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

Impact of Frailty on Post-Treatment Dysphagia in Patients with Head and Neck Cancer

In the rising and frail head and neck cancer (HNC) population, geriatric assessments are crucial. Frail HNC patients often experience dysphagia. The coexistence of dysphagia and frailty presents complex health challenges, however, there is limited evidence on the prognostic value of frailty on post-treatment dysphagia. This study explores the relationship between pre-treatment frailty status and post-treatment dysphagia in HNC patients. A retrospective data analysis from the OncoLifeS data-biobank at the University Medical Center Groningen of 242 patients diagnosed with HNC between 2014 and 2016. The study involved several physical, functional and psychological pre-treatment geriatric assessments, and frailty screening using the Groningen Frailty Indicator (GFI) and the Geriatric-8 screening tool (G8). Outcome measures were swallowing-related quality of life (HNSW-QoL) and toxicity-related dysphagia evaluations (CTCAE-D) at 3, 6, 12 and 24 months. Linear mixed-effects models assessed factors associated with HNSW-QoL and CTCAE-D. Frail patients consistently reported worse HNSW-QoL and CTCAE-D than non-frail patients over time, with symptoms increasing at 3 months, but gradually decreasing by 24 months. Frailty status (G8 or GFI) was a significant predictor for lower HNSW-QoL (β = 11.770 and 10.936, both p < 0.001), and lower CTCAE-D (β = 0.245, p = 0.058; β = 0.331, p = 0.019), respectively. In this study, frailty was found to be associated with a worse of swallowing-related quality of life, and with increased toxicity-related dysphagia. These findings provide insights for the identification of HNC patients at higher risk of post-treatment swallowing-related issues, and offer opportunities for optimizing their post-treatment swallowing 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.

Fluorescence imaging to visualize the recurrent laryngeal nerve during thyroidectomy procedures: analysis of 65 cases and 81 nerves

BACKGROUND

Recurrent laryngeal nerve (RLN) injury after thyroidectomy is relatively common. Locating the RLN prior to thyroid dissection is paramount to avoid injury. We developed a fluorescence imaging system that permits nerve autofluorescence. We aimed to determine the sensitivity and specificity of fluorescence imaging at detecting the RLN relative to thyroid and other background tissue and compared it to white light.

METHODS

In this prospective study, 65 patients underwent thyroidectomy from January to April 2022 (16 bilateral thyroid resections) using white and fluorescent light. Fluorescence intensity [relative fluorescence units (RFU)] was recorded for RLN, thyroid, and background. RFU mean, minimum, and maximum values were calculated using Image J software. Thirty randomly selected pairs of white and fluorescent light images were independently reviewed by two examiners to compare RLN detection rate, number of branches, and length and minimum width of nerves visualized. Parametric and nonparametric statistical analysis was performed.

RESULTS

All 81 RNLs observed were visualized more clearly under fluorescence (mean intensity, µ = 134.3 RFU) than either thyroid (µ = 33.7, p < 0.001) or background (µ = 14.4, p < 0.001). Forest plots revealed no overlap between RLN intensity and that of either other tissue. Sensitivity and specificity for RLN were 100%. All 30 RLNs and all 45 nerve branches were clearly visualized under fluorescence, versus 17 and 22, respectively, with white light (both p < 0.001). Visible nerve length was 2.5 × as great with fluorescence as with white light (µ = 1.90 vs. 0.76 cm, p < 0.001).

CONCLUSIONS

In 65 patients and 81 nerves, RLN detection was markedly and consistently enhanced with autofluorescence neuro-imaging during thyroidectomy, with 100% sensitivity and specificity.

Direct Transvestibular Feminization Thyroid Laryngochondroplasty

BACKGROUND

Feminization laryngochondroplasty (FLC) methods have evolved from using a midcervical incision to a submental, less visible incision. The scar may be unacceptable to the patient because it signals gender reassignment surgery. An endoscopic transoral approach to FLC inspired by transoral endoscopic thyroidectomy was recently suggested to avoid the neck scar; however, it requires special equipment and has a long learning curve. A vestibular incision is used to approach the chin in lower-third facial feminization surgery. The authors propose that this incision may be extended to the thyroid cartilage in performing direct FLCs. The authors describe their experience with a novel, minimally invasive, direct transvestibular use of the chin-reshaping incision.

