Changes in Swallowing Symptoms and Esophageal Motility After Thyroid Surgery: A Prospective Cohort Study

Postoperative laryngeal granuloma in mediastinal goitre with gastro-oesophageal reflux disease

Reported postoperative complications of mediastinal goitre include recurrent laryngeal nerve palsy, hypoparathyroidism and tracheomalacia. Voice and swallowing symptoms after thyroid surgery have been associated with laryngopharyngeal reflux, but it is unclear whether the retrograde flow of gastric contents into the oesophagus, larynx and pharynx worsens after thyroid surgery. We present the case of a man in his 40s with gastro-oesophageal reflux disease (GERD) who developed heartburn and laryngeal granuloma after total thyroidectomy for mediastinal goitre. Vonoprazan therapy effectively controlled these symptoms. Although the exact cause remains unclear, we suggest that changes in pressure dynamics after thyroidectomy may worsen the retrograde flow of gastric contents into the oesophagus, larynx and pharynx, contributing to GERD symptoms and laryngeal granuloma. This case highlights the need to consider the management of retrograde flow of gastric contents into the oesophagus, larynx and pharynx in the postoperative care of mediastinal goitre resections.

Voice and Swallowing Disorders After Thyroid Surgery

OBJECTIVE

The aim of the study was to evaluate voice and swallowing function following thyroid surgery, to identify dynamic changes during the follow-up period of 12-18 month and to find possible indicative signs of permanent or temporary vocal fold palsy.

METHODS

All participants (N = 110) were prospectively enrolled from the preoperative thyroid surgery patients between September 2013 and December 2016. All subjects underwent preoperatively, first week and 12-18 month postoperatively videolaryngostroboscopy, filled in subjective evaluation of voice (voice handicap index, [VHI]) and swallowing (swallowing impairment score) complaints. Acoustic voice analysis (AVA), maximum phonation time (MPT) measurement and perceptual voice evaluation were conducted. In the presence of laryngeal damage, additional first and sixth-month follow-up visits were planned. Patients, whom we suspected laryngeal nerve damage, underwent laryngeal electromyography 4 weeks after the operation.

RESULTS

On first postoperative week evaluation, no objective voice changes within patients with postoperatively intact laryngeal nerves were found. Subjective evaluations showed decline in VHI physical domain and increased strain in postoperative voice. Patients with postoperative nerve damage had a drastic decline in subjective voice quality (VHI all subscales and total score), AVA parameter jitter, MPT and perceptual voice quality. Subjective evaluation of swallowing revealed disturbances in all patients regardless of the nerve damage. We noticed remarkable differences in first week and first month visits between patients with permanent and temporary palsy in VHI total score and physical domain, MPT and perceptual breathiness and asthenia in voice. Regardless of the nerve injury, by the end of the follow-up period all changes had become statistically insignificant with the exception of perceptual evaluation of voice quality.

CONCLUSIONS

Patients with postoperative laryngeal nerve damage experience substantial deterioration of both subjective and objective voice quality with more extensive impairment in patients with permanent paralysis. Thyroid surgery causes subjective swallowing changes irrespective of laryngeal nerve damage. In patients without laryngeal nerve damage, swallowing function improves following thyroidectomy. Possible indicators for permanent paralysis are delayed recovery in the values of MPT and jitter and persistent perceptual breathiness and asthenia.

Mortality after benign thyroid surgery in patients aged 80 years or older

Introduction

A recent report from the United Nations showed that aged people are increasing worldwide. Few data exist on overall survival for patients 80 years or older undergoing benign thyroid surgery. Short- and long-term survival and risk factors for death in patients undergoing thyroid surgery for benign disease were evaluated, using a nationwide, population-based quality register.

Methods

Patients operated for benign thyroid disease, 2004 to 2017, were collected from the national quality register for thyroid surgery. Mortality data were retrieved from the Swedish National Board of Health and Welfare. Mortality at 30 days, 90 days, and 1 year after surgery, for patients 80 years or older, was calculated. Overall survival was calculated using the Kaplan–Meier estimate. Risk factors for mortality were assessed with Cox’s multiple regression analysis. The standardized mortality ratio was calculated.

Results

There were 17,969 patients. Among them, 483 patients were 80 years or older, and of these, 397 (82.2%) were women. The mortality rate at 0–30 days, 31–90 days, and at 91–365 days after surgery was 0.4%, 0.2%, and 2.5%, respectively. The median (IQR) follow-up time was 4.5 (2.9–7.2) and the median (IQR) survival time was 8.0 (4.1–12.5) years. Apart from age, there was no other risk factor for death. The standardized mortality ratio (SMR) was 0.67 (0.49–0.91) for men and 0.76 (0.65–0.89) for women.

