Recurrent laryngeal nerve damage and phonetic modifications after total thyroidectomy: surgical malpractice only or predictable sequence?

Patient-perceived dysphagia and voice change post thyroid surgery: a telephone questionnaire

OBJECTIVE

This study analyses the incidence of subjectively experienced dysphagia and voice change in post-thyroidectomy and parathyroidectomy patients without recurrent laryngeal nerve palsy.

METHODS

A total of 400 patients were invited to participate in a telephone questionnaire based on the Dysphagia Handicap Index and Voice Handicap Index. At 6-24 months following surgery, participants were divided into: post-thyroid surgery (total, hemi-, parathyroidectomy) groups and controls (other ENT procedures). A total of 254 responses were received (127 following thyroid surgery, 127 controls).

RESULTS

Twenty-two per cent of post-thyroidectomy patients had a Voice Handicap Index score of more than 3, compared to 15 per cent of parathyroid patients and 4 per cent of controls. The mean Dysphagia Handicap Index score for patients post thyroidectomy and hemi-thyroidectomy was 2.0. Parathyroidectomy patients had a mean Dysphagia Handicap Index score of 1.3, higher than controls at 1.0.

CONCLUSION

Dysphagia and voice alteration are common following thyroid surgery, even in the absence of recurrent laryngeal nerve injury. Both deficits occur more frequently following thyroid surgery than parathyroid surgery.

Effects of Intraoperative Nerve Monitoring Techniques on Voice and Swallowing Disorders after Uncomplicated Thyroidectomy: Preliminary Report of a Bi-Institutional Prospective Study

Background: Voice and swallowing problems are frequently associated with thyroidectomy. Intermittent nerve monitoring (i-IONM) seems to provide a positive effect in reducing its prevalence. The aim of this study was to test the hypothesis that continuous intraoperative nerve monitoring (c-IONM) may reduce the prevalence of these disorders even further than i-IONM. Methods: This 3-arm prospective bi-institutional study compared 179 consecutive patients that underwent thyroidectomy: 56 without IONM, 55 with i-IONM and 67 with c-IONM. Neck dissections and laryngeal nerve palsies were excluded. Two questionnaires (VHI-10 for voice disorders and EAT-10 for swallowing disorders; both validated for Italian language use) were administered before and 1 month after surgery. Statistical significance was analyzed by the chi-squared test. Results: After thyroidectomy, no statistically significant differences were found in the three groups concerning EAT-10. although these symptoms seemed to be influenced by gastro-esophageal reflux. VHI-10 worsened in the “no-IONM” group compared with both i-IONM (p < 0.09, not quite statistically significant) and c-IONM (p < 0.04). Conclusion: Both i- and c-IONM improve voice quality independently of laryngeal nerve integrity. Reduced dissection and particularly restrained manipulation could explain these results, being particularly favorable for c-IONM.

Varied Recurrent Laryngeal Nerve Course Is Associated with Increased Risk of Nerve Dysfunction During Thyroidectomy: Results of the Surgical Anatomy of the Recurrent Laryngeal Nerve in Thyroid Surgery Study, an International Multicenter Prospective Anatomic and Electrophysiologic Study of 1000 Monitored Nerves at Risk from the International Neural Monitoring Study Group

Background: The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of the RLN on nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM). Methods: A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed. Results: A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports. Conclusions: Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.

How the Severity and Mechanism of Recurrent Laryngeal Nerve Dysfunction during Monitored Thyroidectomy Impact on Postoperative Voice

Simple Summary

Recurrent laryngeal nerve (RLN) dysfunction remains a major source of morbidity after thyroid surgery. Intraoperative neuromonitoring can qualify and quantify RLN function according to the laryngeal electromyography (EMG) response evoked by electrical stimulation of the RLN. To the best of our knowledge, this is the first report to discuss the severity and mechanism of RLN dysfunction and postoperative voice in patients who have received monitored thyroidectomy. For optimal voice and swallowing outcomes after thyroid surgery, thermal injury must be avoided, especially when using energy-based devices, and mechanical injury must be identified early to avoid a more severe dysfunction. Adherence to standard intraoperative neuromonitoring (IONM) procedures for thyroid surgery is suggested, including standard procedures for acquiring and interpreting intraoperative RLN signals, for identifying and classifying RLN injury mechanisms, for performing laryngeal examinations and comprehensive voice assessments (subjective and objective voice analysis) before and after surgery, and for performing standard follow-up procedures.

Abstract

Intraoperative neuromonitoring can qualify and quantify RLN function during thyroid surgery. This study investigated how the severity and mechanism of RLN dysfunction during monitored thyroid surgery affected postoperative voice. This retrospective study analyzed 1021 patients that received standardized monitored thyroidectomy. Patients had post-dissection RLN(R2) signal <50%, 50–90% and >90% decrease from pre-dissection RLN(R1) signal were classified into Group A-no/mild, B-moderate, and C-severe RLN dysfunction, respectively. Demographic characteristics, RLN injury mechanisms(mechanical/thermal) and voice analysis parameters were recorded. More patients in the group with higher severity of RLN dysfunction had malignant pathology results (A/B/C = 35%/48%/55%, p = 0.017), received neck dissection (A/B/C = 17%/31%/55%, p < 0.001), had thermal injury (p = 0.006), and had asymmetric vocal fold motion in long-term postoperative periods (A/B/C = 0%/8%/62%, p < 0.001). In postoperative periods, Group C patients had significantly worse voice outcomes in several voice parameters in comparison to Group A/B. Thermal injury was associated with larger voice impairments compared to mechanical injury. This report is the first to discuss the severity and mechanism of RLN dysfunction and postoperative voice in patients who received monitored thyroidectomy. To optimize voice and swallowing outcomes after thyroidectomy, avoiding thermal injury is mandatory, and mechanical injury must be identified early to avoid a more severe dysfunction.

