Impact of thyroidectomy without laryngeal nerve injury on vocal quality characteristics: An objective multiparameter approach

A Prospective Comparative Analysis to Study the Impact on Voice Changes Following Endoscopic Thyroidectomy

BACKGROUND

Endoscopic approach has come up as a safe and feasible procedure for thyroidectomy with better cosmetic outcomes. However, concerns over its safety in terms of nerve injury and postoperative voice changes remain. This prospective study evaluated the role of vocal cord function assessment using laryngeal examination and voice analysis in patients who underwent endoscopic hemithyroidectomy either by the trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) or the bilateral axillobreast approach (BABA).

METHODS

Thirty-nine consecutive patients were randomly allocated to either of the 2 groups of endoscopic hemithyroidectomy; 19 in TOETVA and 20 in the BABA groups. Vocal cord function was assessed subjectively using the GRBAS scale and objectively by acoustic analysis of parameters such as jitter, shimmer, mean frequency (F 0 ), noise-to-harmonic ratio (NHR), and maximum phonatory time (MPT) at baseline, postoperative day 10, and 3 months after surgery.

RESULTS

There were no significant differences in mean GRBAS scores and values of mean frequency, jitter and shimmer between the 2 groups and on postoperative day 10 and at 3 months compared with baseline. The mean NHR and MPT showed no differences between the 2 procedures. However, there was a significant decrease in their values on day 10 postsurgery, compared with baseline. These values returned to their baseline at 3 months. The other operative parameters were comparable between the 2 groups, except for the shorter mean operative time in the TOETVA group.

CONCLUSIONS

Perioperative quantitative voice parameters were comparable with no statistically significant difference between the 2 techniques of endoscopic thyroidectomy.

Translation and Cross-Cultural Adaptation of the Thyroidectomy-Related Voice Questionnaire (TVSQ) in Greek Population

OBJECTIVES

The Thyroidectomy-Related Voice Questionnaire (TVSQ) is a useful tool in the detection of voice changes and dysfunctions and the diagnosis of other symptoms related to transient or permanent laryngeal nerve damage in patients after thyroidectomy. The aim of our study is the translation and validation of (TVSQ) in the Greek language and in Greek population for the first time.

METHODS

The TVSQ was translated from English to Greek and vice versa by two independent researchers, while before the application of the TVSQ in clinical practice, a control group of 20 people was used. The following methods were used for the weighting and analysis of the TVSQ: Polychoric correlation, Cronbach's alpha, confirmatory factor analysis, and item response theory (IRT).

RESULTS

Polychoric correlations revealed that questions 1-10 have a strong positive correlation with each other, while the correlation of the rest of the TVSQ items is positive. Subsequently, for the first subgroup of questions ("voice change") Cronbach's alpha was equal to 0.950, while for the second ("throat and neck discomfort") Cronbach's alpha was equal to 0.846. Thus, we conclude that the internal consistency reliability is high for both subgroups of TVSQ questions. With the IRT method we showed that for the first subgroup of questions ("voice change"), the item with the least predictive value is question 5, while for the second subgroup of questions ("throat and neck discomfort"), the item with the least educational value was question 15.

CONCLUSIONS

Our team translated and validated the TVSQ with the above statistical methods in the Greek language, so that it can be used as a valuable tool in clinical practice, and more specifically in patients undergoing thyroidectomy. TVSQ can play a significant role on the diagnosis of either postoperative voice disorders and other symptoms related to thyroidectomy.

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.

Phonetic features of patients with transoral endoscopic thyroidectomy

OBJECTIVE

The objective of this study was to compare phonetic outcomes of TOETVA with those of conventional transcervical thyroidectomy(OPEN).

METHODS

Retrospective chart review of total 61 patients who received thyroidectomy through OPEN (n = 34) or TOETVA (n = 27) approach in single tertiary center were enrolled.

RESULTS

There were significant differences in F0 between the two groups and there were significant changes from different time points within each group in jitter for vowel /i/. Aerodynamically, there were significant differences in mean sound pressure level for vowel /a/ and mean sound pressure level, mean air pressure, and aerodynamic resistance for syllable /pa/ between the two groups. In subjective VHI evaluations, there were no significant differences between the two groups.

CONCLUSION

This study is significant in that it has investigated voices of patients with TOETVA. Results of this study are expected to be useful for voice evaluation, treatment, and prevention in the future.

LEVEL OF EVIDENCE: 3

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.

Evaluation of voice function after BABA robotic thyroid lobectomy: A comparative analysis with endoscopic thyroid lobectomy

The purpose of this study was to compare the effect of robotic thyroid lobectomy via Bilateral Axlio-Breast Approach (BABA) and endoscopic thyroid lobectomy on the voice function. A total of 125 patients with thyroid cancer from March 2021 to July 2022 were divided into the robotic thyroid lobectomy group and the endoscopic thyroid lobectomy group. Acoustic index and voice handicap index (VHI-10) were compared between the 2 groups before and after (1 week, 1 month, 3 month) the surgery. In the robotic group, VHI-10 score was not significantly different before and after the surgery. In the endoscopic group, VHI-10 score after the surgery was significantly higher than that before the surgery. In the endoscopic group, the fundamental frequency (F0) declined significantly 1 week and 1 month after the surgery compared with that before the surgery. One week after surgery, F0 in the endoscopic group was (197.91 ± 24.15) Hz, which was significantly lower than that (206.77 ± 20.13) Hz in the robotic group. In the robotic group, there was no obvious decline in F0 and MPT in each follow-up period after surgery compared with those before surgery. In the endoscopic group, MPT declined significantly 1 week after the surgery compared with that before surgery. One week after surgery, MPT in the endoscopic group was (13.02 ± 9.28) s, which was significantly lower than that (17.55 ± 9.25) s in the robotic groups. There were no significant differences in Shimmer, Jitter, DSI and NHR during all postoperative follow-up periods compared with those before surgery in both groups. The voice function of robotic thyroid lobectomy via BABA is superior to endoscopic thyroid lobectomy.

