Management of Post-Thyroidectomy Hoarseness

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 • 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?

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 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

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 weeksafter 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

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 • 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

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

Video-Stroboscopy Indirect Laryngoscopy Flexible Nasolaryngoscopy • Simple to perform • View is clear but restricted • Satisfactory diagnostic accuracy • Gag reflex • Utilizes a high frequency strobe light to analyze the vibration of the cords • Very high diagnostic accuracy • Requires specialized expertise and equipments • More physiological position and wider vision to the larynx • High diagnostic accuracy • Less discomfort Diagnostic Evaluation and Management of HoarsenessTed 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 • 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

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 • 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 forManagement 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 HoarsenessTed 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

Management of Post-Thyroidectomy Hoarseness