the role of screening for compromise.

METHODS

A retrospective cohort analysis of voice, swallowing, and respiratory difficulty was performed among pediatric patients undergoing cervical ECMO cannulation and decannulation from 2012 to 2019. Data collected included weight, age, length of hospital stay, duration of intubation, ECMO procedure details, feeding interventions, and swallowing and airway evaluations.

RESULTS

This study included 77 patients with a median age of 3 days. Right vocal cord hypomobility or immobility was identified in 23 % of patients (n = 18), and 26 % (n = 20) had swallowing dysfunction. Twelve (15.6 %) patients had concurrent VFMI and swallowing dysfunction following decannulation. Median weight at cannulation was significantly lower in patients with VFMI (3.15 kg) than those without (3.93 kg). No significant differences were detected when comparing age, gestational age, type and location of ECMO procedure, and intubation duration/attempts. Despite concern for dysphonia in 42 patients, only 26 underwent flexible fiberoptic laryngoscopy.

CONCLUSION

VFMI and swallowing dysfunction are common in pediatric ECMO patients. This study is the first to document a clinically significant risk of vocal and swallowing dysfunction in children requiring ECMO. The study may underestimate the incidence of VFMI and swallowing dysfunction in these patients. In the future, we aim to prospectively evaluate patients after successful ECMO decannulation and extubation to identify VFMI and dysphagia promptly and provide appropriate follow-up and intervention for patients with persistent or prolonged respiratory and feeding difficulty.

2024 International Expert Consensus on US-guided Thermal Ablation for T1N0M0 Papillary Thyroid Cancer

Thermal ablation has started to gain acceptance as a therapeutic approach for the management of papillary thyroid cancer (PTC), mainly in the T1 stage (tumor size ≤ 2 cm in greatest dimension and limited to the thyroid). Despite its increasing popularity, a lack of uniformity in the technical details persists, and existing guidelines do not fully align with recent research advancements. To standardize the use of US-guided thermal ablation for T1N0M0 PTC, a panel of experts jointly issued this expert consensus on thermal ablation for PTC. This consensus was developed by experts with specific competence and expertise in this field through rounds of the modified Delphi method. An evidence-based approach incorporating the practical experience of the panelists was adopted. The consensus was developed through extensive discussions, systematic literature review with meta-analysis, and expert evaluations. In this consensus, a total of 27 recommendations are made, addressing the indications and contraindications for thermal ablation for PTC, physician training, preoperative preparation, technical procedures, complications, efficacy assessment, and follow-up strategies. This expert consensus provides up-to-date, high-quality, standardized guidance to harmonize treatment practices, enhance patient outcomes, and potentially shape future research and policy developments in the management of T1N0M0 PTC using US-guided thermal ablation.

Proposal of integrated clinical pathway in the management of perioperative recurrent laryngeal nerve injury post thyroid and parathyroid surgery

Early intervention is the current paradigm shift in the management of recurrent laryngeal nerve (RLN) injury post thyroidectomy and parathyroidectomy. Thus, an integrated clinical pathway is needed to enable early detection of RLN injury. A prospective longitudinal study was conducted from 2015 until 2021 in a single tertiary centre. A clinical pathway was developed where routine perioperative laryngeal assessments were implemented for all patients who underwent thyroidectomy and parathyroidectomy. Following an RLN injury, early surgical intervention was performed for unilateral vocal fold paralysis (UVFP). Data on patient demographics, risk factors, timing of RLN injury detection and type of intervention received were recorded in a proforma and analysed. 397 patients were included, involving 660 nerves at risk. The incidences of permanent RLN injury following thyroidectomy and parathyroidectomy were 5% and 1.8% respectively. The usage of intraoperative neuromonitoring was the only significant factor that affected the RLN injury according to multivariate analysis. 15% of RLN injuries were detected intraoperatively and 98% within two days. 70% of patients with UVFP received intervention in less than two weeks. The integrated clinical pathway has improved the validity of RLN injury incidence. It allows early detection of RLN injury and facilitates immediate intervention.

Brazilian Consensus on the Application of Thermal Ablation for Treatment of Thyroid Nodules: A Task Force Statement by the Brazilian Society of Interventional Radiology and Endovascular Surgery (SOBRICE), Brazilian Society of Head and Neck Surgery (SBCCP), and Brazilian Society of Endocrinology and Metabolism (SBEM)

There is increasing interest in ultrasound-guided ablation treatments for thyroid diseases, including benign and malignant ones. Surgeons, radiologists, and endocrinologists carry out these treatments, and various organizations within these specialties have recently released multiple international consensus statements and clinical practice standards. The aim of the present consensus statement is to provide guidance, cohesion, and standardization of best practices for thermal ablation procedures of thyroid nodules. The statement includes the indications for these procedures, preprocedural evaluations, technical aspects of the procedures, posttreatment care, follow-up, complications, and training recommendations. This document was written by a panel of specialists from the Brazilian Society of Interventional Radiology and Endovascular Surgery (SOBRICE), the Brazilian Society of Head and Neck Surgery (SBCCP), and the Brazilian Society of Endocrinology and Metabolism (SBEM). The statement does not aim to provide criteria for assessing the capability of specialists to perform the procedure. Instead, it aims to promote the standardization of best practices to reduce potential adverse outcomes. Additionally, it strives to enhance the delivery of high-quality care and the widespread adoption of these technologies on a national level. The recommendations collectively serve as a guidebook for applying best practices in thyroid ablation.

Outcomes of a first point of contact speech language therapy clinic for patients requiring vocal cord check pre and post thyroid/parathyroid surgery

INTRODUCTION

Speech Language Therapy First Point of Contact Clinic (SLT-FPOCC) models can assist assessment of low-risk patient populations referred to ear, nose and throat (ENT) services. To further improve ENT waitlist management and compliance with best-practice care, consideration of other low-risk populations that could be safely managed through this service model is needed. The aims of this paper are to evaluate the clinical and service outcomes of completing vocal cord check (VCC) assessments for patients' pre and post thyroid/parathyroid surgery within an SLT-FPOCC model and examine consumer perceptions.

METHODS & PROCEDURES

The service followed existing SLT-FPOCC procedures, with ENT triaging referrals, then SLT completing pre- and postoperative VCC assessment (interview, perceptual assessment, flexible nasendoscopy), with assessment data later reviewed by ENT to diagnose laryngeal pathology. Clinical and service outcomes were collected prospectively. Patients completed an anonymous post-service satisfaction survey.

RESULTS

Of the first 100 patients referred for preoperative VCCs, SLT assessment identified 42 with dysphonia and 30 reporting dysphagia, while ENT confirmed 9 with significant preoperative anatomical findings. Eighty-three underwent surgery, with 63 (95 nerves at surgical risk) returning for a postoperative VCC. Postoperative VCC identified three temporary neuropraxias (3.2%) and three unilateral vocal fold paresis (3.2%). Patients were highly satisfied with the service. All 163 pre-/postoperative VCCs were completed with no adverse events.

