Voice quality after surgical treatment for thyroid cancer

Effect of the intraoperative head hypsokinesis on sore throat after thyroid surgery: a randomized controlled trial

PURPOSE

Postoperative sore throat (POST) after thyroidectomy is a major concern.A roll is typically inserted under the shoulder to achieve head hypsokinesis and neck extension to better expose the surgical site during thyroid surgery. However, POST and impaired voice function have been attributed to neck overextension. This study aimed to explore the rational angle of head hypsokinesis that both reduced sore throat intensity and protects voice function after thyroid surgery.

METHODS

A total of 210 patients who underwent thyroidectomy were enrolled and randomized into high-tilt (Group H) and low-tilt angle groups (Group L). The primary outcome was the incidence of POST 6 h after surgery. Secondary outcomes included the severity of postoperative pharyngeal pain, voice function, swallowing pain, and coughing.

RESULTS

The incidence of POST 6 h after thyroidectomy was significantly lower in Group L than that in Group H. In addition, the intensity of postoperative sore throat and swallowing pain was more severe in Group H. A lower degree of head hypsokinesis in Group L prevented transient postoperative voice injury.

CONCLUSIONS

A lower degree of head hypsokinesis effectively mitigated sore throat severity after thyroidectomy and improved postoperative voice function.

REGISTER INFORMATION

The trial was registered in the Chinese Clinical Trial Registry on 21 June 2022 (ChiCTR2200061329). The trial is registered at https://www.chictr.org.cn/showproj.html?proj=166254 .

The risk factors for postoperative temporary vocal cord paralysis after thyroid cancer surgery: an observational retrospective cohort study

OBJECTIVE

To analyze the potential factors influencing new-onset postoperative transient vocal cord paralysis (VCP) in thyroid cancer patients.

METHODS

Case information of 8340 thyroid cancer patients hospitalized at China-Japan Union Hospital of Jilin University, Jilin Province, China, in the Thyroid Surgery Department from January 2018 to December 2020 was collected retrospectively and analyzed. The possible influencing factors were analyzed using a χ2 test, rank-sum test, and multiple logistic regression analysis. A nomogram was used to construct the clinical prediction model that was validated in the validation set by receiver operating characteristic, calibration curves, and Decision curve analysis.

RESULTS

The strengthening the reporting of cohort, cross-sectional, and case-control studies in surgery (STROCSS) guideline was followed to conduct a retrospective cohort study. A total of 8340 patients, including 1817 (21.8%) men and 6523 (78.2%) women, were enrolled in this study. The rate of temporary VCP was 3.6% (308/8340). Based on the results of postoperative laryngoscopy, the patients were divided into VCP group and non-VCP group. Comparative analysis between the groups revealed that potential factors associated with postoperative transient VCP were tumor location on the dorsal side of the gland ( P =0.042), ultrasound showing a maximum nodal diameter >1 cm ( P =0.002), multifocal carcinoma ( P <0.001), invasion of surrounding tissue ( P =0.005), lymph node metastases in the central compartment ( P =0.034), lateral cervical lymph node metastasis ( P <0.001), and prolonged operation ( P <0.001). A multiple logistic regression analysis showed that the independent risk factors in postoperative transient VCP were T stage (OR=1.411, P =0.013, 95% CI: 1.075-1.853), multifocal carcinoma (OR=1.532, P =0.013, 95% CI: 1.095-2.144), and duration of surgery (OR=1.009, P <0.001, 95% CI: 1.006-1.012). Finally, a clinical prediction model was established via a nomogram and was validated in the validation set, although its diagnostic efficacy needs to be improved further.

CONCLUSION

High T stage, multifocal carcinoma, and prolonged operation time may be independent risk factors for the occurrence of postoperative transient VCP in patients undergoing initial surgery for thyroid cancer.

Role of Prehabilitation and Rehabilitation on Functional Recovery and Quality of Life in Thyroid Cancer Patients: A Comprehensive Review

BACKGROUND

This narrative review aims to provide a comprehensive overview of the current prehabilitation and rehabilitation strategies for thyroid cancer survivors to optimize functional outcomes and enhance their quality of life.

METHODS

The review follows the SANRA quality criteria and includes an extensive literature search conducted in PubMed/Medline, Web of Science, and Scopus.

RESULTS

The review emphasizes the role of a comprehensive rehabilitation approach in targeting the different domains that generate disability in thyroid cancer patients. In this context, physical activity, range of motion exercises, myofascial release, joint mobilization, and postural exercises are crucial for improving functional outcomes and reducing treatment-related discomfort and disability. Moreover, tailored rehabilitative management addressing dysphonia and dysphagia might have a positive impact on the quality of life of these patients. Despite these considerations, several barriers still affect the implementation of a multimodal rehabilitative approach in common clinical practice. Thus, sustainable and effective strategies like digital innovation and patient-centered approaches are strongly needed in order to implement the rehabilitative treatment framework of these subjects.

