Over the past 30 years, the rates of thyroid surgery have tripled in the United States, according to recent estimates. Studies indicate that between 118,000 and 166,000 patients in the U.S. undergo thyroidectomy each year for benign or malignant disease. The goals of thyroid surgery are to remove abnormal thyroid tissue and any involved lymph nodes, preserve parathyroid gland function, and maintain or improve voice and swallowing. In some cases, however, unintended consequences after these procedures can reduce quality of life. These may include the need for lifelong medication, temporary thyroid suppression, radioactive scanning or treatment, and voice disturbances.
Research indicates that voice disturbances occur at least temporarily in up to 80% of patients after they undergo thyroid surgery. About 10% of patients experience voice disturbance directly due to (usually) temporary and (rarely) permanent laryngeal nerve injuries after surgery, with some experiencing voice problems that last for a long time after the procedure. These voice problems include breathiness with loss of air during vocalization, change in pitch, inability to project the voice, and early vocal fatigue, any and all of which can impair communication. “Voice problems after thyroid surgery can significantly reduce quality of life,” says Sujana S. Chandrasekhar, MD. “Surgeons need to realize the importance of evaluating voice in thyroid surgery patients. Early diagnosis and treatment can result in much better outcomes. Physicians should not take a wait-and-see approach.”
In 2013, the American Academy of Otolaryngology—Head and Neck Surgery Foundation released a clinical practice guideline that is intended to guide surgeons in using strategies that help minimize voice impairment after thyroid surgery. “Because of the higher prevalence of thyroid disease, these surgeries are increasingly being performed by diversely trained and experienced surgeons,” says Dr. Chandrasekhar, who was the chair of the guidelines. “The guidelines are designed to highlight the importance of a patient’s voice and to improve voice outcomes in patients after these procedures.”
Using a thorough review of the literature and consensus from the panel, a planned protocol was developed and included several recommendations on strategies to use during the preoperative, intraoperative, and postoperative stages (Table 1). Several preoperative factors may be associated with extrathyroidal extension in patients with a preoperative diagnosis of thyroid malignancy. Historical factors to consider during the preoperative phase include voice abnormality, dysphagia, airway symptoms, hemoptysis, pain, and rapid progression. Physical exam factors that should be considered include large or firm masses and masses fixed to the larynx or trachea. Radiographic factors—usually ultrasound and/or axial scanning, including CT or MRI—include malignant masses with extension of the nodule’s capsule to the periphery of the thyroid lobe, especially posterior extension.
“Surgeons need to realize the importance of evaluating voice
in thyroid surgery patients.”
Even without suspicion of extrathyroidal extension, it is important to assess a patient’s voice before surgery, says Dr. Chandrasekhar. “If the voice is impaired, we should explore the causes of this impairment by examining the larynx in all cases. If the patient’s voice is normal, we should examine vocal fold mobility under defined circumstances.” The guidelines indicate that early treatment of voice disturbance can be beneficial. Interventions—ranging from early speech therapy to injections of paralysed vocal folds to more extensive procedures for vocal fold paralysis—can allow patients to function better and more quickly after their procedure. Early postoperative treatments may also minimize the need for further phonatory surgery in the future.
A critical component of improving voice outcomes after thyroid surgery is to educate patients about the possible vocal effects associated with these procedures. The guidelines recommend several strategies to enhance discussions with patients before and after surgery (Table 2). “Taking the time to educate patients before and after surgery can go a long way toward managing expectations throughout the course of treatment,” Dr. Chandrasekhar says.
For cases in which patients have voice changes after thyroidectomy, several discussion points are recommended by the guidelines. “First, we should inform patients that their voice matters,” says Dr. Chandrasekhar. “Patients should understand that voice changes can be problematic after surgery. They should also understand why certain voice changes may occur and other experiences they may encounter postoperatively. We need to encourage patients to discuss voice changes with their providers and inquire about treatment options to improve their voice.”
More to Come
Several research gaps must be addressed in future studies with regard to improving voice outcomes after thyroid surgery. In the meantime, Dr. Chandrasekhar says clinicians should use the guideline to become better educated on the importance of voice outcomes after these procedures. “We should take steps before, during, and after surgery to preserve the voice,” she says. “We must also use the available treatment options at our disposal for voice rehabilitation.”
Readings & Resources (click to view)
Chandrasekhar SS, Randolph GW, Seidman MD, et al. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148:S1-S37. Available at: http://oto.sagepub.com/content/148/6_suppl/S1.full.
Sinagra DL, Montesinos MR, Tacchi VA, et al. Voice changes after thyroidectomy without recurrent laryngeal nerve injury. J Am Coll Surg. 2004;199:556-560.
Ho TW, Shaheen AA, Dixon E, Harvey A. Utilization of thyroidectomy for benign disease in the United States: a 15-year population-based study. Am J Surg. 2011;201:570-574.
Cohen SM, Kim J, Roy N, Asche C, Courey M. Direct health care costs of laryngeal diseases and disorders. Laryngoscope. 2012;122:1582-1588.