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Guidelines for Improving Voice Outcomes Post-Thyroid Surgery

Guidelines for Improving Voice Outcomes Post-Thyroid Surgery
Author Information (click to view)

Sujana S. Chandrasekhar, MD

Director, New York Otology

Past Chair, Board of Governors
American Academy of Otolaryngology—Head and Neck Surgery

Director of Neurotology, James J. Peters VA Medical Center

Clinical Associate Professor, Department of Otolaryngology
Mount Sinai School of Medicine

Director of Neurotology, New York Head and Neck Institute
Lenox Hill Hospital, Northshore-LIJ Health System

Figure 2 (click to view)
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Sujana S. Chandrasekhar, MD (click to view)

Sujana S. Chandrasekhar, MD

Director, New York Otology

Past Chair, Board of Governors
American Academy of Otolaryngology—Head and Neck Surgery

Director of Neurotology, James J. Peters VA Medical Center

Clinical Associate Professor, Department of Otolaryngology
Mount Sinai School of Medicine

Director of Neurotology, New York Head and Neck Institute
Lenox Hill Hospital, Northshore-LIJ Health System

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A clinical practice guideline has been released for surgeons performing thyroid surgery to help improve voice outcomes. The document highlights the importance of a patient’s voice and strategies to improve voice outcomes in people undergoing these procedures.
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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.”

Voice-Thyroid-Callout

New Recommendations

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.”

Preoperative Factors

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.

Patient Education

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.

57 Comments

  1. I had half of my thyroid removed about three days ago. I was scared when I tried to sing a note and could not sing in pitch…I’ve sung for my whole life…Music has been one of my passions…I just don’t want to believe that this will be permanent…

    Reply
  2. I had surgery for Stage 3 Thyroid Cancer in January of 2016. I have an incision from mid neck to the bottom of my face. I have no feeling in my lower right face, right ear, and right side of my neck. I can’t sing to this day. If I do, my voice cracks. I was an alto/second soprano. Now I can only sing low tenor. I’ve had reflux surgery to eliminate that as the reason why. Apparently not. My voice box and vocal cords are okay. But I lost 40 lymph nodes and some muscle in my neck. I did months of physical therapy. I’m discouraged because I think it’s just something I have to give up.

    Reply
    • Hello. I had a total thtroidectomy done July 6, 2017. My hard better as time goes by. I’m way better than I was after surgery but still have a way to go for my voice to be back to its normal range. I sing Alto, Second soprano and now I can sing Alto again. I still have a little struggle on some notes but breathing is key. Keep exercising your voice everyday as much as you can without much strain.How is in control and knows your gift. Relax and be patient. Philippians 4:13 I can do all things through Christ who strengthens me. You are victoriousover this. Be blessed and I pray full recovery and restoration in your voice and singing

      Reply
  3. ATTENTION!! POSITIVE STORY HERE!! Don’t forget were all different as is our diagnosis and stage of disease. They told me the only way I would have voice damage as IF one or more of my tumors were wrapped around my laryngeal nerve. After surgery they said it was tangled up bad. I could barely project over a whisper for the first couple weeks, but I started singing and working my voice days after surgery and within 3 months my range was better than its been for years! ….don’t give up! its not all bad stories!!!!! xo Good luck with all your battles!

    proof—->> I had my Surgery on Feb 7th this was done Mid April!
    https://www.youtube.com/watch?v=Ns6ojWTc20Y

    Reply
  4. This is so depressing- is there anyone out there whose singing voice has come back to the extent that they can participate again- even if not as before?
    I had my partial thyroidectomy on 7th June. Still numbness at the front of my neck and can feel as if I’m swallowing past a “thickening”- scar tissue I’m presuming.
    I have sung with a choir for 32 years and I am really struggling. Has anyone else found doing the warm ups etc helpful at all? I need to know things will improve otherwise my life really will be impacted by the loss of taking part in my beloved music.

    Reply
    • I can’t say much. I just posted. It’s been over a year for me and I still can’t sing. I was asked to join the choir at my new church. I went to one rehearsal. I can’t do it. It really makes me sad.