CONCLUSIONS

This narrative review provides valuable insights into the current prehabilitation and rehabilitation strategies to treat thyroid cancer survivors, addressing physical, psychological, and vocational needs to optimize functional outcomes and enhance their quality of life.

Analysis of Voice Quality After Thyroid Surgery

OBJECTIVES

Voice changes are a common complication after a thyroidectomy, which is a surgical procedure involving partial or total removal of the thyroid gland. The main objective of this work is to examine the possible voice disorders after thyroid surgery. More precisely, it is an investigation of partial and total thyroidectomy, as well as the effects that cancerous and noncancerous thyroid glands can have regarding postsurgical vocal and their association with age and gender.

METHODS

Patients were evaluated using acoustic voice parameters, including harmonics-to-noise ratio (HNR), fundamental frequency (F0), jitter, speaker phonation frequency (SPF) range, cepstral peak prominence (CPP), maximum phonational frequency range (MPFR), and shimmer at the preoperative stage and postoperatively at the 1 day, and first-month stages.

RESULTS

Results demonstrated a significant change in F0 parameters, SPF range, and CPP feature 1 month after surgery, depending on the type of thyroidectomy and thyroid pathology. No significant changes were observed in the HNR, shimmer, and jitter features. Age was associated with the CPP parameter in the entire sample. In contrast, the MPFR parameter was also related to the type of thyroidectomy in the entire sample. However, maximum F0 was significantly associated with the type of thyroidectomy, specifically in the female sample.

CONCLUSIONS

Results indicated that a thyroidectomy can have a negative impact on voice quality. The age and type of thyroidectomy performed are not responsible for this change. Potentially this change can be due to factors such as nerve damage or the subjects' experience, such as job, anxiety, and their physical condition, as well as treatments they may have undergone before thyroidectomy. Further efforts are needed to fully understand the background of voice changes after thyroidectomy.

Persistent subjective voice symptoms for two years after thyroidectomy

BACKGROUND

Voice change after thyroidectomy is an important issue in thyroid surgery. However, little is known about long-term voice outcomes after thyroidectomy. This study investigates the long-term voice outcomes of thyroidectomy up to two years after surgery. Also, we analyzed the pattern of recovery through acoustic tests over time.

METHODS

We reviewed data from 168 patients who underwent thyroidectomy between January 2020 and August 2020 at a single institution. The Thyroidectomy-related Voice and Symptom Questionnaire (TVSQ) score and acoustic voice analysis results were examined preoperatively and postoperative one, three, and six months, and one and two years after surgery. We divided patients into two groups based on the TVSQ score (≥15 or <15) at two years postoperatively. We investigated the difference of acoustic characteristics between the two groups and analyzed correlations between acoustic parameters and various clinical and surgical factors.

RESULTS

Voice parameters tended to recover, but some parameters and TVSQ scores exhibited deterioration two years after surgery. In the subgroups, among the many clinicopathologic factors examined, voice abuse history including professional voice users (p = 0.014), greater extent of thyroidectomy and neck dissection (p = 0.019, p = 0.029), and high pitch voice (F0; p = 0.005, SFF; p = 0.016) were associated with high TVSQ score at two years.

CONCLUSIONS

Patients frequently experience voice discomfort after thyroidectomy. After surgery, voice abuse history including professional voice users, greater extent of surgery, and higher pitch voice are associated with worse voice quality and increased risk of persistent voice symptoms over the long-term.

Longitudinal experience of patients with post-thyroidectomy vocal cord paralysis

BACKGROUND

Prior studies of post-thyroidectomy vocal cord paralysis (VCP) present static and limited evaluations. We comprehensively assessed the experience of patients with VCP post-thyroidectomy over 1 year.

METHODS

Voice Handicap Index (VHI), Eating Assessment Tool (EAT-10), 12-Item Short Form Survey (SF-12), and qualitative interviews were assessed preoperatively, and 2-weeks, 6-weeks, 6-months, and 1-year postoperatively.

OUTCOMES

7 of 44 patients (15.9%) had postoperative VCP. Compared to those without complication, mean VHI scores for VCP patients increased significantly from baseline at 2-weeks (27.9 point increase vs 1.6, p < 0.01) and 6-weeks (26.3 vs. -0.3, p < 0.01) postoperative. There were no significant differences between groups in SF-12 or EAT-10 scores at any point. Qualitative interviews showed that both groups noted bothersome voice symptoms at 2-weeks; however, by 6-weeks, only VCP patients noted voice symptoms negatively affecting their life.

CONCLUSION

While both patients with and without VCP reported subjective voice symptoms immediately postoperatively, those with VCP had worse quantitative measures. Understanding the longitudinal experience of VCP can help providers tailor counseling for these patients.

Prospective voice assessment after uncomplicated thyroidectomy: A comprehensive analysis of a single centre experience

OBJECTIVES

Voice change after uncomplicated thyroidectomy has been an important issue in the field of thyroid surgery. The aim of this study was to promote understanding of voice change after uncomplicated thyroidectomy by analysing the results for a large number of patients from a single institute.

