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

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.

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.

Quantitative comparison of three thyroidectomy approaches in neck muscles, voice, and swallowing functions

OBJECTIVE

This study compares endoscopic thyroidectomy by gasless unilateral axillary approach (ETGUA) and sternocleidomastoid leading-edge approach (SLEA) with conventional open thyroidectomy (COT) in hemithyroidectomy. The main focus is on the protection of neck muscles (sternocleidomastoid, omohyoid, sternothyroid) and the postoperative function of voice and swallowing yielded through these common approaches.

METHODS

A total of 302 patients who underwent hemithyroidectomy were enrolled and divided into three groups: ETGUA (n = 101), SLEA (n = 100), and COT (n = 101). Ultrasound was used to measure the thickness of bilateral neck muscles, including the sternocleidomastoid, omohyoid, and sternothyroid. The changes in thickness on the surgical side compared to the non-surgical side. Analyzed factors included muscle thickness changes, Swallowing Impairment Score (SIS), Voice Handicap Index (VHI), Scar Cosmesis Assessment and Rating (SCAR), Neck Injury Index (NII), surgery duration, drainage volume, hospitalization, and number of lymph nodes.

RESULTS

The clinical characteristics among the three groups were consistent except for differences in sex, age, and BMI. Metrics such as sternocleidomastoid muscle, NII, hypocalcemia, postoperative PTH, transient hoarseness, and number of lymph nodes showed no significant differences among the three groups. However, significant differences were found in the duration of surgery, drainage volume, hospitalization period omohyoid muscle, Sternohyoid muscle, VHI, SIS, and SCAR (all p < 0.001).

CONCLUSION

In comparison to COT, ETGUA and SLEA demonstrate superiority in protecting neck muscles and preserving voice and swallowing function without compromising surgical safety or radicality.

A comparison of swallowing related quality of life in patients undergoing transoral endoscopic versus open thyroid surgery

INTRODUCTION

It is important for the endoscopic thyroid surgeon to understand the pros and cons of trans-oral endoscopic thyroidectomy-vestibular approach (TOETVA) vis-à-vis, open conventional thyroidectomy (OTx) so he/she can help patients in making informed choices regarding the type of procedure to opt for. Swallowing related quality of life (SWAL-QoL) has not been compared between the two approaches. Using a rigorous qualitative methodology and validated reliable tool, this study set out to compare the swallowing related quality of life in patients undergoing TOETVA versus OTx.

METHODS

Prospective study at 3 time points in patients planned for hemithyroidectomy (Preoperative, 1 week and 12 weeks). Data were collected on patients at a tertiary teaching institute in India. Participants ranged from age 18-60 years with a diagnosis of benign euthyroid nodule undergoing hemithyroidectomy. Exclusion criteria were-(1) pre-existing vocal cord abnormalities, (2) undergoing surgery for recurrent nodules, and (3) any neuro-muscular disease affecting swallowing ability. Main outcome measure was comparison of swallowing related quality of life domain scores between patients undergoing hemithyroidectomy via either endoscopic trans-oral or open approach.

RESULTS

Of the 82 included patients, 40 underwent TOETVA and 42 OTx. Both the groups were comparable in terms of demographic and clinicopathological profile. The mean preoperative SWAL-QOL scores were comparable in all domains. Mean SWAL-QoL scores for all domains on postoperative day 7 were significantly better in TOETVA group with domains burden, eating desire, mental health and communication having medium effect sizes. Physical symptom domain was better in the OTx group but had a small effect size. The difference in SWAL-QoL domains between the two groups persisted for 3 months also.

CONCLUSION

Swallowing related quality of life after trans-oral endoscopic thyroidectomy compared to conventional open surgery has not been reported in the literature. Our findings suggest that trans-oral endoscopic thyroidectomy results in significant superior swallowing related quality of life in the majority of domains.

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.

Effect of chewing gum of different weights before surgery on sore throat after total thyroidectomy: A randomized controlled trial

BACKGROUND

Postoperative sore throat (POST) is a common postoperative complication.

COMPLICATION

Chewing gum can inhibit the growth of oral bacteria, cleanse, and lubricate the oral cavity, which can help reduce postoperative sore throat. We hypothesize that chewing gum before surgery could relieve POST.

METHODS

Patients planned to undergo total thyroidectomy under general anesthesia with tracheal intubation were randomized to swallow saliva twice or chew 1.4 g/2.8 g of gum for 2 minutes before surgery. A standard anesthesia protocol was performed. The numerical rating scale scores of POST at 1, 24, and 48 h after surgery were collected. The primary outcome was the incidence of moderate/severe POST (numerical rating scale score >3) within 48 h.

RESULTS

Data from 148 patients (control group, n = 50; 1.4 g group, n = 48; and 2.8 g group, n = 50) were included in the analysis. Within 48 h, there was a significant difference among the three groups in the incidence of moderate/severe POST (control group: 74% vs. 1.4 g group: 65% vs. 2.8 g group: 50%. P = 0.04). The 2.8 g group had less incidence of moderate/severe POST than the control group (Odds Ratio = 0.351 95% Confidence Interval: (0.152 and 0.814) P = 0.02).