      Reply
  5. I undergo total thyroidectomy, three weeks ago. I have similar issue, a weak voice. What I did is to exercise my voice by singing nursery rhyme ABC’s. It was painful in the neck, at first, as your muscle in the neck after surgery will contract. I do this exercise in the morning after I wake-up, then on the evening before I sleep. There’s a little improvement to my voice, as I was able to finished the song with less struggle. I hope this will continue to improve, and my muscle on my neck will relax. I hope this will help a little. I am 34 years old male, fighting!

    Reply
  6. I had a total thyroidectomy on 9/06/17 and all is well and I feel great…except for my voice.It is weak,raspy and I run out of breath while talking.I was told by my surgeon that it does take about 6 months to return to normal and only about 1% of patients never regain a normal voice so it means being patient until it returns.I am lucky that I am retired and not reliant on my voice for my job but my husband is partially deaf and it is a struggle having to repeat myself.

    Reply
  7. Surgery was 2 weeks ago. Weak voice and hoarseness are still present. My husband has loss of hearing and vision problems. A text to speech app on phone is helping us to communicate. When driving, if it’s plugged in, he can hear me.

    Also keeping throat moisturized seems to help some. Funny how people sympathize with you thinking it’s just a sore throat. You want to explain, but it takes so much effort, you don’t.

    Also, when you talk quieter, if they want to listen, they really have to pay attention. If they don’t want to hear what you have to say, it won’t matter how loud you say it, they really won’t hear you.

    Reply
    • I had my right lobe removed along with a fist size tumor that was attached to the right lobe Feb. 23rd, 2017. I still cannot speak very well, raspy, quite voice, everyone thinks I’m sick with a sore throats and cold…..etc.. just like others here that I read about! I need my voice for my job and my voice is not getting any better, by the end of the day, I have no voice! I sound like Minnie Mouse most of the time; I practice the A-E-I-O-U theory but that still is not helping. Coming up on six months; I’m hoping my surgeon was right! Keeping the Faith!

      Reply
  8. My daughter had partial thyroid removal 6 weeks ago, and her voice is just a hoarse whisper still. She is in law enforcement, now on light duty, and will be fired at the end of 3 months if her voice does not return. Her nodules were large, non-malignant, but she was never forewarned about this possibility. The surgery was done by an experienced ENT who says one cord is “bowed” and might recover. His only suggestions have been to wait or to consider a collagen injection. Has anyone done this. It’s serious. Losing her voice means losing her job, her retirement benefits and her insurance.

    Reply
  9. These comments make me feel sick, I had a right thyroid lobectomy for a benign nodule on May 23rd and woke up with no voice. After a few days it’s still the same so I was wondering what happens and I guess I got my answer. Some people suffer with this for weeks, months or years after the surgery. My Doctor didn’t explain this to me at all.

    Like everyone else here I use my voice in my career and depend on it. I’m a crimes against children detective and I interview victimized children at the worst time in their life. I have lots of good still to do and cannot have this happen to my voice permanently.

    Reply
    • I have undergone right lobe thyroid surgeryon18 May 17. Only pblm i m facing now is my weak voice. I went to an ENT specialist. He told me that right vocal cotd is paralised. Now he told me to just wt and watch. It may recover its own. Lets hope…

      Reply
  10. I had my surgery June 20, 2016 and my voice never recovered yet. I still have a husky voice and I cannot sing. I do not have tones in my voice. I cannot yell or call my kids or pets. It is awful. It has been almost a year and I do not think my voice is going to be normal ever. My grand kids were scared of me initially because of my voice.

    Reply
    • That is so sad. This is what is happening to me. It is actually getting worse instead of better. Had Total thyroidectomy May 11th 2017. I talk for a living, and used to sing. Did you ever get treatment? They said that treatment early on has the best success.

      Reply
      • Just wondering how you are doing? I had a tt on May 12th and 5 weeks later i feel worse off. I still cannot talk and get extremely breathless trying. I am starting to choke up a bit when drinking and sometimes eating and just feel weak. I will be unable to return to work as scheduled ( i am a floor nurse) and am becoming very anxious.