CONCLUSION & IMPLICATIONS

The current data support SLT-FPOCC service expansion to include pre and post thyroid/parathyroid surgery VCC checks, with positive consumer perception. The model supports delivery of best practice management (i.e., pre- and postoperative VCC) for patients receiving surgery for thyroid/parathyroid dysfunction, and associated efficiencies for ENT services.

WHAT THIS PAPER ADDS

What is already known Assessment of laryngeal function via flexible nasoendoscopy is recommended best practice for patients pre and postthyroid/parathyroid surgery, as recurrent laryngeal nerve injury is a low incidence (<10%), yet well-recognised risk of these surgeries. Traditionally, general surgeons refer presurgical patients to ear, nose and throat (ENT) for vocal cord check (VCC) assessment. However, with access to specialist outpatient services under increasing pressure, there is growing support for utilisation of other health professionals, such as speech-language therapists working in first point of contact (FPOCC) models, to assist with the administration of pre- and postsurgical assessments of such low-risk populations. What this study adds This work expands on the emerging body of evidence for speech language therapy (SLT) led FPOCC models within ENT outpatient services, providing clinical and service outcomes to support the safety of a new model designed to administer VCCs for patients pre and post thyroid/parathyroid surgery. Adopting a similar model to a prior published SLT-led FPOCC model, the trained SLT completes the pre- and postsurgical VCC including flexible nasoendoscopy and videostroboscopy, with images and clinical information then presented to ENT for diagnosis and management planning. This study also provides the first data on consumer perceptions of this type of service model. Clinical implications of this study Data on 100 consecutive presurgical patients revealed positive service findings, supporting the safety of this model. Nature and incidence of clinical findings pre and post surgery were consistent with previously published studies using traditional models of care (i.e., ENT completing the flexible nasendoscopy). Consumer perception was positive. This model enables delivery of pre-and postsurgical assessments for patients receiving thyroid/parathyroid surgery, consistent with best practice care, and reduces burden on ENT services. In total 163 ENT appointments were avoided with this model, with positive implications for ENT waitlist management.

Voice Changes Without Laryngeal Nerve Alterations After Thyroidectomy: The Need For Prospective Trials - A Review Study

BACKGROUND

Thyroidectomy is a commonly performed surgical procedure that is offered for different thyroid pathologies. The most frequent complication after total thyroidectomy is transient or permanent hypoparathyroidism followed by transient or permanent recurrent laryngeal nerve palsy. Patients may experience voice impairment despite intact laryngeal nerve function. These patients are of special interest because they experience subjective symptoms which are difficult to measure and therefore to treat.

SUMMARY

The Voice Handicap Index (VHI) and VHI-10 are the most commonly used subjective questionnaires. Their results correlate with objective findings. Female sex, in particular after menopause, is a dominant factor for developing voice impairment after thyroidectomy. The extent of neck surgery and the weight and volume of the removed thyroid correlates directly with both objective and subjective voice impairment after surgery. Videolaryngostroboscopy should be considered to examine vocal cord pathologies in this patient group. Surprisingly, there are no studies showing that speech and voice therapy are beneficial for patients with voice alterations but with intact laryngeal nerves.

CONCLUSIONS

While recurrent laryngeal nerve (RLN) paralysis can be evaluated by objective exams postoperatively, we are still left with the issue of possible partial or complete external branch of superior laryngeal nerve (EBSLN) injury. It is therefore quite difficult to segregate neural (RLN and EBSLN) and non-neural voice change populations, regardless of the method of literature evaluation. Perhaps patients' perspectives on how they experience voice functionality should play a superior role in deciding which patients should be investigated further with laryngoscopy, acoustic or perceptual analysis, and which patients should be offered treatment.

Preoperative Evaluation of Thyroid Cancer: A Review of Current Best Practices

OBJECTIVE

The incidence of thyroid cancer has significantly increased in recent decades. Although most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer, which is associated with increased rates of morbidity and mortality. The management of thyroid cancer requires a thoughtful individualized approach to optimize oncologic outcomes and minimize morbidity associated with treatment. Because endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer.

METHODS

A clinical review based on current literature was generated by a multidisciplinary author panel.

RESULTS

A review of considerations in the preoperative evaluation of thyroid cancer is provided. The topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed.

CONCLUSION

Thorough and thoughtful preoperative evaluation is critical for formulating an appropriate treatment strategy in the management of thyroid cancer.

Paediatric differentiated thyroid carcinoma: a UK National Clinical Practice Consensus Guideline

This guideline is written as a reference document for clinicians presented with the challenge of managing paediatric patients with differentiated thyroid carcinoma up to the age of 19 years. Care of paediatric patients with differentiated thyroid carcinoma differs in key aspects from that of adults, and there have been several recent developments in the care pathways for this condition; this guideline has sought to identify and attend to these areas. It addresses the presentation, clinical assessment, diagnosis, management (both surgical and medical), genetic counselling, follow-up and prognosis of affected patients. The guideline development group formed of a multi-disciplinary panel of sub-speciality experts carried out a systematic primary literature review and Delphi Consensus exercise. The guideline was developed in accordance with The Appraisal of Guidelines Research and Evaluation Instrument II criteria, with input from stakeholders including charities and patient groups. Based on scientific evidence and expert opinion, 58 recommendations have been collected to produce a clear, pragmatic set of management guidelines. It is intended as an evidence base for future optimal management and to improve the quality of clinical care of paediatric patients with differentiated thyroid carcinoma.

Mapping complications in thyroid surgery: statistical data are useful for medico-legal management of a recurrent safety issue

Quality of care assessment is a crucial tool for patient safety implementation. Litigation relating to thyroid surgery is one of the most represented sectors also due to the continuous increase in the number of thyroid interventions. Given the incidence of the problem, the present study aims to outline an operational methodology for risk mapping and litigation management in thyroid surgery. The study was conducted through the analysis of data collected at Umberto I General Hospital in Rome from 2007 to 2018. All thyroid surgery claims were included and, subsequently, a descriptive statistical analysis of the categorical variables was performed with the representation of frequencies in absolute terms and as a percentage. The results obtained show that in 94% of cases (44 cases) the reported event consists of incorrect treatment. The most frequent adverse events were identified in unilateral or bilateral recurrent nerve lesions (31; 70%); incomplete removal of the thyroid gland (6; 14%), post-surgical hypoparathyroidism (4; 9%), aesthetic damage secondary to surgical scars (2; 5%), dental avulsion during intubation maneuvers (1; 2%). The experience derived from the risk mapping through management of thyroid claims proved it to be a reactive tool of considerable importance in clinical governance. The promotion of measures aimed at improving the satisfaction of some critical parameters identified in the litigation management activity such as adherence to the indications for surgery, the preoperative diagnostic path, and the adequacy of the surgical report allows to further implement the quality of care in the surgical treatment of thyroid pathology.

