Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery

Abstract

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 anesthesi...

Voice outcomes after thyroidectomy without superior and recurrent laryngeal nerve injury: VoiSS questionnaire and GRBAS tool assessment

“…A single preoperative dose of dexamethasone may decrease voice changes after thyroidectomy [17]. The AAO Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery published in 2013 recommends to implement below mentioned steps to the standard care [1]; and the group agreed that voice outcomes could potentially be improved preoperatively, intraoperatively and postoperatively. Steps should include preoperative laryngoscopy and voice assessment, preserve the external branch of the superior laryngeal nerve, document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery, refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; or counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation [1].…”

“…Thyroid surgery rates have tripled over the past three decades [1]. One of the major complications of the thyroid surgery is an injury of recurrent laryngeal nerve which can cause permanent damage of the patient's voice.…”

Videoendoscopic Evaluation of Swallowing After Thyroidectomy: 7 and 60 Days

“…Our findings support some previous findings that demonstrated around 58 % of dysphagia incidence in this kind of patient [1,7] (Tables 4, 5). The current guideline used to follow-up patients with surgery indication to treat thyroid disease focuses on the postoperative investigation of voice [27]. Both in manual and in clinical routine, there is no concern to investigate swallowing complaints or even to evaluate this function.…”

Management of the exterior branch of the superior laryngeal nerve among thyroid surgeons – Results from a nationwide survey

“…In this survey, endocrine surgeons reported a much lower frequency of pre-and postoperative laryngoscopy and voice recording, than H&N surgeons. The German Association of Endocrine Surgeons recommends routine laryngoscopy in all patients both before and after thyroid surgery [19], whereas the British Association of Endocrine Surgeons [20], as well as the more recent American Academy of Otolaryngology-Head and Neck Surgery [21] advocate a more selective approach, restricting laryngoscopy to patients with subjective voice impairment before or after thyroid surgery, patients with previous surgery on the neck, and patients with thyroid cancer with extrathyroidal extension. The most likely explanation for the relationship between the rate of pre-and postoperative laryngoscopy and/or voice recording between endocrine and H&N surgeons, respectively, might be in differential access to the procedure.…”