Thyroid surgery and voice-related outcomes

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 on Voice Quality of Thyroidectomy: A Qualitative and Quantitative Study Using Voice Maps

OBJECTIVES

This study aims to explore the effects of thyroidectomy-a surgical intervention involving the removal of the thyroid gland-on voice quality, as represented by acoustic and electroglottographic measures. Given the thyroid gland's proximity to the inferior and superior laryngeal nerves, thyroidectomy carries a potential risk of affecting vocal function. While earlier studies have documented effects on the voice range, few studies have looked at voice quality after thyroidectomy. Since voice quality effects could manifest in many ways, that a priori are unknown, we wish to apply an exploratory approach that collects many data points from several metrics.

METHODS

A voice-mapping analysis paradigm was applied retrospectively on a corpus of spoken and sung sentences produced by patients who had thyroid surgery. Voice quality changes were assessed objectively for 57 patients prior to surgery and 2months after surgery, by making comparative voice maps, pre- and post-intervention, of six acoustic and electroglottographic (EGG) metrics.

RESULTS

After thyroidectomy, statistically significant changes consistent with a worsening of voice quality were observed in most metrics. For all individual metrics, however, the effect sizes were too small to be clinically relevant. Statistical clustering of the metrics helped to clarify the nature of these changes. While partial thyroidectomy demonstrated greater uniformity than did total thyroidectomy, the type of perioperative damage had no discernible impact on voice quality.

CONCLUSIONS

Changes in voice quality after thyroidectomy were related mostly to increased phonatory instability in both the acoustic and EGG metrics. Clustered voice metrics exhibited a higher correlation to voice complaints than did individual voice metrics.

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.

Impact of Sternothyroid Muscle Division on Patient-Reported Voice Outcomes After Thyroid Surgery: A Prospective Study

OBJECTIVE

Division of the sternothyroid muscle during thyroidectomy is a widely accepted surgical technique to provide improved exposure of the thyroid gland, thus facilitating the ligation of superior pole vessels and identification of the laryngeal nerves. However, few have examined the impact on voice outcomes. We evaluate the impact of sternothyroid muscle division on patient-perceived voice outcomes after thyroidectomy.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary academic institution.

METHODS

A prospective cohort study was conducted comparing pre- and postoperative voice outcome data after thyroidectomy, measured using Voice Handicap Index-10. The cohort of 109 patients underwent lobectomy or total thyroidectomy by a single surgeon at 1 institution. The sternothyroid muscle was fully divided in all surgeries. The integrity of the recurrent laryngeal and external branches of the superior laryngeal nerve was assessed using intraoperative nerve monitoring and postoperative laryngoscopy. Pre- and postoperative Voice Handicap Index-10 scores were compared.

RESULTS

No statistically significant difference was found between total pre- and postoperative Voice Handicap Index-10 scores (μpreop  = 1.92, μpostop  = 1.83, p = .87). There were no questions yielding statistically significant responses between pre- and postoperative groups. This was consistent regardless of whether the sternothyroid muscle was cut unilaterally or bilaterally. Men showed a statistically significant improvement in score after surgery.

CONCLUSION

These findings support no difference in postoperative voice outcomes after the intraoperative division of the sternothyroid muscle. This supports the usage of this technique as a safe means to facilitate exposure during thyroid surgery and will serve as important information to guide intraoperative surgical decision-making.

Validity and Reliability of the Arabic Thyroidectomy-Related Voice and Symptom Questionnaire (A-TVSQ) for Assessing Post-Thyroidectomy Patients

OBJECTIVE

Post-thyroidectomy patients commonly experience voice changes, swallowing symptoms, and neck discomfort, a condition known as post-thyroidectomy syndrome. The Thyroidectomy-Related Voice and Symptom Questionnaire (TVSQ) is a validated tool showing strong correlations with established tools with a potential predictive value for post-thyroidectomy voice outcomes. Our study aims to translate and validate the TVSQ into Arabic.

METHODS

This validation study was conducted at King Abdulaziz University Hospital and King Khalid University Hospital in Riyadh, Saudi Arabia. Forward and backward translations ensured the conceptual equivalence of the Arabic TVSQ (A-TVSQ) and were reviewed by an expert panel. A pilot test assessed the A-TVSQ's face validity and clarity, leading to necessary cultural adjustments. The final A-TVSQ was preoperatively and postoperatively administered to thyroidectomy patients to evaluate its test-retest reliability.

RESULTS

Data were collected from 116 participants (53 cases [45.6%] and 63 controls [54.3%]). The internal consistency analysis showed strong intercorrelation among the A-TVSQ items, with Cronbach's alpha coefficients (0.951) indicating excellent estimated internal consistency within both domains. Test-retest reliability showed a moderate level of reliability with an intraclass correlation coefficient of 0.696. A-TVSQ item discrimination analysis showed significant associations between the total and domain scores pre- and post-thyroidectomy. External validity analysis showed significant changes in A-TVSQ voice change (P < 0.010) and neck discomfort (P = 0.011) domains and total scores (P < 0.010) between before and 2 weeks after thyroidectomy. However, no significant changes were observed between 2 and 4 weeks after thyroidectomy.

CONCLUSIONS

The translated and validated A-TVSQ showed excellent internal consistency and moderate test-retest reliability, comparable to the original version. Voice change significantly worsened after thyroidectomy, highlighting the need for continued monitoring and management strategies for this complication.

Prethyroidectomy voice and swallowing disorders and the possible role of laryngopharyngeal reflux disease

OBJECTIVES

The aim of the study was to evaluate voice and swallowing function before thyroid surgery and to explore the possible role of thyroid enlargement and laryngopharyngeal reflux (LPR).