Morbidity and mortality analysis in general surgery operations. Is there any room for improvement?

BACKGROUND

The aim of this work is to examine the performance of surgeries, by evaluating the results. The evaluation of the results, with particular attention to complications, is the corner stone to identify the causes leading to correction of any predisposing factors and reducing risks, to improve quality of care.

METHODS

We performed a retrospective analysis of 952 consecutive patients who had elective or emergency surgery from November 1, 2018 to October 31, 2019. We classified surgical intervention according to their complexity. The Clavien Dindo classification was used to categorize the complications. We performed a stepwise multivariate logistic-regression analysis, with the presence of post-operative complications as dependent variable and age, gender, BMI, ASA, type of surgery procedures, complexity of surgery, operative time as covariates.

RESULTS

A total of 952 surgical procedures were included in this study. Abdominal procedures were the most frequent type of surgery performed (52.1%). Post-operative complications occurred in 120 surgical procedures (12.6%), these are related to the increase of the ASA score and the longer average operative time, with an increase of developing complication of 5% for each additional 10 minutes of surgery.

CONCLUSIONS

many factors influence postoperative morbidity and mortality. Particular attention was due to complication's evaluation, about all in abdominal surgery and high complexity procedures. We argue that key factors which influence the favourable surgical outcome are: compliance with standardized safety procedures, volume of activity of the structure, presence of interdisciplinary care groups, and ability of health professionals in recognizing and promptly treating complications.

Patient Self-Assessment and Acoustic Voice Analysis in Screening of Postoperative Vocal Fold Paresis and Paralysis

Background and objective:

The aim of this study was to evaluate the utility of two items in vocal fold paresis and paralysis screening after thyroid and parathyroid surgery: patient self-assessment of voice using the Voice Handicap Index and computer-based acoustic voice analysis using the Multi-Dimensional Voice Program.

Methods:

This was a prospective study of 181 patients who underwent thyroid or parathyroid surgery over a 1-year study period (2017). Preoperatively, all patients underwent laryngoscopic vocal fold inspection and acoustic voice analysis, and they completed the Voice Handicap Index questionnaire. Postoperatively, all patients underwent laryngoscopy prior to hospital discharge; 2 weeks after the surgery, they completed the Voice Handicap Index questionnaire a second time. Two weeks postoperatively, patients with vocal fold paresis or paralysis and 20 randomly selected controls without vocal fold paresis or paralysis underwent a follow-up acoustic voice analysis.

Results:

Fourteen patients had a new postoperative vocal fold paresis or paralysis. Postoperatively, the total Voice Handicap Index score was significantly higher (p = 0.040) and the change between preoperative and postoperative scores was greater (p = 0.028) in vocal fold paresis or paralysis patients. A total postoperative Voice Handicap Index score > 30 had 55% sensitivity, and 90% specificity, for vocal fold paresis or paralysis. In the postoperative Multi-Dimensional Voice Program analysis, vocal fold paresis or paralysis patients had significantly more jitter (p = 0.044). Postoperative jitter > 1.33 corresponded to 55% sensitivity, and 95% specificity, for vocal fold paresis or paralysis.

Conclusions:

In identifying postoperative vocal fold paresis or paralysis, patient self-assessment and jitter in acoustic voice analysis have high specificity but poor sensitivity. Without routine laryngoscopy, approximately half of the patients with postoperative vocal fold paresis or paralysis could be overlooked. However, if the patient has no complaints of voice disturbance 2 weeks after thyroid or parathyroid surgery, the likelihood of vocal fold paresis or paralysis is low.

Perceptual Assessment and Acoustic Voice Analysis as Screening Tests for Vocal Fold Paresis After Thyroid or Parathyroid Surgery

Background

The aim of this study was to evaluate the reliability of clinician-based perceptual assessment of voice and computerized acoustic voice analysis as screening tests for vocal fold paresis or paralysis (VFP) after thyroid and parathyroid surgery.

Methods

This was a prospective study of 181 patients undergoing thyroid or parathyroid procedure with pre and postoperative laryngoscopic vocal fold inspection, perceptual voice assessment using grade, roughness, breathiness, asthenia, and strain (GRBAS) scale and acoustic voice analysis using the multi-dimensional voice program (MDVP). Patients were divided into 2 groups for comparison; those with new postoperative VFP and those without. Potential screening tools were evaluated using the receiving operating characteristic (ROC) analysis.

Results

Fourteen (6.6%) patients had a new postoperative VFP. Postoperative GRBAS scores were significantly (P < 0.05) higher in patients with VFP compared to those without. However, there were no statistically significant differences in MDVP values between the groups. Postoperative GRBAS grade score (cut off > 0) had the best sensitivity, 93%, for predicting VFP, but the specificity was only 50%. Postoperative jitter (cut off > 1.60) in MDVP had a good specificity, 90%, but only 50% sensitivity. Combining all the GRBAS and MDVP variables with P < 0.05 in the ROC analysis yielded a test with 100% sensitivity and 55% specificity.

Conclusions

Physician-based perceptual voice assessment has a high sensitivity for detecting postoperative VFP, but the specificity is poor. The risk of VFP is low in patients with completely normal voice at discharge. However, routine laryngoscopy after thyroid and parathyroid surgery is still the most reliable exam for VFP screening.

