Dexamethasone for the Prevention of Recurrent Laryngeal Nerve Palsy and Other Complications After Thyroid Surgery

Abstract

Importance: Recurrent laryngeal nerve dysfunction and hypoparathyroidism are well-recognized, important complications of thyroid surgery. The duration of convalescence after noncomplicated thyroid operation may depend on several factors, of which pain and fatigue are the most important. Nausea and vomiting occur mainly on the day of operation. Glucocorticoids are well known for their analgesic, anti-inflammatory, immunemodulating and antiemetic effects. However, there is little information in the literature on the use of steroids in thyroid surgery, and the information that is available is conflicting.Objective: To investigate whether preoperative dexamethasone could improve surgical outcome in patients undergoing thyroid surgery.Design: A randomized double-blind placebocontrolled trial. A 30-day follow-up for morbidity was performed in all cases.Setting: All patients were hospitalized in a public hospital.Participants: From June 2008 through August 2011, 328 patients were randomized to receive either intravenous dexamethasone, 8 mg, administered 90 minutes before skin incision, or saline solution (placebo).Interventions: Intravenous dexamethasone, 8 mg. Main Outcomes and Measures:The primary end points were temporary or permanent recurrent laryngeal nerve palsy. Transient and definitive hypoparathyroidism, pain and fatigue scores, nausea, and the number of vomiting episodes were also registered. Preoperatively and at several times during the first 24 postoperative hours, we measured C-reactive protein, interleukin 6, and interleukin 1␤ levels.Results: In the dexamethasone group, the rate of temporary recurrent laryngeal nerve palsy (4.9%) was significantly lower compared with the placebo group (8.4%) (P=.04). Also, postoperative transient biochemical hypoparathyroidism occurred more frequently in the placebo group (37.0%) than in the dexamethasone group (12.8%). Dexamethasone use significantly reduced postoperative levels of C-reactive protein (P =.01) and interleukin 6 and interleukin 1␤ (P=.02), fatigue (P=.01), and overall pain during the first 24 postoperative hours (P = .04), as well as the total analgesic (ketorolac tromethamine) requirement (P=.04). Dexamethasone use also reduced nausea and vomiting on the day of operation (P =.045). Conclusions and Relevance:Preoperative administration of dexamethasone, 8 mg, reduced postoperative temporary recurrent laryngeal nerve palsy and hypoparathyroidism rates and reduced pain, fatigue, nausea, and vomiting after thyroid surgery. However, these data require further analysis in randomized prospective studies.Trial Registration: clinicaltrials.gov Identifier: NCT01690806 Otolaryngol Head Neck Surg. 2013;139(5):471-478 T OTAL THYROIDECTOMY OR thyroid lobectomy has been accepted as the current surgical therapy for benign and malignant thyroidal disorders, 1-5 but extensive resection might increase the risk of postoperative complications. JAMA6,7 Recurrent laryngeal nerve (RLN) dysfunction and hypoparathyroidism are well-recognized, important complications of thyro...

Epidemiology of Vocal Fold Paralyses after Total Thyroidectomy for Well‐Differentiated Thyroid Cancer in a Medicare Population

“…Supporting this hypothesis is a systematic review that analyzed 27 studies with over 25,000 cumulative thyroidectomy patients and found 9.8% and 2.3% mean incidences of temporary and permanent post-thyroidectomy vocal fold paralyses 22 , which are nearly identical rates to those in the present study (9.5% overall, 2.1% “permanent”/requiring intervention). More reinforcing evidence is gained from studies that actively examined patients immediately post-operatively from thyroidectomy and reported similar rates to those herein (4.9 – 8.4%) 46,47 . Interestingly, Bergenfelz et al .…”

American Association of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: Postoperative Hypoparathyroidism - Definitions and Management

“…Care should be taken in cases of hyperparathyroidism not to cause a further significant elevation of serum calcium. Dexamethasone (8 mg intravenously [IV]) given 90 minutes before skin incision is not yet a standard but has been shown to reduce the rate of transient hypoparathyroidism and laryngeal nerve palsy in a single 2013 study (15).…”

Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: The International Neural Monitoring Study Group's POLT study

“…In keeping, other investigators reported that a comparable single shot of intraoperative steroids did not reduce postoperative RLN palsy rates, shortening only the recovery time for transient vocal fold palsies from 40.5 to 28.6 days . The roles of edema or vasospasm which steroids may help decrease are not well established pathophysiologically for RLN injury and the hypothetical benefit of calcium channel blockers …”

“…17 The roles of edema or vasospasm which steroids may help decrease are not well established pathophysiologically for RLN injury and the hypothetical benefit of calcium channel blockers. 18,19…”