METHODS

We conducted a prospective study of patients who underwent hemi- or total thyroidectomy (n = 118) and compared the results with patients of laparoscopic cholecystectomy (n = 110). All subjects underwent videolaryngostroboscopy, filled in subjective evaluations of voice, swallowing and reflux complaints. Acoustic voice analysis (AVA), maximum phonation time (MPT) and perceptual voice evaluation were conducted.

RESULTS

We found no difference in voice quality between study and control group, neither in subjective complaints nor in AVA or perceptual evaluation. We did find indicative signs of minor laryngeal changes in thyroid group. Swallowing Impairment Score (SIS) revealed worse swallowing function in thyroid patients (p = 0.0006). Comparison of Reflux Symptom Index (RSI) scores revealed that thyroid group patients have higher values compared to control group (p = 0.006). Nevertheless, Reflux Finding Score (RFS) showed identical scores in both groups (p = 0.220). In thyroid group there was a strong positive correlation between RSI and SIS (ρ = 0.641), but no correlation between RFS and SIS (ρ = -0.002). In addition, we found a weak positive correlation between thyroid weight and RFS (ρ = 0.379).

CONCLUSIONS

Changes in laryngeal area caused by thyroid disorders do not lead to subjective but indicate slight objective disturbances in voice quality. We detected a decline in swallowing quality within thyroid patients. Higher RSI scores and a positive correlation between RFS and thyroid weight, indicate a possible role of thyroid gland in LPR.

Prospective voice assessment after uncomplicated thyroidectomy: A comprehensive analysis of a single centre experience

OBJECTIVES

Voice change after uncomplicated thyroidectomy has been an important issue in the field of thyroid surgery. The aim of this study was to promote understanding of voice change after uncomplicated thyroidectomy by analysing the results for a large number of patients from a single institute.

DESIGN

We retrospectively reviewed the medical records of 2879 consecutive patients who underwent thyroidectomy and voice evaluation between January 2014 and December 2019 in a single institute. All the patients had their vocal status assessed using videostroboscopy, acoustic voice analyses, aerodynamic study, and Thyroidectomy-related Voice and Symptom Questionnaire (TVSQ) scores preoperatively and at 1, 3, and 6 months postoperatively. We analysed the pattern of voice changes over time and differences in voice parameters based on clinical factors. To confirm the usefulness of the TVSQ, the correlation between TVSQ scores and objective parameters was analysed. Lastly, predictive factors for persistent voice symptoms were analysed.

SETTING

Tertiary referral hospital.

RESULTS

The frequency ranges and TVSQ scores exhibited significant deterioration until 6 months following surgery. Among clinical factors, the extents of thyroidectomy and neck dissection were associated with worse voice parameters. The TVSQ score was significantly correlated with objective voice parameters. The extents of thyroidectomy and neck dissection were predictive of persistent voice symptoms at 6 months after thyroidectomy.

CONCLUSION

After uncomplicated thyroidectomy, most voice parameters tended to recover, but some parameters remained aggravated even at 6 months after surgery. With more extensive surgery, worse voice quality and the higher risk of persistent voice symptoms may be anticipated.

Impact of Thyroid surgery on Voice: A prospective study

Thyroidectomy is one of the most common neck surgery done worldwide. It is associated with debilitating post-operative voice changes even without recurrent laryngeal nerve (RLN) injury. Aims and Objectives: To study the impact of thyroidectomy on voice parameters in the absence of Recurrent Laryngeal Nerve and External Branch of Superior Laryngeal Nerve injury and comparison between the pre and post-operative changes in the subjective and objective voice parameters. Methodology: Patients fulfilling the inclusion criteria underwent thyroidectomy. The Subjective voice assessment was done using Voice Impairment Score (VIS) and objective parameters were analyzed using Multi-Dimensional Voice Program (MDVP) pre-operatively and post-operatively at 1 week, 1 month and 3 months interval. Results: On MDVP analysis of patients, a fall in Mean F0 (Hz), Minimum F0 (Hz) and Maximum F0 (Hz) values was noted at 1 week after surgery. But a trend toward the pre-operative values was observed at 3 months post-operatively.

Efficacy of laryngeal mask airway against postoperative pharyngolaryngeal complications following thyroid surgery: a systematic review and meta-analysis of randomized controlled studies

This meta-analysis aimed at investigating the effectiveness of laryngeal mask airway (LMA) against postoperative pharyngolaryngeal complications after thyroidectomy. MEDLINE, Cochrane Library, google scholar, and EMBASE databases were searched from inception through February, 2021, for randomized controlled trials (RCTs) comparing the incidence of pharyngolaryngeal complications following the use of LMA or endotracheal tube (ETT). Pooled results from seven RCTs involving 600 patients showed an association of LMA with a reduced risk of postoperative sore throat (POST) at 24 h [risk ratio (RR) 0.75, p = 0.006, four trials], but not at 1 h and 48 h after thyroidectomy. POST severity and hoarseness risk were lower in the LMA group than the ETT group at 1 h, 24 h, and 48 h (all p < 0.05). Nevertheless, hoarseness severity was lower in the LMA group only at postsurgical 48 h [standardized mean difference = - 0.35, p = 0.008, three trials]. Moreover, the risk of emergence cough was lower in patients using LMA than those receiving ETT (RR = 0.14, p = 0.002, two trials). The two groups did not differ in the severity of dysphagia at postoperative 1 h, 24 h, and 48 h. This meta-analysis showed that LMA may be associated with fewer pharyngolaryngeal complications compared to ETT without airway impacts. The limited number of included studies warrants further research to support our findings.