Posture and dysphonia associations in patients undergoing total thyroidectomy: stabilometric analysis

The aim of this study is the analysis of postural changes of patients affected by vocal disorders post-thyroidectomy, in the absence of post-operative organ damage, through a stabilometry analysis, evaluating the effectiveness of a speech-language intensive treatment in phoniatric and postural quality recovery. 260 patients with vocal dysfunction after surgery without iatrogenic damage were enrolled. 130 patients were subject to post-surgical logopedic rehabilitative training (Group A); other 130 patients were not subject to any post-surgical treatment (Group B). For all patients, vocal and stabilometric parameters were evaluated before and after 2 days and 1 month from surgery. Vocal parameters evaluated were Voice Handicap Index-10, Maximum Phonation Time and objective evaluation of voice with Multidimensional Voice Program (MDVP). Stabilometric parameters evaluated were Sway area (mm²) and Sway velocity (mm/s) in firm surface and foam pad with eyes opened and closed. Regarding the stabilometric parameters, Group A obtained a statistically significant recovery of the correct posture statistically significant compared to Group B, after a month of speech therapy. Vocal parameters (VHI, MPT, MDVP) were statistically different between the two groups (p < 0.05), with a better improvement in Group A. Thanks to our study, we have shown that a logopedic rehabilitation therapy in patients with dysfunctional post-thyroidectomy dysphonia improves both the vocal and postural outcomes.

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.

Dysphagia following uncomplicated thyroidectomy: a systematic review

OBJECTIVE

Dysphagia after uncomplicated thyroidectomy is commonly reported and it includes a broad spectrum of swallowing complaints. Though various causes have been hypothesized, it remains not completely understood.

METHODS

A systematic review was performed to identify studies concerning dysphagia post uncomplicated thyroid surgery. A qualitative analysis of data extracted was conducted.

RESULTS

We have included 16 studies of which 15 are prospective and one are retrospective. The number of subjects varied from 12 to 254, the mean age from 39 to 54 years with an overall prevalence of females. The duration of the follow-up ranges from 1 month to 4 years. All the included trials documented postoperative dysphagia, 12 of which have detected it in the early postoperative period. Considering long-term follow-up period, 12 studies reported an overall improvement of swallow symptoms. The instrumental findings revealed non-specific alterations of swallowing.

CONCLUSIONS

Dysphagia after uncomplicated thyroidectomy can arise early in the postoperative period resolving spontaneously in the first year. Diagnostic methods failed to identify the physio pathological mechanism of swallow alteration leaving this condition still unclear. Since these symptoms can reduce patient's quality of life, we suggest an appropriate education before thyroid surgery.

Laryngeal and vocal alterations after thyroidectomy

Introduction

Objective

Methods

Results

Conclusion

Effect of wound massage on neck discomfort and voice changes after thyroidectomy

BACKGROUND

Neck discomfort and voice change are common complications after thyroidectomy. These symptoms might be due to damaged laryngeal nerves, intrinsic structures, or extralaryngeal muscles. They can also occur without injury to any structure as with wound adhesion after thyroidectomy. The objective of this study was to determine causes of neck discomfort and voice change after thyroidectomy and to evaluate the effect of wound massage on symptom relief.

METHODS

Forty-five female patients who underwent total thyroidectomy were included (21 in the experimental group and 24 in the control group). Wound massage was used as an intervention to release surgical adhesion. After wound massage education, participants in the experimental group received wound massage from 4 to 12 weeks after thyroidectomy. Analysis was performed for both groups.

RESULTS

No laryngeal pathology was found after thyroidectomy. The experimental group had significantly better recovery from surgical adhesion and subjective visual analog scale, voice impairment score, and swallowing impairment score (all P < .01) compared with the control group. Voice analysis results associated with laryngeal movement (speaking fundamental frequency, voice range profile maximum, voice range profile range) also indicated significant recovery (P < .01) in the experimental group. These results indicate that local adhesion after thyroidectomy might affect general movement of the larynx and that wound massage could help patients recover normal general movement of the larynx.

CONCLUSION

Neck discomfort and voice change after thyroidectomy are related to local wound adhesion, possibly associated with impairment of laryngeal vertical movement. Release of wound adhesion could help patients recover from neck discomfort and voice changes after thyroidectomy.

Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society Consensus Statement

"I have noticed in operations of this kind, which I have seen performed by others upon the living, and in a number of excisions, which I have myself performed on the dead body, that most of the difficulty in the separation of the tumor has occurred in the region of these ligaments…. This difficulty, I believe, to be a very frequent source of that accident, which so commonly occurs in removal of goiter, I mean division of the recurrent laryngeal nerve." Sir James Berry (1887).

Lateral neck dissection affects the voice in thyroid cancer patients

Objective:

This study aimed to identify the effect of lateral neck dissection on voice change in thyroidectomised patients.

Methods:

Medical records from 264 patients who underwent thyroidectomy with (n= 65) or without (n= 199) lateral neck dissection were reviewed. Clinical and voice evaluation data were compared between the two groups.

Results:

Patients who underwent surgery that included lateral neck dissection had lower fundamental frequencies and speaking fundamental frequencies. They also had a higher incidence of asymmetric mucosal wave and vocal fold oedema on videostroboscopy during the first month after surgery, with the incidence of vocal fold oedema remaining significantly higher at three months. Self-assessed voice quality scores were significantly higher in lateral neck dissection patients at both one and three months after surgery.

Conclusion:

In thyroidectomised patients, lateral neck dissection lowers the vocal pitch in the initial period after surgery and induces vocal fold oedema that persists for several months. Although most objective parameters improved within a month, subjective symptoms lasted for longer.

Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation

Aim of the present paper is the review of the principal complications associated to endocrine neck surgery considering how expertise, full adoption of guidelines, appropriate technology and proper informed consent may limit the medicolegal claims at the light of the incoming new regulation of the medical professional legal responsibility. A literature search, using the Medline/PubMed database for full-length papers, was used. Postoperative recurrent laryngeal nerve (RLN) palsy and hypoparathy-roidism remain the principal causes of surgical malpractice claims . In the procedure of neck lymphadenctomy intra-operative haemorrhage, thoracic duct injury, injuries to loco-regional nerves can be observed and can be source of claims. After many years of increased medicolegal litigations, the Italian government is proposing a drastic change in the regulations of supposed medical malpractice in order to guarantee the patient's right to a safe treatment and in the meantime to defend clinicians from often unmotivated and prejudicial legal cases. Surgical errors and complications in neck surgery are a relevant clinical issue. Only the combination of surgical and clinical expertise, application of guidelines, appropriate technology and a routinely use of specific informed consent can contain potential medicolegal implications.

The weepy nerve-different sensitivity of left and right recurrent laryngeal nerves under tensile stress in a porcine model

PURPOSE

Recurrent laryngeal nerve palsy in thyroid surgery is still a threatening complication. Our aim was to analyze the impact of prolonged tensile stress on the recurrent laryngeal nerve (RLN) in an animal model using continuous intraoperative neuromonitoring (C-IONM).

METHODS

Constant tensile stress was applied to left and right RLNs in 20 pigs (40 RLN). In a pilot study, five animals were subjected to a tensile force of 0.34 ± 0.07 N for 10 min and changes in amplitude were documented using C-IONM. In the main study, a force of 1.2 N was applied until the signal amplitude was reduced by 85 %, in 15 pigs. Nerve conductivity was analyzed by threshold current measurements.

RESULTS

Good correlation was found between stress and amplitude decrease in the pilot study as well as between signal decrease and duration of trauma in the main study. Great variations were found inter- and intra-individually. These variations were most prominent at 85 % signal reduction (median 36 min, range 0.3-171 min). There was no side specificity (left 0.3-171 min, right 0.3-168 min, respectively, p = 0.19). However, in each individual animal, there was a sensitive (0.3-98.9 min) and less sensitive nerve (26.8-171 min). These differences became highly significant at 85 % of signal reduction (p = 0.008), where the vulnerability is 1.4 to 146.4 times higher on one side (mean 4.3).

CONCLUSIONS

Our study demonstrates the presence of a sensitive RLN that was 4.3 times more vulnerable than the contralateral nerve (range 1.4-146.4 times, p = 0.008). Thus, the right and the left nerves cannot be assumed to be of equal sensitivity to trauma. In our data, the more sensitive nerve does not occur predominantly on one side and was named the "weepy nerve."

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

This American Head and Neck Society (AHNS) consensus statement discusses the techniques of laryngeal examination for patients undergoing thyroidectomy and parathyroidectomy. It is intended to help guide all clinicians who diagnose or manage adult patients with thyroid disease for whom surgery is indicated, contemplated, or has been performed. This consensus statement concludes that flexible transnasal laryngoscopy is the optimal laryngeal examination technique, with other techniques including laryngeal ultrasound and stroboscopy being useful in selected scenarios. © 2016 Wiley Periodicals, Inc. Head Neck 38: 811-819, 2016.

Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years

INTRODUCTION

Prognosis of thyroid cancer is strictly related to loco-regional metastases. Cervical lymphadenectomy has a specific oncologic role but may lead to significant increase of morbidity. Aim of the study is the analysis of surgical morbidity in cervical lymphadenectomy for thyroid cancer.

METHODS

We retrospectively analyzed 1.765 thyroid cancers operated over a period of 25 years at S. Maria University Hospital, Terni, University of Perugia, Italy. Type of lymphadenectomy, histology and complications were analysed.

RESULTS

A prevalence of differentiated and medullary cancers was observed (respectively 88% and 7.2%). Central lymphadenectomy was carried out in 425 patients, lateral modified and radical lymphadenectomy respectively in 651 and 17 cases. Following central neck dissection we observed: bilateral and unilateral temporary recurrent nerves palsy respectively of 0.7% and 3.5%, unilateral permanent palsy in 1.6% of cases, temporary and permanent hypoparathyroidism respectively in 17.6% and 4.4%. After lateral neck dissection we observed: intra and post-operative haemorrhage respectively in 2% and 0.29%, respiratory distress in 0.29%, lesions of facial nerve in 0.44%, of vagus in 0.14%, of phrenic nerve in 0.14%, of hypoglossal nerve in 0.29%, of the accessory nerve, transient in 1.34% and permanent in 0.29%, permanent lesion of cervical plexus in 0.29%, salivary fistula in 0.14% and chylous fistula in 1.04% of patients. Student's t test was used to compare groups when appliable.

CONCLUSION

Central and lateral cervical lymph node dissection are associated to severe morbidity. Correct indication, surgical expertise, high volume of patients and early multidisciplinary management of complications is the key of an acceptable balance between oncologic benefits and surgical morbidity.

Voice outcomes following reoperative central neck dissection for recurrent/persistent thyroid cancer

OBJECTIVES/HYPOTHESIS

We aimed to assess voice outcomes following reoperative central neck dissection (RCND) to characterize postoperative voice difficulties experienced, determine the natural progression of vocal recovery, and identify risk factors for the development of voice disorders postoperatively.

STUDY DESIGN

Prospective cohort study.

METHODS

Consecutive patients with recurrent/persistent thyroid cancer who were deemed appropriate candidates for RCND were eligible for participation in this study. A battery of voice evaluation measures was administered both preoperatively and 2 to 4 weeks postoperatively.

