Patient Perspectives on Dysphonia After Thyroidectomy for Thyroid Cancer

Patient Perspectives on Dysphonia After Thyroidectomy for Thyroid Cancer *Maggie A. Kuhn, †Gary Bloom, and *David Myssiorek, *yNew York, New York Summary: Objectives. To determine the frequency and consequences of patient-reported post-thyroidectomy voice disorder (PTVD) after surgery for thyroid cancer. Study Design. Retrospective review of data gathered from a survey. Participants. Members of the Thyroid Cancer Survivors’ Association (ThyCa). Methods. ThyCa members were asked about their thyroid disease and surgery, voice disturbance, impact on quality of life, treatment, and non-identifying demographics in a 36-item electronic questionnaire. Patients with preoperative voice disturbance or vocal fold immobility and those reporting postoperative vocal fold paralysis were excluded. Results. A total of 4426 members responded (37% response rate), and PTVD was reported by 51.1% of responders. Most were temporary (85.9%), with a minority reporting permanent hoarseness. Rates of postoperative dysphonia were similar between the extent of surgery and histology. Patients with PTVD predominantly characterized their impairment as loss of loudness and an inability to shout or sing. Nearly a quarter of patients reporting PTVD identified detrimental impact to their professional or personal lives. Only 57 patients (3.4%) were offered voice therapy; however, more than two-thirds of them (73.7%) experienced at least partial improvement. Conclusions. We report the results of a large-scale patient survey to underscore the commonness of postoperative hoarseness and its impact on patients. Level of Evidence. 4 Key Words: Postoperative dysphonia–Thyroidectomy–Thyroid cancer. INTRODUCTION Voice disturbance is a known and feared complication of thyroid surgery. Rates of dysphonia have been reported in up to 87% of individuals after thyroidectomy,1 and with more than 80 000 individuals undergoing thyroidectomy in the United States each year, the potential disability from postoperative voice disorders (post-thyroidectomy voice disorder [PTVD]) is sizable.2 Causes of dysphonia after thyroidectomy include recurrent laryngeal nerve (RLN) or external branch of superior laryngeal nerve (EBSLN) injury, intubation,3 laryngotracheal fixation of strap muscles,4 and altered laryngeal venous drainage.5 Reported rates of RLN injury, once thought to be the primary cause of post-thyroidectomy dysphonia, vary from less than 1% to 13.3%.6,7 Such injury is devastating but is the source of dysphonia in a minority of patients, specifically in the early postoperative period. No formal recommendations exist to guide the thyroid surgeon’s pre- and postoperative evaluation of patients’ voice quality. Both subjective and objective means of evaluation have been studied. In the absence of laryngeal nerve injury, there is no correlation between postoperative voice complaints and videostroboscopic laryngeal findings.8,9 However, clinician and patient scoring using voice assessment tools such as the Accepted for publication July 18, 2012. Financial Disclosure: None. Conflict of interest: None. Presented at the Triological Society Annual Meeting; January 28, 2011; Scottsdale, Arizona. From the *Department of Otolaryngology, New York University Langone Medical Center, New York, New York; and the yThyroid Cancer Survivors’ Association, Inc, New York, New York. Address correspondence and reprint requests to David Myssiorek, NYU Clinical Cancer Center, 160 E34th Street, 9th floor, New York, NY 10016. E-mail: David.Myssiorek@ nyumc.org Journal of Voice, Vol. 27, No. 1, pp. 111-114 0892-1997/$36.00 Ó 2013 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2012.07.012