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.

Functional results of endoscopic arytenoid abduction lateropexy for bilateral vocal fold palsy

Purpose

Endoscopic arytenoid abduction lateropexy (EAAL) is a reliable surgical solution for the minimally invasive treatment of bilateral vocal fold palsy (BVFP), providing a stable airway by the lateralization of the arytenoid cartilages with a simple suture. The nondestructive manner of the intervention theoretically leads to higher regeneration potential, thus better voice quality. The study aimed to investigate the respiratory and phonatory outcomes of this treatment concept.

Methods

61 BVFP patients with significant dyspnea associated with thyroid/parathyroid surgery were treated by unilateral EAAL. Jitter, Shimmer, Harmonics to Noise Ratio, Maximum Phonation Time, Fundamental frequency, Voice Handicap Index, Dysphonia Severity Index, Friedrich’s Dysphonia Index, Global-Roughness-Breathiness scale, Quality of Life, and Peak Inspiratory Flow were evaluated 18 months after EAAL.

Results

All patients had a stable and adequate airway during the follow-up. Ten patients (16.4%) experienced complete bilateral motion recovery with objective acoustic parameters in the physiological ranges. Most functional results of the 13 patients (21.3%) with unilateral recovery also reached the normal values. Fifteen patients (24.6%) had unilateral adduction recovery only, with slightly impaired voice quality. Eleven patients (18.0%) had false vocal fold phonation with socially acceptable voice. In 12 patients (19.7%) no significant motion recovery was detected on the glottic level.

Conclusion

EAAL does not interfere with the potential regeneration process and meets the most important phoniatric requirements while guaranteeing the reversibility of the procedure—therefore serving patients with transient palsy. Further, a socially acceptable voice quality and an adequate airway are ensured even in cases of permanent bilateral vocal fold paralysis.

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.

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.

Vocal tract discomfort and voice handicap index in patients undergoing thyroidectomy

PURPOSE

This study aims to investigate the frequency and severity of vocal tract discomfort (VTD) symptoms and to determine the relationship between VTD and type of thyroidectomy, voice problem history, vocal abuse, and misuse behaviors, and the voice handicap index (VHI) in the thyroidectomy patients undergoing thyroidectomy, pre- and post-operatively pre- and post-thyroidectomy.

MATERIALS

The sample comprised 21 thyroidectomy patients undergoing thyroidectomy, including 10 patients with total thyroidectomy and 11 patients with partial thyroidectomy. The participants underwent videolaryngoscopy examination and completed the voice history questionnaire, the VTD scale, and the VHI, before and after the surgery.

RESULTS

Dryness was the most frequently occurring symptom, pre- and post-thyroidectomy. Participants with total thyroidectomy reported significantly higher frequency and severity of tickling than those in the preoperative status (p<.05). The frequency and severity of many VTD symptoms in the participants with voice problems and a vocal abuse and misuse history were higher than those without such a history at both assessment times (p<.05). There was significant correlation between the frequency and severity of VTD and VHI scores, pre-thyroidectomy pre-operatively (r = 0.488-0.575, p<.05).

CONCLUSIONS

An increment in the frequency and severity of tickling was reported by total thyroidectomy patients, post-thyroidectomy post-operatively. The type of thyroidectomy, voice problem history, and vocal abuse and misuse behaviors seem to influence the frequency and severity of VTD. Considering the correlation between VTD and VHI, the VTD scale provides important clinical information and can be used for evaluation and consultation purposes.

Singing voice range profile: New objective evaluation methods for voice change after thyroidectomy

BACKGROUND

After surgery in the thyroid region, patients may present with phonation or singing difficulty, even within their vocal range. We designed a novel voice evaluation method that reflects subjective and objective voice complications of the surgery.

METHODS

This tool recorded patients' voice ranges while singing, which was named the singing voice range profile (singing VRP). Patients were asked to sing "Happy Birthday," which has a one-octave scale, at a comfortable tone and intensity. The singing VRP, standard VRP and voice handicap index-10 (VHI-10) results were recorded before thyroidectomy and 1 and 3 months after thyroidectomy for 128 patients. For subgroup analysis, a group where the maximum F₀ of standard VRP in 1 month postoperatively was lower than the highest singing F₀ of the preoperative singing VRP was defined as "Collapsed group" and the other group was "Preserved group."