Morbidity following thyroid and parathyroid surgery: Results from key performance indicator assessment at a high-volume centre in New Zealand

BACKGROUND

Complications following thyroid/parathyroid surgery include recurrent laryngeal nerve (RLN) injury, hypocalcaemia and return to theatre for haematoma evacuation. Rates of these form the basis of key performance indicators (KPI). An endocrine database, containing results from 1997, was established at the North Shore Hospital in Auckland, New Zealand. We aimed to measure complication rates by procedure (thyroid and parathyroid), explore a temporal change in our unit and compare our results against international literature.

METHODS

A retrospective review of the database between July 1997 and February 2020 was performed. The results for each KPI were analysed in total and over consecutive time periods. A review of the literature was carried out to find international complication rates for comparison. A cumulative sum (CUSUM) analysis was performed to give visual feedback on performance.

RESULTS

There were 1062 thyroidectomies and 336 parathyroidectomies from July 1997 to February 2020. Thyroid surgery results found rates of temporary/permanent RLN injury of 1.9%/0.3%, temporary/permanent hypocalcaemia of 22.3/2.5%, and return to theatre for haematoma evacuation of 1.1%. Parathyroid surgery results were, temporary RLN injury of 0.8% (no permanent injury), temporary/permanent hypocalcaemia of 1.7%/0.4%, and return to theatre for haematoma evacuation of 0.3%. CUSUM analysis found KPI results to be comparable with international literature.

CONCLUSION

Our unit's KPI results are comparable to published results in the literature. The use of this clinical database will help in future monitoring of performance and help drive improvement in the service. Embedding prospective data collection as routine practice allows for continuous improvement for the unit.

Neck complaints before and after uncomplicated thyroidectomy: prevalence, postoperative outcome and relationships with thyroid weight and reflux like symptoms

PURPOSE

The surgical thyroid disease includes upper aerodigestive complaints with not homogenous prevalence and specific features. The purpose was to analyze before and after total thyroidectomy (TT) the prevalence and severity of voice, swallowing, respiratory, and reflux airway symptoms in relation with thyroid weight.

METHODS

A total of 98 consenting patients undergoing TT were enrolled. Preoperatively, 1 and 3 months after TT, patients underwent videolaryngoscopy, subjective evaluation of voice (VIS), swallowing (SIS and EAT-10), respiratory (mMRC), and reflux symptoms (RSI, Gerd-Q). The scores were analyzed based on thyroid weight (<25 gr, 26-50 gr, 51-75 gr, >75 gr) and post-operative score gain was calculated from the score before TT and the follow-up examination.

RESULTS

In total, 40/98 selected cases of uncomplicated TT completed the postoperative evaluation. Endoscopic signs suggestive of reflux disease were observed in 1/40 (2.5%) and 0/19 cases before and after TT respectively. The prevalence of cases with abnormal reflux symptom index decreased significantly after surgery (8/40 vs 1/40) (p < 0.05), similarly occurred for the Gerd-Q (4/40 vs 1/40) (p < 0.05). Three months after TT the voice, swallowing and respiratory scores were significantly lower than the preoperative ones (p < 0.05). The SIS correlated positively with EAT-10 and RSI. After 3 months the postoperative score gain of voice, swallowing, respiratory, and reflux symptoms (Gerd-Q) was statistically higher (p < 0.05) in the cases with heaviest gland.

CONCLUSIONS

The surgical thyroid disease is associated to mild aerodigestive preoperative compressive symptoms, that include respiratory abnormalities and reflux like symptoms, regardless of the gland weight. In absence of endoscopic signs of airway reflux the presence of reflux symptoms suggests an overlapping with thyroid neck complaints. The patients undergoing uncomplicated TT had improvement in compressive symptoms and the greatest improvement is seen in larger goiters.

Care and Management of Voice Change for Thyroid Surgery: Korean Society of Laryngology, Phoniatrics and Logopedics Clinical Practice Guideline

Voice change is a common complaint after thyroid surgery and has significant impacts on quality of life. The Korean Society of Laryngology, Phoniatrics, and Logopedics set up a task force team to establish guideline recommendations on education, care, and management related to thyroid surgery. The guideline recommendations include preoperative voice education, management of anticipated voice change during surgery, and comprehensive voice care after thyroid surgery, including in-depth information and up-to-date knowledge based on validated literature. The committee constructed 14 key questions (KQ) in three categories: preoperative (KQ1-2), 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. Detailed evidence profiles are presented for each recommendation. The level of evidence for each recommendation is classified into high, moderate, and low-quality. The recommendation's strengths are adjusted to consider the level of evidence resulting in the recommendation and are divided into strong and weak. 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.

Long-term voice quality outcome after thyroidectomy without laryngeal nerve injury: a prospective 10 year follow up study

PURPOSE

This study investigates the long-term voice outcome of thyroidectomy up to 10 years after the surgery using a longitudinal prospective study design.

METHODS

Eighteen participants (6 men and 12 women, mean age: 54 years) who underwent a thyroidectomy between September 2006 and May 2007 were included in this study. A voice assessment protocol consisting of subjective (videolaryngostroboscopic evaluation, auditory- perceptual evaluation, patients' self-report) and objective voice assessments (maximum performance task, acoustic analysis, voice range profile and Dysphonia Severity Index) was used to evaluate the participants' pre- and postoperative voice. Voice measurements were compared before and one week, six weeks, three months and 10 years after the surgery.

RESULTS

No significant differences over time in auditory-perceptual and objective voice parameters were found, except for shimmer. Only in the first postoperative condition, significantly more patients reported vocal complaints. A progressive amelioration of the vocal folds' movement patterns was observed in the postoperative conditions.

CONCLUSION

The findings of this small longitudinal prospective study suggest that thyroidectomy without laryngeal nerve injury does not cause a permanent deterioration of the laryngeal aspect or function, vocal fold behavior and the self-perceived, perceptual and objective vocal quality. The increase of the shimmer 10 years post-thyroidectomy may be related to vocal aging.

How Can We Predict the Recovery from Pitch Lowering After Thyroidectomy?

