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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 16-20

Management of vocal complications post thyroidectomy at king abdullah medical city from 2011 to 2018


1 Head and Neck Skull Base Surgery Center, King Abdullah Medical City, Makkah, Saudi Arabia
2 Umm Al-Qura University, College of Medicine, Makkah, Saudi Arabia
3 Taif University School of Medicine, Taif, Saudi Arabia
4 Department of Otology and Cochlear Implant Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
5 Department of Head and Neck Surgical Oncology, Head and Neck and Skull Base Surgery Center, King Abdullah Medical City, Makkah, Saudi Arabia

Date of Submission01-Jun-2020
Date of Decision27-Jun-2020
Date of Acceptance31-Aug-2020
Date of Web Publication22-Apr-2021

Correspondence Address:
Dr. Rawan Rajallah Aljohani
Umm Al-Qura University, Makkah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJOH.SJOH_25_20

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  Abstract 


Background: The most common critical complication after thyroidectomy is vocal cord dysfunction. The leading cause of that problem is injury to the recurrent laryngeal nerve (RLN). Materials and Methods: A retrospective cohort study was applied to 266 patients who underwent thyroidectomy procedures at King Abdullah Medical City between the years of 2011 and 2018. Patients with preexisting vocal cord abnormalities and neurological conditions affecting the voice or swallowing ability were excluded. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics V21.0). Results: Out of the 266 patients, the incidence of RLN injury was significantly higher if the patient had a previous thyroid surgery, especially among cancer patients (30.4% in cancer vs. 9.2% in noncancer, P = 0.001). Patients who presented with postoperative vocal complications were only five; four of them developed temporary unilateral vocal cord palsy (1.6%) and were managed with speech therapy, however, one patient had a permanent bilateral vocal cord palsy (0.4%) that was managed with tracheostomy and laser vocal cordotomy. Conclusion: The incidence of vocal cord complication due to thyroidectomies was comparatively rare. Thyroid complications were present more in cancer patients.

Keywords: Management, nerve monitoring, recurrent laryngeal nerve injury, thyroidectomies, vocal complications


How to cite this article:
Alghamdi SA, Alyamani AM, Aljohani RR, Benjabi WM, Althobaiti RA, Takrooni WA, Alotaibi YZ, Badr KM, Abdelmonim SK. Management of vocal complications post thyroidectomy at king abdullah medical city from 2011 to 2018. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:16-20

How to cite this URL:
Alghamdi SA, Alyamani AM, Aljohani RR, Benjabi WM, Althobaiti RA, Takrooni WA, Alotaibi YZ, Badr KM, Abdelmonim SK. Management of vocal complications post thyroidectomy at king abdullah medical city from 2011 to 2018. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jun 25];23:16-20. Available from: https://www.sjohns.org/text.asp?2021/23/1/16/314386




  Introduction Top


Although, thyroidectomy clinical procedures are performed as a primary treatment to different diseases such as thyroid malignancies, compressive symptoms of benign lesion, and multinodular goiter, but one of the most common critical complications after thyroidectomy is vocal cord dysfunction (VCD).[1] VCD causes episodic shortness of breath, wheezing and stridor that results from inappropriate adduction of vocal cords during inhalation and exhalation.[2] The leading cause of that problem is injury to the recurrent laryngeal nerve (RLN) because this nerve is responsible for the supplement of all intrinsic muscles of the larynx except the cricothyroid muscle.[3] Thus, the issue owes to the close relationship between the RLN and the thyroid gland. A study done by Neri et al. had shown that the incidence of postthyroidectomy vocal cord injury has been reported in the range of 14%–20%.[4]

Vocal cord paralysis might be unilateral or bilateral, temporary, or permanent.[3] Unilateral injury is the most common type which causes dyspnea and hoarseness of voice that will gradually resolve opposite cord compensation.[5] It is frequently well tolerated but is risky for elderly patients because of aspiration pneumonia.[1] Bilateral paralysis causes aphonia and dyspnea.[5] This injury is the most dangerous because of stridor. Symptoms vary from hoarseness to severe life-threatening respiratory distress.[3] It is seriously affecting patients' quality of life.[5]

Studies revealed that the incidence of permanent RLN paralysis could be as high as 13% during thyroid cancer operations and 30% with redo thyroidectomy.[6] As a result, identifying and carefully tracing the path of the recurrent nerve is of utmost importance.[5] Furthermore, the rates of temporary and permanent vocal fold paralysis were analyzed based on underlying diseases and increasing their complications in advanced stage of the disease.[7] The mean incidence of the temporary paralysis is stated to be 9%, and the permanent injury is 2.3% with surgical expertise.[7] The goal of management of the bilateral abductor paralysis is to provide an adequate airway and to perform either a permanent tracheotomy, arytenoidopexy, or arytenoidectomy.[8] Arytenoid surgery displaces the posterior portion of the vocal cord laterally, thus producing an adequate airway, but causes further deterioration of the voice.[8] As a result, it is very important to know how to prevent and deal with RLN injury during thyroid surgery. In addition, nonsurgical management options such as speech therapy are available for improving voice and swallowing functions through restoring voice function and achieving sufficient glottic closure, and thus, successful therapy for vocal fold paralysis can substantially improve daily function and quality of life.[9] The aim of this research is to find the best procedures for managing and dealing with complications and to document patient's improvement.