RESULTS

Twenty consecutive patients were included. Postoperatively, six (30%) new incidents of vocal fold motion impairment (VFMI) were identified, with two (10%) being due to intentional recurrent laryngeal nerve (RLN) transection. On 1-year follow-up, two patients had full restoration of vocal fold mobility and four had persistent VFMI. No preoperative voice/laryngeal exam factors were predictive of postoperative VFMI. Clinically relevant change in postoperative Voice Handicap Index score was absent in all patients without VFMI and present in five of six patients with VFMI (P=.0004). Patients with VFMI had significantly poorer overall dysphonia grade, less glottic closure, and elevated jitter in contrast to those individuals without VFMI. Patients with malignant tissue in the remnant thyroid were four times more likely to develop VFMI than those with central neck lymph node metastases alone (P=.06).

CONCLUSION

Patients undergoing RCND are at risk for postoperative VFMI, even when the RLN is anatomically preserved, with subsequent impact on quality of life. Presence of malignant disease in the remnant thyroid appears to be the best predictor for postoperative VFMI.

LEVEL OF EVIDENCE

2b.

Thyroidectomy in the professional singer-neural monitored surgical outcomes

BACKGROUND

Voice changes commonly occur from thyroidectomy and may be due to neural or nonneural causes. Such changes can be a source of significant morbidity for any patient, but thyroidectomy in the professional singer carries special significance. We test the hypothesis that the career of singers and professional voice users is not impaired after neural monitored thyroid surgery.

METHODS

A quantitative analysis of pre- and postoperative neural monitored thyroid surgery voice outcomes utilizing three validated vocal instruments-Voice Handicap Index (VHI), Singing Voice Handicap Index (SVHI), and Evaluation of Ability to Sing Easily (EASE)-in a unique series of professional singers/voice users was performed. Additional quantitative analysis related to final intraoperative electromyography (EMG) amplitude, the time to return to performance, and vocal parameters affected during this interval was performed.

RESULTS

Twenty-seven vocal professionals undergoing thyroidectomy were identified, of whom 60% had surgery for thyroid cancer. Pre- and postsurgery flexible fiberoptic laryngeal exams were normal in all patients. Return to performance rate was 100%, and mean time to performance was 2.26 months (±1.61). All three vocal instrument mean scores, pre-op vs. post-op, were unchanged: VHI, 4.15 (±5.22) vs. 4.04 (±3.85), p=0.9301; SVHI, 11.26 (±14.41) vs.12.07 (±13.09), p=0.8297; and EASE, 6.19 (±9.19) vs. 6.00 (±7.72), p=0.9348. The vocal parameters most affected from surgery until first performances were vocal fatigue (89%), high range (89%), pitch control and modulation (74%), and strength (81%). Final mean intraoperative EMG amplitude was within normal limits for intraoperative stimulation and had no relationship with time to first professional performance (p=0.7199).

CONCLUSIONS

Neural monitored thyroidectomy, including for thyroid malignancy, in professional voice users is safe without any changes in three different voice/singing instruments, with 100% return to performance. Intraoperative EMG data at the conclusion of surgery and postoperative laryngeal exam were normal in all patients. Specific vocal parameters are transiently affected during the postoperative recovery phase, which is important to outline in the consent process of this unique patient population and may provide insight into the physiologic state of the larynx subsequent to thyroid surgery.

Prospective randomized controlled trial on the use of flexible reinforced laryngeal mask airway (LMA) during total thyroidectomy: effects on postoperative laryngopharyngeal symptoms

BACKGROUND

Sore throat, hoarseness, dysphagia, and cough are common laryngopharyngeal discomforts after thyroidectomy. The incidence and severity of laryngopharyngeal symptoms after the use of a flexible reinforced laryngeal mask airway (LMA) were compared with those that occur after the use of a plain endotracheal tube in patients after thyroidectomy.

METHODS

Seventy-six patients scheduled for total thyroidectomy were randomized into a plain endotracheal tube group (group E) or a flexible reinforced LMA group (group L). Total intravenous anesthesia (propofol and remifentanil) was used for maintenance of anesthesia. Hemodynamic variables were recorded during induction of anesthesia. The incidence and severity (100-point numerical rating scales) of laryngopharyngeal symptoms, including sore throat, hoarseness, dysphagia, and cough, were assessed at 1, 24, and 48 h after surgery.

RESULTS

All patients were placed successfully with an endotracheal tube or a flexible reinforced LMA. The postoperative incidence and severity of sore throat (25 vs. 33 at 24 h, p = 0.035, 17 vs. 28 at 48 h, p = 0.017; 50 [0-100] vs. 80 [20-100] at 1 h, p = 0.002; 30 [0-80] vs. 50 [0-100] at 24 h, p < 0.001; 0 [0-40] vs. 30 [0-90] at 48 h, p < 0.001) and hoarseness were lower in group L than in group E. At 48 h postoperatively, dysphagia (p = 0.005) and cough (p = 0.028) occurred less frequently in group L than in group E patients.

CONCLUSION

A flexible reinforced LMA placed during surgery decreases the incidence and severity of laryngopharyngeal symptoms and is a feasible anesthetic tool compared with a conventional endotracheal tube for thyroidectomy.

A single surgeon's experience and surgical outcomes of 300 robotic thyroid surgeries using a bilateral axillo-breast approach

OBJECTIVES

We introduce surgical outcomes regarding 300 cases of robotic thyroidectomy using a bilateral axillo-breast approach (BABA).

METHODS

From April 2010 to October 2013, 300 patients who underwent robotic thyroidectomy were analyzed and compared with 300 cases of open total thyroidectomy. Robotic surgery was performed with a snake retractor to allow for complete central lymph node dissection. We performed robotic surgery using BABA without drains in 170 cases; subfascial dissection was performed to reduce post-operative wound adhesion.