CONCLUSION

Chewing 2.8 g gum before total thyroidectomy can reduce the incidence of moderate/severe POST within 48 h after surgery.

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.

Voice Changes Without Laryngeal Nerve Alterations After Thyroidectomy: The Need For Prospective Trials - A Review Study

BACKGROUND

Thyroidectomy is a commonly performed surgical procedure that is offered for different thyroid pathologies. The most frequent complication after total thyroidectomy is transient or permanent hypoparathyroidism followed by transient or permanent recurrent laryngeal nerve palsy. Patients may experience voice impairment despite intact laryngeal nerve function. These patients are of special interest because they experience subjective symptoms which are difficult to measure and therefore to treat.

SUMMARY

The Voice Handicap Index (VHI) and VHI-10 are the most commonly used subjective questionnaires. Their results correlate with objective findings. Female sex, in particular after menopause, is a dominant factor for developing voice impairment after thyroidectomy. The extent of neck surgery and the weight and volume of the removed thyroid correlates directly with both objective and subjective voice impairment after surgery. Videolaryngostroboscopy should be considered to examine vocal cord pathologies in this patient group. Surprisingly, there are no studies showing that speech and voice therapy are beneficial for patients with voice alterations but with intact laryngeal nerves.

CONCLUSIONS

While recurrent laryngeal nerve (RLN) paralysis can be evaluated by objective exams postoperatively, we are still left with the issue of possible partial or complete external branch of superior laryngeal nerve (EBSLN) injury. It is therefore quite difficult to segregate neural (RLN and EBSLN) and non-neural voice change populations, regardless of the method of literature evaluation. Perhaps patients' perspectives on how they experience voice functionality should play a superior role in deciding which patients should be investigated further with laryngoscopy, acoustic or perceptual analysis, and which patients should be offered treatment.

Effects of Endotracheal Tube with Adhesive Superficial Laryngeal Electrodes for Intraoperative Nerve Monitoring on Laryngopharyngeal Complications during Thyroidectomy

The endotracheal tube (ETT) with laryngeal adhesive electrodes for intraoperative neural monitoring (IONM) may be related to laryngopharyngeal complications, such as postoperative sore throat (POST), hoarseness, and coughing. We aimed to evaluate the effects of the ETT with laryngeal adhesive electrodes for IONM on the occurrence of laryngopharyngeal complications during thyroidectomy. In this retrospective study, we included 176 patients who underwent thyroidectomy for thyroid cancer between September 2020 and February 2021. The patients were categorized into control (n = 108) and IONM (n = 68) groups. Patients in the IONM group were intubated with the ETT with surface electrodes. Characteristics of the patients and surgery, perioperative variables, and laryngopharyngeal complications, including POST, hoarseness, and cough, were evaluated. The severity and incidence of POST were comparable between the two groups on postoperative days 0, 1, and 2 (p = 0.103, 0.386, and 0.056, respectively). Furthermore, no significant differences were observed in the occurrence of postoperative hoarseness and cough between the groups. The ETT with laryngeal adhesive electrodes for IONM during thyroidectomy did not affect the incidence and severity of postoperative laryngopharyngeal complications, including POST, hoarseness, and cough. Further prospective, double-blinded, randomized clinical trials are required to gain a clearer understanding.

Artificial neural network prediction of post-thyroidectomy outcome

OBJECTIVES

The goal of this study was to develop a deep neural network (DNN) for predicting surgical/medical complications and unplanned reoperations following thyroidectomy.

DESIGN, SETTING, AND PARTICIPANTS

The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to extract patients who underwent thyroidectomy. A DNN consisting of 10 layers was developed with an 80:20 breakdown for training and testing.

MAIN OUTCOME MEASURES

Three primary outcomes of interest, including occurrence of surgical complications, medical complications, and unplanned reoperation were predicted.

RESULTS

Of the 21 550 patients who underwent thyroidectomy, medical complications, surgical complications and reoperation occurred in 1723 (8.0%), 943 (4.38%) and 2448 (11.36%) patients, respectively. The DNN performed with an area under the curve of receiver operating characteristics of .783 (medical complications), .709 (surgical complications) and .703 (reoperations). Accuracy, specificity and negative predictive values of the model for all outcome variables ranged 78.2%-97.2%, while sensitivity and positive predictive values ranged 11.6%-62.5%. Variables with high permutation importance included sex, inpatient versus outpatient and American Society of Anesthesiologists class.

CONCLUSIONS

We predicted surgical/medical complications and unplanned reoperation following thyroidectomy via development of a well-performing ML algorithm. We have also developed a web-based application available on mobile devices to demonstrate the predictive capacity of our models in real time.