Consensus Auditory-Perceptual Evaluation of Voice and Voice Handicap Index is predictive of postoperative voice complaints.10 Objective measures less consistently correspond to patients’ vocal complaints. Normal acoustics have been recorded in the patients who reported dysphonia,11 whereas others have demonstrated correlation of postoperative voice complaints with acoustic analysis of speaking voice.5,12,13 A multiparameter objective tool, the Dysphonia Severity Index, predicts immediate postoperative vocal complaints but does not correlate with dysfunction lasting over a month.8 Until a standardized method is widely accepted to accurately identify dysphonia in patients with post-thyroidectomy vocal complaints, we rely on the patients’ reports of voice quality. The vocal complaints of a large population of postthyroidectomy patients have not been previously reported. We sought to determine the frequency of patient-identified voice disturbance after thyroidectomy by surveying a large group of thyroid cancer survivors and report commonly identified characteristics and consequences of their dysphonia. MATERIALS AND METHODS Members of the Thyroid Cancer Survivors’ Association (ThyCa) were asked to participate in a Web-based survey. ThyCa is an international nonprofit organization and a resource for thyroid cancer survivors, family members, and health care professionals. Participants voluntarily responded to a 36-item electronic questionnaire, which collected information on demographics, thyroid disease, extent of surgery, preoperative and postoperative voice quality, impact on quality of life, treatment, and non-identifying demographics. Patients with preoperative voice disturbance and those reporting postoperative vocal fold paralysis or tracheotomy were excluded. The data were analyzed with Pearson chi-square method, and P < 0.05 was accepted as the significance level.

112

Journal of Voice, Vol. 27, No. 1, 2013

RESULTS A total of 4426 ThyCa members participated in the survey, and with membership exceeding 12 000, this was a response rate of approximately 37%. Seven hundred fifty-nine individuals reported preoperative hoarseness, 358 experienced postoperative vocal fold immobility, and 150 required tracheotomy. Responders with any or multiple of these characteristics totaled 1111 (25.1%) and were excluded, leaving 3315 patients for analysis. A majority of responders (51.1%, n ¼ 1693) endorsed PTVD. Of patients with PTVD, 88.8% were female and 10.5% were male; 77.1% were aged between 30 and 59 years. The most common type of thyroid carcinoma reported by PTVD patients was papillary (85.3%). The remainder had follicular variety (8.1%) or another histology (3.9%) including medullary and poorly differentiated thyroid carcinoma. Total thyroidectomy was performed in 82.6% of patients, and 14.5% had completion thyroidectomy. A minority (2.7%) reported having subtotal thyroidectomy. Surgery for 53.6% of patients reporting PTVD included lymph node dissection. When comparing individuals with and without PTVD, there was no statistically significant difference in gender, age, histology, or extent of surgery (Table 1). Rates of PTVD were compared among patients with thyroid cancer undergoing similar types of surgery. Post-thyroidectomy voice complaints were identified by 52.4% of individuals who

TABLE 1. Characteristics of Patients With and Without Postoperative Voice Complaints Characteristics Gender Female Male Age (y) 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Histology Papillary Follicular Other Surgery Total Completion Subtotal Neck dissection

PTVD (n ¼ 1693) (%)

Normal (n ¼ 1549) (%)

88.8 10.5

84.6 14.4

0.2 0 12.4 25.8 29.7 21.6 6.0 0.8 0.2

0.1 0 14 24.7 30.0 20.3 6.6 0.8 0

85.3 8.1 3.9

84.5 9.2 3.9

86.2 14.5 2.7 53.4

80 16.3 3.6 52.9

Notes: Normal represents no postoperative voice complaints. Abbreviation: PTVD, post-thyroidectomy voice disorder.

PERMANENT 9.0%

NR 5.1%

DAYS 49.5% MONTHS 36.4%

n=1693

FIGURE 1. Portion of individuals with post-thyroidectomy voice disorder who reported a given duration of symptoms. NR, no response. had total thyroidectomy. A similar fraction (52.9%) reported PTVD after subtotal thyroidectomy. Among those who underwent completion thyroidectomy, 48.6% reported postoperative dysphonia. Most PTVDs were temporary, with 85.9% lasting days or months (Figure 1). Patients most commonly characterized their voice impairment as an inability to shout or sing and loss of loudness as seen in Table 2. Nearly a quarter of dysphonic patients reported a detrimental impact on their professional (n ¼ 384) or personal (n ¼ 393) lives. Specifically, among those who reported a negative impact to their personal life, 41.5% experienced depression and 21.4% had relationship problems. In their professional lives, 3.6% reported demotions and 7.7% reported firings. Most individuals (77.6%) who reported negative impact on their personal lives had only temporary voice complaints. Likewise, most patients whose dysphonia adversely affected their professional lives reported temporary vocal disturbance (81.5%), and of 28 participants who reported a job loss or demotion, 78.6% had temporary dysphonia.