RESULTS

The learning curve for robotic thyroidectomy was 40 cases; after that, the operation time significantly decreased (233 min vs. 185 min, P=0.001). A snake retractor was selectively useful for the dissection of paratracheal lymph nodes located in the deep areas. In patients who underwent drainless BABA, additional aspirations were required in only 19 (6.3%). The number of retrieved lymph nodes of robot and open surgery were 6.7 ± 0.2 and 8.9 ± 0.3, respectively (P<0.001). The mean serum thyroglobulin of thyroid hormone was 0.80 ± 0.19 and 1.77 ± 0.29 ng/ml, respectively (P=0.001). Post-operative complications of robot surgery, including transient hypocalcemia (n=33, 23.0%) in total thyroidectomy, transient recurrent laryngeal nerve palsy (n=8, 2.6%) without permanent palsy rarely observed.

CONCLUSION

Robotic thyroidectomy using BABA is an effective and comparable treatment option. J. Surg. Oncol. 2015 111:135-140.

Postoperative hypocalcemia: assessment timing

180 total thyroidectomy case studies performed by the same operator in the years 2006-2010, all done with sutureless technique (Ligasure precise(®)). The monitoring of patients involved a dose of serum calcium on the 1st, 2nd, 3rd and seventh post-operative, before the ambulatory monitoring of the patient. Treatment of post-operative thyroidectomy also includes the administration from the first day of post-surgery, of 2 g/day of calcium (calcium lactate gluconate 2940 mg, calcium carbonate 300 mg). Hypocalcemia was observed in 27 cases (15%) of which 23/180 (12.8%) were transitional and 4/180 (2.2%) were permanent. The average postoperative hospitalization was 2.5 days with a minimum of 30 h. The peak of hypocalcemia was of 11 patients on the first postoperative day (40.7%) in 6 patients on the second postoperative day (22.2%), in 8 patients on the third postoperative day (29.6%), in 1 patient on the fourth postoperative day (3.7%) and in another one on the fifth postoperative day (3.7%). The second postoperative day is crucial for the determination of early discharge (24-30 h). When the surgeon identifies and manages to preserve at least 3 parathyroid glands during surgery, the risk of hypocalcemia together with evaluations of serum calcium on the first and second post-operative day, eliminates the hypocalcemic risk.

Hoarseness after thyroidectomy: blame the endocrine surgeon alone?

OBJECTIVE

Hoarseness is a postoperative complication of thyroidectomy, mostly due to damage to the recurrent laryngeal nerve (RLN). Hoarseness may also be brought about via vocal cord dysfunction (VCD) due to injury of the vocal cords from manipulations during anesthesia, as well as from psychogenic disorders and respiratory and upper-GI related infections. We reviewed the literature aiming to explore these potential surgical and non-surgical causes of hoarseness beyond thyroidectomy and the role of the endocrine surgeon. Is he/she alone to blame?

METHODS/MATERIAL

The MEDLINE/PubMed database was searched for publications with the medical subject heading "hoarseness" and keywords "thyroidectomy", "RLN", "VCD" or "intubation". We restricted our search till up to May 2013.

RESULTS

In our final review we included 80 articles and abstracts that were accessible and available in English. We demonstrated the incidence of hoarseness stemming from surgical and non-surgical causes and also highlighted the role of intubation as a potential cause of injury-related VCD.

CONCLUSIONS

Hoarseness is a relatively common complication of thyroidectomy, which can be attributed to many factors including surgeon's error or injuries during intubation as well as to other non-surgical causes. However, compared to procedures such as cervical spine surgery, mediastinal surgery, esophagectomy and endarterectomy, thyroidectomy would seem to be a procedure with a relatively low rate of recurrent laryngeal nerve palsies (RLNPs). It is often difficult to determine whether the degree of hoarseness after thyroidectomy should be attributed only the surgical procedure itself or to other causes, for example intubation and extubation maneuvers. The differential diagnosis of postoperative hoarseness requires the use of specific tools, such as stroboscopy and intra- and extralaryngeal electromyography, while methods like acoustic voice analysis, with estimation of maximum phonation time and phonation frequency range, can distinguish between objective and subjective deterioration in the voice. The importance of medical history should be also emphasized.

Clinical Practice Guideline

Objective

Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient’s voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.

Purpose

The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.

Results

The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient’s voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient’s voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient’s voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

Antiadhesive effect and safety of oxidized regenerated cellulose after thyroidectomy: a prospective, randomized controlled study

PURPOSE

To evaluate the antiadhesive effects and safety of an oxidized regenerated cellulose (Interceed) after thyroidectomy.

METHODS

Seventy-six thyroidectomized patients were prospectively randomized into two groups with regard to the use of Interceed. We evaluated each group for their adhesive symptoms using four subjective and four objective items at the 2nd week, 3rd and 6th month after thyroidectomy. All patients were examined for vocal cord motility by indirect laryngoscope at each period.

RESULTS

Total adhesion scores at each postoperative follow-up period decreased with time, but were not significantly different in each group. The median score for swallowing discomfort for liquid was significantly lower in the Interceed group than in the control group 2 weeks after surgery. In addition, the severity of skin adhesion to the trachea was reduced in the Interceed group compared with the control group 6 months after surgery. During the study, there were no adverse effects or significant differences in postoperative complications between the groups.

CONCLUSION

Interceed appeared to be safe and effective in improving neck discomfort at early postoperative periods and preventing skin adhesion to the trachea 6 months after thyroidectomy.

Esophageal Motility Changes after Thyroidectomy; Possible Associations with Postoperative Voice and Swallowing Disorders

Objective

Swallowing and voice impairment are common after thyroidectomy. We evaluated short-term functional changes in esophageal motility in a series of patients who had undergone total thyroidectomy. Several studies have investigated these symptoms by means of interviews or questionnaires.