Pre- and Postoperative Ultrasound and MRI Examinations in Assessing Vocal Folds in Patients with Goiter

Aim of the study: To determine the value of dynamic examinations ultrasound (US) and MRI in the 1.5T field in the assessment of the mobility of vocal folds (VF) in comparison to laryngoscopy in patients with thyroid gland resection. Materials and methods: A total of 44 patients with goiter, before and after thyroidectomy, were subjected to videolaryngoscopy and dynamic examinations of the vocal folds using ultrasound and the following MRI sequences: generic gradient echo (GRE) and true fast imaging with steady-state precession (TRUFI). The qualitative and quantitative data were analyzed, i.e., the angles of deviation from the midline of the vocal folds and the area of the right and left rima glottidis compartments. Results: The analysis of qualitative data showed that the results obtained by laryngoscopy, US and MRI are independent of the diagnostic method used in the group of patients pre and post thyroidectomy. Between the pre- and postoperative examinations in the group of paralyzed vocal folds, statistically significant differences were found in the minimum and maximum values of the angles for the MRI-GRE and MRI-TRUFI sequences and the maximum value of the angles in the US examination, but also in the maximum value of the area of the glottis compartments in both MRI-GRE and MRI-TRUFI dynamic sequences and the minimum value of the area in the sequence MRI-GRE. Statistically significant differences were found in both MRI sequences during phonation, both for the value of the angles and the area of the affected vocal folds. However, no statistically significant differences were found in the values of the angles or the areas in both vocal fold imaging methods without identified mobility abnormalities. Conclusions: Ultrasound and MRI examinations using dynamic sequences have a similar diagnostic value to laryngoscopy in the assessment of vocal fold paralysis in patients with goiter. The GRE sequence seems to be the most reliable one in determining vocal fold paralysis, and the most reliable parameter is the maximum area of the rima glottidis compartment. The inclusion of dynamic short sequences widely available in 1.5T scanners in standard neck examination protocols represents a novelty of the method and a promising diagnostic perspective in the diagnosis of vocal fold paralysis.

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Swallowing disorders after thyroidectomy: a systematic review and meta-analysis

PURPOSE

Swallowing disorders following thyroidectomy are common, even after surgery without confirmed complications. The purpose of the current systematic review is to investigate the prevalence of dysphagia at various time points after thyroidectomy, at the whole spectrum of it (total/partial, open/endoscopic, for benign/malignant disease).

METHODS

The literature available at PubMed, SciELO and Cochrane Library databases was reviewed, according to PRISMA guidelines, using the terms "dysphagia", "swallowing disorder", "deglutition disorder", "thyroidectomy" and "thyroid surgery" in the appropriate combinations. A quantitative synthesis of the results followed.

RESULTS

The systematic review of the literature resulted in 35 articles, which met the inclusion criteria and were analyzed regarding their type, sample, follow-up and results regarding post-thyroidectomy dysphagia in multiple follow-up times. A significant increase of swallowing impairment compared to baseline was recorded shortly after surgery. Dysphagia reverted to pre-operative levels 2-3 months later. Dysphagia continued to be reported in a significantly lower proportion of patients, even 1 year after surgery. No significant difference was noticed between open and endoscopic thyroid surgery at 2-3 months post-surgery.

CONCLUSIONS

The swallowing disorders reported after thyroidectomy should be expected, but are not always detectable through objective methods. This should not lead to underestimation of symptoms, since the patients' quality of life is negatively affected by the symptomatology.

Selective laryngoscopy before thyroidectomy: a risk assessment

BACKGROUND

Patients presenting for thyroidectomy may have an unrecognized pre-existing vocal cord palsy (VCP). This raises the danger of bilateral VCP if a patient sustains an injury to the RLN on the sole functioning side. Part of the rationale for routine preoperative laryngoscopy is to eliminate such a risk. This paper endeavours to quantify the relevant potential risk.

METHODS

Patients who underwent laryngoscopy prior to thyroid or parathyroid surgery in an endocrine surgical unit over a 5 year period were identified. Literature review revealed four papers in which VCP prevalence in patients without risk factors was reported. Using our data, combined with that of these other authors, the background rate of pre-existing VCP was ascertained, and the subsequent risk of bilateral VCP estimated.

RESULTS

Of our 632 patients who underwent preoperative laryngoscopy, there were four patients (0.63%) who were found to have a unilateral VCP, but all had voice symptoms or previous neck surgery. When patients with these risk factors are excluded, our data combined with the published data provides a pre-existing VCP rate of 0.2%. Calculations estimate that if preoperative laryngoscopy is omitted in patients with no risk factors, the risk of bilateral VCP, due to the nerve on the sole functioning side being injured, would be between 1/50000 and 1/150000, depending on an individual surgeon's level of experience.

CONCLUSION

Selective use of laryngoscopy prior to thyroidectomy would result in an acceptably low statistical risk of bilateral VCP. Routine laryngoscopy for all patients is not necessary.

Ultrasonography of the thyroid, parathyroids, and beyond

Background

Ultrasonography has become an essential tool for the evaluation and management of thyroid and parathyroid diseases. Its applications extend beyond neck endocrine conditions to a multitude of pathologies within the head and neck region.

Objectives

Our study aimed to: (1) provide a broad review of neck ultrasonography and key findings in neck endocrine diseases; (2) support skilled performance office-based diagnostic ultrasonography and its varied applications.

Materials and methods

A review of the current literature was supplemented with clinical examples of key ultrasonographic findings.

Results

Current applications and key findings of ultrasonography in the diagnosis and management of neck endocrine conditions are reviewed.

Conclusion

Ultrasonography is a fundamental component in the evaluation and management of neck endocrine diseases. The reader is encouraged to use this review to enhance office-based performance and application of ultrasonography.

Video online

The online version of this article contains 11 additional videos. They are provided to illustrate some of the dynamic aspects of US performance. The article and the videos are available online (10.1007/s00106-022-01162-0). The videos can be found in the article back matter as “Electronic Supplementary Material”.

[Diagnostic efficiency of transcutaneous laryngeal ultrasound in assessing the mobility of vocal cord in patients with thyroid disease]

OBJECTIVE

To assess the diagnostic efficiency of transcutaneous laryngeal ultrasound.

MATERIAL AND METHODS

Ultrasound examination of the larynx and laryngoscopy was performed in 103 patients with thyroid disease. 26 (34.21%) patients who underwent surgery on the thyroid gland direct laryngoscopy and ultrasound of the vocal folds were performed twice, before and after the operation.

RESULTS

Voice folds were visualized in 76 (73.8%) people. Of the 24 men, these anatomical structures were visualized in 8 (33.3%) and in 68 (86.1%) women out of 79 cases. Violations of the function of the vocal cords during laryngoscopy were detected in 5 people, sonographically in 6 people. The coincidence of the revealed pathology with ultrasound was in 4 patients, in 3 - with sonography the diagnosis was erroneous, in 1 patient it was falsely negative and in 2 cases it was falsely positive.

CONCLUSIONS

In connection with the diagnostic capabilities of the method, it is advisable to use it as a screening study in the perioperative period in patients with diseases of the thyroid gland. Laryngoscopy is indicated for patients with non-visualized vocal folds, with identified pathology with ultrasound, and with clinical signs of dysfunction of the vocal cords.

Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force, Ryu CH, Lee SJ, Cho JG, Choi IJ, Choi YS, Hong YT, Jung SY, Kim JW, Lee DY, Lee DK, Lee GI, Lee SJ, Lee YC, Lee YS, Nam IC, Park KN, Park YM, Sung ES, Son HY, Seo IH, Lee BJ, Lim JY. Care and Management of Voice Change in Thyroid Surgery: Korean Society of Laryngology, Phoniatrics and Logopedics Clinical Practice Guideline

Voice change is a common complaint after thyroid surgery and has a significant impact on quality of life. The Korean Society of Laryngology, Phoniatrics and Logopedics assembled a task force to establish guideline recommendations on education, care, and management related to thyroid surgery. The guideline recommendations encompass preoperative voice education, management of anticipated voice change during surgery, and comprehensive voice care after thyroid surgery, and include in-depth information and up-to-date knowledge based on validated literature. The committee constructed 14 key questions (KQs) in three categories-preoperative (KQ 1-2), intraoperative (KQ 3-8), and postoperative (KQ 9-14) management-and developed 18 evidence-based recommendations. The Delphi survey reached an agreement on each recommendation. A detailed evidence profile is presented for each recommendation. The level of evidence for each recommendation was classified as high-quality, moderate-quality, or low-quality. The strength of each recommendation was designated as strong or weak considering the level of evidence supporting the recommendation. The guidelines are primarily targeted toward physicians who treat thyroid surgery patients and speech-language pathologists participating in patient care. These guidelines will also help primary care physicians, nurses, healthcare policymakers, and patients improve their understanding of voice changes and voice care after thyroid surgery.

Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association

BACKGROUND

The use of ultrasound-guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international interdisciplinary evidence-based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies.

METHODS

A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel.

RESULTS

A review of the current state of ultrasound-guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided.

CONCLUSIONS

As ultrasound-guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence-based and thoughtful application of best practices is warranted.

Improving classification of the external branch of the superior laryngeal nerve with neural monitoring: a research appraisal and narrative review

Objective

To review the published literature on external branch of superior laryngeal nerve (EBSLN) neural monitoring and propose a new EBSLN classification system using intraoperative neural monitoring (IONM).

Background

The injury rate of the external branch of the superior laryngeal nerve (EBSLN) in thyroid surgery is 0-58%. Symptoms of EBSLN injury are not consistent, and patients often complain of modification of the voice timbre with the preservation of vocal cord function. Standards for the diagnosis of EBSLN injury are lacking.

Methods

The PubMed database was searched using the terms 'External branch of the superior laryngeal nerve' and 'Intraoperative neuromonitoring' from 2010 through March 2020.

Conclusions

This paper reviewed the anatomy of the EBSLN, the diagnosis and treatment of injury, and the application of IONM in the EBSLN. The traditional EBSLN classification method was analyzed and compared with our new classification method. The diagnosis of EBSLN injury is a problem that still needs to be resolved. For anatomic classifications of the EBSLN, we found that the conventional classification systems may not accurately reflect the real status of the EBSLN and the surgical risks that may occur intraoperatively. Using IONM, we developed an EBSLN classification method that was consistent with conventional diagnosis and treatments and can be widely and easily utilized during surgery.

Ultrasound prediction for vocal cord dysfunction in patients scheduled for anterior cervical spine surgeries: a prospective cohort study

Prediction of vocal cord dysfunction is essential after anterior cervical spine surgeries. This study aimed to detect the validity of transcutaneous laryngeal ultrasonography by both anterior and novel lateral approaches for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries. A prospective cohort study conducted on 90 patients scheduled for anterior cervical spine surgeries underwent consecutive pre and postoperative vocal cord examination for edema and paralysis by both anterior and lateral approaches laryngeal ultrasonography. Rigid laryngoscopy was the standard confirmatory tool. For postoperative vocal cord edema, the anterior ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 78.9% with PPV = 78.9% and NPV = 88.2% and the novel lateral ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 94.7% with PPV = 93.75% and NPP = 90%. While for paralysis, the anterior ultrasonography approach diagnostic sensitivity = 86.7%, specificity = 85.7% with PPV = 81.25% and NPV = 90% and the novel lateral ultrasonography approach diagnostic (sensitivity, specificity with PPV and NPP) = 100%. The diagnostic accuracy of the novel lateral approach was more correlated to rigid laryngoscopy (91.7% and 100%) compared to anterior approach for vocal cord edema and paralysis (83.3% and 80.6%). Overall incidence of vocal cord paralysis was 16.6%. Risk of vocal cord paralysis was statistically significant more in female, multiple disc herniation, lower and mixed disc levels, Langenbeck retractor, cage and plate and duration of surgery ≥ 1.5 h. Transcutaneous Laryngeal ultrasound is a valid comfortable tool for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries with superiority of the novel lateral over anterior approach.

The value of 1.5T MRI in the evaluation of vocal fold mobility in patients with goiter

The laryngoscopic examination remains the gold standard in the perioperative evaluation of the mobility of the vocal folds in patients with goiter. During the COVID-19 pandemic, many medical procedures, including laryngoscopy are optimized in terms of epidemiological safety. Therefore, it seems deeply justified to implement methods like i.e. ultrasound or MRI which can provide the diagnostic information usually obtained via laryngoscopic examination.

Aim of the study

To determine the value of dynamic MRI examination in the 1.5 T field in the assessment of the mobility of vocal folds in patients with goiter compared to healthy people and in relation to ultrasound examinations and routine laryngoscopy.

Materials and methods

35 healthy volunteers and 44 patients with goiter were subjected to videolaryngoscopy, dynamic examinations of the vocal folds during respiration and phonation using ultrasound and the MRI sequences: generic gradient echo (GRE) and true fast imaging with steady-state precession (TRUFI). The qualitative and quantitative data were analyzed, i.e. the angles of deviation from the midline of the vocal folds and the area of the right and left rima glottidis compartments.

Results

No statistically significant differences were found between the groups of healthy volunteers and patients with goiter in the values of the angles of deviation of the vocal folds with the use of ultrasound and two MRI dynamic sequences - GRE and TRUFI. There were also no statistically significant differences in the areas of the rima glottidis compartments between these two groups with the use of two MRI dynamic sequences - GRE and TRUFI. Among the analyzed parameters, the maximum size of each rima glottidis compartment was the only one to show features of sexual dimorphism and was significantly higher in men (GRE p < 0.001 and TRUFI p = 0.001). There was no correlation between the size of the minimum and maximum rima glottidis compartment and the total volume of the thyroid lobes in patients with goiter for the GRE and TRUFI sequences.

Conclusions

MRI is a promising tool for the objective assessment of the mobility of the vocal folds in patients with goiter, as well as for the qualification for treatment and monitoring its effects. It is particularly important during an epidemiological emergency due to its safety compared to laryngoscopy. The presence of the goiter and its volume do not limit the possibility of performing dynamic imaging studies of the vocal folds and do not affect the surface area of the glottis.

Intraoperative Ultrasonographic Assessment of Vocal Cord motion under sedation, following paediatric thyroidectomy in the Era of COVID-19: A double-blinded preliminary study

INTRODUCTION

Unilateral vocal cord paralysis (UVCP) is a known complication of thyroid surgery, due to iatrogenic recurrent laryngeal nerve injury, with reported rates of 2%-5% in children. The gold standard for assessing vocal cord function in flexible nasendoscopy (FNE) examination, which is considered high-risk for contraction of the COVID-19 virus. Intraoperative ultrasonographic assessment (IUA) of vocal cord function is a non-invasive and relatively simple procedure performed in a supine position, performed during spontaneous breathing, following reversed anaesthesia, while the patient is still sedated.