METHODS

The medical records of all patients who underwent direct transvestibular FLC (DTV-FLC) from December of 2019 to September of 2021 were retrieved and reviewed for this retrospective cohort study. Data on the operative, postoperative, and follow-up courses, complications, and functional and cosmetic results were retrieved.

RESULTS

Nine transgender women were included. Seven DTV-FLCs were performed during lower-third facial feminization surgery, and two were isolated DTV-FLCs. One was a revision DTV-FLC. Transient minor complications were encountered and resolved by the postoperative visit at 1 to 2 months. Vocal fold function and voice quality remained intact. Eight available patients were satisfied with the surgical results. A blinded assessment by eight plastic surgeons determined that seven procedures were successful.

CONCLUSION

The novel DTV-FTLC approach either in isolation or as part of lower-third facial feminization surgery facilitated scar-free FLC with satisfactory cosmetic and functional results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Prevalence and risk factors for dysphagia in older adults after thyroid and parathyroid surgery

BACKGROUND

We aimed to determine the prevalence and risk factors for dysphagia in adults 65 years and older before and after thyroidectomy or parathyroidectomy.

METHODS

We performed a longitudinal prospective cohort study of older adults undergoing initial thyroidectomy or parathyroidectomy. We administered the Dysphagia Handicap Index questionnaire preoperatively and 1, 3, and 6 months postoperatively. We compared preoperative and postoperative total and domain-specific scores using paired t tests and identified risk factors for worse postoperative scores using multivariable logistic regression.

RESULTS

Of the 175 patients evaluated, the mean age was 71.1 years (range = 65-94), 73.7% were female, 40.6% underwent thyroidectomy, 57% underwent bilateral procedures, and 21.1% had malignant diagnoses. Preoperative swallowing dysfunction was reported by 77.7%, with the prevalence 22.4% greater in frail than robust patients (P = .013). Compared to preoperative scores, 43.4% and 49.1% had worse scores at 3 and 6 months postoperatively. Mean functional domain scores increased by 62.3% at 3 months postoperatively (P = .007). Preoperative swallowing dysfunction was associated with a 3.07-fold increased likelihood of worse functional scores at 3 months. Whereas frailty was associated with preoperative dysphagia, there was no association between worse postoperative score and age, sex, race, frailty, body mass index, smoking status, gastroesophageal reflux disease, comorbidity index, malignancy, surgical extent, or type of surgery.

CONCLUSION

Adults 65 years and older commonly report swallowing impairment preoperatively, which is associated with a 3.07-fold increased likelihood of worsened dysphagia after thyroid and parathyroid surgery that may persist up to 6 months postoperatively.

Patient-reported swallowing outcomes after transoral robotic thyroidectomy: Comparison with conventional transcervical thyroidectomy

BACKGROUND

This study aimed to evaluate the swallowing outcomes after transoral robotic thyroidectomy (TORT) and compare them with those of conventional transcervical thyroidectomy.

METHOD

We enrolled 146 patients who underwent thyroidectomy (73 TORT; 73 conventional approach). We prospectively analyzed swallowing outcomes using the Swallowing Impairment Index-6 (SIS-6) questionnaire, a patient-reported measure, before and 1, 3, and 6 days; 1, 3, and 6 months; and 1 year after surgery. Propensity score-matched analysis was performed using three covariates: age, sex, and extent of thyroidectomy.

RESULTS

SIS-6 scores worsened significantly immediately after surgery and progressively recovered 1 year postoperatively in both groups. Propensity score matching generated two matched groups of 22 patients each. In the propensity score-matched samples, the SIS-6 scores did not differ between the TORT and conventional groups, except at 1 day postoperatively.

CONCLUSION

Patient-reported swallowing outcomes of TORT were comparable to those of the conventional transcervical procedure.

The Underreported Postoperative Suffering after Thyroid Surgery: Dysphagia, Dysphonia, and Neck Pain-A Cross-Sectional Study

Background and Aims

Postoperative voice change, difficulty of swallowing, throat pain, and neck pain are the most commonly complaint after thyroid surgery. However, little emphasis is given to the problem, especially a place where the surgical and anesthesia services' unmet need is highly observed, i.e., the problem gets little attention especially in the countries where the gaps of surgery and anesthesia services are observed. Hence, this study aims to determine the magnitude and associated factors of voice change and related complaints after thyroid surgery.

