Are pre-operative vocal fold checks necessary?

A large-scale study of patients with preoperative vocal cord paralysis associated with thyroid disease and related clinicopathological features

BACKGROUND

The performance of thyroidectomies has been increasing over the last decade due to the growing prevalence of thyroid diseases. The purpose of this study was to investigate the clinical significance of preoperative vocal cord paralysis (VCP) associated with thyroid disease and other incidences of malignant or benign lesions, as well as different thyroid pathological features. Additionally, the epidemiological changes of thyroid diseases with preoperative VCP were investigated.

METHODS

Ninety-nine out of 12,530 patients with preoperative VCP who had undergone thyroid surgery for various diseases in the Zhejiang Cancer Hospital from January 2007 to December 2015 were identified. Their clinicopathological data was recorded and case distributions from different years and intraoperative recurrent laryngeal nerve statuses were retrospectively analyzed.

RESULTS

The incidence of preoperative VCP in 2007 was reported to be 1.53% (9/590) and had decreased to 0.53% (12/2,247) by 2015 (P < 0.05). Among the 99 patients with preoperative VCP, 81 had malignancies (81.82%), while 18 (18.18%) had benign thyroid diseases. The incidences of preoperative VCP in malignant and benign diseases were 1.13% (81/7,159) and 0.35% (18/5,371), respectively (P < 0.05). There were only 5 (0.04%, 5/12,530) cases of papillary thyroid microcarcinoma with preoperative VCP. There was no statistical difference between the incidence of preoperative hoarseness in malignant 69.14% (56/81) and benign diseases 61.11% (11/18) with preoperative VCP.

CONCLUSIONS

The preoperative VCP incidence rate had gradually decreased with an increased proportion of papillary thyroid cancer. Preoperative voice symptoms do not necessarily suggest a malignancy. Selective rather than routine preoperative laryngoscopic examinations should be performed on papillary thyroid microcarcinomas. The probability of preoperative VCP in malignancy was significantly higher than in benign lesions.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Beeinträchtigung der Lebensqualität bei Patienten mit einseitiger Rekurrensparese nach thoraxchirurgischen Eingriffen

BACKGROUND

Postoperative unilateral vocal cord paralysis (URLNP) may lead to a lower quality of life due to dysphonia, dysphagia, and reduced breathing control. The aim of this study was to evaluate quality of life in a group of patients with URLNP compared to a group without URLNP.

PATIENTS AND METHODS

Laryngoscopically, 379 patients were examined before and after thoracic surgery. Of the group with permanent URLNP (n=14), nine patients were compared to ten without URLNP regarding voice function and quality of life using selected European Organization for Research and Treatment of Cancer questionnaires (QLQ-C30, H&N35, OES18, and LC13) and the voice dysfunction index by Nawka.

RESULTS

Patients with URLNP reported more voice problems and less effective coughing. Further, they had a reduced of quality of life.

CONCLUSION

We recommend early diagnosis of URLNP and therapy management by routine laryngoscopic examinations following thoracic surgery.

The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery

OBJECTIVE

The objective of this study was to evaluate the utility of screening laryngoscopic examination in evaluating vocal fold (VF) mobility before thyroid surgery.

METHODS

The authors conducted a retrospective chart review of 340 patients who have undergone thyroid surgery from January 1998 to June 2005 and had preoperative laryngoscopy by mirror, fiberoptic, or videostroboscopic examination. Reports of preoperative voice change or complaint and reports of preoperative VF examination, including the method of examination, were recorded. For patients with VF motion impairment, reports of the intraoperative condition of the recurrent laryngeal nerve (RLN), preoperative diagnosis based on fine needle aspiration, and final postoperative histopathologic examination results were recorded.

RESULTS

Twenty-two patients were found to have preoperative VF motion impairment, of which seven (32%) patients were asymptomatic with no detectable subjective or objective voice problems. This differs significantly from the hypothesis that patients with VF motion impairment are always symptomatic (P=.009). Using voice symptoms as a screening test to predict VF motion impairment in 340 patients reveals that the sensitivity was 68%, specificity was 91%, positive predictive value (PPV) was 31%, and negative predictive value (NPV) was 98%. Among the 22 patients with preoperative VF motion impairment, five (72%) of the seven asymptomatic patients had benign, slowly progressive disease on their final histopathology reports. Six of these asymptomatic patients had their preoperative VF evaluation by fiberoptic examination, whereas one patient had indirect mirror laryngoscopy. Of 22 patients with preoperative VF motion impairment, five (22.5%) patients had abnormal VF mobility contralateral to the thyroid lesion on their preoperative evaluation, and only two of them had nerve injury reported after a previous thyroid surgery. This result differs significantly from the hypothesis that impaired mobility is ipsilateral to the side of the lesion (P=.05).

CONCLUSIONS

Patients without voice complaints can have VF motion impairment. Patients can also have VF motion impairment contralateral to the thyroid lesion. Preoperative VF examination helps counsel patients appropriately about the risks of surgery and helps outline a plan for the extent of surgery while minimizing the medicolegal ramifications of iatrogenic RLN injury.

External vocal fold medialization in patients with recurrent nerve paralysis following cardiothoracic surgery

OBJECTIVES

Recurrent laryngeal nerve injury is a possible complication following cardiothoracic surgery. Due to insufficient glottal closure, dysphonia and dysphagia with aspiration may occur. The purpose of the study was to outline the effect of vocal fold medialization thyroplasty on voice, swallowing and breathing impairments.

METHODS

Between 1999 and 2001, medialization thyroplasty using the titanium implant (TVFMI) according to Friedrich was performed in 14 patients with postoperative left-sided recurrent nerve paralysis (five female and nine male patients, mean age 64 years) by an external approach. Previous surgical procedures comprised six lobectomies (combined with resection and replacement of the subclavian artery in one case), two pneumonectomies, one resection of a schwannoma in the aortopulmonary window, two replacements of the descending aorta, one aortocoronary bypass procedure (with LIMA), and two esophageal resections using Akiyama technique, respectively. Before and after thyroplasty, the patients underwent an otolaryngological/phoniatric examination including videostroboscopy, voice sound analysis, voice range profile measurement, pulmonary function testing, and in selected cases videofluoroscopy of swallowing.

RESULTS

Following thyroplasty, all patients reported on subjective improvement of voice, swallowing and breathing functions. Videostroboscopy revealed an improved glottal closure (six complete, six with posterior gap). All voice related parameters (e.g. roughness, breathiness, hoarseness, maximum sound pressure levels of the singing and shouting voices) were significantly improved.

CONCLUSIONS

Due to potential risk of recurrent nerve alteration in left-sided intrathoracic procedures, a preoperative and postoperative laryngoscopic examination is recommended. The external medialization of the vocal folds can be regarded as an excellent method for improvement of voice, swallowing and breathing, in particular, when the quality of life is impaired due to persistent recurrent nerve paralysis.