Conclusion

Mortality after surgery for benign thyroid disease in patients 80 years or older was lower than the general population with no specific risk factors for death except for age.

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.

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.

The Impact of Post-thyroidectomy Paresis on Quality of Life in Patients with Nodular Thyroid Disease

Objective

To investigate the impact of postoperative paresis on disease-specific quality of life (DSQoL) after thyroidectomy in patients with benign nodular thyroid disease.

Study Design

Observational study.

Setting

University hospital.

Subjects and Methods

Patients were evaluated before and 3 weeks and 6 months after surgery in an individual prospective cohort study using videolaryngostroboscopy (VLS), voice range profile, voice handicap index (VHI), multidimensional voice program, maximum phonation time (MPT), and auditory perceptual evaluation. Changes in DSQoL were assessed by the Thyroid-specific Patient-Reported Outcome measure. Cohen’s effect size was used to evaluate changes.

Results

Sixty-two patients were included, 55 of whom completed all examinations. Three weeks after surgery, a blinded VLS examination showed signs of paresis of either the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve (RLN/EBSLN) in 13 patients (24%). A paresis corresponded to a 12 ± 28 point increase in VHI ( P = .002) and was associated with a significant 4.3 ± 7.5 semitone decrease in the maximum fundamental frequency ( P < .001) and a 5.3 ± 8.2 dB reduction in maximum intensity. Further, it was associated with a 4.5 ± 11.2 second reduction in MPT ( P = .001) and an increase of 0.40 ± 1.19 in grade, 0.42 ± 1.41 in roughness, and 0.36 ± 1.11 in breathiness. Signs of postoperative RLN/EBSLN paresis correlated with an 11.0-point ( P = .02) poorer improvement in goiter symptoms at both 3 weeks and 6 months after surgery.

Conclusion

Signs of RLN/EBSLN paresis after thyroidectomy were associated with less pronounced improvement in goiter symptoms in patients with thyroid nodular disease. However, thyroidectomy was associated with an overall improved DSQoL by 6 months after surgery.

The Impact of Esophageal Compression on Goiter Symptoms before and after Thyroid Surgery

INTRODUCTION

Benign nodular goiter may be associated with swallowing difficulties, but insight into the associated pathophysiology is limited. The aim of this study was to investigate the effect of surgery on the degree of esophageal compression, and its correlation to swallowing difficulties.

METHODS

Esophageal compression and deviation were evaluated blindly on magnetic resonance imaging (MRI) of the neck, prior to and 6 months after thyroid surgery for symptomatic benign goiter. Goiter symptoms and swallowing difficulties were measured by the Goiter Symptom Scale of the Thyroid-Specific Patient-Reported Outcome (ThyPRO) questionnaire. Cohen's d was used for evaluating effect sizes (ES).

RESULTS

Sixty-four patients completed the study. Before surgery, median goiter volume was 57 (range 14-642) mL. The smallest cross-sectional area of the esophagus (SCAE) increased from a median of 95 (47-147) to 137 (72-286) mm² (ES = 1.31, p < 0.001). Median esophagus width increased from 15 (range 10-21) to 17 (range 12-24) mm (ES = 0.94, p < 0.001) after surgery, while no statistically significant change was observed for the sagittal dimension (anterior-to-posterior), thus reflecting an increasingly ellipsoid esophageal shape. Median esophageal deviation decreased moderately after surgery from 4 (0-23) to 3 (0-10) mm (ES = 0.54, p = 0.005). The goiter symptom score improved considerably from (mean ± SD) 40 ± 21 to 10 ± 10 points (ES = 1.5, p < 0.001) after surgery, and the improvements were associated with improvements in SCAE (p = 0.03).

CONCLUSIONS

In patients with goiter, thyroidectomy leads to substantial improvements in esophageal anatomy, as assessed by MRI, and this correlates with improved swallowing symptoms. This information is valuable in qualifying the dialogue with goiter patients, before deciding on the mode of therapy. Clinicaltrials.gov (NCT03072654).

The Impact of Goiter and Thyroid Surgery on Goiter Related Esophageal Dysfunction. A Systematic Review