Effects of Intraoperative Nerve Monitoring Techniques on Voice and Swallowing Disorders after Uncomplicated Thyroidectomy: Preliminary Report of a Bi-Institutional Prospective Study

Background: Voice and swallowing problems are frequently associated with thyroidectomy. Intermittent nerve monitoring (i-IONM) seems to provide a positive effect in reducing its prevalence. The aim of this study was to test the hypothesis that continuous intraoperative nerve monitoring (c-IONM) may reduce the prevalence of these disorders even further than i-IONM. Methods: This 3-arm prospective bi-institutional study compared 179 consecutive patients that underwent thyroidectomy: 56 without IONM, 55 with i-IONM and 67 with c-IONM. Neck dissections and laryngeal nerve palsies were excluded. Two questionnaires (VHI-10 for voice disorders and EAT-10 for swallowing disorders; both validated for Italian language use) were administered before and 1 month after surgery. Statistical significance was analyzed by the chi-squared test. Results: After thyroidectomy, no statistically significant differences were found in the three groups concerning EAT-10. although these symptoms seemed to be influenced by gastro-esophageal reflux. VHI-10 worsened in the “no-IONM” group compared with both i-IONM (p < 0.09, not quite statistically significant) and c-IONM (p < 0.04). Conclusion: Both i- and c-IONM improve voice quality independently of laryngeal nerve integrity. Reduced dissection and particularly restrained manipulation could explain these results, being particularly favorable for c-IONM.

Impact of Thyroid surgery on Voice: A prospective study

Thyroidectomy is one of the most common neck surgery done worldwide. It is associated with debilitating post-operative voice changes even without recurrent laryngeal nerve (RLN) injury. Aims and Objectives: To study the impact of thyroidectomy on voice parameters in the absence of Recurrent Laryngeal Nerve and External Branch of Superior Laryngeal Nerve injury and comparison between the pre and post-operative changes in the subjective and objective voice parameters. Methodology: Patients fulfilling the inclusion criteria underwent thyroidectomy. The Subjective voice assessment was done using Voice Impairment Score (VIS) and objective parameters were analyzed using Multi-Dimensional Voice Program (MDVP) pre-operatively and post-operatively at 1 week, 1 month and 3 months interval. Results: On MDVP analysis of patients, a fall in Mean F0 (Hz), Minimum F0 (Hz) and Maximum F0 (Hz) values was noted at 1 week after surgery. But a trend toward the pre-operative values was observed at 3 months post-operatively.

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.

Effect of an anti-adhesion agent on vision-based assessment of cervical adhesions after thyroid surgery: randomized, placebo-controlled trial

Many patients experience cervical adhesions after thyroid surgery. To date, however, no studies have objectively measured the effects of anti-adhesion agents on cervical adhesion symptoms. This study evaluated the effects of an anti-adhesion agent on cervical adhesions after thyroid surgery, as determined using a system that measures the extent of marker movement objectively. One hundred patients were randomized in a 1:1 ratio to undergo thyroid surgery with or without the anti-adhesion agent Collabarrier. Using specially manufactured recording equipment, the position of the marker on neck skin was measured before surgery, and 2 weeks, 3 months, and 9 months after surgery. Relative change in marker distance, calculated by subtracting the marker position before surgery from the marker positions 2 weeks, 3 months, and 9 months after surgery, differed significantly in the groups of patients who underwent thyroid surgery with and without the anti-adhesion agent (P < 0.05). A novel measuring system can objectively evaluate the effectiveness of a thyroid anti-adhesion agent. The anti-adhesion agent used significantly reduced adhesions compared with the control group. The trial is registered at www.cris.nih.go.kr (KCT0005745; date of registration, 08/01/2021).

Aggravation of Reflux Finding Score (RFS) after thyroidectomy

Laryngopharyngeal reflux (LPR) has been suggested as a possible cause of post-thyroidectomy syndrome. However, the pathophysiology and relationship between thyroidectomy and LPR have not been well investigated. We aimed to evaluate the correlation between thyroidectomy and LPR by assessing changes in LPR-related symptoms and laryngoscopic findings before and after thyroidectomy. Ninety-five patients who underwent thyroidectomy with or without central neck dissection were included. The reflux finding score (RFS) and reflux symptom index (RSI) were investigated one day before surgery and two, four, six, and twelve months after surgery. The RFS scores increased significantly after thyroidectomy and decreased to the preoperative level 12 months after surgery. The RSI scores increased after surgery and decreased gradually by 12 months postoperatively, although it was not statistically significant. The RSI and RFS scores improved with the administration of proton pump inhibitors. In conclusion, LPR-related laryngoscopic findings were exacerbated after uncomplicated thyroidectomy. Further studies using pH-monitoring and esophageal manometry are required to investigate the possible deterioration of LPR itself and the UES pressure after thyroidectomy.

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.

Incidence of Dysphonia and Dysphagia Exceeds Recurrent Laryngeal Nerve Injury During Thyroid Surgery

OBJECTIVES

To determine the prevalence of separate and combined voice and swallowing impairments before and after total thyroidectomy and to delineate risk factors for these symptoms.

METHODS

Retrospective review of 592 consecutive patients who underwent total thyroidectomy from July 2003 to August 2015.