RESULTS

The changes in the highest, lowest and range of singing fundamental frequency (F₀ ) had decreased at 1 month postoperatively. Subsequently, they had improved significantly at 3 months postoperatively but were lower than those preoperatively (all P < .05, except for the change in the lowest singing F₀ between 1 and 3 months postoperatively, P = .274). In the subgroup analysis, the singing range of the collapsed group (n = 65) showed significantly lower VHI-10 scores, range of vocal F₀ and singing F₀ than those of the preserved group (n = 63) at 1 and 3 months postoperatively (all P < .001). At 3 months postoperatively, the singing F₀ range in the preserved group had recovered to the range before surgery (13.0 ± 1.3 vs. 13.1 ± 1.4, P = .746 for the preserved group, and 13.0 ± 1.3 vs 11.5 ± 2.4, P < .001 for the collapsed group).

CONCLUSIONS

Parameters measured by singing VRP showed a trend similar to the change in VHI-10 and the maximum F₀ of standard VRP. In addition, singing VRP allowed a qualitative classification of the postoperative voice function when combined with standard VRP. Therefore, it can be used as a supplementary voice evaluation tool to reflect the physiologic and functional aspects of voice.

Voice change after thyroidectomy without vocal cord paralysis: Analysis of 2,297 thyroidectomy patients

BACKGROUND

Some patients experience long-term voice change after thyroidectomy. One of the most common symptoms of voice change is pitch lowering, which is closely related to unfavorable voice quality. Here we observed voice outcomes for 6 months of follow-up after thyroidectomy to identify factors closely related to low-pitched voice.

METHODS

We retrospectively reviewed the records of 2,297 patients who underwent thyroidectomy between January 2014 and December 2017. All the patients had their vocal status examined using videostroboscopy, acoustic voice analyses, aerodynamic study, and Thyroidectomy-Related Voice Questionnaire scores. We stratified patients into 2 groups (low-pitched voice versus favorable voice) according to pitch lowering (reduction in speaking fundamental frequency ≥12 Hz 1 month after thyroidectomy compared to the preoperative value). We compared preoperative data with postoperative data collected 1, 3, and 6 months after thyroidectomy to identify factors contributing to low-pitched voice.

RESULTS

Univariate logistic regression analyses showed that factors related to low-pitched voice were female sex, older age, low body weight, short stature, and a high positive lymph node ratio. Multivariate analyses showed that female sex and older age were significantly associated with a negative prognosis for low-pitched voice 1 month after thyroidectomy (odds ratios 0.41 and 1.04, respectively; P < .001). Receiver operating characteristic curves for predicting sustained low-pitched voice during 6 months showed that speaking fundamental frequency ≥12.48 Hz 1 month after thyroidectomy was the optimal cutoff value, with 87.9% sensitivity and 95.8% specificity (P < .001).

CONCLUSION

Female sex and older age are strongly associated with increased risk for low-pitched voice after thyroidectomy. Speaking fundamental frequency ≥12.48 Hz 1 month after thyroidectomy can be used to predict sustained low-pitched voice after thyroidectomy.

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.

Development and Validation of the Thyroidectomy-Related Voice and Symptom Questionnaire (TVSQ)

OBJECTIVES

Common symptoms after thyroidectomy include voice change and throat and neck discomfort. But no common questionnaire has been developed. This study was performed to evaluate the reliability and validity of the Thyroidectomy-related Voice and Symptom Questionnaire (TVSQ).

METHODS

Fourty items of the TVSQ were divided into 20 items related to the "voice change" and "throat and neck discomfort" subcategories, using item generation. Through a reduction process, 20 items were removed and 20 items were used. For the patients after thyroidectomy, we evaluated the reliability and validity of each of the 20 items through item discrimination, test-retest reliability, concurrent validity, and external validity by comparing normal group and laryngeal disease patients. Also, the patients were compared before as well as 2 and 4 weeks after thyroidectomy.

RESULTS

Item discrimination assessment showed a significant correlation between TVSQ total score and both the TVSQ "voice change" score (r = 0.908**) and TVSQ "throat and neck discomfort" score (r = 0.862**). Test-retest reliability assessment showed a significant correlation between TVSQ total scores at 2 and 4 weeks postoperatively (r = 0.764**). Concurrent validity assessment revealed that the TVSQ showed high correlations with other voice questionnaires (Voice Handicap Index, Reflux Finding Index, and Vocal Track Discomfort Scale; r = 0.538**-0.830**). External validity assessment revealed that the TVSQ was suitable for patients after thyroidectomy (P < 0.000**).

CONCLUSIONS

Validity and reliability tests revealed that the TVSQ was suitable for assessment of the subjective feelings of patients with voice change and throat and neck discomfort after thyroidectomy.

Clinical Significance of the Preoperative Thyroidectomy-Related Voice Questionnaire Score in Thyroid Surgery

BACKGROUND

The thyroidectomy-related voice questionnaire (TVQ) is an efficient screening tool for detecting postoperative vocal dysfunction. The aim of this study was to confirm the significance of the preoperative TVQ score in thyroid surgery.

METHODS

We examined 180 women who underwent total thyroidectomy with central lymph node dissection from March 2014 to May 2016. Based on the preoperative TVQ score, participants were categorized under "normal" (TVQ score <5) and "abnormal" (TVQ score ≥5) groups. The laryngoscopic examination and acoustic analysis were performed and the TVQ score assessed before and after surgery (2 weeks, 2 months, and 8 months).