BACKGROUND

Some of patients are suffered from pitch lowering of voice after thyroidectomy. We sought to identify factors predictive of a recovery from lowered pitch voice after thyroid surgery.

METHODS

We retrospectively reviewed the records of 133 patients who underwent total thyroidectomy to treat papillary carcinoma between January 2012 and February 2013. Of these, we enrolled 78 who exhibited a lower-pitched voice (SFF fall > 12 Hz) at 2 weeks post-operatively than pre-operatively and investigated pitch recovery after 3 months. We subclassified patients into recovery and non-recovery groups and compared videostroboscopic findings, acoustic voice data, and thyroidectomy-related voice questionnaire scores pre-operatively and 2, 8, and 12 weeks post-operatively.

RESULTS

Vocal cord asymmetry on videostroboscopic examination at 2 weeks post-operatively (odds ratio 19.056, p = 0.001*) was more frequent in the non-recovery group. In acoustic analysis, mean pre-operative SFF was higher in the non-recovery group than the recovery group (190.9 ±  27.5 and 180.9 ±  24.6 Hz, respectively; p = 0.030*). Also, a reduction in the SFF of > 19.6 Hz, at 2 weeks post-operatively versus pre-operatively, predicted non-recovery of pitch-lowering in patients with reduced SFF within post-operative 3 months, with 72.0% sensitivity and 71.2% specificity. After 6 months of follow-up, no patient who exhibited an SFF fall > 19.6 Hz recovered to within 10 Hz of the pre-operative value.

CONCLUSION

A reduction in the speaking fundamental frequency (SFF) > 19.6 Hz at 2 weeks post-operatively predicted persisting lowering of voice pitch after thyroidectomy among those with lower-pitched voices after surgery. Pre-operative high SFF and post-operative stroboscopic findings including vocal cord asymmetry at 2 weeks post-operatively also predicted persisting lowering of voice pitch for 3 months.

Evaluation of one-year incidence of vocal dysfunction and associated demographic factors in thyroidectomy patients: A descriptive analytical study

Background

Voice changes are common complaint following thyroidectomy that might or might not be associated with laryngeal nerve damage. Objective: The aim of this study is to evaluate the effect thyroidectomy on voice alteration and its association with gender and age.

Methods

In this descriptive analytical study, patients who underwent thyroidectomy at (XXX) without laryngeal nerve damage were included. These patients were evaluated based on subjective (self-reported) and objective (videostroboscopy) voice assessment. The data was collected immediately after the surgery and 6 months after the surgery during the follow-up.

Results

Of 76 patients included, the mean age of patients was 46.3 year. 25 (43.4%) were males and 51 (56.6%) were female. 28.9% patients were presented with apparent damage to the vocal cords, of which 8 (10.5) had voice changes. There was no statistically significant difference between sex and postoperative vocal cord dysfunction (P = 0.592). However, in male gender, late postoperative voice changes were significantly more, p = 0.013. The age was also not associated with immediate or late postoperative changes and damage to vocal cords, p > 0.05.

Conclusion

Our study reported that male gender can be an important factor in deterring voice changes after thyroidectomy nonetheless, it can not predict the risk of vocal cord damage. Furthermore, age might not a risk factor either. Studies with greater sample size are required to confirm these findings.

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Voice changes are common complaint following thyroidectomy.

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That might or might not be associated with laryngeal nerve damage.

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Male gender can be an important factor in deterring voice changes after thyroidectomy.

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Studies with greater sample size are required to confirm these findings.

Can Voice Pitch Be Preserved in Patients after Transoral Endoscopic Thyroidectomy Vestibular Approach?

Introduction: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has become increasingly popular. Several reports have emphasized the safety and efficacy of this new approach. However, there is no report on functional voice outcomes, including voice pitch change after TOETVA. Methods: The functional voice outcomes of patients undergoing TOETVA were compared with those of patients undergoing conventional thyroidectomy. A total of 82 consecutive patients were included in the study: 44 underwent thyroid lobectomy via TOETVA (transoral group) and 38 underwent thyroid lobectomy via the classic cervical approach (open group). Thyroidectomy-related voice questionnaire (TVQ), perceptual voice analysis, fiberoptic laryngoscopic and videolaryngostroboscopic examinations, and acoustic analysis were carried out before and one month after surgery. The changes in these values after surgery and the differences between the transoral and open groups were analyzed. Results: We found no significant postoperative change in voice workups in either group. The mean high pitch decreased (from 367.91 ± 120.98 to 325.80 ± 100.86 Hz, p = 0.069) in the transoral group, but statistical significance was not attained. Clinically significant changes in pitch (postoperative change in speaking fundamental frequency, ΔSFF ≥ 12) after surgery were evident in seven (15.91%) patients in the transoral group and eight (21.05%) patients in the open group without significant difference (p = 0.579). Conclusions: This is the first study to assess functional voice outcomes (including pitch) after TOETVA compared with conventional open surgery. TOETVA was associated with good voice outcomes without any significant drop in pitch.

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.

U-shaped strap muscle flap for difficult thyroid surgery

Background

Open thyroidectomy via conventional midline approach can be challenging in complex thyroid surgeries. This study proposes a U-shaped strap muscle flap (USMF) technique that provides adequately wide exposure of the surgical field.

Methods

Strap muscles were cut close to the clavicle and along the anterior margin of both sternocleidomastoid muscles followed by total thyroidectomy in 20 patients as USMF group, and surgical outcomes were compared with 40 patients who had received total thyroidectomy via midline approach.

Results

No patient had postoperative hematoma, vocal cord paralysis, permanent hypocalcaemia, wound infection or flap necrosis. At 2 months post-surgery, objective voice analysis and subjective assessment of voice and swallowing showed no significant difference between groups.