RESULTS

Combined voice and swallowing problems occurred preoperatively in 4.7% (11/234), 3.3% (3/92), and 6.0% (16/266) of patients with malignancy, hyperthyroidism, and benign euthyroid disease, respectively. Postoperatively, prevalence was 5.1%, 2.2%, and 1.9%, respectively. Benign euthyroid disease (20.7%) had the greatest risk of preoperative dysphagia (P = 0.003) and the largest glands (P < 0.001). Comparing before and after surgery, the cancer and benign euthyroid groups had decreased dysphagia (cancer: 11.5% vs. 6.0%, P = 0.034; benign: 20.7% vs. 3.8%, P < 0.001) but increased dysphonia (cancer: 19.2% vs. 28.6%, P = 0.017; benign: 15.8% vs. 27.1%, P = 0.002). Overall, 23/592 (3.9%) developed new dysphagia and 122/592 (20.6%) developed new dysphonia after surgery. Intraoperative recurrent laryngeal nerve transection occurred in 12 cases (2.0%).

CONCLUSIONS

Total thyroidectomy resolved dysphagia but increased dysphonia in benign and malignant euthyroid patients. Voice and swallowing problems following thyroidectomy occurred more frequently than intraoperative recurrent laryngeal nerve transection, confirming symptoms often occur in the absence of suspected nerve injury.

Changes in Tracheal Respiratory Mucosa After Thyroidectomy: A Rat Model

BACKGROUND/AIM

This study aimed to investigate changes in the tracheal mucosa after thyroidectomy, that can be a cause of post-thyroidectomy discomfort.

MATERIALS AND METHODS

Forty rats were divided into normal controls and 3 surgical groups: (i) thyroid isthmectomy with cauterization, (ii) isthmectomy by a cold instrument without hemostasis, and (iii) sham (exposure of the trachea and thyroid gland without thyroidectomy by dissection through pretracheal fascia). Animals were euthanized at 1 and 4 weeks. Mucosal edema and glandular hyperplasia were measured. Mucin production and basal cell activities were evaluated by mucin 5AC (MUC5AC) and keratin 5 (KRT5) using immunofluorescence staining.

RESULTS

Larger mucosal areas were observed in all surgical groups at 1 and 4 weeks. More submucosal glandular hyperplasia was noted in the group with isthmectomy without hemostasis. MUC5AC and KRT5 expressions were significantly higher in the surgical groups.

CONCLUSION

The tracheal mucosa may change after surgery, which could explain postoperative discomfort after thyroidectomy.

The Impact of Coexistent Hashimoto's Thyroiditis on Central Compartment Lymph Node Metastasis in Papillary Thyroid Carcinoma

BACKGROUND

Hashimoto's thyroiditis (HT) is the most prevalent inflammatory disorder of the thyroid gland. Current studies have reported the coexistence rate between HT and papillary thyroid carcinoma (PTC) is quite high. The objective of this study was to evaluate the impact of HT on the predictive factors of central compartment lymph node metastasis (CLNM) in PTC.

METHODS

A retrospective investigation was performed on PTC patients. They were subclassified into HT and non-HT groups. The results of preoperative neck ultrasound (US) examinations were reviewed. The clinical characteristics and the predictive value for CLNM were explored and compared between the two groups.

RESULTS

A total of 756 patients were included in this study. There were more female patients (86.1%) in the PTC coexistent with the HT group than non-HT group. The patients with HT group had higher preoperative serum level of TSH. There was statistically significant difference between the HT patients and non-HT patients in nodular vascularization. Univariate and multivariate analyses showed that male, age ≤45 years old, tumor diameter >1 cm, and presence of suspicious central compartment lymph node on US, irregular nodular shape, multifocal carcinoma were independent predictive factors of CLNM in PTC patients. It was showed that male, age ≤45 years old, tumor diameter >1 cm, multifocality, and presence of suspicious central lymph node on US were risk factors for CLNM in non-HT patients. Only tumor diameter >1 cm and presence of suspicious central lymph node on US were independently correlated with CLNM in HT patients. The sensitivity of the multivariate model was 63.5%, and specificity was 88.9% for prediction CLNM in HT patients. For non-HT patients, the AUC was 80.6%, the sensitivity of the multivariate model was 64.5%, and specificity was 85.2.

CONCLUSION

PTC combined with HT is more common in women, and TSH level in HT group is higher than that in patients with PTC alone. Regardless of that HT is not a related risk factor of CLNM in PTC, our result suggested that different predictive systems should be used for HT and non-HT patients respectively to have a more accurate evaluation of CLNM in clinic.

Should Contralateral Nodules Be an Indication of Total or Completion Thyroidectomy for Patients With Unilateral Papillary Thyroid Carcinoma?

OBJECTIVE

To determine whether papillary thyroid carcinoma (PTC) patients with benign or nonsuspicious nodules in the contralateral lobe have a higher rate of recurrence or worse survival after lobectomy compared to those without nodules in the contralateral lobe.

METHODS

Adult patients who underwent lobectomy and were diagnosed with unilateral PTC (2013-2015), were identified from an institutional database. Patients who previously had cytologically benign nodules or nonsuspicious nodules in the contralateral lobe comprised the contralateral nodule (CN) group. Patients who did not have nodules in the contralateral lobe comprised the unilateral nodule (UN) group.