RESULTS

In the normal group, the TVQ score increased up to 2 months postoperatively and had decreased at 8 months postoperatively but was significantly higher than the preoperative TVQ score. In the abnormal group, the TVQ score increased up to 2 months postoperatively but had recovered similar to the preoperative TVQ score 8 months postoperatively. The preoperative TVQ score in the abnormal group moderately correlated with the final TVQ score; however, the preoperative TVQ score in the normal group did not correlate with the TVQ score 8 months postoperatively.

CONCLUSION

During preoperative patient counseling, it is important to explain that voice changes without vocal cord palsy may occur postoperatively and that it may take a long time to resolve, particularly in patients with a normal preoperative TVQ score.

Comparison Between Patient-Perceived Voice Changes and Quantitative Voice Measures in the First Postoperative Year After Thyroidectomy: A Secondary Analysis of a Randomized Clinical Trial

Importance

Voice changes after thyroidectomy are typically attributed to recurrent laryngeal nerve injury. However, most postoperative voice changes occur in the absence of clinically evident vocal fold paralysis. To date, no study has compared the prevalence, duration, and consequences of voice-related disability from the patient perspective with use of quantitative vocal measures.

Objectives

To assess the quality-of-life consequences of postthyroidectomy voice change from the perspective of patients with thyroid cancer and to compare patient-perceived voice changes with changes in quantitative vocal variables at 5 time points in the first postoperative year.

Design, Setting, and Participants

This prospective mixed methods observational study within a randomized clinical trial occurred at the University of Wisconsin Hospital and Clinics. Participants were 42 patients with clinically node-negative papillary thyroid cancer without a preexisting vocal cord paralysis who were recruited and enrolled from outpatient clinics between June 6, 2014, and March 6, 2017, as part of the ongoing randomized clinical trial.

Intervention

Total thyroidectomy.

Main Outcomes and Measures

Semistructured interviews, symptom prevalence, and instrumental voice evaluations (laryngoscopy, phonation threshold pressure, Dysphonia Severity Index, and Voice Handicap Index) occurred at baseline (n = 42) and 2-week (n = 42), 6-week (n = 39), 6-month (n = 35), and 1-year (n = 30) postoperative time points.

Results

Participants had a mean age of 48 years (interquartile range, 38-58 years; age range, 22-70 years) and were mostly female (74% [31 of 42]) and of white race/ethnicity (98% [41 of 42]). Impaired communication was the primary theme derived from patient interviews from before thyroidectomy to after thyroidectomy. Voice changes were perceived by 24 participants at 2 weeks after thyroidectomy. After surgery, voice symptoms were prevalent and persisted for 50% (21 of 42) of participants out to at least 1 year of follow-up. Quantitative vocal perturbations were detected in the Dysphonia Severity Index and Voice Handicap Index at the 2-week follow-up but returned to baseline levels by the 6-week follow-up visit.

Conclusions and Relevance

Voice changes are common after surgery for papillary thyroid cancer and affect quality of life for many patients out to 1 year of follow-up. Directly querying patients about postoperative voice changes and questioning whether commonly used aerodynamic and acoustic variables detect meaningful voice changes are important in identifying patients whose quality of life has been affected by postthyroidectomy dysphonia.

Trial Registration

ClinicalTrials.gov Identifier: NCT02138214.

Massed Versus Spaced Practice in Vocology: Effect of a Short-Term Intensive Voice Therapy Versus a Long-Term Traditional Voice Therapy

Purpose The aim of this study was to compare the effect of a short-term intensive voice therapy (IVT) with a long-term traditional voice therapy (TVT) on the vocal quality, vocal capacities, psychosocial impact, vocal tract discomfort, laryngological anatomy/physiology, and session attendance of patients with dysphonia. An additional comparison was made between an individual IVT (IVT-I) and a group IVT (IVT-G). Method A longitudinal, prospective controlled trial was used. Forty-six adults diagnosed with dysphonia were assigned to 1 of the 3 treatment groups. The IVT groups practiced with a frequency of 1 hr 20 min a day and a duration of 2 weeks. The TVT group practiced with a frequency of two 30-min sessions a week and a duration of 6 months. Both therapy programs were content-identical and guided by the same voice therapist. A multidimensional voice assessment consisting of both objective (maximum performance task, aerodynamic measurements, voice range profile, acoustic analysis, multiparametric voice quality indices) and subjective (subject's self-report, auditory-perceptual evaluation, flexible videolaryngostroboscopy) outcomes was used to evaluate the participants' voice. Results IVT made an equal progress in only 2 weeks and 12 hr of therapy compared with TVT that needed 6 months and 24 hr of therapy. IVT-I and IVT-G showed comparable results. Session attendance was clearly higher in IVT compared with TVT. Long-term follow-up results (1 year) were positive for the 3 groups, except for the self-reported psychosocial impact that increased in the IVT-I group. Conclusions Short-term IVT is at least equally effective in treating patients with dysphonia as long-term TVT. Group treatment seemed as effective as individual treatment. Attendance and cost-effectiveness are important advantages of IVT. A potential drawback might be an insufficient psychosocial progress. The golden mean between intensive and traditional treatment might therefore be an achievable, effective, and efficient solution for everyday clinical practice. Supplemental Material https://doi.org/10.23641/asha.7761872.

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.