        Reply
    • Hello. We have the same situation. I had thyroidectomy last 2015 and until now I have my voice is like that of a man, oftentimes when I talk over the phone, misconstrued me as a man. I used to sing but until now, I haven’t reached even a pitch higher than my normal tone now.

      I just hope everything will be back to normal. Its so frustrating that you cant sing anymore. 🙁

      Reply
      • I feel your pain. I used to sing with a wide vocal range and since my surgery April 25th 2017 I can’t go above middle C or below a G below C.
        Everyone says I sound angry when I talk and it makes me so sad.

        Reply
    • Same here. Can’t yell. Can’t sing. I have my normal speaking voice minus the projection. This sucks.

      Reply
  11. I had a total thyroidectomy 10 days ago. My voice has a high pitch at times and sometimes a low pitch . I stil cannot project my voice . My Doctor started me on a steroid which I need to take for 5 days in hopes that maybe some swelling will go away and my voice will get better. Will my voice return to normal if,so how long? Is there anything else I could do to improve my voice??

    Reply
    • I had surgery May 9th 2017
      And voice is still bad no changes .. I can’t yell or sing as well ,, I get short breath a lot and can’t swallow that well either .. I pray I get Better soon because it’s very annoying and I get very frustrated.. becuz my family can’t understand me at times.. and I have to constantly repeat myself and It can get annoying after a while..

      Reply
  12. I had a partial thyroidectomy at the end of Dec 2016 and went back to work two weeks later in January 2017. I am a teacher and my voice was very hoarse all the way through my second surgery in March 2017 and three weeks after that. For my thyroidectomy completion I asked for 3 weeks off work because I felt that it hurt my voice to go back only two weeks after the first surgery. Now I am on spring break so I will have a total of 4 weeks resting my voice. The hoarseness is finally going away. The reason our vocal chords are affected more than with other surgeries is because the thyroid is next to the vocal chord nerves on either side and sometimes they get damaged, but nerves can repair themselves, but not always. Also my doctors told me that the breathing tube that they put in during surgery goes between the vocal chords and the surgeon has to scrape the thyroid off of the trachea causing the vocal chords to get hurt or irritated. From what I have been reading most people regain their voice after 6 months, but not everyone. My surgeon said it is ok to talk but not to strain my voice. I bought a wireless headset and speaker too for when I return to teaching after spring break. Also I cut dairy out of my diet because my vocal chords were inflamed and my nurse said dairy causes inflamation. I hope this helps.

    Reply
    • Thank you for letting me assurance that my voice will still come back as I’m having a similar voice problem like yours

      Reply
  13. I had my whole thyroid taken out on March 6, 2017. I really hate having a hard time talking my regular voice. I would like to know when will I get my voice back.

    Reply
    • I had a thyroid lobectomy in April and my voice is very weak. I know it’s only been two and half weeks but I’m struggling as I’m a teacher. I am only audible one to one and at the end of the day have barely any sound. Is this normal?

      Reply
      • I am exactly the same, three weeks after thyroid lobe to your. Very frustrating.

        Reply
  14. Also, is anyone experiencing any severe ear aches? I have been suffering from these sporadic earaches in my right ear. This pain has me confined to my bed sitting straight up because I can’t move my head from left to right. This pain is so severe that I’m in tears and on my knees screaming. My ear burns and it’s very sensitive from the entire ear and down the back side of my neck and to my jaw. Please help me to find any information about this. This has been going on since my surgery. No pain medication has ever been given. I just went to see a Neurologist at the VA and I have had another MRI done. He’s never heard of anything like this…he’s too young & possibly inexperienced (my opinion). I’ve been to the ENT and they suggested me to see the Neurologist.