Conclusions

USMF provides superb surgical field exposure, and the voice and swallowing functions after USMF are comparable to those obtained by midline approach. The USMF approach is a feasible option for selective difficult thyroid surgery.

Contribution of Weight and Volume of the Extirpated Thyroid Gland on Voice Alterations After Total Thyroidectomy in Patients With Papillary Carcinoma of the Thyroid

PURPOSE

Voice change after thyroid surgery is common despite preservation of laryngeal nerves. In this study, we sought to find if the change in voice after total thyroidectomy is related to the weight and volume of the removed thyroid gland.

METHODS

This is a prospective cohort study of 50 patients of papillary carcinoma of the thyroid treated with total thyroidectomy from December 2016 through May 2018. Both objective and subjective voice parameters were analyzed preoperatively and at 1 and 3 months following surgery.

RESULTS

A cohort of 29 patients, with a median age of 31 years (18-64 years), comprising 22 women were eligible for final analysis. Speaking fundamental frequency showed a mean change of 17.21 Hz (SD 34.49) while the mean intensity change was 5.54 dB (SD 18.21). The mean weight and volume of thyroid gland was 18.99 g (SD 8.93) and 15.67 ml (SD 8.70), respectively. On multivariate analysis, both weight and volume affected the range of frequency (P = 0.002 and 0.035, respectively) and range of intensity (P = 0.014 and 0.008, respectively).

CONCLUSION

Larger thyroid tumors are more likely to be associated with transient change in voice quality following their surgical removal despite physical preservation of external and recurrent laryngeal nerves, which may persist up to 3 months. This study affirms that perturbations in voice after thyroidectomy can still exist in spite of clinical demonstration of integrity of neuromuscular function.

Voice Characteristics in Patients with Thyroid Disorders

Objective

This study investigated acoustic and perceptual characteristics of the voice of patients with thyroid gland disorders such as hypothyroidism and hyperthyroidism immediately after the diagnosis was made and six months later, after using drug therapy.

Materials and Methods

The study includes 20 female outpatients with hypothyroidism and 27 female outpatients with hyperthyroidism. The criterion for the selection of the patients was a thyroid gland disorder medical diagnosis, no history of voice disorders and absence of other possible causes of voice changes. Acoustic, perceptual and aerodynamic parameters were assessed. Acoustic analysis was performed by specific software. Experienced speech and language pathologists made perceptual voice assessment by using grade, roughness, breathiness, asthenia, and strain (GRBAS) scale.

Results

Significant differences in patients with hypothyroidism were established on parameter amplitude perturbation, jitter and noise-to-harmonics ratio between pretreatment and posttreatment period, in which patients took drug therapy. In group of patients with hyperthyroidism significant difference was noted only on aerodynamic parameter maximum phonation time. There were a significant differences in all perceptual parameters in both groups of patients (p<0.05) in pre and posttreatment, except on grade and asthenia parameter in the group of patients with hypothyroidism and parameter grade was borderline insignificant in the group of patients with hyperthyroidism.

Conclusion

Voice quality is affected by thyroid disease. Thyroid gland disorders cause minor changes in acoustic voice parameters of patients with hypothyroidism and hyperthyroidism, but perceptual deviations in these patients are especially noticeable.

Association Between Age and Patient-Reported Changes in Voice and Swallowing After Thyroidectomy

OBJECTIVES

Despite intact recurrent laryngeal nerves, patient-reported voice and swallowing changes are common after thyroidectomy. The association between patient age or frailty status and these changes is unknown. The aim of this study was to evaluate the impact of age and frailty on the incidence of voice and swallowing alterations after thyroidectomy.

METHODS

We performed an institutional review board (IRB)-approved retrospective review of consecutive patients who underwent total thyroidectomy with intraoperative recurrent laryngeal nerve (RLN) monitoring at a single institution between January 2014 and September 2016. Patients with RLN injury were excluded. After data extraction, a modified frailty index (mFI) was calculated for each patient. The association among risk factors, including age, mFI, prior history of neck surgery, frequent voice use, presence of malignancy or gastroesophageal reflux disease, and smoking status and reported voice and/or swallowing changes was examined.

RESULTS

Of 924 patients undergoing thyroidectomy, 148 (16.0%) reported only changes in voice; 52 (5.6%) reported only difficulty in swallowing; and 26 (2.8%) reported changes with both voice and swallowing. On multivariate analysis, we found a significant increase in voice or swallowing alterations up to the age of 50 years (5% increased odds per year), after which these changes plateaued. We found that mFI was not associated with voice or swallowing changes.

CONCLUSION

Age ≥ 50 years is independently associated with the development of voice or swallowing changes after thyroidectomy, despite intact RLN. Additional prospective studies are needed to validate these findings, further define this association, and identify risk factors for developing these changes.

LEVEL OF EVIDENCE

2b Laryngoscope, 129:519-524, 2019.

Changes in Voice- and Swallowing-Related Symptoms After Thyroidectomy: One-Year Follow-Up Study

Objective:

We analyzed the changes in voice- and swallowing-related symptoms that occurred over time in patients who underwent thyroidectomy and identified any associated risk factors.

Methods:

One hundred and three patients who underwent thyroidectomy were enrolled.

Results:

The mean thyroidectomy voice-related questionnaire (TVQ) score before surgery was 12.41 ± 12.19; it significantly increased to 28.24 ± 18.01 ( P < .001) 1 month postoperatively, decreased to 24.02 ± 17.30 ( P = .014) and 20.66 ± 15.29 ( P = .023) 3 and 6 months postoperatively, respectively. It was continuously decreased to 18.83 ± 14.63 twelve months postoperatively. The temporal changes in TVQ scores between patients who underwent total thyroidectomy or lobectomy were significantly different. There was a statistically significant difference in the temporal changes in TVQ according to whether neck dissection was performed. The temporal changes in TVQ in patients with and without extrathyroidal extension were significantly different.