Background: Patients with goiter referred for thyroidectomy report swallowing difficulties. This might be associated with esophageal compression and deviation as this is present in a significant number of patients. Studies on how goiter and subsequently its treatment affect the esophagus are sparse and point in various directions. Our aim was to investigate, through a systematic review, the impact of goiter and thyroidectomy on esophageal anatomy, esophageal physiology, and subjective swallowing dysfunction. Methods: The search period covered 1 January 1975 to 1 July 2018, using the scientific databases PubMed and EMBASE. Inclusion criteria were adult patients with goiter who were either observed or underwent thyroidectomy. Search terms were variations of the terms for goiter, esophagus, swallowing, and dysphagia. From an initial 3,040 titles, 55 full text evaluations led to the final inclusion of 27 papers. Seventeen papers investigated, prospectively, the impact of thyroidectomy on the esophagus, while five observational and five retrospective studies were also included. Results: Esophageal anatomy impairment: Esophageal deviation occurred in 14% and esophageal compression in 8-27% of goiter patients. The prevalence increased with goiter size and with the extent of substernal extension. The smallest cross-sectional area of the esophagus increased by median 34% after thyroidectomy. Esophageal physiology changes: Goiter patients had increased esophageal transit time, positively correlated with goiter size, but unrelated to esophageal motility disturbances. Decrease in the upper esophageal sphincter pressure occurred early after surgery, and normalized within 6 months. Swallowing related patient-reported outcomes: Evaluated by validated questionnaires, swallowing symptoms worsened in the early period after thyroidectomy, but improved after 6 months, as compared to baseline. Conclusions: Thyroidectomy relieved patients with goiter from dysphagia, within 6 months of surgery probably via increase in the cross-sectional area of the esophagus. Attention to the impact by goiter on the esophagus is needed, and balanced and individualized information about the potential benefits and risks of thyroid surgery is crucial in the management of patients with goiter.

Thyroidectomy Improves Tracheal Anatomy and Airflow in Patients with Nodular Goiter: A Prospective Cohort Study

OBJECTIVE

A large goiter may cause compression of the trachea. The aim of this study was to investigate the impact of thyroidectomy on tracheal anatomy and airflow and to correlate this with changes in health-related quality of life (HRQoL) in patients with benign nodular goiter.

METHODS

Magnetic resonance images of the neck and respiratory flow-volume curves, including both inspiration and expiration, were performed prior to and 6 months following surgery. HRQoL was measured by selected scales from the thyroid-specific patient-reported outcome (ThyPRO). Cohen's effect size (ES) was calculated as mean change divided by standard deviation at baseline. ES of 0.2-0.5 were defined as small, 0.5-0.8 as moderate, and values >0.8 as large.

RESULTS

Sixty-five patients completed all examinations. Median goiter volume was 58 mL (range, 14-642 mL) before surgery with surgical removal of a median of 43 g (range, 8-607 g). Six months after surgery, tracheal narrowing and deviation were diminished by a median of 26% (ES = 0.67, p < 0.001) and 33% (ES = 0.61, p < 0.001), respectively. Correspondingly, each 10% decrease in goiter volume resulted in 1.0% less tracheal narrowing (p < 0.001). Concomitantly, a small improvement was seen in forced inspiratory flow at 50% of forced vital capacity (ES = 0.32, p < 0.001). A reduction in tracheal narrowing was associated with improvements in the Impaired Daily Life scale (0.33 points per 1% decrease in tracheal narrowing, p = 0.03) of the ThyPRO questionnaire.

CONCLUSIONS

In patients with symptomatic benign nodular goiter, thyroidectomy resulted in substantial improvements in tracheal anatomy and improvements in inspiratory flow, which were followed by gains in HRQoL. This information is pertinent when counseling patients before choice of treatment.

The compensatory enlargement of the remaining thyroid lobe following hemithyroidectomy is small and without impact on symptom relief

According to previous studies, hemithyroidectomy results in growth of the remaining thyroid lobe by up to 30% in first 12 months after surgery. However, this estimate is based on imprecise methods, high inter- and intra-observer variability, and lack of blinding of the measurements. Furthermore, it is unknown whether enlargement of the remaining hemi-thyroid interferes with the improvement in symptoms after surgery for goiter. We aimed to assess the impact of postoperative thyroid growth on goiter symptom relief following hemithyroidectomy in patients with benign nodular goiter. Outcomes were measured before and 6 months after hemithyroidectomy in 44 patients. Thyroid volumes were determined by two independent and blinded observers using magnetic resonance imaging (MRI). Inter- and intra-observer variability was visualized by Bland-Altman plots. Goiter symptoms were assessed by the Thyroid-Specific Patient-Reported-Outcome Questionnaire (ThyPRO) on a scale from 0 to 100 points. After hemithyroidectomy, the remaining thyroid lobe was 13.7 ± 6.4 mL, and enlarged by a mean of 1.8 mL over 6 months [95% confidence interval (CI) (1.6; 2.1), p < 0.001], corresponding to an increase of 17% [95% CI (12; 22)]. The Goiter Symptom score improved by 27 points [95% CI (21; 34), p < 0.0001] from median 39 points (range 2-86) at baseline, and was unaffected by the compensatory thyroid growth. Six months after hemithyroidectomy, using blinded MRI evaluations, we demonstrated a small but significant postoperative growth of the remaining hemi-thyroid, which did not significantly affect the considerable improvement in goiter symptoms.