Methods

A cross-sectional study was conducted on 151 patients who had had thyroid surgery from June 1 to December 30, 2021. Data were retrieved during the postoperative period after the patient regains consciousness.

Result

Out of 151 participants, 98 (64.9%) patients complained of either voice change or difficulty of swallowing and neck pain after thyroid surgery within 24 hours. Majority (58.3%) of the participants aged more than 30 years with a mean age of 33.7 ± 8.3 years and females 102 (67.5%). Neck pain is the most (52.3%) complained suffering after thyroid surgery, followed by voice change 38.4% and difficulty in swallowing 37.7%. Difficulty in swallowing after thyroid surgery significantly associated with a patient who frequently experience intraoperative hypotension (AOR = 23.24, 95% CI 4.6-116.7, and p = 0.01), type of surgical procedure (total thyroidectomy) (AOR = 8.62, 95% CI 1.21-61.50, and p = 0.03), and larger ETT size (AOR = 4.92, 95% CI 1.34-18.01, and p = 0.02). Postoperative voice change is associated with larger endotracheal tube (AOR = 15.47, 95% CI 3.4-69.5, and p ≤ 0.001), surgery lasting more than 2 hours (AOR = 7.34, 95% CI 1.5-35.1, and p = 0.01), and intraoperative hypotension (AOR = 23.24, 95% CI 4.6-116.7, and p ≤ 0.001).

Conclusion

The complaint of postthyroidectomy neck pain and throat discomfort is higher than 64.9%. Intraoperative hypotension, blood loss, higher ETT size utilization, and duration of surgical procedure are the identified possible risk factors and have to be minimized as much as possible. Patient reassurance has to be considered during the postoperative time.

Post-thyroidectomy voice and swallowing disorders and association with laryngopharyngeal reflux: A scoping review

Objective

Postthyroidectomy voice and swallowing symptoms (PVSS) may occur even in absence of laryngeal nerve injuries, which remains poorly understood. The objective of this review was to investigate the occurrence of PVSS and the potential etiological role of laryngopharyngeal reflux (LPR).

Design

Scoping review.

Methods

Three investigators search PubMed, Cochrane Library, and Scopus databases for studies investigating the relationship between reflux and PVSS. The authors adhered to PRISMA statements and the following outcomes were investigated: age, gender, thyroid features, reflux diagnosis, association outcomes, and treatment outcomes. Based on the study findings and bias analysis, authors proposed recommendations for future studies.

Results

Eleven studies met our inclusion criteria, accounting for 3829 patients (2964 females). Postthyroidectomy swallowing and voice disorders were found in 5.5%-64%; and 16%-42% of patients, respectively. Prospectively, some results suggested an improvement of swallowing/voice disorders postthyroidectomy, whereas others did not observe significant changes. The prevalence of reflux ranged from 16.6% to 25% of subjects who benefited from thyroidectomy. There was an important heterogeneity between studies regarding the profile of included patients, the PVSS outcomes used, the delay of PVSS assessment and reflux diagnosis, making difficult the study comparison. Some recommendations were provided to guide future studies, especially about the reflux diagnosis approach and clinical outcomes.

Conclusion

The potential etiological role of LPR in PVSS is not demonstrated. Future studies are needed to demonstrate an increase of pharyngeal reflux events with objective findings from prethyroidectomy to postthyroidectomy.

Level of Evidence

3a.

Nerve autofluorescence under near-ultraviolet light: cutting-edge technology for intra-operative neural tissue visualization in 17 patients

BACKGROUND

Nerve visualization and the identification of other neural tissues during surgery is crucial for numerous reasons, including the prevention of iatrogenic nerve and neural structure injury and facilitation of nerve repair. However, current methods of intra-operative nerve detection are generally expensive, unproven, and/or technically challenging. Recently, we have documented, in both in vivo animal models and ex vivo human tissue, that nerves autofluorescence when viewed in near-ultraviolet light (NUV). In this paper, we describe our use of nerve autofluorescence to facilitate the visualization of nerves and other neural tissues intra-operatively in 17 patients undergoing a range of surgical procedures.

METHODS

Employing the same prototype axon imaging system previously documented to markedly enhance nerve visualization in both in vivo animal and ex vivo human models, surgical fields were observed in 17 patients under both white and NUV light during parotid tumor resection (n = 3), thyroid tumor resection (n = 7), and surgery for peripheral nerve and spinal tumors and injury (n = 7).