Conclusions:

Voice- and swallowing-related discomfort in patients who received thyroidectomy showed dynamic changes over time. There was a significant difference in the degree of change according to clinicopathological factors. Patients with these risk factors may benefit from appropriate patient education and various rehabilitation programs for symptom relief.

Occult invasion of sternothyroid muscle by differentiated thyroid cancer

PURPOSE

To determine the incidence of occult invasion of sternothyroid by differentiated thyroid cancer (DTC) and identify clinico-pathological features associated with the same.

METHODS

Retrospective study of a consecutive series of DTC patients undergoing surgery, with preoperative ultrasound showing no evidence of strap muscle invasion. All had en bloc excision of sternothyroid muscle along with thyroidectomy. Incidence of microscopic invasion of sternothyroid and clinicopathologic features associated with the same, were studied.

RESULTS

A total of 76 patients with DTC (2010-2014) were identified, of whom 62 met the inclusion criteria and were included in this study. Of these, 22 (36%) had no extrathyroidal extension (ETE), 30 (48%) had minimal ETE without sternothyroid invasion and 10 (16%) had minimal ETE with microscopic sternothyroid invasion. The mean tumor sizes of the three sub-groups were 1.9, 3.1 and 4.9 cm, respectively, with a significant difference between no ETE and sternothyroid invaded sub-groups (p = 0.03). Out of the 40 cases with minimal ETE, 3 (7.5%) had positive tumor microscopic margin. Retaining sternothyroid in situ would have theoretically increased this proportion to 27.5%. Over a median follow-up of 52 months, 58 (94%) patients remained structurally disease free, with only 1 local recurrence.

CONCLUSION

Occult invasion of sternothyroid muscle occurred in 16% of DTC in this series. Excision of the muscle en bloc with thyroidectomy, particularly in larger tumors, may confer benefit in accurately staging the disease, encompassing occult ETE and achieving clear microscopic margins.

Preoperative information for thyroid surgery

The preoperative information necessary to communicate to the patient to obtain informed consent in thyroid surgery is not detailed in length in the current medical literature. Advances in technology and the advent of remote access approaches in thyroid surgery have increased the need for a detailed communication of risks, benefits and alternatives to achieve an informed consent. In this review article, we outline the indications for thyroid surgery, risks of thyroid surgery, different approaches to thyroidectomy, and possible consequences of using advanced technology using intraoperative nerve monitoring (IONM) as an example. A truly detailed informed consent in the modern age of thyroid surgery is crucial. This article not only details the risks, benefits and alternatives of thyroid surgery, but also incorporates new practices, guidelines and technologies to allow patients to achieve a comprehensive preoperative understanding of treatment recommendations.

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.

Retrograde Thyroidectomy for preservation of the External Branch of the Superior Laryngeal Nerve: A case series

BACKGROUND

The external branch of the Superior Laryngeal nerve (EBSLN) is at high risk of injury in surgery for large multinodular goitre (MNG) since the upper pole is high in the neck, well cephalad to the EBSLN. We present a technique of drawing the lobe caudally by retrograde thyroidectomy in order to minimize nerve injury.

DESIGN & METHOD

All patients having surgery for benign MNG were included. Cases with previous thyroid surgery, malignant and toxic disease were excluded. The thyroid lobe was mobilized from its inferior aspect and capsular dissection performed cephalad with bipolar or ligasure cautery, lifting the gland off the trachea while separating it from the parathyroids and branches of the inferior thyroid vessels. The ligament of Berry is divided and the entire lobe freed, attached only by the superior pedicle which is drawn caudally well below the EBSLN prior to ligation. Patients were followed for voice change at 24 hours, 7 days and 3 months.

RESULTS

Ninety-one consecutive lobectomies were done in 60 patients, 31 bilateral. Forty-four (73%) patients had voice change at 24h, 10 (11%) at 7days and 1 at 3 months. The patient with persistent voice change complained of change in tone but not volume; vocal cords were normal on indirect laryngoscopy.

CONCLUSION

Retrograde thyroidectomy is recommended for large MNG where the EBSLN lies well below the upper pole; it minimizes risk to the nerve.

Multivariate Analysis of Risk Factors in the Development of a Lower-Pitched Voice After Thyroidectomy

Objectives:

Thyroid surgeons frequently encounter outpatients with mobile vocal cords complaining of lower-pitched voices following thyroidectomy. This study investigated the clinical and pathological parameters affecting voice pitch following thyroid surgery.

Methods:

We analyzed the data of 393 patients with mobile vocal cords and who also underwent thyroid surgery. Speaking fundamental frequency (SFF) and fundamental frequency (F0) were compared before and after surgery.

Results:

Approximately 26.7% of patients had significantly lowered SFFs (ΔSFF ≥ 12 Hz), and 30.2% exhibited significantly lower sustained vowel F0s (ΔF0 ≥ 12 Hz) following thyroid surgery. On multivariate analysis, only gender: female remained a significant predictor of a clinically significant change in SFF following thyroid surgery ( P < .001). Gender: female and extent of surgery: total remained significant predictors of a clinically significant change in F0 after surgery ( P = .006 and P = .007, respectively).

Conclusions:

Appreciable proportions of patients experience lower-pitched voice and related vocal symptoms early after thyroid surgery. Such problems develop more frequently in females who underwent total thyroidectomy.

Influence of change in surgical practice for benign thyroid disease on postsurgical outcome-Single-center experience in 1400 patients

PURPOSE

To evaluate the rate of surgical complications during the change from subtotal resection to hemithyroidectomy or thyroidectomy over a period of 17 years.

