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The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery

The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery. Laryngoscope , February 2006 Farrag, Tarik Y. MD; Samlan, Robin A. MS, MBA; Lin, Frank R. MD; Tufano, Ralph P. MD

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The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery

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  1. The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery Laryngoscope , February 2006 Farrag, Tarik Y. MD; Samlan, Robin A. MS, MBA; Lin, Frank R. MD; Tufano, Ralph P. MD From Johns Hopkins University School of Medicine, Department of Otolaryngology–Head & Neck Surgery, Baltimore, MD. R1康焜泰

  2. evaluate the utility of screening laryngoscopic examination in evaluating vocal fold (VF) mobility before thyroid surgery.

  3. INTRODUCTION • Thyroid pathologic conditions  11% of the general population. • surgical trauma during thyroid operations  recurrent laryngeal nerve (RLN) dysfunction vocal fold (VF) motion impairment

  4. some researchers : up to 50% of patients with unilateral RLN paralysis may be asymptomatic • Rueger RG. Benign disease of the thyroid gland and vocal cord paralysis. Laryngoscope 1974;84:897–907.

  5. use of routine VF examination before thyroid surgery ? • This study  • 1. findings in assessing the benefits of VF examination as a routine procedure before thyroid surgery • 2. evaluate impact on the extent of thyroid surgery.

  6. METHODS • retrospective study • 340 patients : thyroid surgery and have had VF examination preoperatively • from January 1998 to June 2005 • 114 males : 226 females. • Age :18 to 87 years • 32.5% (n = 111) indirect mirror laryngoscopy • 67.5% (n = 229) fiberoptic examination or videostroboscopy

  7. Two main categories (based on VF mobility preoperatively • 1) with normal VF mobility • 2) with VF motion impairment

  8. Preoperative diagnosis : • fine needle aspiration • intraoperative condition of RLN • history of previous thyroid surgery • Reports of final postoperative histopathologic examination

  9. RESULTS • Category I (normal vocal fold mobility on preoperative examination; 93.5%, n = 318) • 90% asymptomatic (n = 285) • 10% symptomatic (n = 33) • Fiberoptic or videostroboscopy :214 patients (67%) • indirect mirror laryngoscopy :104 patients (33%)

  10. Category II (vocal fold motion impairment on preoperative examination; 6.5%, n = 22) • seven patients (32%) :asymptomatic without any voice problems (95% confidence interval, 14–55%)

  11. Voice Symptoms as a Screening Test for Vocal Fold Mobility Impairment • Sensitivity was 0.68 (68%)proportion of preoperative thyroid patients with VF motion impairment who were correctly identified as “positive/vocal fold motion impairment” using voice symptoms. • Specificity was 0.9 (90%); this is the proportion of preoperative thyroid patients with normal VF mobility who were correctly identified as “negative/no motion impairment” using voice symptoms

  12. Voice Symptoms as a Screening Test for Vocal Fold Mobility Impairment • Positive predictive value (PPV) was 0.31 (31%); this is the proportion of preoperative thyroid patients with positive voice symptoms who actually had VF motion impairment. • Negative predictive value (NPV) was 0.98 (98%); this is the proportion of preoperative thyroid patients with no voice symptoms who did not have VF motion impairment.

  13. In category II, • 59% (n = 13) malignancy on histopathologic examination • 62% (n = 8) of these malignant cases demonstrated papillary thyroid carcinoma (PTC)

  14. 7 patients :asymptomatic +VF motion impairment  5 benign disease on their histopathology reports. • 15 patients: symptomatic + VF motion impairment  11 patients had malignant disease

  15. presence of VF motion impairment plus positive symptoms is strongly suggestive, but not conclusive, of malignancy (P = .07)

  16. differs significantly from the hypothesis that VF motion impairment will only be seen ipsilateral to the thyroid lesion

  17. DISCUSSION • recommend vocal fold examination as a routine preoperative investigation for all patients undergoing thyroid surgery. • 1. high incidence of asymptomatic VF motion impairment (32%) • 2. some patients (10%) with normal VF mobility had positive voice symptoms.

  18. 1.asymptomatic + preoperative VF motion impairment  majority : slowly progressive benign 2. some cases VF motion impairment contralateral to the side of the thyroid lesion  possibility that RLN paralysis independent of the existing thyroid pathology  Further diagnostic studies would be needed to explain this possibility

  19. Documenting asymptomatic VF motion impairment preoperatively may provide the surgeon medicolegal protection • Proper preoperative counseling is important, and with preoperative VF evaluation •  easier to clearly inform patients about their disease process • explain the risks of thyroid surgery to the RLNs and the resultant functional impairment that comes with injury

  20. CONCLUSION • status of VF mobility is essential information that should be known to both the patient and surgeon before thyroid surgery.

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