Prevalence of long-term upper aerodigestive symptoms after uncomplicated bilateral thyroidectomy

[Diagnosis and treatment of functional oropharyngeal dysphagia. Features of interest to the digestive surgeon]

Digestive surgeons should form part of the multidisciplinary team managing patients with oropharyngeal dysphagia. These patients can be diagnosed through clinical methods and complementary investigations such as videofluoroscopy and pharyngoesophageal manometry. These techniques also allow specific treatment to be selected. Up to one-third of patients with dysphagia suffer from malnutrition as a result of alterations in food bolus transport. Furthermore, up to two-thirds show alterations in swallowing safety (penetrations and aspirations, especially when swallowing liquids), as well as a high risk of respiratory infections and aspiration pneumonia. Increasing food bolus viscosity to 3500-4000 mPas (pudding viscosity) improves the effectiveness of swallowing and reduces the risk of aspirations. Botulinic toxin injection in the upper esophageal sphincter is indicated in patients with spasticity of neuromuscular origin. Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum and is also indicated in patients with alterations in the upper esophageal sphincter and preserved oropharyngeal motor response.

Long-term prevalence of oropharyngeal dysphagia in head and neck cancer patients: Impact on quality of life

BACKGROUND & AIMS

To determine the prevalence of dysphagia in head and neck cancer patients treated with surgery and radiotherapy or chemoradiotherapy. To study the impact of dysphagia on food habits, nutritional status, and quality of life.

METHODS

Retrospective cross-sectional study of 87 head and neck cancer patients treated with surgery and radiotherapy or chemoradiotherapy from January 2000 through May 2005. Time since surgery was 28.5+/-17.8 months. A clinical test was used to detect dysphagia. A nutritional assessment was performed in all patients. A questionnaire was used to evaluate quality of life.

RESULTS

Oropharyngeal dysphagia was present in 50.6% of patients, mostly to solid foods (72.4%). Patients with total glossectomy and chemoradiotherapy had the highest rate of dysphagia. Nutritional support was necessary in 57.1% of patients. Malnutrition was present in 20.3% of patients, mainly marasmus (81%). Fifty-one percent of patients reported a decrease in their quality of life due to dysphagia.

CONCLUSIONS

We found a high prevalence of dysphagia in head and neck cancer patients treated with surgery and coadjuvant treatment. This problem negatively affects their quality of life. It is important that nutritional surveillance be provided to detect it and to prevent malnutrition.

Esophageal Overtube Facilitation of Transesophageal Echocardiography in Patients with Previously Difficult Esophageal Intubation

BACKGROUND

In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients.

OBJECTIVE

We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations.

METHODS

We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE.

CONCLUSIONS

Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.

Determination of the function of the internal branch of the superior laryngeal nerve after thyroidectomy

BACKGROUND

Several unique complications of thyroidectomy exist because of its regional anatomy; they are well studied and reported. A majority of thyroidectomy patients report vague upper aerodigestive tract complaints. Despite this, no formal assessment of the integrity of the internal branch of the superior laryngeal nerve after thyroidectomy exists in the literature.

METHODS

Thirty three patients undergoing thyroidectomy were prospectively evaluated with preoperative and postoperative laryngopharyngeal sensory testing.

RESULTS

Preoperatively, 16 patients (49%) reported dysphagia, and 19 (58%) complained of globus sensation. Postoperatively, 24 (73%) patients complained of dysphagia, and 25 (76%) reported globus sensation. Preoperative sensory testing showed a mean sensory threshold of 2.79 +/- 0.51 mm Hg. The mean change in thresholds postoperatively was trivial (0.07 +/- 0.29 mm Hg), and did not differ significantly from zero (p = .19).

CONCLUSIONS

Although most patients report significant difficulty swallowing after thyroidectomy, the sensory nerve to the laryngopharynx remains intact and is not at risk during thyroid surgery.

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.

Voice and vocal self-assessment after thyroidectomy

BACKGROUND

Voice alterations after thyroidectomy can be found even with preserved function of laryngeal nerves. The purpose of this study was to evaluate voice before and after thyroid surgery and the role of orotracheal intubation on voice changes.

METHODS

We conducted a prospective nonrandomized study of patients who underwent thyroid surgery and compared the results with a control group of patients who underwent breast surgery. Subjects underwent a videolaryngoscopic exam, a subjective and an objective voice analysis and a Voice Handicap Index (VHI) questionnaire before and after surgery.

RESULTS

A total of 100 patients who underwent thyroidectomy and 30 who underwent breast surgery were studied. Both groups were similar in demographic, clinical, and surgical variables. Postoperative videolaryngoscopy showed larynx alterations in 28% of the thyroidectomized patients, without significant alterations in the control group. There were subjective voice changes in 29.7% of the patients without vocal fold immobility after thyroid surgery and no statistically significant changes after breast surgery. Acoustic analysis showed significant increased values in the voice turbulence index (VTI) parameter in both groups, although higher in the thyroid one. In the VHI assessment, voice complaints were more frequently registered in the thyroid group rather than in the control group.

CONCLUSIONS

Voice alterations are frequent after thyroidectomy even with preserved vocal fold mobility. Such alterations were more frequently detected in that group than in patients who underwent breast surgery. Orotracheal intubation is just one of the multiple factors involved.