Management of Post-Thyroidectomy Hoarseness

General Surgeons’ Perspective

Dr. Chan Shun Yan

Ruttonjee Hospital

Introduction

• Incidence– Up to 5-19% of patients develop voice

change after thyroid surgery, despite contemporary effort to identify and preserve recurrent laryngeal nerve

– Recurrent laryngeal nerve palsy • Permanent 1–3%

• Temporary 5–8%

- Ravindra Singh Mohil et al. Ann R Coll Surg Engl 2011; 93: 49–53- British Association of Endocrine and Thyroid Surgeons Audit

Introduction• Vocal cord mobility dysfunction

– Affects quality of life

– Associated with other complications, such as aspiration

• Lack of consensus – No widely adopted guideline/protocol for

management of post-thyroidectomy hoarseness

• Multidisciplinary Approach– Collaboration between General Surgeons and ENT

Surgeons and speech therapists

Management of Post-Thyroidectomy Hoarseness

What are the causes of post-thyroidectomy hoarseness?

What is the best timing to investigate?

What investigations to order?

When to refer?

Management of Post-Thyroidectomy Hoarseness

What are the causes of post-thyroidectomy hoarseness?

What is the best timing to investigate?

What investigations to order?

When to refer?

• 761 patients recruited between 1990 and 2002.

• Preoperative and postoperative (Day 3 - 4) endoscopic laryngostroboscopy performed by an experienced otolaryngologist

• 356 vocal cord alterations (42.0%) were noted in 640 vocal cords under study

Matthias Echternach et al. Arch Surg. Feb 2009;144(2)

Postoperative findings• Thickening of mucosa 104 (13.7%)• Recurrent nerve palsy 84 (11.0%)• Hematoma 70 (9.2%)• Granuloma 68 (8.9%)• Edema 29 (3.8%)• Subluxation of arytenoid

cartilage 1 (0.1%)

Not always the surgeon.

Matthias Echternach et al. Arch Surg. Feb 2009;144(2)

Documented Causes of Post-Thyroidectomy Change of Voice

Radu Mihai et al. World Journal of Endocrine Surgery, Sep-Dec 2009;1(1):1-5

Recommendation: Causes of hoarseness other than recurrent laryngeal nerve palsy need to be considered

Neural InjuryRecurrent laryngeal nerve palsy

External branch of superior laryngeal nerve

Regional non-neural effectsMuscle injury

Regional scarring

Endotracheal tube associated Vocal cord injury/edema

Arytenoid dislocation

Coincidental (non-iatrogenic)Viral infection

Vocal cord nodules

Management of Post-Thyroidectomy Hoarseness

What are the causes of post-thyroidectomy hoarseness?

What is the best timing to investigate?

What investigations to order?

When to refer?

Formal Laryngeal Examination

• Indication for formal laryngeal examination– Any suspicion of voice change or swallowing

difficulty

• Best timing?

Adam D. Rubin et al. Vocal Fold Paresis and Paralysis: What the Thyroid Surgeon Should Know. Surg Oncol Clin N Am 17 (2008) 175–196

“Voice dysfunction must be investigated if symptoms persist beyond 2 weeks after surgery”

• First systematic study to evaluate the impact of time interval of the postoperative vocal cord study after thyroid surgery

• 434 patients with postoperative examination of the vocal folds in a university surgical center

• Flexible nasolaryngoscopy was performed at intervals of post-op day 0, day 2, and 2 weeks, 2 months, 6 months, 12 months

Gianlorenzo et al. Langenbecks Arch Surg (2010) 395:327–331

• Summative outcome of patients with temporary and permanent vocal cord palsy

• Recovery of temporary paralysis most prominent between Day 2 and 6 months

Post-op Vocal Cord palsy

Day 0 6.4%

Day 2 6.7%

Day 14 4.8%

2 months 2.5%

6 months 0.8%

1 year 0.7%

Gianlorenzo et al. Langenbecks Arch Surg (2010) 395:327–331

Perfect timing of investigation still a controversy

• Various studies have advocated different timing of first formal laryngeal investigation– From post-op day 2 to post-op 8 weeks

• Most studies agree minimum follow-up for 12 months if vocal cord palsy identified

Recommendations

• First formal investigation – Between post-op 2 weeks to post-op 4 weeks

• Follow-up investigations – Close follow-up up to 6 months, repeat examination 1 year

• Rationale– If screen too early

• Transient causes of hoarseness (e.g. cord edema) may present after a few days, and they usually resolve within 4 weeks

– If screened too late • Risk of aspiration and poor voice outcome

– Patients with temporary vocal cord paralysis mostly recover between 2 weeks and 6 months

Management of Post-Thyroidectomy Hoarseness

What are the causes of post-thyroidectomy hoarseness?

What is the best timing to investigate?

What investigations to order?

When to refer?