OBJECTIVES

To evaluate the validity of IUA modality in children undergoing thyroidectomy and to compare it to the standard FNE.

DESIGN

A prospective double-blind study covering 24 months (March 2019-March 2021). Twenty thyroid lobectomies were performed, during 15 surgeries. Vocal cord function was assessed three times: Pre-operatively by FNE, intraoperative (IUA) following extubation, and a second FNE on the first post-operative day.

SETTINGS

A tertiary paediatric hospital.

RESULTS

The overall accuracy of IUA results in our study was 92%. IUA sensitivity, specificity, positive and negative predictive values were 100%, 89%, 33% and 100%, respectively. Patient's age demonstrated borderline significance (p = .08). The resident's experience was associated with a better correlation between IUA and FNE results (p < .05).

CONCLUSIONS

IUA of vocal cord motion has a high accuracy rate for detection of iatrogenic vocal cord paralysis, similar to FNE. It is easily learned by residents, well-tolerated by children, and it provides a safe and valid alternative modality while ensuring the safety of the medical staff in treating patients, especially in times of COVID-19 pandemic.

Total thyroidectomy with intraoperative neural monitoring and near-infrared fluorescence imaging

PURPOSE

To describe our personal experience during aclassic complete thyroidectomy adopting both intraoperative neural monitoringand near-infrared autofluorescence.

METHODS

In October 2021, 20 patients underwent totalthyroidectomy for benign and malignant conditions: 13 patients were affected bymultinodular goiter, 2 by Graves' disease, and 5 by indeterminate lesions (3Tir-3B and 2 Tir-3A). For each patient, intraoperative neural monitoring of therecurrent laryngeal nerve and near-infrared autofluorescence were used.

RESULTS

Overall, 76/80 (95.0%) parathyroid glands weredetected: 34/76 (44.7%) were identified by the surgeon during the dissection,while 42/76 (55.3%) were detected by the near-infrared camera before thesurgeon saw them with naked eye. Indocyanine green angiography was adopted inall the patients, and in 2 cases, parathyroid gland autotransplantation wasperformed since 2 parathyroid glands resulted devascularized after dissection.Operative time ranged from 113 to 201 min (mean 156 min).

CONCLUSION

Together with intraoperative neural monitoring,near-infrared autofluorescence is a reliable device in thyroid surgery. Furtherprospective studies are necessary to establish if the adoption ofautofluorescence may result in long-term benefit in terms of calcemia.

Critical Review and Consensus Statement for Neural Monitoring in Otolaryngologic Head, Neck, and Endocrine Surgery

BACKGROUND

Enhancing patient outcomes in an array of surgical procedures in the head and neck requires the maintenance of complex regional functions through the protection of cranial nerve integrity. This review and consensus statement cover the scope of cranial nerve monitoring of all cranial nerves that are of practical importance in head, neck, and endocrine surgery except for cranial nerves VII and VIII within the temporal bone. Complete and applied understanding of neurophysiologic principles facilitates the surgeon's ability to monitor the at-risk nerve.

METHODS

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) identified the need for a consensus statement on cranial nerve monitoring. An AAO-HNS task force was created through soliciting experts on the subject. Relevant domains were identified, including residency education, neurophysiology, application, and various techniques for monitoring pertinent cranial nerves. A document was generated to incorporate and consolidate these domains. The panel used a modified Delphi method for consensus generation.

RESULTS

Consensus was achieved in the domains of education needs and anesthesia considerations, as well as setup, troubleshooting, and documentation. Specific cranial nerve monitoring was evaluated and reached consensus for all cranial nerves in statement 4 with the exception of the spinal accessory nerve. Although the spinal accessory nerve's value can never be marginalized, the task force did not feel that the existing literature was as robust to support a recommendation of routine monitoring of this nerve. In contrast, there is robust supporting literature cited and consensus for routine monitoring in certain procedures, such as thyroid surgery, to optimize patient outcomes.

CONCLUSIONS

The AAO-HNS Cranial Nerve Monitoring Task Force has provided a state-of-the-art review in neural monitoring in otolaryngologic head, neck, and endocrine surgery. The evidence-based review was complemented by consensus statements utilizing a modified Delphi method to prioritize key statements to enhance patient outcomes in an array of surgical procedures in the head and neck. A precise definition of what actually constitutes intraoperative nerve monitoring and its benefits have been provided.

Quantitative laryngeal electromyography (LEMG) in unilateral vocal fold paralysis: Developing normative values using the opposite normal mobile vocal fold

OBJECTIVE

Laryngeal electromyography (LEMG) is used to confirm neuropathy; traditionally, it is evaluated qualitatively. This study aimed to develop normative values for the thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex by determining the mean turns (MT) and mean amplitudes (MA) using the opposite normal mobile vocal fold in unilateral vocal fold paralysis (VFP). This study also compared the MT and MA of the paralyzed vocal fold with that of the normal side and analyzed their correlations.

METHODS

This is a cross-sectional study in which 77 patients (18 males, 59 females, mean age of 48) with unilateral VFP with an opposite normal mobile vocal fold underwent LEMG with a standardized protocol. Koufman gradings and MT and MA were used for the qualitative and quantitative evaluations. Mann-Whitney U test was performed to compare the median of the turns and amplitudes between the opposite normal mobile vocal fold and the paralyzed side. A linear-scale graphical "cloud" of the normal TA-LCA muscle complex was generated using logarithmic regression analysis. The qualitative and quantitative parameters were analyzed using multiple analysis of variance and Kruskall-Wallis test. Post-hoc analysis was performed to further determine the differences of the significance between both parameters. The correlation between the qualitative and quantitative parameters was analyzed using Spearman correlation.

RESULTS

The MT and MA were significantly higher for the normal TA-LCA muscle complex than the paralyzed side (582 vs. 336; 412 vs. 296, respectively) and the median of the turns and amplitudes were significantly lower in the paralyzed side with p-values <0.001. A significant difference was observed between the Koufman grading and the combination of MT and MA [F (8,144) = 73.254] and between the Koufman grading and MT and MA individually [H (4, 72) = 18.3 and H (4, 72) =33.4], in which both had p-values <0.001. A moderate negative linear relationship was seen between the Koufman grading and MT and MA. On further analysis, it was revealed that only certain pairs of Koufman grading were statistical significant.

CONCLUSIONS

This study was the first to present the quantitative normative values and "cloud" of the TA-LCA muscle complex using the opposite normal mobile vocal fold in patients with unilateral VFP in which it is comparable to healthy controls. We concluded that quantitative LEMG supports the qualitative Koufman grading method however it cannot be used independently to determine the severity of neuropathy.