DESIGN

We retrospectively reviewed the medical records of 2879 consecutive patients who underwent thyroidectomy and voice evaluation between January 2014 and December 2019 in a single institute. All the patients had their vocal status assessed using videostroboscopy, acoustic voice analyses, aerodynamic study, and Thyroidectomy-related Voice and Symptom Questionnaire (TVSQ) scores preoperatively and at 1, 3, and 6 months postoperatively. We analysed the pattern of voice changes over time and differences in voice parameters based on clinical factors. To confirm the usefulness of the TVSQ, the correlation between TVSQ scores and objective parameters was analysed. Lastly, predictive factors for persistent voice symptoms were analysed.

SETTING

Tertiary referral hospital.

RESULTS

The frequency ranges and TVSQ scores exhibited significant deterioration until 6 months following surgery. Among clinical factors, the extents of thyroidectomy and neck dissection were associated with worse voice parameters. The TVSQ score was significantly correlated with objective voice parameters. The extents of thyroidectomy and neck dissection were predictive of persistent voice symptoms at 6 months after thyroidectomy.

CONCLUSION

After uncomplicated thyroidectomy, most voice parameters tended to recover, but some parameters remained aggravated even at 6 months after surgery. With more extensive surgery, worse voice quality and the higher risk of persistent voice symptoms may be anticipated.

Preoperative voice analysis and survival outcomes in papillary thyroid cancer with recurrent laryngeal nerve invasion

Objective

To investigate the clinicopathological characteristics of papillary thyroid cancer (PTC) and identify risk factors for postoperative recurrence of PTC with recurrent laryngeal nerve (RLN) involvement.

Methods

In total, 171 patients (112 women and 59 men, age: 18-80 years, and 65 patients aged ≥ 55) with T4a PTC with RLN involvement, treated at Beijing Tongren Hospital, Capital Medical University, from January 2006 to December 2020, were retrospectively examined. Clinicopathological characteristics, including voice analysis results, and survival outcomes were assessed. The Mann-Whitney U and Kruskal-Wallis H tests were used to analyze differences in acoustic parameters. The Kaplan-Meier method was used to calculate the overall survival (OS) and recurrence-free (RFS) rates. Univariate and multivariate Cox regression analyses were performed of the clinical data.

Results

The postoperative follow-up period ranged from 12 to 196 months (mean: 66.18 months). Of the 171 patients, 16 had recurrence and 8 died of thyroid-related diseases. The 5-year OS rate was 95.22%. The 5-year RFS rate was 89.38%. Jitter and shimmer were higher and maximum phonation time was shorter in patients with preoperative vocal cord paralysis (VCP) than in those without RLN involvement, and in those with RLN involvement but without preoperative VCP. Acoustic parameters were similar in patients with no preoperative VCP and those without RLN involvement. Voice analysis results did not differ between cases with RLN adhesion and RLN invasion. Univariate analysis showed that age at onset ≥ 55 years, preoperative RLN palsy, and esophageal invasion were risk factors for postoperative recurrence of PTC with RLN involvement. Multivariate analysis showed that onset age ≥ 55 years (OR 4.52, 95% confidence interval: 1.44-14.19, P = 0.010) was an independent risk factor for recurrence.

Conclusions

PTC patients with RLN invasion can achieve good outcomes. Preoperative voice analysis may offer insights into RLN function. Age of onset ≥ 55 years is an independent risk factor for postoperative recurrence in T4a PTC patients.

Objective Analysis Of Voice Quality In Patients With Thyroid Pathology

OBJECTIVE

The goal of this study is to analyze the voice in patients with thyroid pathology through two objective indexes with great diagnostic accuracy. Overall vocal quality was evaluated with the Acoustic Voice Quality Index (AVQI v.03.01) and the breathy voice with the Acoustic Breathiness Index (ABI).

DESIGN

Observational case-control study.

SETTING

Hospital Universitario Nuestra Señora de Candelaria.

PARTICIPANTS

Fifty-eight subjects, 29 controls and 29 thyroidectomy candidates.

MAIN OUTCOME MEASURES

All participants with thyroid pathology completed the Spanish version of Voice Handicap Index-10. Also, patient complaints relating to possible laryngeal dysfunction were assessed through closed questions. A sustained vowel and three phonetically balanced sentences were recorded for each subject (118 samples). AVQI v.03.01 and ABI were assessed using the Praat program. Two raters perceptually evaluated each voice sample by using the Grade parameter of GRABS scale.

RESULTS

Acoustic analysis shows that 55.17% of subjects present values above the pathological threshold of the AVQI, and 58.62% above that of the ABI. Results of the Student's test comparisons of the AVQI and ABI values between the control group and the thyroid group show significantly higher values of AVQI (t_[56]  = -3.85, p < .001) and ABI (t_[54.39]  = -4.82, p < .001) in thyroidectomy candidates.

CONCLUSION

A mild decrease in vocal quality is part of the symptomatology presented by thyroidectomy candidates.