RESULTS

In all 17 patients, the intra-operative use of the imaging system both was feasible and markedly enhanced the localization of all neural tissues throughout their course within the surgical field. All 17 procedures were successful and devoid of any peri-operative complications or post-operative neurological deficits.

CONCLUSIONS

Intra-operatively visualizing auto-fluorescent peripheral nerves and other neural tissues under NUV light is feasible in human patients across a range of clinical scenarios and appears to appreciably enhance nerve and other neural tissue visualization. Controlled studies to explore this technology further are needed.

Swallowing disorders after thyroidectomy: a systematic review and meta-analysis

PURPOSE

Swallowing disorders following thyroidectomy are common, even after surgery without confirmed complications. The purpose of the current systematic review is to investigate the prevalence of dysphagia at various time points after thyroidectomy, at the whole spectrum of it (total/partial, open/endoscopic, for benign/malignant disease).

METHODS

The literature available at PubMed, SciELO and Cochrane Library databases was reviewed, according to PRISMA guidelines, using the terms "dysphagia", "swallowing disorder", "deglutition disorder", "thyroidectomy" and "thyroid surgery" in the appropriate combinations. A quantitative synthesis of the results followed.

RESULTS

The systematic review of the literature resulted in 35 articles, which met the inclusion criteria and were analyzed regarding their type, sample, follow-up and results regarding post-thyroidectomy dysphagia in multiple follow-up times. A significant increase of swallowing impairment compared to baseline was recorded shortly after surgery. Dysphagia reverted to pre-operative levels 2-3 months later. Dysphagia continued to be reported in a significantly lower proportion of patients, even 1 year after surgery. No significant difference was noticed between open and endoscopic thyroid surgery at 2-3 months post-surgery.

CONCLUSIONS

The swallowing disorders reported after thyroidectomy should be expected, but are not always detectable through objective methods. This should not lead to underestimation of symptoms, since the patients' quality of life is negatively affected by the symptomatology.

Voice-related quality of life and emotional symptoms before and after thyroidectomy

PURPOSE

To correlate voice-related quality of life, anxiety, and depression symptoms pre- and post-thyroidectomy.

METHODS

Observational, longitudinal, prospective, and quantitative study. Twenty patients participated in the study, with a mean age of 54 years, who underwent thyroidectomy, laryngeal visual examination, and the Voice-Related Quality of Life and Hospital Anxiety and Depression Scale questionnaires at different times: preoperative, 1 week and 3 months post-thyroidectomy, with a higher prevalence of females (85%; n=17) and partial thyroidectomy (70%; n=14).

RESULTS

There was no statistical difference in voice quality of life between the moments, but lower preoperative scores were observed, especially in the physical domain. We observed a slight trace of anxiety in the preoperative period, with a reduction after 1 week and an increase after 3 months. There was a moderate negative correlation between the physical domain of QVV and the anxiety subscale and the total HADS score after 1 week and between the total domain of QVV with the total HADS score after 1 week, weak negative correlation between the total domain of QVV and the HADS anxiety subscale after 1 week and the total HADS score after 3 months.

CONCLUSION

The patients evaluated in this study self-perceived their voice-related quality of life as positive. Mild anxiety traits were identified, with a reduction after one week postoperatively and an increase after three months. The self-perception of better voice-related quality of life in the postoperative period is weakly related to the reduction of anxiety levels.

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.

Does neuromonitoring affect voice quality in patients subjected to a complete thyroidectomy ?

Voice dysfunction is the most common complication of thyroid surgery. The use of intraoperative neuromonitoring (IONM) is to protect the recurrent laryngeal nerves, the damage of which causes voice dysfunction. The aim of the study was to evaluate voice quality in patients who underwent complete thyroidectomy operated on with the application of IONM as well as a group of patients operated on with only macroscopic nerve visualization. In the analysis, clinical voice assessment was performed with particular focus on voice efficiency using the Voice Handicap Index (VHI), Vocal Tract Discomfort (VTD) and GRBAS scale. The study group consisted of 205 patients operated on with IONM. The control group consisted of 162 patients subjected to surgery only with macroscopic visualization of recurrent laryngeal nerves, without IONM. During the follow-up period from 2 to 10 years after surgery, checkups were performed. Each patient who came for a checkup was subjected to perceptual voice evaluation with the use of the GRBAS scale, indirect laryngoscopy procedure and voice selfevaluation with two questionnaires (VHI and VTD). The frequency of vocal fold palsy did not differ significantly statistically in the study group and the control group. Both in the study group and in the control group, patients with vocal fold paralysis had statistically significantly higher results in the VHI and VTD questionnaires as well as in the GRBAS study. Patients with recurrent laryngeal nerve injury show significant differences in the scope of voice handicap, both in the voice quality assessment with the use of the GRBAS scale, and self-evaluation questionnaires: VHI and VTD. All voice disorders evaluated with self-assessment are medium voice disability.