    Reply
    • My right ear has started to burn and I feel pressure on my right head. I didn’t realize it was related to the surgery until reading your post and someone else mentioning it also. It’s uncomfortable more than painful and comes periodically throughout the day. If you come up with solution, please let us know. The other problem is definitely the hoarseness and voice going in and out. It is frustrating and I hope it gets better over time. I just have to be thankful that it was caught in time and that I still do have a voice. I can’t yell at my son’s games or call him from another room. I did buy a whistle and use it sometimes if he is upstairs and I need him.. lol

      Reply
      • Take double/triple dose of Calcium.

        Reply
    • I just had a total thyroidectomy May 11, 2017. I’m having a lot of voice problems, but also have experienced an earache in my left ear. I was surprised as it feels like swimmer’s ear, which is very painful, even though there is no way that there is any water in my ear. I think I’m very lucky, I don’t have it nearly as bad as you do. Mine comes and goes, but is noticeable.

      Reply
    • Sharon, have you ever been diagnosed with TMJ? Pain in the ear and jaw is very common with TMJ. The intubation during surgery could have aggravated the inflammation causing the pain.

      Reply
  15. I had a total thyroidectomy on November 2, 2015 and my voice is still raspy and heavy like a man! I’m currently going to a Doctor outside of the VA (Veterans Affairs) because they sent me…I go to see him tomorrow and if I get any information from him to help us all I’ll be sure to post it here.

    Reply
    • Hi! I too had my surgery through the VA. I am one year post op and have been complaining about my voice and lack of this entire time. My doc hasn’t done anything. I am to the point that I am going to file a complaint against her. My private ins has such a high co pay but it’s my best bet at this point. I’m curious what your second opinion said?

      Reply
  16. I am 1 month shy of a partial thyroidectomy to remove papillary carcinoma. I just went back to work yesterday from surgery and I wake up today with a changed voice (after the initial voice issues it returned to normal). I am a phone-based customer service rep and need my voice to be able to speak to my customers. I have a call in to my surgeon to see what I need to do next.

    Reply
    • The same thing happened to me. Surgery was March 22nd 2017. I had a benign nodule removed and the right thyroid and some lymph nodes. I was a little hoarse from the tubes but that went away after a couple days, then I started having a sore throat every night on the right side only about 2 1/2 weeks ago. Then my voice went, and I run out of breath mid sentence. I have an appt tomorrow with the endocrinologist. I read online it’s possible that the nerve was somehow damaged or even cut. There are some therapeutic exercises to strengthenthe nerve, I’ve been doing them a little, but I’m hoping for the best. I’ll keep you posted on what the doc says and hopefully can help!

      Reply
      • How did everything go after seeing the doctor? I am having similar problem. I run out of breath midsentence and cannot talk at a high pitch.

        Reply
      • Praying that all goes well. Please let me know what they say. Thanks! Michelle

        Reply
  17. TT done 29 December 2016, and still no voice. I know of two other people having the same problem. They regained their ability to speak after 6 weeks. They were fortunate enough to have a job where very little of their voice had to be used. I, however, need my voice for my job. I worked so hard to finish school so that I can earn a good paying job, and now I might lose it because I am unable to do my job 100%. I’m becoming emotional because I have three children who depend on me. My youngest would calm down immediately after singing to him. Now he just looks into my eyes with that “okay. I’m waiting,” Look. He’s one. Sorry for the story.

    Reply
    • We’re you trached also?

      Reply
      • yes I was. I strongly believe that was the problem.

        Reply
    • hi there. I am a teacher and I too just had my whole thyroid as well as multi-nodule goiter on jan 11. 2017. I have barely a voice. And when I do talk it is like a whisper, I am straining too much to just get out words. My surgeon says it will take 6 months or more to improve if its going to. Now I am left so discouraged! I returned to work 2 weeks after surgery and find it so hard to teach my class. I just bought a voice amplifier that is used in teaching, so i do not strain my voice. I don’t know what else to do to save my career ?? anyone have any advise i am listening. Thank you!!

      Reply
    • Our voices are so important. I noticed that my voice made it much easier to deliver bad news to our customers than others with lower voices. Now mine is really bad. I’m really scared at how they will react and how temporary or not this really is going to be.