High-Resolution Laryngeal US: Imaging Technique, Normal Anatomy, and Spectrum of Disease

Although US is one of the most used modalities for head and neck imaging, its use in the diagnosis of laryngeal abnormalities is much less widespread. The standard assessment of laryngeal abnormalities currently involves direct laryngoscopy and cross-sectional imaging (either CT or MRI) but rarely US. US is readily available, noninvasive, and radiation free, and it allows real-time imaging (with video for dynamic assessment), higher resolution than that of cross-sectional imaging, and the performance of targeted fine needle aspiration cytology or biopsy. This modality, particularly with the advent of high-resolution US, has been found to be at least comparable to CT or MRI for diagnosis of malignant lesions and benign abnormalities such as vocal nodules, polyps, cysts, and Reinke edema. Furthermore, it has been found to be more sensitive for diagnosis of abnormalities such as small glottic tumors, and its dynamic capability can be used to identify functional abnormalities such as vocal cord palsy. The authors outline the technique of laryngeal US, which includes strategies to avoid calcified laryngeal cartilage by imaging through the thyrohyoid and cricothyroid membranes with a five-sweep strategy supplemented by cine film of the technique. They also provide US images of common laryngeal abnormalities such as tumors with and without extralaryngeal extension; vallecular, thyroglossal, and vocal cord cysts; laryngeal mucoceles; and vocal cord palsy. Online supplemental material is available for this article. ^©RSNA, 2020.

2021 American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer

Background: Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Since the guidelines for the management of ATC by the American Thyroid Association were first published in 2012, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, and researchers on published evidence relating to the diagnosis and management of ATC. Methods: The specific clinical questions and topics addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of the Task Force members (authors of the guideline). Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. Results: The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, targeted/systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues, including end of life. The guidelines include 31 recommendations and 16 good practice statements. Conclusions: We have developed evidence-based recommendations to inform clinical decision-making in the management of ATC. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with ATC.

Association of Hypocalcemia and Magnesium Disorders With Thyroidectomy in Commercially Insured Patients

Importance

Hypocalcemia is a common complication of total thyroidectomy.

Objectives

To identify factors associated with hypocalcemia after total thyroidectomy and to explore the association between hypocalcemia, magnesium disorders, and costs of care.

Design, Setting, and Participants

A retrospective cross-sectional analysis was performed using data from the MarketScan Commercial Claim and Encounters database on 126 766 commercially insured patients younger than 65 years undergoing total thyroidectomy between January 1, 2010, and December 31, 2012. Statistical analysis was performed from January 1, 2016, to May 30, 2019.

Main Outcomes and Measures

Short- and long-term hypocalcemia and the costs of care were examined using multivariable regression modeling.

Results

Among the 126 766 patients in the study (81.6% women; mean age, 46.5 years [range, 18-64 years]), postoperative hypocalcemia was present in 19.1% of patients in the initial 30-day postoperative period and in 4.4% of patients at 1 year. Magnesium disorders were present in 2.1% of patients at the time of surgery. Short- and long-term hypocalcemia were significantly more likely in women (short-term: odds ratio [OR], 1.39 [95% CI, 1.29-1.50]; long-term: OR, 1.69 [95% CI, 1.52-1.89]), those younger than 40 years (short-term: OR for ages 40-64 years, 0.83 [95% CI, 0.78-0.87]; long-term: OR for ages 40-64 years, 0.73 [95% CI, 0.67-0.79]), those with a diagnosis of thyroiditis (short-term: OR, 1.48 [95% CI, 1.16-1.89]; long-term: OR, 1.60 [95% CI, 1.13-2.26]) or cancer (short-term: OR, 1.32 [95% CI, 1.05-1.67]; long-term: OR, 1.17 [95% CI, 0.83-1.63]), vitamin D deficiency (short-term: OR, 1.96 [95% CI, 1.74-2.21]; long-term: OR, 3.72 [95% CI, 3.30-4.18]), concurrent lateral neck dissection (short-term: OR, 1.51 [95% CI, 1.37-1.66]; long-term: OR, 1.95 [95% CI, 1.69-2.26]), concurrent central neck dissection (short-term: OR, 1.15 [95% CI, 1.07-1.24]; long-term: OR, 1.25 [95% CI, 1.12-1.40]), intraoperative parathyroid (short-term: OR, 1.58 [95% CI, 1.46-1.71]; and long-term: OR, 2.05 [95% CI, 1.82-2.31]) or recurrent laryngeal nerve injury (short-term: OR, 1.49 [95% CI, 1.27-1.74]; long-term: OR, 2.04 [95% CI, 1.64-2.54]), and magnesium disorders (short-term: OR, 8.40 [95% CI, 7.21-9.79]; long-term: OR, 25.23 [95% CI, 19.80-32.17]). Compared with the initial postoperative period, the odds of hypocalcemia decreased by 90.0% (OR, 0.10 [95% CI, 0.09-0.11]) at 6 months and 93.0% (OR, 0.07 [95% CI, 0.06-0.08]) at 1 year. After controlling for all other variables, magnesium disorders were associated with the highest odds of short- and long-term postoperative hypocalcemia. Hypocalcemia ($3392) and magnesium disorders ($14 314) were associated with increased mean incremental 1-year costs of care.

Conclusions and Relevance

Hypocalcemia is common after total thyroidectomy but resolves in most patients by 1 year. Magnesium disorders are significantly independently associated with short- and long-term hypocalcemia and are associated with greater costs of care. These data suggest a potentially modifiable target to reduce the incidence and cost of long-term hypocalcemia at patient and systemic levels.

Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Consensus Statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

In-Practice Endocrine Surgery Fellowship: A Novel Training Model

OBJECTIVE

Endocrine surgery is an expanding field within otolaryngology. We hypothesized that a novel endocrine surgery fellowship model for in-practice otolaryngologists could result in expert-level training.

STUDY DESIGN

Qualitative clinical study with chart review.

SETTING

Urban community practice and academic medical center.

METHODS

Two board-certified general otolaryngologists collaborated with a senior endocrine surgeon to increase their endocrine surgery expertise between March 2015 and December 2017. The senior surgeon provided intensive surgical training to both surgeons for all of their endocrine surgeries. Both parties collaborated with endocrinology to coordinate medical care and receive referrals. All patients undergoing endocrine surgery during this time frame were reviewed retrospectively.

RESULTS

A total of 235 endocrine surgeries were performed. Of these, 198 thyroid surgeries were performed, including 98 total thyroidectomies (48%), 90 lobectomies (45%), and 10 completion thyroidectomies (5%). Sixty cases demonstrated papillary thyroid carcinoma, 11 follicular thyroid carcinoma, and 4 medullary thyroid carcinoma. Neck dissections were performed in 14 of the cases. Thirty-seven parathyroid explorations were performed. There were no reports of permanent hypoparathyroidism. Thirteen patients (5.5%) developed temporary hypoparathyroidism. Six patients (2.5%) developed postoperative seroma. Three patients (1.3%) developed postoperative hematomas requiring reoperation. One patient (0.4%) developed permanent vocal fold paralysis, and 3 patients (1.3%) had temporary dysphonia. Thirty-five of 37 (94.5%) parathyroid explorations resulted in biochemical resolution of the patient's primary hyperparathyroidism.