TABLE 2. Frequency of Voice Complaints Voice Complaints Inability to shout at sporting event at theater Inability to sing in car in shower in house of worship Loss of loudness Not heard in noisy places Pain with speaking

n (%), n ¼ 1693 964 (55.9) 289 (30.0) 234 (24.3) 916 (54.1) 295 (32.2) 258 (28.2) 269 (27.6) 888 (52.5) 362 (40.8) 494 (29.2)

Reported among patients with post-thyroidectomy voice disorder.

Maggie A. Kuhn, et al

Patient Perspectives on Dysphonia After Thyroidectomy

FIGURE 2. Portion of individuals with post-thyroidectomy voice disorder who received a given intervention. Both, voice therapy + procedure; NR, no response. Only 3.4% (n ¼ 57) of individuals with PTVD received treatment for their voice complaints. Treatment included voice therapy, a surgical procedure, or both (Figure 2). Most individuals receiving treatment (73.7%) experienced at least partial improvement. DISCUSSION Numerous studies have examined the effects of thyroid surgery on voice quality and report the prevalence, etiologies, characteristics, and consequences of post-thyroidectomy dysphonia. To this body of literature, we add the results of a large-scale survey of patients with thyroid cancer regarding their voice perceptions after thyroidectomy. This survey-based study may avoid a challenge of many prospective studies, which are often hampered by poor follow-up of patients who report normal voice or mild impairment. Additionally, analyzing the outcomes of a diverse group of individuals treated by a variety of surgeons in various geographic locations may provide a better sense of the true scope and impact of PTVD. We observed PTVD rate of 51.1% among patients with thyroid cancer, which falls within the published range of 16–89% for patients without evidence of RLN injury.1,10 However, our results suggest that voice complaints may persist longer than has previously been reported. At 3 months after surgery, dysphonia has been reported at rates up to 14.6%.9 Our data show that voice disorders persist at least 1 month after thyroidectomy in 45.4% of individuals with PTVD, which represents 23% of survey responders. This observation may be because of all participants in the present study undergoing thyroidectomy for thyroid cancer. Most had total or completion thyroidectomies and more than 50% had lymph node dissections. It is known that total thyroidectomy does not result in higher rates of RLN injury over lobectomy,14 but reoperative thyroidectomy, surgery for malignant thyroid disease, and neck dissection are associated with an increased incidence of postoperative RLN palsy.15 Although patients in the present analysis did not have vocal fold paralysis or RLN palsy, both contribute to the overall rates of postoperative dysphonia.

113

Commonly reported voice changes among responders were loss of loudness and impaired singing ability. Such complaints may be attributed to EBSLN injury, which is integral for vocal range and pitch. Routine postoperative examinations will not reveal diminished neural input from the EBSLN. This would explain underreporting and relatively high recovery rates over months. Additional plausible etiologies of PTVD in this population include laryngotracheal fixation of strap muscles, scarring of the cricoarytenoid muscle(s), sequelae of intubation, and postoperative decompensation. Surprisingly, fewer than a quarter of patients felt that postthyroidectomy dysphonia adversely affected their personal and professional lives. It is possible that most responders do not rely on their voices professionally and that the changes in voice quality, though bothersome, did not significantly affect their day-to-day activities. The discrepancy between rates of PTVD and its actual impact on patients’ lives ought to reassure patients when counseled about postoperative dysphonia. An assumption might be that dysphonic patients do not experience more consequences in their social and professional lives because most PTVDs are temporary. However, among the hundreds of individuals who identified adverse effects on their personal and professional lives, the majority suffered temporary, rather than permanent, dysphonia. This implies that the potential impact of even transient dysphonia is considerable. A very small number of patients (n ¼ 57) received treatment for their voice complaints after thyroidectomy. In the absence of vocal fold paralysis, surgeons are presumably unlikely to offer intervention for voice disturbances that are predictably temporary. However, of the individuals who received voice therapy, a supplemental procedure, or both, nearly three-fourths experienced at least partial improvement. This may reflect an area of improvement for surgeons in the management of PTVD. Our study has limitation inherent to its survey-based design. Because involvement was voluntary, rates of postthyroidectomy dysphonia may be overestimated, given the propensity for unhappy patients to participate. Contributors came from an international organization and were not subject to standardized preoperative evaluations, surgical interventions, or postoperative examinations. We also could not access participants’ pre- and postoperative evaluations including endoscopic laryngeal examinations and laryngeal electromyography.

