Voice Problems Common, Undertreated After Thyroid Cancer Surgery

By Marilynn Larkin

July 30, 2019

NEW YORK (Reuters Health) - Patient-reported voice problems are prevalent after thyroid cancer surgery and should be part of the preoperative risk-benefit discussion and postoperative rehabilitation, researchers say.

"Although the risk of voice changes is often acknowledged pre-operatively, since many physicians quote data from select high-volume centers, the risks are often underestimated," Dr. Megan Haymart of the University of Michigan told Reuters Health by email.

"By evaluating voice outcomes in a large, diverse, population-based cohort, with use of a validated scale, we were able to obtain data that likely reflects the 'real-world' scenario for most patients," she said.

Dr. Haymart and colleagues surveyed patients in 2017 and 2018 who had undergone surgery for differentiated thyroid cancer from 2014 through 2015, to determine factors associated with abnormal voice as measured by the Abnormal Voice Handicap Index (VHI-10) score (i.e., a score greater than 11).

As reported online July 18 in JAMA Otolaryngology-Head and Neck Surgery, 2,325 patients who responded to the survey met the inclusion criteria (weighted mean age, 49.4; weighted percentage, 77.4% women).

A total of 599 (25.8%) reported voice changes lasting more than three months following surgery: 272 (12.7%) had an abnormal VHI-10 score and 105 (4.7%) reported vocal fold motion impairment (VFMI) diagnosed by laryngoscopy.

In multivariable analysis, factors associated with an abnormal VHI-10 score included age 45 to 54 years (OR, 1.49), black race (OR, 1.73), Asian race (OR, 1.66), gastroesophageal reflux disease (OR, 1.67), and lateral neck dissection (OR, 1.99).

Overall, patients with VFMI were more likely than those without to have an abnormal VHI-10 score; 60.5% of those with VFMI had VHI-10 scores higher than 11 compared to 10.3% of those without VFMI. In addition, 79.3% of patients with VFMI reported prolonged voice changes lasting more than three months following surgery versus 23.3% of those without VFMI.

Further, 89% of the cohort was surveyed three years after diagnosis, 8% at two years, and 3% at four years. There was no significant difference in the proportion with abnormal VHI-10 based on years since diagnosis.

The three most commonly cited problems were the same for those with VHI-10 scores greater than 11, those with VFMI and for the overall study population, although the proportions differed in each group. Those were: "my voice makes it difficult for people to hear me"; "the clarity of my voice is unpredictable"; and "I feel as though I have to strain to produce voice."

Dr. Haymart said, "The unexpectedly high prevalence of abnormal voice two-to-four years post-operative emphasizes the need for heightened awareness of voice complaints following surgery. Patients and physicians should know that long-term voice abnormalities after surgery for thyroid cancer are common. They should discuss this pre-operatively and consider this risk when planning surgery."

"In addition, if patients have voice problems that persist postoperatively, they should alert their doctors and discuss options for postoperative evaluation and potential rehabilitation," she noted. "Since patients use voice in their daily life, both work and socially, the impact of voice problems should not be minimized."

Dr. Miriam Lango, Professor, Department of Surgical Oncology at Fox Chase Cancer Center in Philadelphia, commented by email, "Prevention is the best strategy to reduce the impact on voice post-surgery. Nevertheless, the study highlights the need for awareness of voice abnormalities following thyroid surgery."

"Our understanding of voice alternations following surgery has become more nuanced, enhanced by feedback from patients and the development of surgical techniques to prevent voice-related sequela," she told Reuters Health.

"Historically, thyroid surgery was performed by surgeons with no specific expertise in voice or laryngeal function. Many surgeons did not have the training to even assess laryngeal function after thyroid surgery," she noted.

"However, this has changed, and novel techniques have also made it possible to improve surgical outcomes," she said. "The identification of a surgeon with the necessary experience and skill may be the most important factor for a good recovery after thyroid cancer surgery."

SOURCE: http://bit.ly/2YqkTuE

JAMA Otolaryngol Head Neck Surg 2019.