Thyroid Surgery: Guidelines for Improving Voice Outcomes

Lara C. Pullen, PhD

June 04, 2013

The new clinical practice guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation includes a strong recommendation that surgeons performing thyroid surgery identify the recurrent laryngeal nerve or nerves. The guidelines are designed to highlight the importance of a patient's voice and to improve voice outcomes in patients receiving thyroid surgery.

Sujana S. Chandrasekhar, MD, from New York Otology in New York City, and colleagues published the evidence-based recommendations in a supplement to the June issue of Otolarynology–Head and Neck Surgery.

"These results are supported by a thorough review of the literature and consensus from a multidisciplinary panel," noted Michael Benninger, MD, chairman of Cleveland Clinic's Head and Neck Institute in Ohio, in an email to Medscape Medical News.

The multidisciplinary panel included consumers, physicians specializing in otolaryngology–head and neck surgeries, and physicians from related specialties. The panel used a planned protocol.

"[The guideline] means that doctors need to realize the importance of evaluating voice in thyroid surgery patients. Early diagnosis and treatment can result in much better outcomes," Dr. Benninger said. He also explained that physicians should not take a wait-and-see approach to voice problems in this patient population: "An early diagnosis and treatment leads to better outcomes. Our data and that of others suggest that early injections of vocal fold paralysis not only allows patients to functionally do better sooner but may minimize the need for further surgery in the future.

The guidelines included 10 recommendations for clinicians, in addition to the strong recommendation to locate the recurrent laryngeal nerve. The recommendations include:

  1. assess patient's voice prior to surgery,

  2. examine vocal fold mobility if the patient's voice is impaired,

  3. examine vocal fold mobility under defined circumstances if the patient's voice is normal,

  4. educate the patient about the possible effect of thyroid surgery on the voice,

  5. inform the anesthesiologist of any abnormal preoperative laryngeal assessment,

  6. preserve the external branch of the superior laryngeal nerve during surgery,

  7. document any voice change after surgery,

  8. examine vocal fold mobility in patients with voice change,

  9. refer patients with abnormal vocal fold mobility to an otolaryngologist, and

  10. counsel patients on voice rehabilitation options.

Each year, approximately 118,000 to 166,000 patients in the United States undergo thyroidectomy, and voice problems may occur in as many as 80% of these patients. "Thyroid surgery rates have tripled over the last three decades," said Dr. Chandrasekhar in a press release. "This new guideline will help educate physicians and patients of the importance of voice outcomes after thyroid surgery, steps that can be taken during surgery to preserve the voice, and available options for voice rehabilitation."

This study was supported by the American Academy of Otolaryngology—Head and Neck Surgery Foundation. Dr. Chandrasekhar is a shareholder and board member of Scientific Development & Research Inc and a grant recipient from Med El Corporation. Full conflict-of-interest information is available on the journal's Web site. Dr. Benninger has disclosed no relevant financial relationships.

Otolaryngol Head Neck Surg. 2013;148:S1-S37. Full text

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