Study Design

Prospective study.

Setting

Academic research.

Materials and Methods

Thirty-six consenting patients were prospectively recruited. Eligibility criteria were thyroid volume ≤60 mL, benign disease, and age between 18 and 65 years. Exclusion criteria were previous neck surgery, severe thyroiditis, hyperthyroidism, and pre- or postoperative vocal cord palsy. Voice impairment score, swallowing impairment score, lower esophageal sphincter pressure, esophageal motility, upper esophageal pressure, and coordination were evaluated preoperatively and 30 to 45 days after surgery.

Results

Postoperative swallowing impairment (appearance or worsening of dysphagia) was found in 20% of patients and voice impairment in more than 30%. Both preoperative and postoperative esophageal motility were similar. All patients showed an average decrease of 25% in upper esophageal pressure, although the pressure was within normal range. Swallowing alterations were associated with upper esophageal incoordination ( P < .03), and proximal acid reflux was significantly associated with voice impairment ( P < .02).

Conclusion

After uncomplicated thyroidectomy, decreased upper esophageal pressure may explain both pharyngeal (dysphagia) and laryngeal (vocal impairment) exposure to acid. In the future, proton pump inhibitor therapy protocols should be evaluated.

Prevalence of upper aerodigestive symptoms in patients who underwent thyroidectomy with and without the use of intraoperative laryngeal nerve monitoring

BACKGROUND

Upper aerodigestive symptoms (UADS) have been reported by patients who have had thyroidectomies. This study evaluated the long-term prevalence of UADS after thyroidectomy in patients who did and who did not have intraoperative neuromonitoring (IONM).

METHODS

This was a cross-sectional study of patients with normal vocal fold mobility who had a thyroidectomy. It included patients who did and did not have this surgery with IONM. All patients answered a questionnaire regarding UADS occurring one or more years after thyroidectomy. The questionnaire dealt with UADS relating to voice and swallowing symptoms and sought to quantify their severity. The 208 patients who underwent thyroidectomy without IONM were designated the control group (CG). The 100 patients who underwent thyroidectomy with IONM were designated the neuromonitored group (NMG).

RESULTS

The proportion of patients in the CG who reported UADS was 45%; 25.9% of these patients reported voice symptoms, and 33.6% reported swallowing symptoms. The proportion of patients in the NMG who reported UADS was 39%; 27% of these patients reported voice symptoms, and 22% reported swallowing symptoms. Thus, patients in the CG had more swallowing symptoms and a greater severity of UADS-related symptoms than patients in the NMG.

CONCLUSIONS

In this study, IONM had a favorable effect in terms of decreasing the prevalence and severity of UADS occurring one year or more after thyroidectomy.

"Mystic" transient recurrent nerve palsy after thyroid surgery

BACKGROUND

The mechanism of transient recurrent laryngeal nerve (RLN) palsy remains unclear.

METHODS

Samples were harvested from the RLN adjacent thyroid capsule and perineural fascia during 223 lobectomies and 89 RLNs from cadavers were used for histologic and immunohistologic evaluation. Intraoperative chromoendoscopic features of the RLN were compared with postoperative ear, nose, and throat examinations.

RESULTS

Those nerves that macroscopically seem to be single-branched (35 of 89 = 39.3%), microscopically consist of multiple fascicles in most of the cases (23 of 35 = 65.7%), resembling a plexus more than a single cord. Chronic lymphocytic infiltration of the thyroid capsule adjacent to the RLN was present in 29% (65 of 223) of the cases. The perineural fascia showed lymphocytic (18 of 223 = 8.1%) or granulocytic (7 of 223 = 3.1%) infiltration.

CONCLUSIONS

The origin of transient RLN palsy is multifactorial: plexus shaped microscopic nerve structure with or without branches, frame-like adventitial tissue, variable epineurium, inflammatory changes that involve not only the thyroid capsule but the perineural fascia, resultant nerve edema, and diffuse microhemorrhages by injury of fragile capillaries.

Speech-language cooperation protocol for the fiberoptic laryngoscopy evaluation of larynx mobility

BACKGROUND

Voice protocol.

AIM

To propose a protocol for the fiberoptic laryngoscopy evaluation of larynx mobility in thyroid illnesses (PAN), with the intention of having an objective, precise and consensual instrument for this assessment.

METHOD

The first version of the protocol was elaborated based on data found in the literature; the protocol was judged twice, using the triangulation method; a pilot version was presented and applied in 11 patients; it was then judged again by doctors and speech-language pathologists; based on the analysis of the judges and after the application of the pilot version, the final version of the PAN was proposed.

RESULTS

The final protocol was composed by two parts. The first part, considered a standard procedure, is composed by 4 essential items that necessarily should be evaluated: normal inspiration; forced inspiration; vowel /é/ isolated and sustained; and sharp vowel /i/, isolated and sustained. The second part, considered a speech-language complementation, is composed by items that should be understood as being important for speech-language pathologists as they are informative or predictive of the effectiveness of therapy: vowel /é/ sustained and weak; vowel /é/ sustained and sharp; vowel /é/ sustained and deep; vowel /é/ short with abrupt vocal onset.

CONCLUSIONS

The PAN, in its final version, contributes for the systematization of the assessment procedures based on evidence and on the agreement of professionals. The PAN results in the description of items to be obtained during medical and speech-language assessment during the fiberoptic laryngoscopy evaluation of larynx mobility in thyroid illnesses.

Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review

BACKGROUND

Recurrent laryngeal nerve palsy (RLNP) is a recognised possible complication after thyroid surgery. It may present with a variety of symptoms, such as voice change and respiratory symptoms. However, it may remain undetected and the true incidence may be under-reported. The aim of this study was to determine the reported incidence of temporary and permanent palsy after thyroid surgery using different vocal assessment methods.