Influence of Recurrent Laryngeal Nerve Transient Unilateral Palsy on Objective Voice Parameters and on Voice Handicap Index after Total Thyroidectomy (Including Thyroid Carcinoma)

Introduction: Total thyroidectomy (TT) is one of the most common surgical endocrine surgeries. Voice impairment after TT can occur not only in patients with recurrent laryngeal nerve (RLN) transient paralysis, but also in cases of normal vocal cord mobility. Aim: To compare voice limits using a speech range profile (SRP) in patients before and 14 days after TT and to investigate the influence of the early results of voice quality after TT on the personal lives of patients. We focused on the perception of voice change before and shortly after TT. Materials and methods: A retrospective study, in the period 2018–2020, included 65 patients aged 22–75 years. We compared two groups of patients: group I (n = 45) (without RLN paresis) and group II (n = 20) (with early transient postoperative RLN paresis). Patients underwent video flexible laryngocopy, SRP, and Voice Handicap Index-30 (VHI-30). Results: In group I, the mean values of F_max (maximum frequency) and I_max (maximum intensity) decreased in women (both p = 0.001), and VHI-30 increased (p = 0.001). In group II after TT in women, the mean F_max and I_max values decreased (p = 0.005 and p = 0.034), and the frequency range of the voice was reduced from 5 to 2 semitones. The dynamic range of the voice was reduced by 3.4 dB in women and 5.1 dB in men.VHI-30 increased (p = 0.001). Conclusion: The study documented a worsening of the mean values of SRP, VHI-30, and voice parameters of patients in group II. Voice disorders also occurred in group I without RLN paresis. Non-paretic causes can also contribute to voice damage after TT. SRP and VHI-30 are suitable tools for comparing voice status in two groups of patients, including those with dysphonia. Our data support the claim that the diagnosis of a thyroid cancer does not necessarily imply a higher postoperative risk of impaired voice quality for the patient.

Patient Self-Assessment and Acoustic Voice Analysis in Screening of Postoperative Vocal Fold Paresis and Paralysis

Background and objective:

The aim of this study was to evaluate the utility of two items in vocal fold paresis and paralysis screening after thyroid and parathyroid surgery: patient self-assessment of voice using the Voice Handicap Index and computer-based acoustic voice analysis using the Multi-Dimensional Voice Program.

Methods:

This was a prospective study of 181 patients who underwent thyroid or parathyroid surgery over a 1-year study period (2017). Preoperatively, all patients underwent laryngoscopic vocal fold inspection and acoustic voice analysis, and they completed the Voice Handicap Index questionnaire. Postoperatively, all patients underwent laryngoscopy prior to hospital discharge; 2 weeks after the surgery, they completed the Voice Handicap Index questionnaire a second time. Two weeks postoperatively, patients with vocal fold paresis or paralysis and 20 randomly selected controls without vocal fold paresis or paralysis underwent a follow-up acoustic voice analysis.

Results:

Fourteen patients had a new postoperative vocal fold paresis or paralysis. Postoperatively, the total Voice Handicap Index score was significantly higher (p = 0.040) and the change between preoperative and postoperative scores was greater (p = 0.028) in vocal fold paresis or paralysis patients. A total postoperative Voice Handicap Index score > 30 had 55% sensitivity, and 90% specificity, for vocal fold paresis or paralysis. In the postoperative Multi-Dimensional Voice Program analysis, vocal fold paresis or paralysis patients had significantly more jitter (p = 0.044). Postoperative jitter > 1.33 corresponded to 55% sensitivity, and 95% specificity, for vocal fold paresis or paralysis.

Conclusions:

In identifying postoperative vocal fold paresis or paralysis, patient self-assessment and jitter in acoustic voice analysis have high specificity but poor sensitivity. Without routine laryngoscopy, approximately half of the patients with postoperative vocal fold paresis or paralysis could be overlooked. However, if the patient has no complaints of voice disturbance 2 weeks after thyroid or parathyroid surgery, the likelihood of vocal fold paresis or paralysis is low.

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.

Perceptual Assessment and Acoustic Voice Analysis as Screening Tests for Vocal Fold Paresis After Thyroid or Parathyroid Surgery

Background

The aim of this study was to evaluate the reliability of clinician-based perceptual assessment of voice and computerized acoustic voice analysis as screening tests for vocal fold paresis or paralysis (VFP) after thyroid and parathyroid surgery.

Methods

This was a prospective study of 181 patients undergoing thyroid or parathyroid procedure with pre and postoperative laryngoscopic vocal fold inspection, perceptual voice assessment using grade, roughness, breathiness, asthenia, and strain (GRBAS) scale and acoustic voice analysis using the multi-dimensional voice program (MDVP). Patients were divided into 2 groups for comparison; those with new postoperative VFP and those without. Potential screening tools were evaluated using the receiving operating characteristic (ROC) analysis.