  Materials and Methods Top


A retrospective cohort study was applied to a large group of patients who underwent thyroidectomy procedure at King Abdullah Medical City (KAMC). After obtaining the Institutional Review Board approval, the data were collected from patients' paper files and electronic medical records between the years of 2011 and 2018 to obtain the patient demographics and personal information including medical, surgical, and family history as well as preoperative and post-operative visits reports , complications reports, laboratory result and other follow-ups information. We included all the patients diagnosed with thyroid tumors either benign or malignant and underwent hemi- or total thyroidectomy in the specified time frame. We excluded patients with preexisting vocal fold abnormalities (e.g., polyps and nodules), neurological conditions affecting the voice, or swallowing ability. The total number of patients was 266. End points are to report the diagnosis, type of applied thyroidectomy procedures, the most appropriate management of vocal complications done for those patients, and to highlight the most significant risk factor for RLN injury. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) SPSS Statistics V21.0 Manufactured by International Business Machines Corporation (IBM) Armonk, New York, U.S. Qualitative data variables were expressed as frequencies and percentages, while quantitative variables were expressed as means and standard deviations. An independent sample t-test was used to identify significant differences between variables, and P ≤ 0.05 was considered statistically significant.


  Results Top


The review of 266 patients who underwent thyroid surgery during the study period from 2011 to 2018 showed a mean patient's age of 43.5 ± 15.7 years. Most of them were female.

The demographic data are represented in [Table 1].
Table 1: Demographics of all patients who underwent thyroid surgery from 2011 to 2018 at KAMC

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Postoperative vocal complication, there was a unilateral vocal cord palsy which developed in 4 cases (1.6%) and one case with permanent bilateral vocal cord palsy (0.4%).

In those five patients with RLN injury, four of them were diagnosed with papillary thyroid cancer (PTC): two of them had a Stage I PTC, one had a Stage III PTC, and the fourth one had Stage IVA PTC, and it was the only case with RLN invasion and perineural invasion. The last one out of the five was diagnosed with multinodular goiter.

Compared to the patients with multinodular goiter and other benign lesions, those with thyroid cancer were more likely to have completion thyroidectomy (P = 0.001), but it was shown that there is no significant relationship between completion thyroidectomy with risk of vocal complication (P = 0.326).

However, there was no significant type of vocal complication according to diagnosis [Table 2]. RLN in most of the patients was identified by following the anatomical course of the nerve. In few cases it was identified by applying neuromonitoring and none of them developed vocal complication [Table3]. Patients were presented to the phonatric clinic on an average of 7 days postsurgery. The management of vocal complication was speech therapy in the 4 cases (1.5%) who were diagnosed with unilateral RLN. The management of vocal complications in the patient who had a bilateral RLN injury was a tracheostomy and a laser vocal cordotomy surgery.
Table 2: Type of vocal complication according to diagnosis

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Table 3: Vocal complication according to RLN identification

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The complications for patients who were treated with speech therapy were found to be temporary, and they had improved after 3 months of treatment. However, the patient who was treated with tracheostomy and laser vocal cordotomy had permanent complications, and surgeries were done to aid patient breathing. None of the patients who developed vocal complication had laryngoplasty.


  Discussion Top


One of the most serious complications to thyroid surgery is RLN palsy that builds up its severity to voice disorders, respiratory distress, and aspiration, and therefore, the quality of life may be largely impacted. Injury to the RLN during thyroidectomy may be a consequence of unintentional sectioning, stretching, and thermal injury, entrapment by a ligature, or ischemia.[10] Therefore, it is very important to know how to deal with the RLN and prevent its complication during surgery.

The purpose of this study was to report the percentage of vocal complication in a certain hospital with a long period of time and compare it with previous studies and also to find the most common type of management applied to those patients.

The overall definitive complication rate was five patients which included 4 unilateral RLN injuries (1.6%) and 1 bilateral RLN injury (0.4%).[10]

Our result is comparable with a study published in 2017 for the evaluation of intraoperative neuromonitoring (IONM); 2365 patients who underwent thyroidectomies were subdivided into Group A in which IONM was applied and Group B in which IONM was not applied. In Group A, 29 cases (2.1%) experienced unilateral paralysis and 2 (0.1%) experienced bilateral palsy. In Group B, 26 cases (2.6%) experienced unilateral paralysis and only 2 cases (0.2%) experienced bilateral palsy.[11]

A review paper published in 2013 mentioned that the incidence of vocal complications due to thyroidectomy is generally low, and it depends on various factors such as: the time of postsurgical follow-up and that, at a single year, the mean incidence reported was 2.3% versus 9.8% in the immediate postoperative period. As well as, the mode of post-operative diagnosis that has an incident ranging from 2% to 6% relying on which method is more routinely performed, the more preferable fiberoptic laryngoscopy or indirect mirror laryngoscopy.[12]

The most significant results in this research were that the patients who had previous thyroid surgery were mostly cancer patients (9.2%) with P = 0.001, and out of the 5 (1.5%), only one had a previous thyroid surgery. Moreover, the risk for RLN injury increased if the patient had a previous thyroid surgery. Other factors that increase the risk of RLN injury are the underlying thyroid pathology, the extent of resection, and the volume of the surgeon's practice.[12]

As stated in the results, nearly, all the patients who had complications were diagnosed with PTC, except for one patient who was diagnosed with multinodular goiter.

