Transcript 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?
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
Neural Injury
Recurrent laryngeal nerve palsy
External branch of superior
laryngeal nerve
Endotracheal tube associated
Vocal cord injury/edema
Arytenoid dislocation
Regional non-neural effects
Muscle injury
Regional scarring
Coincidental (non-iatrogenic)
Viral infection
Vocal cord nodules
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
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?
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 weeks
after 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
Post-op
Vocal Cord palsy
Day 0
Day 2
Day 14
2 months
6 months
1 year
6.4%
6.7%
4.8%
2.5%
0.8%
0.7%
• 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
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?
Investigations for
Post-Thyroidectomy
Hoarseness
Indirect
Laryngoscopy
Flexible
Nasolaryngoscopy
Voice
Questionnaire
Videostroboscopy
Computerized
Acoustic
Assessment
Indirect Laryngoscopy
• Simple to perform
• View is clear but
restricted
• Satisfactory
diagnostic
accuracy
• Gag reflex
Flexible
Nasolaryngoscopy
• More physiological
position and wider
vision to the larynx
• High diagnostic
accuracy
• Less discomfort
Video-Stroboscopy
• Utilizes a high
frequency strobe
light to analyze the
vibration of the cords
• Very high diagnostic
accuracy
• Requires specialized
expertise and
equipments
Diagnostic Evaluation and Management of Hoarseness
Ted 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”
• 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
J.-P. Jeannon et al. Int J Clin Pract, April 2009, 63, 4, 624–629
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?
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 for
Management 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
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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 Hoarseness
Ted 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