Results

Fourteen (6.6%) patients had a new postoperative VFP. Postoperative GRBAS scores were significantly (P < 0.05) higher in patients with VFP compared to those without. However, there were no statistically significant differences in MDVP values between the groups. Postoperative GRBAS grade score (cut off > 0) had the best sensitivity, 93%, for predicting VFP, but the specificity was only 50%. Postoperative jitter (cut off > 1.60) in MDVP had a good specificity, 90%, but only 50% sensitivity. Combining all the GRBAS and MDVP variables with P < 0.05 in the ROC analysis yielded a test with 100% sensitivity and 55% specificity.

Conclusions

Physician-based perceptual voice assessment has a high sensitivity for detecting postoperative VFP, but the specificity is poor. The risk of VFP is low in patients with completely normal voice at discharge. However, routine laryngoscopy after thyroid and parathyroid surgery is still the most reliable exam for VFP screening.

Posture and dysphonia associations in patients undergoing total thyroidectomy: stabilometric analysis

The aim of this study is the analysis of postural changes of patients affected by vocal disorders post-thyroidectomy, in the absence of post-operative organ damage, through a stabilometry analysis, evaluating the effectiveness of a speech-language intensive treatment in phoniatric and postural quality recovery. 260 patients with vocal dysfunction after surgery without iatrogenic damage were enrolled. 130 patients were subject to post-surgical logopedic rehabilitative training (Group A); other 130 patients were not subject to any post-surgical treatment (Group B). For all patients, vocal and stabilometric parameters were evaluated before and after 2 days and 1 month from surgery. Vocal parameters evaluated were Voice Handicap Index-10, Maximum Phonation Time and objective evaluation of voice with Multidimensional Voice Program (MDVP). Stabilometric parameters evaluated were Sway area (mm²) and Sway velocity (mm/s) in firm surface and foam pad with eyes opened and closed. Regarding the stabilometric parameters, Group A obtained a statistically significant recovery of the correct posture statistically significant compared to Group B, after a month of speech therapy. Vocal parameters (VHI, MPT, MDVP) were statistically different between the two groups (p < 0.05), with a better improvement in Group A. Thanks to our study, we have shown that a logopedic rehabilitation therapy in patients with dysfunctional post-thyroidectomy dysphonia improves both the vocal and postural outcomes.

Quality of Life in Papillary Thyroid Microcarcinoma Patients Undergoing Radiofrequency Ablation or Surgery: A Comparative Study

Objective: Papillary thyroid microcarcinoma (PTMC) has a good prognosis and a long survival time. Health-related quality of life (HRQoL) is vital for PTMC patients during their survivorship. Ultrasound (US)-guided radiofrequency ablation (RFA), which has high efficacy and safety, is recommended as an alternative treatment to surgery for the patients with low-risk PTMC. However, the assessment of QoL of patients with PTMC has not been specially reported. The purpose of our study was to compare the HRQoL of patients with PTMC who underwent RFA and those who underwent surgery. Methods: From October 2019 to December 2019, 88 PTMC patients were enrolled in our study, including 54 in RFA group and 34 in surgery group. We used three questionnaires which included the 36-item short form health survey (SF-36), thyroid cancer-specific quality of life (THYCA-QOL), and Fear of Progression Questionnaire-Short Form (FoP-Q-SF) for each patient to evaluate their scores of HRQoL. The scores were compared after adjusting for age, sex, medical expense, and follow-up time. Results: According to the SF-36, the scores of the domain for the role limitation due to physical problems and emotional problems (RP, RE) as well as Physical Component Summary (PCS) showed a significant negative linear association between the RFA group and surgery group: RP coefficient [coef]-22.613 [confidence interval (CI) -33.504 to -11.723], p < 0.001, RE (coef: -21.901 [CI -36.737 to -7.064], p = 0.004), and PCS (coef: -8.312 [CI -13.694 to -2.930], p = 0.003). The THYCA-QOL showed that the scores of the surgery group were higher than that of the RFA group regarding scars (coef: 10.246 [CI 1.330 to 19.162], p = 0.025 according to the multivariate analysis), suggesting a higher level of complaint in the surgery group. There was no statistically significant difference in the scores of FoP-Q-SF between the two groups. Conclusions: In patients with PTMC, US-guided RFA offers advantage over surgery in terms of HRQoL, which supports the role of RFA as an alternative strategy to surgery.

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.

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

Importance

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

Objectives

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

Design, Setting, and Participants

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

Intervention

Total thyroidectomy.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT02138214.

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.

Laryngeal and vocal alterations after thyroidectomy

Introduction

Objective

Methods

Results

Conclusion

Assessment of functionality of vocal cords using ultrasound before and after thyroid surgery: An observational study

Background and Aims:

The preservation of recurrent laryngeal nerve (RLN) is an essential part of thyroid surgery. The various methods to test the normal functionality of vocal cords (VCs) include direct visualisation under the fiber bronchoscope, indirect laryngoscopy, laryngeal muscles electromyography, computed tomography (CT), and magnetic resonance imaging (MRI). We aimed to assess the usefulness of ultrasound (USG) in the examination of VC morphology and movement.