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.

Frailty and Quality of Life After Cochlear Implantation in Older Adults

OBJECTIVE

To examine the relationship among frailty index, hearing measures, and hearing-related quality of life (QOL) in older recipients of cochlear implants.

STUDY DESIGN

Cross-sectional survey.

SETTING

Academic medical center.

METHODS

Adults aged ≥65 years at the time of receiving cochlear implants between July 13, 2000, and April 3, 2019, were asked to complete a questionnaire on hearing-related QOL. Chart review was performed to identify patients' characteristics. Correlations were calculated between frailty index and audiologic outcome measures as well as between speech recognition scores and QOL scores. Linear regression models were developed to examine the impact of clinical characteristics, frailty index, and hearing measures on hearing-related QOL.

RESULTS

Data for 143 respondents were included. The mean age was 80.7 years (SD, 7.1), with a mean 27.8 years of hearing loss (SD, 17.4) before implantation. The mean frailty index was 11.1 (SD, 10.6), indicating that patients had 1 or 2 of the measured comorbidities on average. No correlation was found between lower frailty index (better health) and hearing scores, including pure tone averages (PTAs) and speech recognition scores. Lower frailty index and larger improvement in PTA after cochlear implantation predicted better QOL scores on univariate analysis (respectively, P = .002, β = -0.42 [95% CI, -0.68 to -0.16]; P = .008, β = -0.15 [95% CI, -0.26 to -0.04]) and multivariate analysis (P = .047, β = -0.28 [95% CI, -0.55 to -0.01]; P = .006, β = -0.16 [95% CI, -0.28 to -0.05]). No speech recognition scores correlated with QOL after cochlear implantation.

CONCLUSIONS

Frailty index does not correlate with hearing scores after cochlear implantation in older adults. Lower frailty index and more improvement in PTA predict better QOL scores after cochlear implantation in older adults.

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.

Voice- and swallowing-related symptoms after total thyroidectomy: evidence from a Brazilian national survey

ABSTRACT Purpose: to estimate the prevalence of voice- and swallowing-related symptoms in women submitted to total thyroidectomy. Methods: a population-based, observational, cross-sectional, analytical study, based on a Brazilian national survey. A total of 252 women, aged 18 to 58 years, submitted to total thyroidectomy, residing in the five geographical regions of the country participated in the study. All of them answered the version of the Thyroidectomy-Related Voice Questionnaire translated and adapted into Brazilian Portuguese, besides questions on demographic and clinical issues. A descriptive analysis of the categorical and quantitative variables was conducted. The relationship between the total TVQ score and the independent variables was analyzed with the Mann-Whitney and Kruskal-Wallis tests. The significance level used was 5%. Results: the most prevalent symptoms were, tired voice, after talking for a long time (50%), and dry mouth/thirst (43.3%). The voice-related symptoms were more prevalent than those related to swallowing. The total TVQ score was not related to age group (p=0.141), profession (p=0.213), region of residence (p=0.303), time since surgery (p=0.955), and radiotherapy/radioiodine therapy (p=0.666). Conclusion: Brazilian women submitted to total thyroidectomy have a high prevalence of voice- and swallowing-related symptoms, the former being predominant.

Swallowing dysfunction following surgery for well-differentiated thyroid cancer with extrathyroid invasion

BACKGROUND

Differentiated thyroid carcinoma (DTC) can invade the surrounding aerodigestive tract. Radical surgery for locally advanced DTC will require resection of the trachea, recurrent laryngeal nerve (RLN), inferior pharyngeal constrictor muscles (IPCMs), or a part of the esophagus. The purpose of this study was to demonstrate the effect of resection of these surrounding tissues combined with total thyroidectomy and neck dissection on swallowing function following surgery.

