Post on 31-Dec-2015
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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
Radu Mihai et al. World Journal of Endocrine Surgery, Sep-Dec 2009;1(1):1-5
Recommendation: Causes of hoarseness other than recurrent laryngeal nerve palsy need to be considered
Neural InjuryRecurrent laryngeal nerve palsy
External branch of superior laryngeal nerve
Regional non-neural effectsMuscle injury
Regional scarring
Endotracheal tube associated Vocal cord injury/edema
Arytenoid dislocation
Coincidental (non-iatrogenic)Viral infection
Vocal cord nodules
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
• Summative outcome of patients with temporary and permanent vocal cord palsy
• Recovery of temporary paralysis most prominent between Day 2 and 6 months
Post-op Vocal Cord palsy
Day 0 6.4%
Day 2 6.7%
Day 14 4.8%
2 months 2.5%
6 months 0.8%
1 year 0.7%
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 forPost-Thyroidectomy
Hoarseness
Indirect Laryngoscopy
FlexibleNasolaryngoscop
y
Videostroboscopy
Voice Questionnaire
Computerized Acoustic
Assessment
Indirect Laryngoscopy
• Simple to perform
• View is clear but restricted
• Satisfactory diagnostic accuracy
• Gag reflex
Diagnostic Evaluation and Management of HoarsenessTed Mau. Med Clin N Am 94 (2010) 945–960
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
“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
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 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 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