Methods:

After Institutional Ethical Committee (IEC) clearance, 65 American Society of Anesthesiologists physical status I/II patients between the age group 18 and 60 years scheduled for thyroid surgery were enrolled in this observational study. All patients underwent USG examination before, immediately after and 2 days after thyroidectomy. The vocal fold (VF) displacement velocity (VFDV) was recorded and analysed. If any VF disorder was detected, the patients underwent two additional examinations: 2 and 3 months after thyroidectomy. All the findings were correlated with those of video rhinolaryngoscope (VRL).

Results:

The visualisation rate of the VCs with USG was 96.9% whereas with VRL was 100%. Two patients had preoperative VC palsy that was picked up by USG and confirmed by VRL. The sensitivity and specificity of USG as a tool to detect paralysis were 100% CI = (0.34, 1.00) and 93.44% CI = (0.84, 0.97), respectively.

Conclusion:

USG examination can prove to be a good, noninvasive, cheap alternative to VRL in examination for functionality of VCs perioperatively.

Speech therapy after thyroidectomy

Common complaints of patients who have received thyroidectomy include dysphonia (voice dysfunction) and dysphagia (difficulty swallowing). One cause of these surgical outcomes is recurrent laryngeal nerve paralysis. Many studies have discussed the effectiveness of speech therapy (e.g., voice therapy and dysphagia therapy) for improving dysphonia and dysphagia, but not specifically in patients who have received thyroidectomy. Therefore, the aim of this paper was to discuss issues regarding speech therapy such as voice therapy and dysphagia for patients after thyroidectomy. Another aim was to review the literature on speech therapy for patients with recurrent laryngeal nerve paralysis after thyroidectomy. Databases used for the literature review in this study included, PubMed, MEDLINE, Academic Search Primer, ERIC, CINAHL Plus, and EBSCO. The articles retrieved by database searches were classified and screened for relevance by using EndNote. Of the 936 articles retrieved, 18 discussed "voice assessment and thyroidectomy", 3 discussed "voice therapy and thyroidectomy", and 11 discussed "surgical interventions for voice restoration after thyroidectomy". Only 3 studies discussed topics related to "swallowing function assessment/treatment and thyroidectomy". Although many studies have investigated voice changes and assessment methods in thyroidectomy patients, few recent studies have investigated speech therapy after thyroidectomy. Additionally, some studies have addressed dysphagia after thyroidectomy, but few have discussed assessment and treatment of dysphagia after thyroidectomy.

Determination of the Problems Experienced by Patients Post-Thyroidectomy

This descriptive, cross-sectional study investigated problems experienced by patients after undergoing a thyroidectomy. The study included 60 first-time, post-thyroidectomy patients diagnosed with benign thyroid disease from a university hospital's general surgery clinic in Ankara, Turkey. The data were collected in two stages: interviews with patients on the first day following surgery and postoperative follow-up telephone interviews in each of the first 4 weeks following surgery. The follow-ups revealed that patients principally experienced varying degrees of pain and difficulties in connection with work and recreation, communication, body image, and movement, for up to 4 weeks after surgery. These results showed that patients were particularly prone to problems on the first day and during the first week of the postoperative period; therefore, patients should be provided with follow-up telephone interviews to facilitate easier recovery and to help them overcome any problems experienced during the postoperative period.

Lateral neck dissection affects the voice in thyroid cancer patients

Objective:

This study aimed to identify the effect of lateral neck dissection on voice change in thyroidectomised patients.

Methods:

Medical records from 264 patients who underwent thyroidectomy with (n= 65) or without (n= 199) lateral neck dissection were reviewed. Clinical and voice evaluation data were compared between the two groups.

Results:

Patients who underwent surgery that included lateral neck dissection had lower fundamental frequencies and speaking fundamental frequencies. They also had a higher incidence of asymmetric mucosal wave and vocal fold oedema on videostroboscopy during the first month after surgery, with the incidence of vocal fold oedema remaining significantly higher at three months. Self-assessed voice quality scores were significantly higher in lateral neck dissection patients at both one and three months after surgery.

Conclusion:

In thyroidectomised patients, lateral neck dissection lowers the vocal pitch in the initial period after surgery and induces vocal fold oedema that persists for several months. Although most objective parameters improved within a month, subjective symptoms lasted for longer.

Effects of long non-coding RNA H19 and microRNA let7a expression on thyroid cancer prognosis