Single-session high intensity focussed ablation (HIFU) versus open cervical hemithyroidectomy for benign thyroid nodule: analysis on early efficacy, safety and voice quality

BACKGROUND

High intensity focussed ultrasound (HIFU) is a promising non-surgical treatment for symptomatic benign thyroid nodule. We aimed to compare early efficacy, safety and voice quality between HIFU ablation and open thyroidectomy.

METHODS

Consecutive patients who underwent single-session HIFU ablation or a hemithyroidectomy for symptomatic benign thyroid nodule were included. The 6-month extent of nodule shrinkage, symptom improvement score, thyroid function, hospital stay and cost were compared between the two procedures. Safety was defined by absence of major complications like recurrent laryngeal nerve injury and skin burn. Voice quality was assessed by a computerised multi-dimensional voice programme and a Voice Handicap Index (VHI) questionnaire 1-month after treatment.

RESULTS

Altogether, 43 patients had HIFU and 103 patients had a hemithyroidectomy. In the HIFU group, the extent of nodule shrinkage at 6-month was 51.71 ± 16.04%. No patients in the HIFU group suffered skin burn or hypothyroidism. The HIFU group had a significantly shorter length of hospital stay (0.3 vs. 1.0 day, p < 0.001), lower incidence of subclinical hypothyroidism (1/43 vs. 21/103, p = 0.008), higher symptom improvement score (p = 0.009) and was less costly (USD 1923.1 vs. USD 5384.6). Relative to HIFU, pitch quality also worsen after surgery (p < 0.05).

CONCLUSIONS

Relative to surgery, single HIFU ablation appeared efficacious and safe. Apart from shorter hospital stay, less subclinical hypothyroidism, being scar-less, lower cost and more symptom improvement, HIFU patients were less affected by a pitch problem in the first month. This study provides a strong argument for HIFU ablation as a treatment for symptomatic benign thyroid nodule.

Laryngeal electromyographic changes in postthyroidectomy patients with normal vocal cord mobility

Thyroidectomy has been used for the treatment of thyroid disease for more than 100 years. In spite of the advancement of surgical techniques, there is still a risk of laryngeal nerve injury. The risk of partial or complete injury still depends on some surgical and disease-related factors. The aim of this study is to show the partial injury and to establish these risk factors via laryngeal electromyographic analysis (LEMG) in postthyroidectomy patients with normal vocal cord motion and mucosal anatomy. Patients who had undergone thyroid surgery were enrolled in this prospective study. LEMG analysis was performed to all patients with normal vocal cord mobility preoperatively and was repeated after the first and the third months of surgery. Thyroarytenoid (TA) and cricothyroid (CT) muscles were used to evaluate recurrent and external branch of superior laryngeal nerves, respectively. Four of the 32 patients had mild-to-moderate degrees of partial LEMG changes during preoperative LEMG analysis of TA and CT muscles on each side. After 3 months of surgery, there was a statistically significant worsening of LEMG findings in the right and left external branches of superior and left recurrent laryngeal nerves. Disease and surgery-related risk factors were analyzed. However, there was no significant relationship on the progression of LEMG findings according to these parameters. This is the first prospective study which supports the risk of progression of LEMG changes in patients with normal laryngoscopic examination after thyroid surgery. No reliable significant risk factor was found influencing the LEMG progression.

Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial

PURPOSE

The purpose of this study was to evaluate the effect of intraoperative neuromonitoring (IONM) on the injury rate of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy.

METHODS

A total of 133 consenting patients (98 female, 35 male; mean age, 45.6 ± 11.7 years) undergoing thyroidectomy were randomly assigned to 2 groups. In group 1 (n = 65 patients, 105 nerves), superior thyroid pole dissection was performed with no attempt to identify the EBSLN; in group 2 (n = 68 patients, 106 nerves), IONM was used to identify the EBSLN during surgery. EBSLN function was evaluated by intraoperative electromyography of the cricothyroid muscle. The EBSLN Voice Impairment Index-5 (VII-5) was conducted preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was the prevalence of EBSLN injury. The secondary outcomes were the identification rate of the EBSLN using IONM and changes in postoperative voice performance.

RESULTS

EBSLN injury was detected in eight (12.3%) patients and nine (8.6%) nerves in group 1 and in one (1.5%) patient and one (0.9%) nerve in group 2 (patients, p = 0.015; nerves, p = 0.010). IONM contributed significantly to visual (p < 0.001) and functional (p < 0.001) nerve identification in group 2. The VII-5 indicated more voice changes in group 1 than 2 at 1, 3, and 6 months postoperatively (p = 0.012, p = 0.015, and p = 0.02, respectively).

CONCLUSION

IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.

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.

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

Voice symptoms are frequently reported early after thyroidectomy, even in the absence of laryngeal nerves injury. We evaluated the short-term outcomes of these functional alterations. Thirty-nine patients were enrolled in a prospective observational trial, evaluating voice function before and 3 months after uncomplicated thyroidectomy, using VoiSS as assessed using a validated patient rated questionnaire; and perceptual voice analysis using GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain). Impact of dysphonia on patient's life using VoiSS questionnaire revealed differences between pre- and postoperative assessment. There was statistically significant worsening in the impairment subgroup of VoiSS (p = 0.027). GRBAS evaluation was consistent between the three independent raters but showed differences between pre- and postoperative voice assessment. Age, TSH and a preoperative finding of laryngopharyngeal reflux significantly predicted quality of voice after thyroid surgery (all p < 0.004), as identified by the GRBAS assessment tool, but not type of surgery, gender or smoking status; although prediction of total variance in changes of voice was modest (r ² = 0.07). Voice changes may occur after thyroidectomy without evident laryngeal nerve injury. Patients should be made aware of possible mild changes in voice even after uncomplicated thyroid surgery and this might be considered to be part of the informed consent.

