1. Management of Post-Thyroidectomy Hoarseness
General Surgeons’ Perspective
Dr. Chan Shun Yan
Ruttonjee Hospital

2. 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

3. 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

4. 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?

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?

6. 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)

7. 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)

8. 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

9. 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?

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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?

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

18. 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

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

20. J.-P. Jeannon et al. Int J Clin Pract, April 2009, 63, 4, 624–629
Reviewed 27 articles and 25,000 patients between
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

21. 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

22. 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?

23. 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

24. 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

25. “A good surgeon knows how to operate,
A better surgeon knows when to operate,
The best surgeon knows when not to operate.”

26. 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

27. 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

28. 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

29. Special Acknowledgement
Dr. Yuen, Wai Cheung