RESULTS

370 patients were included: 242 in the UN group and 128 in the CN group. After a median follow-up of 62 months (range, 16-85 months), recurrence was confirmed in 4.1% patients in the UN group and 5.5% patients in the CN group (p = 0.559). Clinical contralateral lobe PTC was detected in 2.9% (7/242) of patients from the UN group and 3.9% (5/128) of patients from the CN group (p = 0.601). The 5-year contralateral lobe recurrence-free survival (RFS) rates were 96.8% in the UN group and 97.4% in the CN group (p = 0.396). The 5-year loco-regional RFS rates were 98.4% in the UN group and 97.8% in the CN group (p = 0.690). The 5-year disease-specific survival rates were both 100%.

CONCLUSION

PTC patients with benign or nonsuspicious CNs have similar recurrence and survival rates after lobectomy compared to those without CNs. CNs alone should not be an indication for total or completion thyroidectomy.

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.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Quantitative Ultrasound Assessment of Hyoid Bone Displacement During Swallowing Following Thyroidectomy

The aim of this study was to investigate temporal ultrasound measurements of the hyoid bone displacement during swallowing following thyroidectomy in women and to relate these measures to age, clinical outcomes, and upper digestive airway symptoms. The sample was divided into an experimental group (EG) of 20 women who underwent thyroidectomy (mean age = 49.55 years ± 15.14) and a control group (CG) of 20 healthy women volunteers (mean age = 40.75 years ± 15.92). Both groups were submitted to ultrasound assessment to obtain four temporal measurements of hyoid bone displacement during swallowing: elevation, anteriorization, maximum displacement, and maintenance of maximum displacement. In both groups, swallowing of ten milliliters of liquid and the same volume of thickened liquid (honey) were analyzed. The images were recorded on video (30 frames/second) and analyzed according to a standardized protocol. Temporal measurements of hyoid bone elevation and maximum displacement during swallowing of thickened liquid were significantly shorter in EG (p = 0.034 and p = 0.020, respectively). There were no differences in the swallowing of liquid, and no other variable was related to the ultrasound temporal measurements investigated. This study concludes that women who undergo thyroidectomy have a shorter time of hyoid bone elevation and maximum displacement during swallowing of 10 mL of thickened liquid.

Laryngopharyngeal reflux as a potential cause of persistent local neck symptoms after total thyroidectomy

Purpose

Local neck symptoms (LNS) may be related to goiter, but are also reported by patients suffering from laryngeal–pharyngeal reflux (LPR). The aim of this study was to investigate whether LPR could play a role in the persistence of some LNS after total thyroidectomy (TT).

Methods

A consecutive case series of 160 patients with multinodular goiter (MNG) candidate for TT were included in this study. Each patient was closely studied for both the thyroid pathology and reflux disease before and 6 months after surgery to assess the persistence of LNS after surgery.

Results

Only throat discomfort showed a significant improvement (p  = 0.031) after surgery. On the other hand, swallowing and voice disorders persisted after surgery in 82.3% and 77.3% of patients, respectively (p  = 0.250 and p  = 0.062), such as the correlated reflux laryngopharyngitis (p  = 0.5).

Conclusions

LPR can be considered a predisposing factor or an important concurrent causa to the persistence of LNS after TT, in particular for swallowing disorders and voice disorders. In patients with non-toxic MNG who complain of local neck symptoms, the investigation of a possible coexistence of a reflux disease is appropriate before surgery. Patients should be informed about the possibility that some symptoms can persist even after removal of the goiter.

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.

Simple technique to preserve the external branch of the superior laryngeal nerve during thyroidectomy: Clinical practicability of an attachable nerve stimulator

OBJECTIVE

This study aimed to demonstrate the usefulness of an attachable magnetic nerve stimulator for preservation of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy.

METHODS

We retrospectively analyzed 120 female patients, of which 60 underwent thyroidectomy with an attachable magnetic nerve stimulator (magnetic group) and the remaining 60 underwent thyroidectomy with a conventional method without EBSLN identification (control group). For both groups, objective and subjective voice parameters were investigated on the day before surgery and at 2 weeks and 2 months after surgery.

RESULTS

In the magnetic group, a magnetic nerve stimulator was used to ligate only the site without cricothyroid muscle (CTM) twitching, and thyroid surgery was successfully performed without damage to the EBSLN. In the control group, objective voice parameters, including fundamental frequency, voice range profile (VRP), highest VRP (VRP-H), and maximal phonation time, and the subjective thyroidectomy-related voice questionnaire score were significantly decreased at 2 months after surgery compared to preoperative values. Compared to the control group, the magnetic group did not show a significant decrease in the objective VRP and VRP-H at 2 months after surgery.

CONCLUSION

The use of metallic surgical instruments with an attachable magnetic nerve stimulator may provide surgeons with real-time feedback on CTM twitching feedback and EBSLN status. Compared to direct EBSLN identification during thyroidectomy, this is a simple, easy, and noninvasive method for EBSLN preservation that is useful, especially for less-experienced surgeons.

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.

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.