The surgeon experience was not related to the cause of these complications as the injuries were found to be due to anatomical and structural causes. A meta-analysis that covered the postoperative data of 14,934 patients reported a 3.4% incidence of RLN paralyses for all thyroid pathologies. Moreover, in conjunction with this study, malignant tumor had the higher incidence rate of 5.7%.[12],[13]

Concerning these five patients who had vocal complain, the RLN has been identified anatomically. Nowadays, RLN can be easily identified during surgery by IONM; it facilitates the visual identification of the nerve as well as prediction of the nerve function postoperatively, which may further prevent bilateral nerve injury.[14],[15]

A study was published in 2016 stated that among 236 patients, IONM was applied during surgery and RLN has been identified in 94.93% cases, and the duration of operation has been decreased after IONM introduction.[16] In addition, many publications have documented that postoperative complications have decreased when applying IONM. Barczyński et al. reported that 2.9% of cases presented with early paralysis in high risk operation and 0.9% in low risk operation after demonstration of IONM when compared to the same procedures performed without IONM.[16] However, it is difficult to relate the results of our study as a risk factor for vocal complication, because as mentioned before surgeons' skills, anatomical variation of RLN and extent of the disease play a major role in the operation outcome, so we cannot rely entirely on IONM. Ultimately, precise surgical technique, detailed knowledge of neuroanatomy, and visual identification of RLN intraoperatively remain golden factors. Moreover, the incorrect utilization of monitoring equipment can lead to vocal complications, for instance, the skin burns due to excessive stimulation.[17],[18]

In 2018, a study that aimed to review the most recent literature for the management of dysphonia due to unilateral vocal fold paralysis (UVFP) was published. This study mentioned that the timing of the surgical intervention and/or voice therapy was inconsistent.[19]

In this study, the five patients who were diagnosed postoperatively at phonatric clinic with unilateral and bilateral complications have been examined preoperatively and vocal cords shown to be normal and freely mobile.

Managements of vocal cord injury vary wieldy between surgical and nonsurgical intervention, however, speech therapy is one of the preferred options for unilateral vocal fold palsy, it enhances voice, communication, and swallowing outcomes, and it is performed by phoniatrics or speech-language pathologist.[20] Preoperative assessment is extremely important in order to assess voice and swallowing function, as well as establishment of treatment steps and evaluation of response to therapy, as many patients have the same diagnosis but present different symptoms.[21] It is important to take into consideration some factors that should be assessed before starting speech therapy, such as adequate wound healing and absence of dizziness, which could be due to metabolic disturbances. Our finding is also comparable to a study conducted in 2017 including 19 patients diagnosed with UVFP who received voice therapy within 6 months, and they exhibited considerable improvement in closure of glottis, breathiness, and quality of voice.[22]

Injection laryngoplasty is the preferred surgical method for UVFP, a study conducted in 2017, including 14 patients with UVFP who underwent injection laryngoplasties, showed great improvement.[23] In our study, none of these five patients needed to undergo injection laryngoplasty, despite the wide application of this procedure at KAMC, so increasing sample size could have given finer results.

Regarding bilateral vocal cord palsy (BVCP), it is usually iatrogenic due to several causes, including prolonged endotracheal intubation, surgery within neck, cardiothoracic and neurosurgical procedures, and rarely, the use of IONM.[24],[25],[26] It is a life-threatening condition and needs immediate intervention with tracheostomy or emergent intubation. Other therapeutic options include laser vocal cordotomy through glottic widening in which glottic airway is restored and permits for decannulation, as well as arytenoidectomy. In 2018, a study was conducted analyzing 132 patients with BVCP who underwent CO2 vocal cordectomy, and patients were subdivided into 91 nontracheotomized and 41 tracheotomized; out of the 91 patients, 83 reached respiratory comfort, and out of the 41 patients, 26 were decannulated.[27]


  Conclusion Top


The incidence of vocal cord complications due to thyroidectomies was comparatively rare. For unilateral vocal fold palsy, speech therapy is effective and its advantages are maintained over time. Early referring for specialists seems to be associated with great benefit. Further, large and multicenter studies are needed to confirm and determine the best strategy for treatment.

Recommendation

Speech therapy should be the initial intervention for all patients with unilateral RLN palsy due to its considerable improvement in voice quality and breathing, swallowing, and other outcomes.

Acknowledgment

We would like to thank Dr. Khaled Bader for his advice and assistance during the data collection period as well as the King Abdullah Medical City Research Center for giving us the opportunity and providing the material for conducting this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3]



 

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