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 Lack of consensus 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 Neural Injury Recurrent laryngeal nerve palsy External branch of superior laryngeal nerve Regional non-neural effects Muscle injury Regional scarring Endotracheal tube associated Vocal cord injury/edema Arytenoid dislocation Coincidental (non-iatrogenic) Viral infection Vocal cord nodules Recommendation: Causes of hoarseness other than recurrent laryngeal nerve palsy need to be considered Radu Mihai et al. World Journal of Endocrine Surgery, Sep-Dec 2009;1(1):1-5

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

Day 0 6.4% Day 2 6.7% Day 14 4.8% 2 months 2.5% 6 months 0.8% 1 year 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% Summative outcome of patients with temporary and permanent vocal cord palsy Recovery of temporary paralysis most prominent between Day 2 and 6 months 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 Follow-up investigations 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?

Post-Thyroidectomy Hoarseness Investigations for Post-Thyroidectomy Hoarseness Indirect Laryngoscopy Flexible Nasolaryngoscopy Videostroboscopy Computerized Acoustic Assessment Voice Questionnaire

Indirect Laryngoscopy Video-Stroboscopy Flexible Nasolaryngoscopy Utilizes a high frequency strobe light to analyze the vibration of the cords Very high diagnostic accuracy Requires specialized expertise and equipments Simple to perform View is clear but restricted Satisfactory diagnostic accuracy Gag reflex More physiological position and wider vision to the larynx High diagnostic accuracy Less discomfort Diagnostic Evaluation and Management of Hoarseness Ted Mau. Med Clin N Am 94 (2010) 945–960

“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

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

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 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 for Management 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