This study aims to explore the effects of long non-coding RNA H19 (lncRNA H19) and microRNA let7a (miRNA let7a) expression on the prognosis of thyroid cancer (TC). This may aid in the discovery of more effective treatment and prognosis approaches for TC. Between January 2008 and January 2011, 131 TC tissues and adjacent tissues were obtained from TC patients. An additional 122 normal thyroid tissues were also collected as normal controls from patients with benign thyroid lesions. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to detect lncRNA H19 and miRNA let7a mRNA expression. Five-year follow-ups were conducted. A Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic values of lncRNA H19 and miRNA let7a in TC. The Kaplan-Meier method was applied to analyze the 5-year survival rate of TC patients. Univariate and multivariate factor analyses were employed to analyze the prognostic factors of TC. The lncRNA H19 mRNA expression was higher while the miRNA let7a mRNA expression was lower in TC tissues than, in the normal thyroid tissues and adjacent tissues. The area under the ROC curve (AUC) of lncRNA H19 and miRNA let7a were 0.801 and 0.116, with sensitivity at 72.5% and 84%, as well as specificity 75.4% and 77%, respectively. In TC patients with tumor diameters≥1.0cm, lncRNA H19 mRNA expression was elevated, but miRNA let7a mRNA expression was reduced. This was also evident in TC patients with TNM stages III+IV and those with lymph node metastasis. TC patients with a lower 5-year survival rate showed upregulated levels of lncRNA H19 expression and, downregulated levels of miRNA let7a expression. LncRNA H19 and miRNA let7a expression, tumor diameter, TNM stage and lymph node metastasis were independent prognostic factors of TC. This study demonstrated that increased lncRNA H19 and decreased miRNA let7a expression levels are associated with poor prognosis in TC patients. An inverse relationship between lncRNA H19 and miRNA let7a expression levels was exhibited.

Effect of energy-based devices on voice quality after total thyroidectomy

Voice alteration is an important complication of thyroid surgery and is closely related to patients' quality of life. There are no studies analyzing effect of energy-based devices (EBD) on voice quality (VQ). Aim of this prospective study is to evaluate impact of sutureless total thyroidectomy performed with EBDs on objective voice parameters of patients without recurrent laryngeal nerve (RLN) and/or external branch of superior laryngeal nerve (EBSLN) injury. Sixty patients underwent total thyroidectomy with meticulous dissection of EBSLN. Patients were assigned to Group L (Ligasure™), Group H (Harmonic), or Group C (Conventional) through random ballot. For analysis of alteration in VQ, digital videolaryngostroboscopy (VLS), voice handicap index (VHI), multidimensional voice program (MDVP), and electroglottography (EGG) were used. VLS was performed by 70°-angled indirect laryngoscopy and evaluation was standardized by VLS scale and laryngeal function scoring. This study is registered on clinicaltrials.gov with number NCT01865006. Forty eight patients were female. There was no difference on demographic data. On post-operative laryngoscopic examination, none of the patients had vocal fold palsy. When mean VHI scores at post-operative 1st week and 2nd month were compared to pre-operative values for each groups, groups L and H demonstrated a significant increase in VHI in the early post-operative evaluation, while there was no significant increase for group C. No significant increase was seen in late post-operative period compared to pre-operative period for any groups. In the early post-operative period, VQ is better with the conventional technique than EBDs; however, in late post-operative period, VQ is detected better in EBDs (especially in Group L) than the conventional technique, but no statistical difference was observed.

Long-Term Voice Outcomes After Robotic Thyroidectomy

BACKGROUND

The purpose of this study was to evaluate the long-term voice function after robotic thyroidectomy in comparison with conventional transcervical thyroidectomy.

METHODS

We prospectively evaluated the voice functions of 54 patients with thyroid nodules who underwent robotic thyroidectomy by a gasless unilateral axillary or axillo-breast approach and of 70 patients who underwent conventional thyroidectomy. Subjective voice symptom score (VSS) was evaluated in questionnaires before thyroidectomy and then at 3, 6, 12, and 24 months after surgery. Objective acoustic parameters analyzed during the same period included fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, highest frequency, frequency and intensity range, and maximal phonation time.

RESULTS

At 3 months after surgery, VSS was better in the robotic group than in the conventional group. At 2 years after surgery, VSS had recovered to the pre-operative level in the robotic group, whereas it remained significantly worse at 2 years in the conventional group. The phonatory frequency range and highest frequency were significantly wider and higher, respectively, in the robotic group than the conventional group at 6, 12, and 24 months postoperatively.Within the robotic group, the frequency range and highest frequency recovered to pre-operative levels by 6 months, whereas in the conventional group they remained below the pre-operative levels at 2 years post-operatively. There were no differences in other acoustic parameters between the two groups of patients at any period.

CONCLUSION

Up to 2 years post-operatively, robotic thyroidectomy has advantages in terms of recovery of voice symptoms and acoustic parameters over conventional thyroidectomy.

Innervation of the cricothyroid muscle by extralaryngeal branches of the recurrent laryngeal nerve

Objectives/Hypothesis

A major concern in thyroid surgery is possible changes in the patient's voice due to dysfunction of the laryngeal muscles. The classical understanding of the anatomy is that the cricothyroid muscle (CTM) is innervated solely by the external branch of the superior laryngeal nerve (EBSLN), and the endolaryngeal muscles are covered only by the recurrent laryngeal nerve (RLN). Meticulous anatomical studies found communication between these nerves. Recent neurophysiological studies revealed cross‐innervations among these nerve–muscle sets. Here, we report innervation of the CTM by extralaryngeal branches of the RLN.

Study Design

Clinical observation during thyroid surgery at a hospital center for thyroid diseases.