METHODS

A Medline search was performed. A systematic review was undertaken which included 27 articles and 25,000 patients.

RESULTS

The average incidence of temporary RLNP after thyroid operations is 9.8% and the incidence of permanent RLNP is 2.3%. The RLNP rate varied according to the method of examining the larynx and ranged from 26% to 2.3%. Most of the reviewed studies recommend a follow-up period up to 1 year to assess and evaluate RLNP.

CONCLUSION

Our study has identified that different methods are used to diagnose RNLP and that a wide variety of reported RLNP rates exist. We propose establishment of a 'gold standard' for assessing the voice after thyroidectomy to reduce reporting bias.

Computerized acoustic voice analysis and subjective scaled evaluation of the voice can avoid the need for laryngoscopy after thyroid surgery

BACKGROUND

Because of frequent postoperative alterations in voice, many surgeons include laryngoscopy as a routine examination before/after thyroid surgery. The aim of this work was to determine whether more comfortable and easier subjective or objective postoperative voice assessments could complement or replace laryngoscopy.

METHODS

Sixty-four consecutive patients scheduled to undergo thyroid surgery underwent preoperative objective computerized acoustic voice analysis (CAVA), subjective scaled evaluation of the voice (SSEV) with the GIRBAS scale, and fiberoptic laryngoscopy. All patients had 7- and 30-day postoperative follow-up assessments using the same tests.

RESULTS

CAVA measurements of jitter and noise-to-harmonic ratio showed the most frequent variations (36% and 31%, respectively) between the first and second tests. The mean preoperative SSEV GIRBAS value was 1.3 (range, 0-7) and had deteriorated in 36% of patients at 30 days postoperatively. All patients had a normal preoperative laryngoscopy. At 7 days postoperatively, 5 (8%) patients suffered unilateral vocal cord palsy which recovered in 2 (5%) patients after 1 month. GIRBAS values showed differences between patients with and without a vocal cord palsy both 7 and 30 days postoperatively (P < .05). The vocal parameters jitter and shimmer showed differences (P < .02 each) between patients with or without vocal cord palsy. When there was a change in >or=3 vocal parameters, vocal cord palsy was confirmed by laryngoscopy.

CONCLUSION

After thyroid surgery, vocal cord palsy may be suspected when there is an alteration in GIRBAS scale or in several parameters of the CAVA. Laryngoscopy may only be necessary when the CAVA and SSEV are abnormal.

Does extralaryngeal branching have an impact on the rate of postoperative transient or permanent recurrent laryngeal nerve palsy?

BACKGROUND

This prospective study assessed the prevalence of the extralaryngeal branching of the recurrent laryngeal nerve (RLN) and its impact on the incidence of postoperative transient or permanent RLN palsy.

METHODS

Total or hemithyroidectomy was performed in 115 patients, with a total of 195 RLNs displayed. The RLN extralaryngeal branches were routinely identified and preserved. The postoperative course of each patient was evaluated. Outcomes of patients with and without branching RLN were compared.

RESULTS

In all, 36 of 195 (18.5%) nerves showed extralaryngeal branching: 27 cases (25.5%) on the right and 9 on the left side (10.1%; p = 0.0088).Trifurcation of the RLN was identified in two dissections (1%). Bilateral bifurcations were observed in 3 of 80 (3.7%) patients. We reported four (2.1%) unilateral permanent RLN palsies, eight cases of unilateral transient nerve palsy (4.1%), and one bilateral transient RLN injury (0.6%). The comparative analysis of postoperative outcomes between branched and nonbranched RLNs revealed that the anatomical variation was more frequently associated both with unilateral permanent RLN palsy (relative risk, 13.25; 95% confidence interval, 1.42-123.73; p = 0.0204) and unilateral transient RLN palsy (relative risk, 7.36; 95% confidence interval, 1.84-29.4; p = 0.0061). The only case of bilateral transient RLN injury was associated with a nonrecurrent inferior laryngeal nerve.

CONCLUSIONS

Branched RLNs represent a risk factor both for transient and permanent nerve palsy after surgery. Awareness of this anatomical variation and its routine investigation are essential during thyroid surgery to limit its relevant impact on postoperative RLN injury rate.

Voice and swallowing changes after thyroidectomy in patients without inferior laryngeal nerve injuries

BACKGROUND

We performed a prospective analysis on voice and swallowing alterations following total thyroidectomy (TT), in the absence of recurrent nerve injury.

METHODS

Patients aged 21 to 65 years undergoing TT, in the absence of laryngeal/pulmonary disease, previous neck surgery, or malignant diseases, were subjected to videostrobolaryngoscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) tests preoperatively and 3 months postoperatively. Voice impairment scores (VIS) and swallowing impairment scores (SIS) were obtained preoperatively, and at 1 week, 1 month, and 3 months postoperatively.

RESULTS

Among the 127 selected patients, 39 completed the postoperative evaluation. No recurrent nerve injury was observed during the postoperative VSL in any of the patients. Preoperative and postoperative AVA and MPT scores did not differ significantly. The mean postoperative VIS was significantly higher than the preoperative VIS at 1 week and 1 month after TT (13.7 and 9.6 vs 4.4, respectively; P < .05) but not 3 months after TT (6.7). The mean SIS was higher than the preoperative SIS at 1 week, 1 month, and 3 months after TT (10.3, 6.0, and 2.8 vs 0.5, respectively; P < .05).

CONCLUSIONS

Physicians should inform patients that transient voice and swallowing symptoms may occur following total thyroidectomy, and our data suggest mild symptoms may occur in the majority of operated patients.