Cepstral Analysis of Voice in Patients With Thyroidectomy

Objectives

The vocal changes after a thyroidectomy are temporary and nonsevere, therefore, obtaining accurate analytical results on the pathological vocal characteristics following such a procedure is difficult. For a more objective acoustic analysis, this study used the cepstral analysis method to examine changes in the patients’ voices during the perioperative period regarding sustained vowel phonation.

Methods

The sustained phonation of the five vowels (i.e., /a/, /e/, /i/, /o/, and /u/) by 35 patients with thyroidectomy were recorded by using a Multi-Speech program. Of the 35 patients, 10 were men and 25 were women, with an average age of 51.5 years. Voice data were collected a total of 3 times (preoperatively, 5–7 days after the operation, and 6 weeks after the operation) and were edited according to each fragment (on-set, mid, and off-set) for cepstral analysis.

Results

The cepstral analysis on the patients’ voices revealed no significant differences between the examination periods of all vowel phonations. However, analysis of the on-set fragment of the vowel /i/ revealed pathological characteristics in which the cepstral measurements of the voice were significantly lower after the operation than before the operation, with the cepstral measurements of the voice increasing further 6 weeks following surgery.

Conclusion

The results of the acoustic analysis on the on-set fragment of the vowel /i/ will be important data for characterizing the vocal changes during the perioperative period. This study contributes to future research on the mechanisms underlying changes in the voice of patients with a history of thyroid or neck surgery.

Prevalence of voice & swallowing complaints in Pre-operative thyroidectomy patients: a prospective cohort study

Background

Compressive symptoms are common in patients with thyroid disease and are an accepted indication for thyroidectomy. The objective of this study was to evaluate the prevalence and severity of voice and swallowing complaints in pre-operative thyroidectomy patients and to compare these with thyroid volume, thyroid pathology and laryngopharyngeal reflux.

Methods

A consecutive case series design was performed. All patients undergoing a thyroidectomy (partial or total) at a tertiary care centre during a 2 year period were invited to participate. Fifty nine (10 male, 49 female) aged 19–73 were enrolled (59.3% total thyroidectomy, 40.7% partial thyroidectomy). Voice and swallowing complaints were subjectively evaluated using the Voice Handicap Index (VHI) and the Modified Swallowing Impairment Score (MSIS), respectively. All patients completed the Reflux Symptom Index (RSI) and underwent videostroboscopy. Vocal function was objectively evaluated using perceptual ratings (GRBAS) and acoustic voice analysis (jitter, shimmer, maximum phonation time, maximum fundamental frequency range). The relationship between voice and swallowing symptoms was compared with thyroid volume and surgical pathology.

Results and discussion

The average VHI score was 8.39, representing normal voice scores. Of the objective voice measures, only jitter and a subset of GRBAS measures were slightly elevated. Swallowing complaints were reported at least “some of the time” by 25 patients (41.7%), and “often or always” by 16 patients (26.7%). Of the patients with voice and swallowing complaints, 68.4% and 56%, respectively, had elevated RSI scores consistent with laryngopharyngeal reflux. No correlation was found with thyroid volume or thyroid pathology.

Conclusions

Swallowing complaints appear to be common in pre-operative thyroidectomy patients. A large percentage, however, have associated laryngopharyngeal reflux which may in part account for these symptoms. Patients presenting with compressive thyroid symptoms should be evaluated for laryngopharyngeal reflux, and treated where appropriate.

Neurological complications in thyroid surgery: a surgical point of view on laryngeal nerves

THE CERVICAL BRANCHES OF THE VAGUS NERVE THAT ARE PERTINENT TO ENDOCRINE SURGERY ARE THE SUPERIOR AND THE INFERIOR LARYNGEAL NERVES: their anatomical course in the neck places them at risk during thyroid surgery. The external branch of the superior laryngeal nerve (EB) is at risk during thyroid surgery because of its close anatomical relationship with the superior thyroid vessels and the superior thyroid pole region. The rate of EB injury (which leads to the paralysis of the cricothyroid muscle) varies from 0 to 58%. The identification of the EB during surgery helps avoiding both an accidental transection and an excessive stretching. When the nerve is not identified, the ligation of superior thyroid artery branches close to the thyroid gland is suggested, as well as the abstention from an indiscriminate use of energy-based devices that might damage it. The inferior laryngeal nerve (RLN) runs in the tracheoesophageal groove toward the larynx, close to the posterior aspect of the thyroid. It is the main motor nerve of the intrinsic laryngeal muscles, and also provides sensory innervation to the larynx. Its injury finally causes the paralysis of the omolateral vocal cord and various sensory alterations: the symptoms range from mild to severe hoarseness, to acute airway obstruction, and swallowing impairment. Permanent lesions of the RNL occur from 0.3 to 7% of cases, according to different factors. The surgeon must be aware of the possible anatomical variations of the nerve, which should be actively searched for and identified. Visual control and gentle dissection of RLN are imperative. The use of intraoperative nerve monitoring has been safely applied but, at the moment, its impact in the incidence of RLN injuries has not been clarified. In conclusion, despite a thorough surgical technique and the use of intraoperative neuromonitoring, the incidence of neurological complications after thyroid surgery cannot be suppressed, but should be maintained in a low range.