METHODS

All operations for benign goiter at our hospital were analyzed for the periods 1996-2002 (Group 1) and 2003-2012 (Group 2). The groups were compared for recurrent laryngeal nerve damage, hypocalcemia, and other surgical complications directly postoperatively.

RESULTS

In total, 1462 patients were operated on for goiter between 1996 and 2012. There were 1219 patients who underwent a primary thyroid operation, whereas 50 patients had surgery for recurrence. Postoperative histology revealed thyroid cancer in 193 patients (13.2%). In Group 1, 42.7% of all operated lobes were performed as lobectomies and 57.3% as subtotal resections; in Group 2, 74.4% were performed as lobectomies and 25.6% as subtotal resections. No differences were found for reduced vocal cord function (2.4% vs. 1.9%, p = 0.746) and recurrent laryngeal nerve paralysis in the postoperative laryngoscopy (2.9% vs. 1.8%, p = 0.675). Postoperative hypoparathyroidism was detected in 13.66% in Group 1 and in 19.80% in Group 2 after bilateral resections (p = 0.037). There was no difference in the rate of reoperations for cancer between both groups (43.4% vs. 52.1%, p = 0.182).

CONCLUSION

Surgical practice changed from subtotal to lobectomies for benign goiter over a period of 17 years without change in laryngeal nerve damage but with increasing rates of postoperative hypocalcemia.

Long-Term Voice Outcomes After Robotic Thyroidectomy

BACKGROUND

The purpose of this study was to evaluate the long-term voice function after robotic thyroidectomy in comparison with conventional transcervical thyroidectomy.

METHODS

We prospectively evaluated the voice functions of 54 patients with thyroid nodules who underwent robotic thyroidectomy by a gasless unilateral axillary or axillo-breast approach and of 70 patients who underwent conventional thyroidectomy. Subjective voice symptom score (VSS) was evaluated in questionnaires before thyroidectomy and then at 3, 6, 12, and 24 months after surgery. Objective acoustic parameters analyzed during the same period included fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, highest frequency, frequency and intensity range, and maximal phonation time.

RESULTS

At 3 months after surgery, VSS was better in the robotic group than in the conventional group. At 2 years after surgery, VSS had recovered to the pre-operative level in the robotic group, whereas it remained significantly worse at 2 years in the conventional group. The phonatory frequency range and highest frequency were significantly wider and higher, respectively, in the robotic group than the conventional group at 6, 12, and 24 months postoperatively.Within the robotic group, the frequency range and highest frequency recovered to pre-operative levels by 6 months, whereas in the conventional group they remained below the pre-operative levels at 2 years post-operatively. There were no differences in other acoustic parameters between the two groups of patients at any period.

CONCLUSION

Up to 2 years post-operatively, robotic thyroidectomy has advantages in terms of recovery of voice symptoms and acoustic parameters over conventional thyroidectomy.

Effects of Radioactive Iodine Ablation Therapy on Voice Quality

OBJECTIVE

The goal of this study was to evaluate the effects of radioactive iodine ablation therapy on voice quality of patients diagnosed with well-differentiated thyroid carcinoma.

METHODS

We enrolled 36 patients who underwent total or subtotal thyroidectomy due to well-differentiated thyroid carcinoma. Voice recordings from patients were analyzed for acoustic and aerodynamic voice. The Voice Handicap Index-10 was used for subjective analysis. The control group consisted of 36 healthy participants. Results taken before and after therapy were compared statistically.

RESULTS

There were no differences in the results taken before and after therapy for the radioactive iodine ablation group. The Voice Handicap Index-10 results did not differ between groups before and after therapy.

CONCLUSION

Radioactive iodine ablation therapy has no effect on voice quality objectively or subjectively.

An Analysis on Aerodynamic and Acoustic Changes After Thyroidectomy

The purpose of this study was to investigate the aerodynamic and acoustic changes after thyroidectomy without laryngeal nerve injury by using objective methods. Voice samples of sustained /α/ recorded from 44 adults preoperatively and nearly 1 week and 3 months after thyroidectomy were analyzed for mean vocal fundamental frequency (Mean Fo, Hz), maximum fundamental frequency (Max Fo, Hz), minimum fundamental frequency (Min Fo, Hz), jitter, shimmer, glottal to noise excitation ratio (GNE), irregularity, noise, overall severity, S time, Z time, S/Z ratio, and maximum phonation time (MPT). Voice samples were analyzed using the lingWAVES software. The comparisons of preoperative and early and late postoperative acoustic parameters revealed significant differences in Mean F0, Max F0, MPT, and S Time between the early and late postoperative periods. The voice changes after thyroidectomy were not affected by age, sex, or surgical procedure, but they differed between the benign and malignant nature of the tumor. Patients with malignant tumors showed a greater decrease in Mean F0 and Max F0 compared with the patients with benign tumors, and this difference was statistically significant. Voice changes may occur after thyroidectomy even in the patients with no evidence of laryngeal nerve damage, and these changes can be assessed with objective measurement methods. This information should be explained to the patients during the preoperative counseling, and proper informed consent is ethically and legally required for all planned thyroidectomies.

Voice Changes after Late Recurrent Laryngeal Nerve Identification Thyroidectomy

OBJECTIVES

To assess voice changes in patients after thyroidectomy where the recurrent laryngeal nerve (RLN) was found late in the thyroid dissection and where the RLN was not injured (late RLN identification technique).

METHODS

This study was conducted on 64 patients who underwent thyroidectomy by late RLN identification technique. Voice was assessed preoperatively, 1 week, 3 months, and 6 months after surgery using the voice assessment protocol and Voice Problem Self-Assessment Scale. The study group was divided into two subgroups (hemithyroidectomy: N = 13 and total thyroidectomy: N = 51). Voice assessments of both subgroups were then compared with a control group (N = 20) of patients who recently underwent extracervical surgeries.