Voice outcomes of transoral robotic thyroidectomy: Comparison with conventional trans-cervical thyroidectomy

OBJECTIVES

The purpose of this study was to compare the short-term voice outcomes of transoral robotic thyroidectomy (TORT) and trans-cervical thyroidectomy.

MATERIALS AND METHODS

The acoustic parameters and the voice handicap index (VHI)-10 scores were compared between the two groups preoperatively, and 1 week, 1 month, and 3 months postoperatively.

RESULTS

Forty-two patients in the TORT group and 47 patients in the trans-cervical group completed the VHI-10 questionnaire and acoustic analysis. The highest frequency and pitch range was higher and broader, respectively, in the TORT group than in the trans-cervical group until 3 months after surgery. They were not significantly impaired by surgery in the TORT group. The postoperative VHI-10 score was not significantly different between the two groups at any time point. Surgical approach (TORT vs. trans-cervical) and age were independent factors related to highest frequency and pitch range in multiple regression analysis.

CONCLUSION

TORT has advantages of excellent postoperative voice outcomes compared to trans-cervical thyroidectomy in the short-term period.

Total Versus Completion Thyroidectomy: A Multidimensional Evaluation of Long-Term Vocal Alterations

BACKGROUND

Total thyroidectomy (TT) and completion thyroidectomy (CT) are two common surgical operations that are frequently followed by vocal symptoms despite preservation of the recurrent laryngeal nerve (RLN) and of the external branch of superior laryngeal nerve (EBSLN). The aim of this study was to analyze vocal alterations through endoscopic findings, videolaryngostroboscopy (VLS), acoustic vocal parameters and impact on patients' quality of life after surgery in the absence of laryngeal nerve injury.

METHODS

We enrolled 198 patients who underwent thyroidectomy by the same surgeon. One hundred twenty-six patients underwent TT (group TT) while 72 underwent CT (group CT). All patients underwent preoperative VLS and Voice Handicap Index (VHI) assessment and postoperative VHI, VLS and Acoustic Voice Analysis with Multidimensional Voice Program Analysis 12 to 18 months after surgery.

RESULTS

We observed a statistically significant higher rate of EBSLN injury in CT compared to TT. Even in the absence of RLN and EBSLN injury, patients who underwent TT and CT presented slightly worse acoustic vocal parameters and VHI scores compared to healthy controls. Interestingly, some acoustic vocal parameters and VHI scores were significantly worse in group CT compared to group TT.

CONCLUSIONS

The higher rate of EBSLN injury in CT rather than in TT suggests a higher surgical risk in CT. The vocal parameters of loudness and self-perception of voice were significantly worse after CT, suggesting a larger trauma in patients' vocal outcome in CT if compared to TT, although these alterations were not reported as psychologically limiting daily life of patients. Nevertheless, the existence of multiple factors contributing to vocal alterations after thyroidectomy highlight the importance of a routine comprehensive functional voice analysis before and after surgery.

Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients

PURPOSE

The endocrine surgeon and the endocrinologist should standardize how they deal with patients with an indication for thyroidectomy, as the road to surgery starts well before the operation itself. The patient should be thoroughly informed about where and how surgery will be performed, the postoperative improvements that can be expected, and the possibility and incidence of relevant complications. This short review aims at identifying the most common postoperative issues after thyroidectomy, with the relevant therapeutic suggestions.

METHODS

A revision of studies reporting the morbidity of thyroid surgery, involving the largest numbers of patients.

RESULTS

It has been clearly demonstrated that the outcome of thyroid surgery is significantly better when the procedure is performed by an experienced surgeon. Thus, the number of thyroidectomies performed by a surgeon should drive the endocrinologist when referring a patient.

CONCLUSIONS

Despite the surgeon's experience, thyroidectomy is burdened by a relatively high rate of postoperative issues ranging from less severe ones to others causing significant changes in the patient's quality of life. Minor, non-invalidating symptoms have been described in 40% of patients after thyroidectomy (e.g. hoarseness, mild dysphagia, some degree of voice alteration); however, these symptoms usually resolve within a few months of surgery, with or without early treatment. On the other hand, major postoperative complications are observed in a limited number of patients, but in these cases early diagnosis is important to provide the most appropriate postoperative treatment, and thus hasten full recovery or at least achieve the greatest possible improvement.

The Effect of Adjustment of Endotracheal Tube Cuff Pressure during Scarless Remote Access Endoscopic and Robotic Thyroidectomy on Laryngo-Pharyngeal Complications: Prospective Randomized and Controlled Trial

Scarless remote access endoscopic and robotic thyroidectomy has been recently performed as a safe and feasible method. However, little is known about the laryngo-pharyngeal complications after surgery and the effect of adjusting the endotracheal tube cuff pressure during surgery on laryngo-pharyngeal complications. Patients were randomized into two groups: the control group (n = 52) and adjusted group (n = 52). The initial cuff pressure was set to 25 mmHg and then monitored without adjustment (control group) or with adjustment at approximately 25 mmHg (adjusted group) throughout surgery. The incidences and severity of postoperative sore throat (POST), hoarseness, dysphagia, and cough were recorded at 1, 6, 24, and 48 h after surgery. Cuff pressures of the control group changed significantly over time and were higher than those of the adjusted group. The incidence of POST was lower in the adjusted group at 24 h postoperatively (p = 0.035), and there was a significant difference in the severity of POST at 6 and 24 h postoperatively between the two groups. There were no differences in the incidence of hoarseness, dysphagia, and cough between the two groups, except dysphagia and cough at 6 h postoperatively. Therefore, intraoperative monitoring and adjustment of the cuff pressure can reduce the incidence of laryngo-pharyngeal complications.

