Thyroid lobe size predicts risk of postoperative temporary recurrent laryngeal nerve paralysis

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.

Prevalence and Predictors of Post-Thyroidectomy Voice Dysfunction in a Nigerian Cohort

BACKGROUND

Advances in surgical techniques have significantly improved the safety of thyroidectomy. Quality of life issues, such as voice changes, however continue to be important considerations. This study evaluated the prevalence and determinants of voice changes following thyroidectomies for non-malignant goiters in a Nigerian Hospital.

METHODOLOGY

Consecutive adults who had thyroidectomy for non-malignant goiters were evaluated. Preoperatively, each participant had laryngoscopy and voice assessment using the Voice Handicap Index-10. At surgery, the intubation difficulty score, size of endotracheal tubes, and duration of operation were recorded. Laryngoscopy and VHI-10 assessments were repeated 1 week, 1 month, and 3 months after surgery. Pre and postoperative assessments were compared.

RESULT

Fifty-four patients completed the study. Subtotal thyroidectomy was the commonest operation performed in 17 patients (31.48%), with 14 (25.93%) having total thyroidectomy. Baseline median VHI-10 score was 6.5(IQR-10). Five patients had abnormal preoperative laryngoscopy findings (benign vocal cord lesions). Postoperatively, seven patients had endoscopic evidence of vocal cord paralysis, six were unilateral while one was bilateral. Ten patients (18.5%) had early voice changes. Median VHI-10 score at one week was significantly higher than baseline (10 vs. 6.5, p = 0.01). At 3 months, VHI-10 reverted back to baseline in five of the ten patients while five patients (9.3%) had persistent voice changes. Abnormal endoscopic findings predicted the occurrence of early postoperative voice changes.

CONCLUSION

Thyroidectomy for non-malignant goiters is associated with transient voice changes, many of which revert to normal over time. Abnormal endoscopic findings predict its occurrence.

[Predictive value of strobovideolaryngoscopy, acoustic and aerodynamic measures in the prognosis of temporally unilateral vocal fold paralysis after thyroidectomy]

Objective:To investigate the strobovideolaryngoscopy, acoustic and aerodynamic characteristics of transient unilateral vocal ford paralysis（UVFP） after thyroidectomy. Methods:A retrospective analysis was made of 11 patients with temporary UVFP after thyroidectomy who were treated in Department of Otolaryngology and Head and Neck Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from January 2013 to March 2021; 8 patients with permanent UVFP after thyroidectomy during the same period were included as a control group. The differences in baseline strobovideolaryngoscopy, acoustic and aerodynamic measures were compared between the two groups. Results:The tones of patients with temporary UVFP after thyroidectomy were all normal, and the proportions of abnormal vocal fords（vocal ford bowing, atrophy, and shortening）, ventricular adduction and glottic insufficiency were significantly lower than those of permanent UVFP patients; arytenoid cartilage stability and height mismatch of vocal ford tended to be better than permanent UVFP. The maximal phonation time（MPT） in patients with temporary UVFP was （8.5±4.1） s, which was significantly longer than （3.9±2.1） s in patients with permanent UVFP; fundamental frequency, mean airflow（MeAF） and mean subglottic pressure（SGP） were better in temporary UVFP than those in patients with permanent UVFP, but the difference did not reach statistical significance. Conclusion:None and mild glottic insufficiency, normal tone, ventricular adduction, and vocal ford appearances without vocal fold bowing, atrophy, and shortening, can be served as the predictors for the early recovery of vocal ford movement in temporary UVFP after thyroidectomy. The MPT less than 4 s, and MeAF, and SGP remarkably increased is the predictor of poor prognosis for vocal ford recovery.

Thyroid Gland Flap for Minimally Invasive Reconstructive Head and Neck Surgery

Head and neck surgery sometimes causes small defects, and salvage surgery after chemoradiotherapy poses some risk because of damage to the surgical site from the previous treatment. We have developed a novel thyroid gland flap for head and neck surgical reconstruction and here we describe elevating the flap, including arc rotation, size, and suture technique, and our outcomes to date.

Methods

Thyroid gland flap reconstruction was performed in 13 cases (11 patients) between July 2009 and May 2020. The clinical importance and adverse effects of the procedure were examined. Thyroid function and blood flow of the flap were assessed, and the status of the flap and irradiated recipient tissue was examined histopathologically.

Results

Median age at surgery was 64.6 years (range 49-77 years). Two of the patients underwent reconstruction with a thyroid gland flap twice. There were 4 cases of primary head and neck cancer resection with neck dissection in which the flap was harvested from the thyroid gland as reinforcement. In 1 case, surgery was performed for cervical esophageal diverticulum. In all cases, the arc was limited to 6 cm and suturing was basic. There were no complications of the surgical procedure, and the postoperative course was uneventful. Contrast-enhanced computed tomography revealed adequate enhancement of the flap. Postoperative thyroid function was normal. The thyroid gland flap was firmly adapted and fused with the irradiated recipient tissue.

Conclusion

The thyroid gland flap could be an effective tissue flap fed by the superior thyroid arteriovenous pedicle for head and neck reconstruction.