RESULTS

All voice analysis differences between the control group and the individual study subgroup were nonsignificant. Dysphonia in the study group was significantly worse at 1 week and 3 months postoperatively but became nonsignificant at 6 months postoperatively. The deviations from the preoperative acoustic analysis were significant only in the first week postoperative comparison for fundamental frequency, noise-to-harmonic ratio, and maximal phonation time and thereafter became nonsignificant. Significant Voice Problem Self-Assessment Scale mean score increase (worsening) was also detected only at first week postoperatively.

CONCLUSION

Minimal voice changes were reported early after late RLN identification thyroidectomy in absence of RLN injury and disappeared gradually in a few months. Those changes are comparable with that of other extracervical surgeries, making thyroidectomy with late RLN identification a relatively safe technique as regard voice.

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.

The effect of total thyroidectomy on the speech production

OBJECTIVES

Voice and speech alternations that can occur after total thyroidectomy are usually due to recurrent or superior laryngeal nerve injury. These alterations may also be associated with other extralaryngeal factors, such as neck muscle dysfunction and scar contracture of the neck. We performed a prospective acoustic analysis on speech changes after surgery, in the absence of laryngeal nerve injury.

METHODS

Patients aged 19 to 58 years undergoing total thyroidectomy, in the absence of laryngeal/pulmonary disease, previous neck surgery, or other malignant diseases, were recruited prospectively. For the running speech analysis, the speaking fundamental frequencies (SFo), range of SFo and speaking intensity were evaluated before surgery, 7 days, and 1 and 3 months after surgery. For consonant analysis, the acoustic distinctions of stop consonant, the voice onset time (VOT), vowel duration and closure duration were evaluated at the same periods.

RESULTS

SFo and range of SFo were specifically diminished after surgery, while speaking intensities were not changed significantly after surgery. The thyroidectomized speakers displayed systematically varied VOT for the consonant production, which was phonetically representative. However, VOT after surgery could be longer in the strong aspirated and glottalized stops, but not in the lax stop than before surgery. The vowel and closure durations were not affected before and after surgery.

CONCLUSION

Patients with thyroidectomy have some difficulty of pitch control and consonant articulation during speaking. VOT is also one of the meaningful acoustic parameters and provide a reference for comparing acoustic measures before and after thyroidectomy.

Does Postthyroidectomy Syndrome Really Exist Following Thyroidectomy? Prospective Comparative Analysis of Open vs. Endoscopic Thyroidectomy

OBJECTIVES

This study prospectively evaluated postthyroidectomy syndrome (PTS) through objective and subjective voice changes following thyroidectomy of open vs. endoscopic thyroidectomy.

METHODS

A prospective clinical trial (SCHBC IRB 09 26) was performed from Jan 2008 to Aug 2010 to compare the open thyroidectomy (OPEN group) and endoscopic thyroidectomy (ENDO group). Of the 110 patients, 75 completed the evaluation before and 1 and 6 months after surgery. Subjective parameters included perceptual analysis (GRBAS [grade, roughness, breathiness, asthenia, and strain] scale), stroboscopic or flexible fiberscopic analysis, voice handicap index, and 5-point visual analog scales for vocal fatigue, singing difficulty, difficulty with high-pitch phonation, and neck discomfort. Objective parameters included acoustic, aerodynamic analysis and the electroglottograph.

RESULTS

For the ENDO group (n=36), the operation time was longer than in the OPEN group (n=39; P<0.01). For the OPEN group, two objective and five subjective parameters were worse 1 month postoperatively; of these, two subjective parameters persisted for 6 months (P<0.05). For the ENDO group, three objective and six subjective parameters were worse 1 month postoperatively, and three of the subjective parameters persisted 6 months postoperatively (P<0.05).

CONCLUSION

PTS really exists following simple thyroidectomy and are very common for both OPEN and ENDO groups. Most of the parameters improved gradually over time, but some subjective changes persisted 6 months postoperatively.

Voice outcomes after total thyroidectomy, partial thyroidectomy, or non-neck surgery using a prospective multifactorial assessment

BACKGROUND

Voice alteration remains a significant complication of thyroid surgery. We present a comparison of voice outcomes between total thyroidectomy (TT), partial thyroidectomy (PT), and non-neck (NN) surgery using a multifactorial voice-outcomes classification tool.

STUDY DESIGN

Patients with normal voice (n = 112) were enrolled between July 2004 and March 2009. The patients underwent TT (n = 54), PT (n = 35), or NN (n = 23) surgery under general endotracheal anesthesia as part of a prospective observational study involving serial multimodality voice evaluation preoperatively, and at 2 weeks, 3 months, and 6 months postoperatively. Patients with adverse voice outcomes were grouped into the negative voice outcomes (NegVO) category, including patients with objective (abnormality on videolaryngostroboscopy and substantial voice dysfunction) and subjective (normal videolaryngostroboscopy but with notable voice impairment) NegVO. Voice outcomes were compared among study groups.

RESULTS

Negative voice outcomes occurred in 46% (95% CI, 34-59%) and 14% (95% CI, 6-30%) of TT and PT groups, respectively. No NegVOs were observed after NN surgery. Early NegVOs were more common in the TT group than in the NN or PT groups (p < 0.001). Most voice disturbances resolved by 6 months (TT 84%; PT 92%) with no difference in NegVO among all groups (p = 0.23). Black race and significant changes in certain voice outcomes measures at the 2-week follow-up visit were identified as predictors of late (3 to 6 months) NegVO.

CONCLUSIONS

This comprehensive voice outcomes study revealed that the extent of thyroidectomy impacts voice outcomes in the early postoperative period, and identified risk factors for late NegVO in post-thyroidectomy patients who should be considered for early voice rehabilitation referral.