CONCLUSION Aside from hypocalcemia, dysphonia is the most common complication of thyroidectomy. We report the results of a large-scale patient survey to underscore the commonness of postoperative hoarseness and its impact on patients’ personal and professional lives. These data highlight the importance of thorough preoperative counseling and provide evidence to support reassuring patients that dysphonia is uncommonly permanent. They also demonstrate the need for standardized methods of pre- and post-thyroidectomy voice evaluation and the importance of supporting organizations such as the ThyCa, which provides a forum for patients to share common experiences and provide potential feedback regarding care.

114 APPENDIX Supplementary material Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.jvoice.2012.07.012. REFERENCES 1. Sinagra DL, Montesinos MR, Tacchi VA, et al. Voice changes after thyroidectomy without recurrent laryngeal nerve injury. J Am Coll Surg. 2004;199: 556–560. 2. Harness JK, Organ CHJ, Thompson NW. Operative experience of US general surgery residents in thyroid and parathyroid disease. Surgery. 1995; 118:1063–1070. 3. Echternach M, Maurer CA, Mencke T, Schilling M, Verse T, Richter B. Laryngeal complications after thyroidectomy: is it always the surgeon? Arch Surg. 2009;144:149–153. 4. Hong KH, Kim YK. Phonatory characteristics of patients undergoing thyroidectomy without laryngeal nerve injury. Otolaryngol Head Neck Surg. 1997;117:399–404. 5. Debruyne F, Ostyn F, Delaere P, et al. Acoustic analysis of the speaking voice after thyroidectomy. J Voice. 1997;11:479–482. 6. Bhattacharyya N, Fried MP. Assessment of the morbidity and complications of total thyroidectomy. Arch Otolaryngol Head Neck Surg. 2002; 128:389–392.

Journal of Voice, Vol. 27, No. 1, 2013 7. Roy AD, Gardiner RH, Niblock WM. Thyroidectomy and the recurrent laryngeal nerves. Lancet. 1956;270:988–990. 8. Van Lierde K, D’Haeseleer E, Wuyts FL, Baudonck N, Bernaert L, Vermeersch H. Impact of thyroidectomy without laryngeal nerve injury on vocal quality characteristics: an objective multiparameter approach. Laryngoscope. 2010;120:338–345. 9. Soylu L, Ozbas S, Uslu HY, Kocak S. The evaluation of the causes of subjective voice disturbances after thyroid surgery. Am J Surg. 2007;194: 317–322. 10. Stojadinovic A, Henry LR, Howard RS, et al. Prospective trial of voice outcomes after thyroidectomy: evaluation of patient-reported and cliniciandetermined voice assessments in identifying postthyroidectomy dysphonia. Surgery. 2008;143:732–742. 11. Lombardi CP, Raffaelli M, D’Alatri L, et al. Voice and swallowing changes after thyroidectomy in patients without inferior laryngeal nerve injuries. Surgery. 2006;140:1026–1032. 12. De Pedro Netto I, Fae A, Vartanian JG, et al. Voice and vocal selfassessment alter thyroidectomy. Head Neck. 2006;28:1106–1114. 13. Stojadinovic A, Shaha AR, Orlikoff RF, et al. Prospective functional voice assessment in patients undergoing thyroid surgery. Ann Surg. 2002;236: 823–832. 14. de Roy van Zuidewijn DB, Songun I, Kievit J, van de Velde CJ. Complications of thyroid surgery. Ann Surg Oncol. 1995;2:56–60. 15. Chan WF, Lang BH, Lo CY. The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 1000 nerves at risk. Surgery. 2006;140:866–872.