How can we screen voice problems effectively in patients undergoing thyroid surgery?

BACKGROUND

Voice problems following thyroid surgery are well known, and perioperative voice analysis in patients undergoing thyroidectomy no longer seems optional. However, multiple means of assessing vocal function are time-consuming, require specific instruments and specialists, and increase costs. Therefore, we designed this study to develop an efficient and cost-effective screening tool for detecting voice disorders following thyroidectomy.

METHODS

We developed the Perioperative Voice-Screening Protocol for Thyroid Surgery (PVST) using the Thyroidectomy-Related Voice Questionnaire (TVQ) to provide a cost-effective diagnostic flow chart for patients following thyroidectomy. The TVQ is a simple questionnaire that was developed at our institution and has already demonstrated its effectiveness in detecting pre- and postthyroidectomy voice-related disorders in our previous studies. To investigate the PVST, we enrolled 242 subjects who underwent thyroidectomy and let them follow the PVST. All subjects underwent a voice work-up by a voice specialist to verify the predictive value of the protocol.

RESULTS

Using PVST, we could effectively screen for abnormal preoperative laryngeal findings with sensitivity and specificity of 82.1% and 50.5%, respectively, especially laryngeal benign mucosal disease with sensitivity and specificity of 100% and 45.6%, respectively. We could also screen for postoperative voice-related problems with sensitivity and specificity of 100% and 50.4% for detecting vocal-cord palsy, and 66.7% and 51.2% for detecting a low-pitched voice, respectively. If all 242 patients followed the protocol, US $42,768 would be saved, and the PVST was estimated to decrease costs by 43.5%.

CONCLUSIONS

The PVST is a reliable and cost-effective perioperative screening tool that enables thyroid surgeons to detect patients with voice problems in their routine outpatient clinic for early and appropriate referral to voice specialists.

Voice quality after surgical treatment for thyroid cancer

BACKGROUND

Thyroidectomy is a standard treatment for thyroid cancers. Hoarseness due to the paralysis of the recurrent laryngeal nerve is one of the most common postoperative complications, and has been studied by many investigators. However, voice quality after thyroidectomy in patients in whom recurrent laryngeal nerves were preserved and vocal cord morbidity was endoscopically normal has not been well studied. To understand voice quality after thyroidectomy further, we conducted a time-course analysis of voice quality in patients who had thyroidectomy with normal cord morbidity by various measures.

METHODS

We evaluated voice parameters including the Voice Handicap Index-10 (VHI-10), the vocal efficacy index, the fundamental frequency (F0), the maximum phonation time (MPT), the mean air flow rate (MFR), jitter, shimmer, and the noise-to-harmonics ratio (NHR) before and after total thyroidectomy (TT) or lobectomy (LO) for thyroid cancers in 110 patients in whom the recurrent laryngeal nerves were preserved without apparent injury and normal vocal cord mobility was confirmed by endoscopic examination. Thirteen patients who underwent parotidectomy were enrolled as controls.

RESULTS

Immediately after surgery, significant decreases in MPT (p=0.003) and significant increases in jitters, shimmers, and NHR (p=0.0002, 0.02, and 0.03, respectively) were observed in the patients who underwent TT. In comparison with the controls, jitters and NHR were significantly higher in the patients who had a TT (p=0.03, 0.04). MFR was significantly higher in the patients who had an LO than in the controls (p=0.02). As compared with the patients who had an LO, MPT was significantly shorter (p=0.0004) and MFR and NHR were significantly higher (p=0.004, 0.03) in the patients with a TT. In the patients who had a TT, the MPT immediately after the surgery was significantly longer in the patients who had simultaneously neck dissection (ND) in comparison with the patients who did not have ND. However, all these differences gradually decreased and were not significant at one month after surgery.

CONCLUSIONS

Our results suggest that TT and ND have a distinct impact on voice quality after surgical treatment for thyroid cancer, probably due to slight and transient nerve conduction disorders induced by the manipulation around recurrent laryngeal nerves and/or laryngeal edema induced by the disturbance of venous and lymphatic drainages. However, these changes appear to be temporary, lasting only a few weeks.

Patient perspectives on dysphonia after thyroidectomy for thyroid cancer

OBJECTIVES

To determine the frequency and consequences of patient-reported post-thyroidectomy voice disorder (PTVD) after surgery for thyroid cancer.

STUDY DESIGN

Retrospective review of data gathered from a survey.

PARTICIPANTS

Members of the Thyroid Cancer Survivors' Association (ThyCa).

METHODS

ThyCa members were asked about their thyroid disease and surgery, voice disturbance, impact on quality of life, treatment, and non-identifying demographics in a 36-item electronic questionnaire. Patients with preoperative voice disturbance or vocal fold immobility and those reporting postoperative vocal fold paralysis were excluded.