Investigations forPost-Thyroidectomy

Hoarseness

Indirect Laryngoscopy

FlexibleNasolaryngoscop

y

Videostroboscopy

Voice Questionnaire

Computerized Acoustic

Assessment

Indirect Laryngoscopy

• Simple to perform

• View is clear but restricted

• Satisfactory diagnostic accuracy

• Gag reflex

Diagnostic Evaluation and Management of HoarsenessTed Mau. Med Clin N Am 94 (2010) 945–960

Flexible Nasolaryngoscopy

• More physiological position and wider vision to the larynx

• High diagnostic accuracy

• Less discomfort

Video-Stroboscopy

• Utilizes a high frequency strobe light to analyze the vibration of the cords

• Very high diagnostic accuracy

• Requires specialized expertise and equipments

“The patient should be referred to a specialist practitioner capable of carrying out direct and/or indirect laryngoscopy”

J.-P. Jeannon et al. Int J Clin Pract, April 2009, 63, 4, 624–629

• Reviewed 27 articles and 25,000 patients between 1990-2006

• Compared – Indirect laryngoscopy

– Flexible nasolaryngoscopy

– Videostroboscopy

• Insufficient data to illustrate significant difference in sensitivities, specificities and predictive values for each diagnostic tool

J.-P. Jeannon et al. Int J Clin Pract, April 2009, 63, 4, 624–629

• Indirect Laryngoscopy– Gag reflex common

– NOT considered to be an adequate method

• Videostroboscopy– Requires specialist equipments

– Not a feasible in routine practice

• Recommendation: Flexible nasolaryngoscopy as standard– Most commonly adopted investigation tool currently

– Reliable

– Readily available and relatively inexpensive

Management of Post-Thyroidectomy Hoarseness

What are the causes of post-thyroidectomy hoarseness?

What is the best timing to investigate?

What investigations to order?

When to refer?

Referral to ENT Surgeons

• Vocal cord evaluation– If equipments and facilities not available

– Vocal cord conditions that may require further evaluation (e.g. vocal cord nodule)

• Definitive Treatment– Medialization Surgery

• Prosthesis/Injection to medialize the vocal fold and improve glottic competence

– Reinervation Surgery• To prevent denervation atrophy of laryngeal muscles

Referral to Speech Therapists

• Speech therapists– Objective voice analysis– Progress assessment– Voice therapy to patients

• Compensatory vocal techniques that optimize quality of voice

Adam D. Rubin et al. Vocal Fold Paresis and Paralysis: What the Thyroid Surgeon Should Know. Surg Oncol Clin N Am 17 (2008) 175–196

“A good surgeon knows how to operate,

A better surgeon knows when to operate,

The best surgeon knows when not to operate.”

Algorithm forManagement of Vocal Cord Paralysis

Dana M. Hartl et al. CLINICAL REVIEW: Current Concepts in the Management of Unilateral Recurrent Laryngeal Nerve Paralysis after Thyroid Surgery. J Clin Endocrinol Metab, May 2005, 90(5):3084–3088

Reference• Recurrent laryngeal nerve and voice preservation: routine identification and

appropriate assessment – two important steps in thyroid surgeryRavindra Singh Mohil et al. Ann R Coll Surg Engl 2011; 93: 49–53

• British Association of Endocrine and Thyroid Surgeons Audit• Laryngeal Complications After Thyroidectomy. Matthias Echternach et al. Arch

Surg. Feb 2009;144(2)• Thyroid Surgery, Voice and Laryngeal Examination. Radu Mihai et al. World

Journal of Endocrine Surgery, Sep-Dec 2009;1(1):1-5• Diagnostic Evaluation and Management of Hoarseness

Ted Mau. Med Clin N Am 94 (2010) 945–960• Diagnosis of Recurrent Laryngeal Nerve Palsy After Thyroidectomy – A Systemic

Review. J.-P. Jeannon et al. Int J Clin Pract, April 2009, 63, 4, 624–629• Postoperative Laryngoscopy in Thyroid Surgery – proper timing to detect recurrent

laryngeal nerve injury. Gianlorenzo et al. Langenbecks Arch Surg (2010) 395:327–331

• Vocal Fold Paresis and Paralysis: What the Thyroid Surgeon Should Know. Adam D. Rubin et al. Surg Oncol Clin N Am 17 (2008) 175–196

• CLINICAL REVIEW: Current Concepts in the Management of Unilateral Recurrent Laryngeal Nerve Paralysis after Thyroid Surgery. Dana M. Hartl et al. J Clin Endocrinol Metab, May 2005, 90(5):3084–3088

Recommendations in Management of Post-Thyroidectomy Hoarseness

• Causes of hoarseness other than recurrent laryngeal nerve palsy need to be considered

• Best timing to investigate still a controversy– First study between post-op 2 weeks to post-op 4 weeks– Close follow-up to to 6 months, repeat examination in 1 year– Follow-up for minimum of 1 year

• Flexible nasolaryngoscopy recommended as choice of investigation– Balance availability of facilities and expertise in hospital

• Referral recommended in specific circumstances for – Workup – Definitive treatment – Rehabilitation

Special Acknowledgement

• Dr. Yuen, Wai Cheung