Patient-Reported Dysphagia After Thyroidectomy: A Qualitative Study

Importance

It is important that clinicians understand consequences of thyoridectomy on swallowing from the patient perspective to better care for this population.

Objective

Using rigorous qualitative methodology, this study set out to characterize the effect of swallowing-related symptoms after thyroidectomy on patient quality of life and swallowing-related outcomes.

Design, Setting, and Participants

Prospective, grounded theory analysis of interviews with 26 patients at 3 time points after thyroidectomy (2 weeks, 6 weeks, and 6 months). Data were collected from an ongoing clinical trial (NCT02138214), and outpatient interviews were conducted at the University of Wisconsin Hospital and Clinics. All participants were age 21 to 73 years with a diagnosis of papillary thyroid cancer without cervical or distant metastases and had undergone total thyroidectomy. Exclusion criteria were preexisting vocal fold abnormalities (eg, polyps, nodules), neurological conditions affecting the voice or swallowing ability, and/or development of new-onset vocal fold paresis or paralysis (lasting longer than 6 months) after total thyroidectomy.

Interventions

Total thyroidectomy.

Main Outcomes and Measures

Symptoms of dysphagia and related effects on quality of life elicited through grounded theory analysis of semistructured interviews with patients after thyroidectomy designed to foster an open-ended, patient-driven discussion.

Results

Of the 26 patients included, 69% were women (n = 18); mean (SD) age, 46.4 (14.1) years; mean (SD) tumor diameter 2.2 (1.4) cm. Two weeks after thyroidectomy, 80% of participants (n = 20) reported at least 1 swallowing-related symptom when prompted by the interview cards; during the open interview, 53% of participants (n = 14) volunteered discussion of swallowing-related symptoms unprompted. However, only 8% of participants in this study (n = 2) qualified for a follow-up dysphagia evaluation, indicating that the majority of reported symptoms were subjective in nature. Six weeks and 6 months after thyroidectomy, 42% (n = 11) and 17% (n = 4) of participants, respectively, reported continued swallowing symptoms using the prompts; 12% (n = 3) discussed symptoms without prompting cards at both time points.

Conclusions and Relevance

Swallowing symptoms after thyroidectomy are underreported in the literature. This study revealed that as many as 80% of patients who have thyroidectomy may experience swallowing-related symptoms after surgery, and many develop compensatory strategies to manage or reduce the burden of these symptoms. Considering the large number of individuals who may experience subjective dysphagia, preoperative counseling should include education and management of such symptoms.

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.

Association between postoperative cough and thyroidectomy: a prospective study

Background

This study sought to determine whether thyroidectomy is associated with self-reported cough through a prospective analysis.

Methods

Patients undergoing unilateral thyroidectomy were prospectively enrolled. The control group was selected to avoid the effect of general anaesthesia. The experimental group consisted of 300 patients (202 females and 98 males) who underwent thyroidectomy, with a mean age of 48.6 years, and the control group consisted of 103 patients (53 females and 50 males) who underwent other head and neck operations, with a mean age of 50.3 years. All patients were required to complete the Leicester Cough Questionnaire (LCQ) preoperatively and 2 weeks postoperatively.

Results

The postoperative mean total LCQ scores in the experimental and control groups were 17.9 ± 5.0 and 19.8 ± 4.2, respectively; the difference was significant (p = 0.014). Adverse event analysis showed that patients in the experimental group scored significantly worse on items for chest or stomach pains, phlegm, feeling in control of coughing, sleep disturbances, coughing bouts, frustration, and feeling fed up with coughing. In the analysis of the three LCQ domains, a significant difference was noted in the physical domain between the two groups (p < 0.001). In the one-way analysis of variance, the factors of sex and anaesthesia time were associated with the postoperative LCQ score; in further multifactor analysis of variance, only the factor of sex was significantly related to the postoperative LCQ score.

Conclusion

Thyroidectomy may be associated with postoperative cough, and a higher number of female patients complained of cough and related symptoms.