      Reply
  18. I had a total Thyroidectomy on the 22nd Nov 2016. It’s been 6 weeks since then. I am afraid my voice quality is not improving. It’s hoarse, feeble and I get tired when I speak for more than 20 minutes at a stretch. Also I cannot raise my voice or speak louder than a whisper.

    Reply
  19. Had my total thyroidectomy December 15th, its January 7th and I still can’t talk. I run out of breath when I attempt the low key whisper which is all I have. Surgeon says we have to wait and see, says he did not touch my vocal cords which a scope revealed are paralyzed. I am also unable to work. Did anyone find anything helpful when it came to trying to get your voice back?

    Reply
    • Hi Michelle,
      So sorry you, and everyone on here, are going through this. Do you think it was the breathing tube?

      Reply
  20. It’s been 3 weeks since my thyroid was removed due to hoshimoto disease. My voice is raspy, with no resonance. As of now I cannot sing at all. I am trying to develop my voice to respond at a lower pitch so it sounds closer to normal. I teach and am concerned that I will not be able to be heard by my classes when I return to work this week. Also, since I cannot sing, I am limited with how I teach my students. It may be too soon to be concerned. I am looking for any suggestions to improve my voice and to know if things will improve with time. I was told my pitch would drop. I would gladly live with a lower voice if I could speak normally and sing.

    Reply
  21. After my total on December 19 I lost my voice. I make my living off of lecturing to large groups – this is a disaster! There was no prior warning to this!

    Reply
  22. I had a total thyroidectomy on September 9, 2016. At times my speaking voice is weak. My singing voice went from Contract Alto to a low Tenor almost baritone. What can I do to regain my singing voice and power in speaking voice?

    Reply
  23. at 11 october 2016 for retrosternal goitre extension, total thyroidectomy was total throidectomy was done for me by a major surgeon since 3 weeks , pathology is benign . My voice was very good immediately after surgery for ten days postoperative . REDE VAC drain was removed after these ten days with minimal serous fluid was drained . After two days from removal of drain, dysphonia occured. Indirect laryngoscope was done for me, revealed UVCParalysis . Now iam under low dose of corticosteroid , antiinfammatory( Mbezim), vitamin B complex , in addition to thyrxine nd calcim ( today is 29 october 2016)……PLease advice me? , what is possible prognosis? …..Remmeber that my job is professor of OBS & GYn ( hard worker!!!!!)

    Reply
  24. I had surgery this last February. Lost my voice also my doctor wants to inject my vocal cord or have surgery on it after a year. Not sure what to do???

    Reply
    • I had that injection 2 months after surgery and am still suffering from weak voice. I feel it was a waste of time and money.

      Reply
  25. I loose my voice after thyroid cancer surgeries. My voice become weakness n hoarse and raspy. Peoples cannot understand me when I’m on phone. At works, I do a lot of talking with my customers. Can you help me and guide to bring my voice back to normal please?

    Reply
  26. I just have my total last March 22,2016 due to papillary carcinoma. And my normal voice change after my surgery. My voice become hoarse .Everytime I talk a lot my voice will become weak. I’m so stress about it because people criticize me that my voice is like chipmunks and I felt bad about.what remedy will I do to bring back my normal voice. I need my voice especially in my field of work as liaison officer .please help me.

    Reply
    • A Speech and language therapist will be able to help u..

      Reply
  27. What do you do if there was no discussion about the voice aspect regarding a partial Thyroidectomy? I would like to know what to do right now, present-tense, post surgery. Any suggestions? I asked the ENT about the timeframe and was not really given an answer.
    Thank you for your time.

    Reply
    • My question is exactly the same as the one above. I use my voice for my work and other than the surgeon sticking a scope down my nose to look at my vocal nerve and having me make the sound nothing has been done. I can no longer sing with my family I am no longer in the choir and since I use my voice for my work it has really affected the quality of my work. What can I do, me, personally, right now to help myself?

      Reply
    • I as well am having a lot of issues gaining my voice back after ACDF surgery. I also use my voice for work and to sing but cannot at this time and I am 6 weeks post op. I cannot get any answers at all

      Reply

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