METHODS

We performed total thyroidectomy combined with neck dissection and resection of the RLN in 24 patients with DTC with extrathyroidal invasion (19 unilateral, 1 bilateral), IPCMs (n = 5), or muscle layers of esophagus (n = 9). Nine patients received a tracheostomy placement due to a window resection of the trachea for tumor invasion (n = 6) and necessary upper airway management (n = 3). We used the duration of nasogastric tube feeding to evaluate swallowing function following surgery.

RESULTS

Patients who underwent tracheostomy or IPCM resection showed significantly longer periods of tube feeding (p = 0.0057 and 0.0017, respectively). In contrast, resection of the unilateral RLN or esophageal muscle layer showed no difference in tube feeding duration. Multiple regression analysis indicated that tracheostomy and IPCM resection were significant independent predictors of longer periods of tube feeding (p = 0.04583 and 0.00087, respectively).

CONCLUSION

These results indicate that tracheostomy placement and resection of the IPCMs, together with total thyroidectomy, extends the tube feeding duration in the postoperative period.

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.

Patient Perception of Swallowing after Thyroidectomy in the Absence of Laryngeal Nerve Injury

INTRODUCTION

Swallowing and voice alterations may manifest in patients with thyroid disease, especially after thyroidectomy.

OBJECTIVE

To identify the prevalence of patients with complaints of swallowing disorders after thyroidectomy and to evaluate patients' perceptions regarding swallowing before and after the procedure.

METHODS

A prospective longitudinal study was performed with 26 consecutive patients undergoing a private service thyroidectomy, in which the presence of swallowing dysfunction was evaluated using validated questionnaires that addressed the perception of swallowing by patients before (on the day of surgery) and after the surgery (on the first postoperative day).

RESULTS

Of the 26 patients, 18 (69.2%) were subjected to total thyroidectomy and 8 to partial thyroidectomy. Analysis of the domains of the Swallowing Handicap Index questionnaire showed higher scores when evaluated on the first postoperative day, demonstrating a significant worsening in swallowing after the procedure. The same result was demonstrated for the final score of swallowing perception, with 15.3 and 30.8% of patients reporting moderate alterations before and after the thyroidectomy, respectively, and 11.5% reporting the alterations as severe. Swallowing and vocal symptoms on the first postoperative day were more prevalent in the procedure than previously mentioned. Eight patients (30.8%) noted swallowing alterations before the procedure, compared with 80.8% (21 cases) after thyroidectomy.

CONCLUSION

There was a prevalence of 42.3% in swallowing complaints on the first postoperative day, regardless of the lesion in the laryngeal innervation, and this prevalence was significantly higher than that prior to the procedure.

Minimally Invasive Approaches for Thyroid Surgery-Pitfalls and Promises

PURPOSE OF REVIEW

To provide an overview of the feasibility and safety of current minimally invasive remote-access approaches for thyroid surgery, in view of the amounting new challenges and paradigm shifts in the management of thyroid pathologies.

RECENT FINDINGS

Over the past two decades, several remote-access approaches for thyroid surgery have been developed to improve cosmesis; however, none has been widely adopted extensively in the Western world. The recently emerged transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is the only true minimally invasive approach, completely avoiding skin incisions. It has a relatively short learning curve, midline surgical view, accessible surgical equipment, and relatively broad inclusion criteria with promising surgical outcomes as reported to date. TOETVA has proven to be safe and feasible for carefully selected patients. Further experience and long-term follow-up are needed to define the added value of TOETVA except for improved cosmetic outcome.

What the thyroid cancer patient wants to know: ThyCa survey by the American Head and Neck Society Endocrine Surgery Section

OBJECTIVE

To survey a large cohort of thyroid cancer survivors from ThyCa on information needs and expectations of their treatment to better understand the pretreatment counseling, information, and support needs of this population.

METHODS

Anonymous survey of thyroid cancer survivors.

RESULTS

One thousand one hundred twenty-four patients with thyroid cancer participated in the survey. Three hundred sixty-two (37.44%) reported not having had a full understanding of their treatment plan and 407 (46.41%) reported that their thyroid cancer treatment did not conform to expectations. Patients diagnosed at younger ages were significantly more likely to report inadequate understanding of the treatment, failure of treatment to meet expectations, and call for greater attention to psychological well-being. Older patients were more likely to report unexpected effects on speech and swallowing. Regardless of age, patients most frequently called for greater attention to management of energy levels (endorsed by 61% of respondents), psychological well-being (50%), and weight changes (48%).