Methods

During thyroid cancer surgeries, we encountered four adult Japanese patients who had an extralaryngeal branch of the RLN, the electrical stimulation of which showed contraction of the CTM. The EBSLN and RLN were electrically stimulated. Responses were evaluated by visual observation of contraction of the CTM and palpable laryngeal twitch of the endolaryngeal muscles. Electromyographic studies were also performed in two patients.

Results

Five of the seven RLNs examined showed contraction of the CTM on stimulation. Four of these five RLNs had an extralaryngeal branch that showed contraction of the CTM on stimulation. Stimulation of the RLN proximal to the branch yielded contraction of the CTM and laryngeal twitch, whereas stimulation of the RLN distal to the branch yielded only laryngeal twitch.

Conclusions

Extralaryngeal branches of the RLN innervated the CTM in four patients. This phenomenon might influence voice changes following thyroid surgery.

Level of Evidence

4. Laryngoscope, 126:1157–1162, 2016

Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve

Loss of function in the recurrent laryngeal nerve (RLN) during thyroid/parathyroid surgery, despite a macroscopically intact nerve, is a challenge which highlights the sensitivity and complexity of laryngeal innervation. Furthermore, the uncertain prognosis stresses a lack of capability to diagnose the reason behind the impaired function. There is a great deal of literature considering risk factors, surgical technique and mechanisms outside the nerve affecting the incidence of RLN paresis during surgery. To be able to prognosticate recovery in cases of laryngeal dysfunction and voice changes after thyroid surgery, the surgeon would first need to define the presence, location, and type of laryngeal nerve injury. There is little data describing the events within the nerve and the neurobiological reasons for the impaired function related to potential recovery and prognosis. In addition, very little data has been presented in order to clarify any differences between the transient and permanent injury of the RLN. This review aims, from an anatomical and neurobiological perspective, to provide an update on the current understandings of surgically-induced injury to the laryngeal nerves.

Voice Assessment and Voice-related Quality of Life in Patients with Benign Thyroid Disease

Objective

To identify the relationship between vocal self-assessment, the assessment of voice by a speech-language pathologist (SLP), and the effect of voice on the quality of life of patients with benign thyroid diseases.

Study Design

Cross-sectional study.

Setting

University hospital.

Subjects and Method

A total of 67 women with a mean age of 44.7 ± 14.8 years and a diagnosis of benign thyroid disease were included in the study. Vocal self-assessment and SLP assessment were performed using a visual analogue scale (VAS). The Voice-related Quality of Life Questionnaire (V-RQOL) was used to identify the effect of voice on quality of life. The Mann-Whitney and Kruskal-Wallis nonparametric tests were used. Correlations between assessments were verified by the Spearman correlation test. The significance level was 5%.

Results

Patients with vocal complaints had lower scores in all assessments. Patients with thyroid nodules performed worse on the SLP assessment and on the physical functioning domain of V-RQOL. A moderate correlation was found between the self-assessment and quality of life and between the physical functioning domain of V-RQOL and the SLP assessment. A weak correlation existed between the self-assessment and the SLP assessment.

Conclusion

Patients with benign thyroid diseases had lower scores in vocal self-assessment, the clinical evaluation of voice, and the V-RQOL. These dimensions of voice assessment showed correlations ranging from mild to moderate and should complement the clinical routine.

Voice outcomes after total thyroidectomy, partial thyroidectomy, or non-neck surgery using a prospective multifactorial assessment

BACKGROUND

Voice alteration remains a significant complication of thyroid surgery. We present a comparison of voice outcomes between total thyroidectomy (TT), partial thyroidectomy (PT), and non-neck (NN) surgery using a multifactorial voice-outcomes classification tool.

STUDY DESIGN

Patients with normal voice (n = 112) were enrolled between July 2004 and March 2009. The patients underwent TT (n = 54), PT (n = 35), or NN (n = 23) surgery under general endotracheal anesthesia as part of a prospective observational study involving serial multimodality voice evaluation preoperatively, and at 2 weeks, 3 months, and 6 months postoperatively. Patients with adverse voice outcomes were grouped into the negative voice outcomes (NegVO) category, including patients with objective (abnormality on videolaryngostroboscopy and substantial voice dysfunction) and subjective (normal videolaryngostroboscopy but with notable voice impairment) NegVO. Voice outcomes were compared among study groups.

RESULTS

Negative voice outcomes occurred in 46% (95% CI, 34-59%) and 14% (95% CI, 6-30%) of TT and PT groups, respectively. No NegVOs were observed after NN surgery. Early NegVOs were more common in the TT group than in the NN or PT groups (p < 0.001). Most voice disturbances resolved by 6 months (TT 84%; PT 92%) with no difference in NegVO among all groups (p = 0.23). Black race and significant changes in certain voice outcomes measures at the 2-week follow-up visit were identified as predictors of late (3 to 6 months) NegVO.

CONCLUSIONS

This comprehensive voice outcomes study revealed that the extent of thyroidectomy impacts voice outcomes in the early postoperative period, and identified risk factors for late NegVO in post-thyroidectomy patients who should be considered for early voice rehabilitation referral.

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

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