RESULTS

A total of 4426 members responded (37% response rate), and PTVD was reported by 51.1% of responders. Most were temporary (85.9%), with a minority reporting permanent hoarseness. Rates of postoperative dysphonia were similar between the extent of surgery and histology. Patients with PTVD predominantly characterized their impairment as loss of loudness and an inability to shout or sing. Nearly a quarter of patients reporting PTVD identified detrimental impact to their professional or personal lives. Only 57 patients (3.4%) were offered voice therapy; however, more than two-thirds of them (73.7%) experienced at least partial improvement.

CONCLUSIONS

We report the results of a large-scale patient survey to underscore the commonness of postoperative hoarseness and its impact on patients.

LEVEL OF EVIDENCE

4.

Postoperative functional voice changes after conventional open or robotic thyroidectomy: a prospective trial

PURPOSE

To use objective and subjective voice function analysis to compare outcomes in patients who had undergone conventional open thyroidectomy or robotic thyroidectomy.

METHODS

The study involved 88 consecutive patients who underwent thyroid surgery between May 2009 and December 2009; 46 patients underwent a conventional open thyroidectomy, and 42 underwent a robotic thyroidectomy. Auditory perceptual evaluation was used to make subjective assessments of voice function, and videolaryngostroboscopy, acoustic voice analysis with aerodynamic study, electroglottography, and voice range profile were used to make objective assessments. Each assessment was made before surgery, and at 1 week and 3 months after surgery.

RESULTS

The conventional open and robotic thyroidectomy groups were similar in terms of age, gender ratio, and disease profile. We found that 18 (20.5%) of the 88 patients showed some level of voice dysfunction at 1 week after surgery; that the dysfunction resolved by 3 months after surgery in all cases; and that it was not permanent according to postoperative videolaryngostroboscopy. The conventional open and robotic thyroidectomy groups were found to have similar levels of dysfunction at 1 week after surgery, except for jitter, which was greater in the robotic group. For both groups, any such dysfunction spontaneously resolved by 3 months after surgery, and there were no significant differences between the groups in terms of any voice function parameter.

CONCLUSIONS

Voice dysfunction was present after both open and robotic thyroidectomy (without any evident laryngeal nerve injury). However, function subsequently normalized to preoperative levels at 3 months after surgery in both groups. Voice function outcomes after robotic thyroidectomy are similar to those after conventional open thyroidectomy.

Functional voice and swallowing outcomes after robotic thyroidectomy by a gasless unilateral axillo-breast approach: comparison with open thyroidectomy

BACKGROUND

Voice and swallowing alterations are common complaints after thyroidectomy, even in the absence of laryngeal nerve impairment. However, voice and swallowing functions after robotic thyroidectomy have not been thoroughly investigated. This study compared the functional outcomes for voice and swallowing after robotic thyroidectomy and conventional open thyroidectomy.

METHODS

The study prospectively analyzed the voice and swallowing functions of patients with thyroid nodules who underwent robotic thyroidectomy by a gasless unilateral axillo-breast (GUAB) approach (50 cases) or by conventional open thyroidectomy (61 cases) from September 2009 to October 2010. Videolaryngostroboscopy or flexible laryngoscopy was performed pre- and postoperatively. Subjective voice and swallowing alterations were assessed by questionnaire preoperatively and then 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively. In addition, objective acoustic voice analysis was performed using a Multidimensional Voice Program, with Voice Range Profiles and maximum phonation times measured preoperatively and then 1 week, 1 month, 3 months, and 6 months postoperatively.

RESULTS

Subjective postoperative voice function was significantly better in the robotic group at 1 day, 1 month, and 3 months postoperatively than in the open group. The mean values of fundamental frequency, jitter, shimmer and noise-to-harmonic ratio before and after surgery did not differ between the two groups. However, the frequency range and the highest frequency were significantly better in the robotic group than in the open group at 3 months postoperatively. Subjective swallowing function did not differ between the two groups.

CONCLUSION

Postoperative voice function is better with robotic thyroidectomy using the GUAB approach than with conventional open thyroidectomy. This is an advantage of robotic thyroidectomy by the GUAB approach in addition to the excellent cosmesis.

Aerodynamic evaluation of the postthyroidectomy voice

OBJECTIVES/HYPOTHESES

Changes in vocal function before and after thyroidectomy were examined using aerodynamic and related assessments. Laryngeal airway resistance (R(law)) and phonation threshold pressure (PTP) were hypothesized to be sensitive to changes in laryngeal function that may occur after thyroidectomy separate from changes that may occur from endotracheal intubation alone.

STUDY DESIGN

Prospective longitudinal clinical trial with comparison group.

METHODS

Eighty patients were evaluated preoperatively, and 2 weeks and 3 months postoperatively to assess voice outcomes after thyroidectomy. In addition, 16 patients who underwent a nonneck operation were tested as a control group. Maximum phonation time (MPT), mean airflow, R(law), and PTP were determined at two vocal fundamental frequency (F0) levels (30% and 80% of the F0 range).

RESULTS

No systematic differences were detected for MPT, mean airflow, or R(law) as a short-term or intermediate-term outcome of either surgical group. PTP decreased significantly over time for both groups of participants and at both F0 levels. F0 range decreased significantly at the short-term postsurgical assessment and covaried with the PTP results, thereby explaining some of the variability in the PTP data.

CONCLUSIONS

Aerodynamic assessment did not reveal systematic changes in vocal function associated with thyroidectomy, although PTP decreased postoperatively for both surgical groups. This may be attributable in part to a learning effect or to postoperative reductions in F0 range.