CONCLUSIONS

Improvements are needed in age-specific communication of thyroid cancer diagnosis and treatment.

Thyroidectomy-related Swallowing Difficulties: Review of the Literature

This study aims to provide insight into the etiology and frequency of swallowing complications that arise after thyroidectomy and to outline the available diagnostic procedures by revising the existing literature on this topic. We conducted a bibliographic search using the electronic database MEDLINE/PubMed to identify all relevant articles and 44 studies were included in the review out of a total of 218 published articles. Dysphagia after thyroid surgery is a common postoperative complication which, in the short- or long-term, significantly affects patient life quality. There is no standard diagnostic protocol for thyroidectomy-related swallowing impairment. Among the reviewed studies, 8 questionnaires and 12 instrumental diagnostic tools were used to identify swallowing difficulties related to thyroid surgery. The Swallowing Impairment Index (SIS-6) was the most-used questionnaire. Fiberoptic endoscopy is a standard diagnostic tool performed prior and after thyroid surgery, primarily to identify changes in vocal fold mobility. Although instrumental findings usually reveal non-specific alterations of swallowing; swallowing videofluoroscopy and esophageal manometry can be the most helpful tools in further management of thyroidectomy dysphagia. In patients with thyroidectomy-related swallowing difficulties and suspected laryngopharyngeal reflux, 24-hour MII-pH metry should be performed.

Transoral Vestibular Thyroidectomy: Current State of Affairs and Considerations for the Future

CONTEXT

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a recently described procedure for surgical management of select thyroid pathology that avoids a cutaneous scar. TOETVA is far from the first described remote-access approach to the thyroid. In fact, numerous such techniques have been described over the past 20 years, although none has gained widespread implementation in North America or Europe. However, with its rapid growth worldwide and excellent outcomes to date, TOETVA may succeed where these prior techniques have failed.

EVIDENCE ACQUISITION

The English literature was reviewed using the following keywords: transoral thyroidectomy, remote-access thyroidectomy, minimally invasive thyroidectomy, and TOETVA. Because three systematic reviews of this technique were recently conducted, this manuscript does not seek to provide a fourth. Rather, we summarize salient findings from these reviews and focus on candidates for the procedure, technique-specific characteristics that have led to early success with TOETVA, and prospects for the future.

EVIDENCE SYNTHESIS

TOETVA is the only thyroidectomy approach obviating the need for a cutaneous incision, and it offers several advantages over previously described remote-access thyroidectomy techniques. These include a favorable anatomic surgical perspective, a comparatively short learning curve, no requirement for expensive instrumentation, and a broad inclusion criterion. These characteristics have facilitated the excellent surgical outcomes to date.

CONCLUSIONS

TOETVA is a suitable surgical option with proven safety and feasibility for a carefully selected patient population. The potential value of the procedure outside enhanced cosmesis continues to be defined.

Dysphagia following uncomplicated thyroidectomy: a systematic review

OBJECTIVE

Dysphagia after uncomplicated thyroidectomy is commonly reported and it includes a broad spectrum of swallowing complaints. Though various causes have been hypothesized, it remains not completely understood.

METHODS

A systematic review was performed to identify studies concerning dysphagia post uncomplicated thyroid surgery. A qualitative analysis of data extracted was conducted.

RESULTS

We have included 16 studies of which 15 are prospective and one are retrospective. The number of subjects varied from 12 to 254, the mean age from 39 to 54 years with an overall prevalence of females. The duration of the follow-up ranges from 1 month to 4 years. All the included trials documented postoperative dysphagia, 12 of which have detected it in the early postoperative period. Considering long-term follow-up period, 12 studies reported an overall improvement of swallow symptoms. The instrumental findings revealed non-specific alterations of swallowing.

CONCLUSIONS

Dysphagia after uncomplicated thyroidectomy can arise early in the postoperative period resolving spontaneously in the first year. Diagnostic methods failed to identify the physio pathological mechanism of swallow alteration leaving this condition still unclear. Since these symptoms can reduce patient's quality of life, we suggest an appropriate education before thyroid surgery.