Objective Assessment of Postoperative Swallowing Difficulty Through Ultrasound in Patients Undergoing Thyroidectomy

Swallowing discomfort is a common postoperative complaint in patients undergoing thyroidectomy. Contraction of the strap muscles might cause resistance to elevation of the laryngotracheal unit, and downward movement of the laryngotracheal unit may lead to swallowing discomfort. However, few studies have evaluated the mechanism related to limited laryngotracheal elevation after thyroidectomy. We aimed to objectively verify the presence of postoperative impaired laryngotracheal elevation through ultrasound evaluation in patients undergoing thyroidectomy and evaluate its relationship with limitation of laryngotracheal elevation. This is a prospective clinical study. Among patients undergoing hemithyroidectomy and total thyroidectomy, the patients who were followed up for ≥ 6 months were selected (N = 40). Ultrasound evaluation was done preoperatively and at 1, 3, and 6 months postoperatively. Laryngotracheal movement was recorded and the length of elevation was measured. Symptom after thyroidectomy was evaluated through swallowing-related items of thyroidectomy-related voice questionnaire. Ultrasound evaluation verified the presence of limited laryngotracheal elevation postoperatively in patients undergoing thyroidectomy. After thyroidectomy, the swallowing-related score was significantly increased, and was recovered time-dependently at 1 month. Laryngotracheal elevation showed significant decrease after thyroidectomy. The symptom score of swallowing was significantly correlated with the length of laryngotracheal elevation. Post-thyroidectomy ultrasound evaluation verified that laryngotracheal elevation was significantly impaired. Presence of adhesion between the laryngotracheal unit and the superficial soft tissue was the probable cause of the limitation at 6 months after thyroidectomy. The length of laryngotracheal elevation was related to the symptom score of swallowing after thyroid surgery.

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.

Postoperative swallowing disorder after thyroid and parathyroid resection

Introduction

Dysphagia is frequently reported after thyroidectomy. Here, we investigated the incidence of postoperative dysphagia after uncomplicated thyroidectomy and parathyroidectomy. Further, we analyzed diagnosis and types of therapy to identify possible patients at risk.

Patients and methods

A questionnaire was sent to 372 consecutive patients whose thyroid or parathyroid glands were operated on between May 2013 and October 2014 at Ulm University Hospital. Patients were questioned at least 6 months postoperatively.

Results

In the evaluation, 219 questionnaires could be included. Fifty-three (21.3%) patients reported that the overall postoperative swallowing process was better or more trouble-free. In 110 (50.2%) patients, dysphagia was reported only immediately postoperative and disappeared later spontaneously. Sixteen patients (7.3%) stated that after a maximum of 3 months after surgery they suffered from dysphagia. One (0.5%) patient stated that up to 3 months postoperatively, swallowing problems had been successfully treated by logopedic therapy. In 39 (17.6%) patients, the complaints persisted for more than 3 months or still existed at the time of the interview. We found no correlation between dysphagia and patients’ age or gender, the specimen volume, and patients’ body mass index. The more invasive the operation was, the more patients suffered from dysphagia. Analyzing the frequency of dysphagia according to different diagnoses, we found a significant risk of postoperative dysphagia in patients with Graves’ disease and carcinoma. Patients operated on for hyperparathyroidism were at significantly decreased risk of dysphagia.

Conclusion

Nearly 20% of patients reported postoperative dysphagia after uncomplicated thyroidectomy and parathyroidectomy, especially after major surgical intervention. We found a significant risk of postoperative dysphagia in patients with Graves’ disease and carcinoma and a decreased risk for patients operated on for hyperparathyroidism.

Effect of wound massage on neck discomfort and voice changes after thyroidectomy

BACKGROUND

Neck discomfort and voice change are common complications after thyroidectomy. These symptoms might be due to damaged laryngeal nerves, intrinsic structures, or extralaryngeal muscles. They can also occur without injury to any structure as with wound adhesion after thyroidectomy. The objective of this study was to determine causes of neck discomfort and voice change after thyroidectomy and to evaluate the effect of wound massage on symptom relief.

METHODS

Forty-five female patients who underwent total thyroidectomy were included (21 in the experimental group and 24 in the control group). Wound massage was used as an intervention to release surgical adhesion. After wound massage education, participants in the experimental group received wound massage from 4 to 12 weeks after thyroidectomy. Analysis was performed for both groups.

RESULTS

No laryngeal pathology was found after thyroidectomy. The experimental group had significantly better recovery from surgical adhesion and subjective visual analog scale, voice impairment score, and swallowing impairment score (all P < .01) compared with the control group. Voice analysis results associated with laryngeal movement (speaking fundamental frequency, voice range profile maximum, voice range profile range) also indicated significant recovery (P < .01) in the experimental group. These results indicate that local adhesion after thyroidectomy might affect general movement of the larynx and that wound massage could help patients recover normal general movement of the larynx.

CONCLUSION

Neck discomfort and voice change after thyroidectomy are related to local wound adhesion, possibly associated with impairment of laryngeal vertical movement. Release of wound adhesion could help patients recover from neck discomfort and voice changes after thyroidectomy.

Long-term esophageal motility changes after thyroidectomy: associations with aerodigestive disorders

BACKGROUND

Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months.

PATIENTS AND METHODS

The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again.

RESULTS

After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p<0,001).

CONCLUSIONS

Our study confirms that aerodigestive disorders after uncomplicated thyroidectomy, largely transient, are strictly connected with upper esophageal motility changes. In this viewpoint, the innervation of upper aerodigestive anatomical structures (larynx, pharynx, upper esophagus) and its variations should be focused.