CONCLUSION

This is the first description of a new fellowship paradigm where a senior surgeon provides fellowship training to attending surgeons already in practice.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

What the thyroid cancer patient wants to know: ThyCa survey by the American Head and Neck Society Endocrine Surgery Section

OBJECTIVE

To survey a large cohort of thyroid cancer survivors from ThyCa on information needs and expectations of their treatment to better understand the pretreatment counseling, information, and support needs of this population.

METHODS

Anonymous survey of thyroid cancer survivors.

RESULTS

One thousand one hundred twenty-four patients with thyroid cancer participated in the survey. Three hundred sixty-two (37.44%) reported not having had a full understanding of their treatment plan and 407 (46.41%) reported that their thyroid cancer treatment did not conform to expectations. Patients diagnosed at younger ages were significantly more likely to report inadequate understanding of the treatment, failure of treatment to meet expectations, and call for greater attention to psychological well-being. Older patients were more likely to report unexpected effects on speech and swallowing. Regardless of age, patients most frequently called for greater attention to management of energy levels (endorsed by 61% of respondents), psychological well-being (50%), and weight changes (48%).

CONCLUSIONS

Improvements are needed in age-specific communication of thyroid cancer diagnosis and treatment.

Cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for low-risk thyroid cancer patients

BACKGROUND

Flexible fiberoptic laryngoscopy is performed prior to thyroid surgery to evaluate the function of the recurrent laryngeal nerve. We assess the cost-effectiveness of preoperative laryngoscopy prior to total thyroidectomy for a low-risk thyroid cancer patient without dysphonia.

METHODS

A decision tree analysis was performed from a third-party payer perspective. We assessed the cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for T2N0M0 papillary thyroid carcinoma, such that an ipsilateral vocal fold paralysis alters the surgical plan to hemi-thyroidectomy, when permissible, to avoid the risk of bilateral vocal fold paralysis.

RESULTS

Performing preoperative laryngoscopy to assess vocal fold function has an incremental cost-effectiveness ratio (ICER) of 45 193 USD/QALY compared to no laryngoscopy. At a willingness-to-pay of 100 K/QALY, the intervention is cost-effective if the incidence of vocal fold paralysis is at least 0.57%, or when the permissible rate of hemithyroidectomy in cases of incidental paralysis is at least 41%. Probabilistic sensitivity analysis shows that laryngoscopy is cost-effective in 90.9% of cases.

CONCLUSIONS

Fiberoptic laryngoscopy is a cost-effective prior to total thyroidectomy in asymptomatic, low-risk thyroid cancer patients.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Modern surgery for advanced thyroid cancer: a tailored approach

Surgical treatment of advanced thyroid malignancy can be morbid, compromising normal functions of the upper aerodigestive tract. There is a paucity of guidelines dedicated to the management of advanced disease. In fact, there is not even a uniform definition for advanced thyroid cancer currently. The presence of local invasion, bulky cervical nodes, distant metastases or recurrent disease should prompt careful preoperative evaluation and planning. Surgical strategy should evolve from multidisciplinary discussion that integrates individual disease characteristics and patient preference. Intraoperative neuromonitoring has important applications in surgery for advanced disease and should be used to guide surgical strategy and intraoperative decision-making. Recent paradigm shifts, including staged surgery and use of neoadjuvant targeted therapy hold potential for decreasing surgical morbidity and improving clinical outcomes. Modern surgical planning provides optimal treatment for each patient through a tailored approach based on exact extent and type of disease as well as incorporating appreciation of surgical complications, patient preferences and intraoperative findings.

Laryngeal paralysis detected in preoperative laryngoscopy in malignant and benign thyroid disease. Systematic review and meta-analysis

There is controversy regarding the performance of preoperative laryngoscopy (LP) in thyroid surgery, with different recommendations being made, based on observational studies, in various publications. The aim of the study was to know the prevalence of laryngeal paralysis found in the LPs of patients who underwent thyroidectomy in benign and malignant pathology. A systematic review was carried out with 29 articles included for the qualitative study and a meta-analysis of 13 articles in which the data could be obtained to evaluate the same effect (in all patients in which an LP was carried out, those with preoperative laryngeal paralysis were included, and assigned to malignant or benign postoperative histology groups). The pooled prevalence of preoperative paralysis in benign pathology was 1.1% (95% CI 0.7 to 1.7%, 71% I²) and in 6.3% malignant pathology (95% CI 3.8 to 9.4%; I² 85%). The prevalence was significantly higher among patients with malignant pathology with an estimated effect RR 5.66, 95% CI, 2.48, 12.88. The studies analyzed present biases that will need to be corrected in future research, eliminating blinding biases in the selection and allocation of patients or in the laryngoscopy technique used. The LP in thyroid surgery evaluates possible disorders of laryngeal motility. The prevalence of laryngeal paralysis in thyroid pathology found in LPs in patients with a postoperative diagnosis of malignant pathology was higher than in the benign pathology group. This information is necessary for interpreting the intraoperative neuromonitoring signal and for making informed decisions.

Surgical approach to the substernal goiter

Surgery for substernal goiters can be technically demanding. Extensive mediastinal extension brings the thyroid gland into close quarters with vital intrathoracic structures. Proper preoperative planning is required to determine the potential need for an extracervical approach. Assessing the risk of requiring an extracervical approach is typically based on findings from cross-sectional imaging of the neck and chest. This article addresses the important anatomical considerations when resecting a large substernal goiter and also reviews various extracervical approaches.

Surgical management of the compromised recurrent laryngeal nerve in thyroid cancer

Surgical management of thyroid cancer requires careful consideration of the recurrent laryngeal nerve and its impact on glottic function. Management of the compromised recurrent laryngeal nerve is a complex task, requiring synthesis of multiple elements. The surgeon must have an appreciation for preoperative recurrent laryngeal nerve function, intraoperative anatomic and electromyographic information, disease characteristics, and relevant patient factors. Preoperative clinical evaluation including preoperative laryngoscopy and assessment of recurrent laryngeal nerve risk is essential to formulating a surgical plan and providing appropriate patient counseling. Intraoperative neuromonitoring information has significant implications for surgical management of the injured or invaded recurrent laryngeal nerve and informs strategy with respect to staging of bilateral surgery. Disease characteristics and patient-related factors, including patient preference, must be considered with intraoperative decision-making. Multidisciplinary discussion and patient communication are essential for effective management and successful surgical outcome.

Vocal Cord Palsies Missed by Transcutaneous Laryngeal Ultrasound (TLUSG): Do They Experience Worse Outcomes?

INTRODUCTION

Transcutaneous laryngeal ultrasound (TLUSG) is an innovative, non-invasive tool in detecting post-thyroidectomy vocal cord palsy (VCP). However, TLUSG failed to detect about 6-15% laryngoscopic examination (LE)-confirmed VCP. It is unclear whether the outcome of patients with VCP missed by TLUSG [false negative (FN)] is different from those with VCP diagnosed by TLUSG [true positive (TP)]. Therefore, this study aimed to compare the clinical outcome and prognosis between patients with FN results and TP results.

METHODS

Over 46 months, all consecutive patients undergoing thyroidectomy or endocrine-related neck procedure were recruited. They underwent pre-operative and post-operative voice assessments on symptoms, voice-specific questionnaire [voice handicap index questionnaire (VHI-30)], TLUSG and LE. For patients with post-operative vocal cord palsy, reassessment LE would be arranged at second, fourth, sixth and twelfth months post-operatively until VCP recovered.

RESULTS

In total, 1196 patients, including 74 post-thyroidectomy VCP, were recruited. For those with assessable vocal cords (VC), 58 VCP were correctly diagnosed by TLUSG (TP) and 10 VCP were missed by TLUSG (FN). Sensitivity and specificity of detecting a VCP by TLUSG were 85.3% and 94.7%, respectively. VHI-30 score was significantly increased after operation in TP group [31 (range - 6-105), p < 0.001] but not in FN group [20 (14-99), p = 0.089]. Comparing to TP group, VCP recovered earlier (69 vs. 125 days, p < 0.001) and less patients suffered from permanent VCP in patients with FN results. (34.5% vs. 0.0%, p = 0.027).

CONCLUSION

The VCP missed by TLUSG had a milder course of disease. Early recovery of VC function and non-permanent palsy were expected.

The Impact of Post-thyroidectomy Paresis on Quality of Life in Patients with Nodular Thyroid Disease

Objective

To investigate the impact of postoperative paresis on disease-specific quality of life (DSQoL) after thyroidectomy in patients with benign nodular thyroid disease.

Study Design

Observational study.

Setting

University hospital.

Subjects and Methods

Patients were evaluated before and 3 weeks and 6 months after surgery in an individual prospective cohort study using videolaryngostroboscopy (VLS), voice range profile, voice handicap index (VHI), multidimensional voice program, maximum phonation time (MPT), and auditory perceptual evaluation. Changes in DSQoL were assessed by the Thyroid-specific Patient-Reported Outcome measure. Cohen’s effect size was used to evaluate changes.

Results

Sixty-two patients were included, 55 of whom completed all examinations. Three weeks after surgery, a blinded VLS examination showed signs of paresis of either the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve (RLN/EBSLN) in 13 patients (24%). A paresis corresponded to a 12 ± 28 point increase in VHI ( P = .002) and was associated with a significant 4.3 ± 7.5 semitone decrease in the maximum fundamental frequency ( P < .001) and a 5.3 ± 8.2 dB reduction in maximum intensity. Further, it was associated with a 4.5 ± 11.2 second reduction in MPT ( P = .001) and an increase of 0.40 ± 1.19 in grade, 0.42 ± 1.41 in roughness, and 0.36 ± 1.11 in breathiness. Signs of postoperative RLN/EBSLN paresis correlated with an 11.0-point ( P = .02) poorer improvement in goiter symptoms at both 3 weeks and 6 months after surgery.

Conclusion

Signs of RLN/EBSLN paresis after thyroidectomy were associated with less pronounced improvement in goiter symptoms in patients with thyroid nodular disease. However, thyroidectomy was associated with an overall improved DSQoL by 6 months after surgery.

Conventional Thyroidectomy in the Treatment of Primary Thyroid Cancer

This article focuses on conventional surgical management of thyroid cancer, reviewing long-standing and well-accepted main principles and practices. It also covers newer controversies and techniques to conventional thyroidectomy, including changes in the indications for thyroidectomy, the intraoperative management of the recurrent and superior laryngeal nerves and parathyroid glands, the extent of thyroidectomy, and the importance of outcomes measurement and quality improvement.

Selective Laryngeal Examination: Sensitivity of Endocrine Surgeons in Screening Voice Abnormality

OBJECTIVES

Selective laryngeal examination for patients undergoing thyroidectomy is recommended for patients with voice alterations, history of prior cervical or chest surgery, and patients with proven or suspected thyroid malignancy. The study objective is to measure the sensitivity of surgeons in detecting voice abnormalities in patients undergoing thyroidectomy, parathyroidectomy complicated with laryngeal nerve paralysis, or patients with known vocal cords palsy (VCP) due to other neck surgeries.

DESIGN AND SETTING

Descriptive cross-sectional study in a tertiary center.

PARTICIPANTS AND METHODS

The subjects are 274 audio files of voices of patients undergoing thyroid, parathyroid surgeries, and known VCP due to other neck surgeries. Voice assessments were done by three endocrine surgeons (A, B, and C) with 20, 12, and 4 years of surgical experience.

MAIN OUTCOME MEASURES

Sensitivity and specificity of surgeon documented voice assessment in patients with underlying VCP. Subjects' acoustic analysis and Voice Handicap Index (VHI-10) were analyzed.

RESULTS

Raters A, B, and C have sensitivity of 63.6%, 78.8%, and 66.7%, respectively. Inter-rater reliability shows substantial agreement (ƙ = 0.67). VHI-10 has sensitivity of 75.8% and strong correlation of 0.707 (p value <0.001) to VCP. Subjects with VCP have notably higher jitter, shimmer, and noise-to-harmonic ratio compared to normal subjects with sensitivity of 74.2%, 71.2%, and 72.7%, respectively.

CONCLUSIONS

The results for surgeons documented voice assessment did not reach the desired sensitivity for a screening tool for patients with underlying VCP. Other tools such as VHI-10 and acoustic analysis may not be used as standalone tools in screening patients with underlying VCP. Routine preoperative laryngeal examination may be recommended for all patients undergoing thyroid, parathyroid, or other surgeries that places the laryngeal nerves at risk.

International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.

Current practice in the surgical management of parathyroid disorders: a United Kingdom survey

PURPOSE

Surgery for primary hyperparathyroidism is undertaken by many specialties but predominantly endocrine and ear, nose and throat (ENT) surgeons. There is currently no consensus on the peri-operative management of primary hyperparathyroidism. We sought to determine current surgical practice and identify any inter-specialty variation in the United Kingdom (UK).

METHODS

An online survey was disseminated to members of the British Association of Endocrine & Thyroid Surgeons (BAETS) in the UK.

RESULTS

78 surgeons responded (40 Endocrine, 37 ENT and 1 maxillofacial). 90% of surgeons used ultrasound and sestamibi for pre-operative localisation. Intraoperative frozen section (31%) and parathyroid hormone monitoring (41%) were the most common adjuncts used intraoperatively. 68% of surgeons did not use any wound drains. Nearly two-thirds of surgeons (64%) discharged patients from the clinic within 3 months, There were some significant differences (p < 0.05) in particular areas of practice between endocrine and ENT surgeons (%, p): use of single-photon emission computed tomography (SPECT) (Endocrine 25% vs. ENT 5%), preoperative laryngeal assessment (endocrine 58% vs. ENT 95%), intraoperative laryngeal nerve monitoring (endocrine 35% vs. ENT 68%), use of monopolar diathermy (endocrine 58% vs. ENT 22%), bipolar diathermy (endocrine 60% vs. 89%) and surgical ties (endocrine 48% vs. ENT 19%).

CONCLUSION

Our study demonstrates some similarities as well as some notable differences in practice between endocrine and ENT surgeons, and therefore, highlights the need for national consensus with respect to some key areas in parathyroid surgery.

AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons

BACKGROUND

Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present.

METHODS

A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness.

RESULTS

Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed.

CONCLUSION

Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.