- Email: [email protected]
Preoperative laryngoscopy in thyroid surgery: Do patients' subjective voice complaints matter?
Preoperative laryngoscopy in thyroid surgery: Do patients’ subjective voice complaints matter? Cortney Y. Lee, MD, Kristin L. Long, MD, Roberta J. Eldridge, Daniel L. Davenport, PhD, and David A. Sloan, MD, Lexington, KY
Background. Although routine preoperative laryngoscopy has been standard practice for many thyroid surgeons, there is recent literature that supports selective laryngoscopy. We hypothesize that patients’ preoperative voice complaints do not correlate well with abnormalities seen on preoperative laryngoscopy. Methods. A retrospective chart review of a 3-year, single-surgeon experience was performed. Records of patients undergoing thyroid surgery were reviewed for patient voice complaints, prior neck surgery, surgeon-documented voice quality, and results of laryngoscopy. Results. Of 464 patients, 6% had abnormal laryngoscopy findings, including 11 cord paralyses (2%). Preoperatively, 39% of patients had voice complaints, but only 10% had a corresponding abnormality on laryngoscopy. Only 4% of patients had a surgeon-documented voice abnormality with 72% corresponding abnormalities on laryngoscopy, including 8 cord paralyses. When eliminating patient voice complaints and using only history of prior neck surgery and surgeon-documented voice abnormality as criteria for preoperative laryngoscopy, only 1 cord paralysis is missed and sensitivity (91%) and specificity (86%) were high. Also, when compared with routine laryngoscopy, 84% fewer laryngoscopies are performed. Conclusion. When using patients’ voice complaints as criteria for preoperative laryngoscopy, the yield is low. We recommend using surgeon-documented voice abnormalities and history of prior neck surgery as criteria for preoperative laryngoscopy. (Surgery 2014;156:1477-83.) From the University of Kentucky, Lexington, KY
RECURRENT LARYNGEAL NERVE INJURY is a serious complication of thyroid surgery occurring in a small percentage of patients (1.2–10.2% transient, 0.3–5.8% permanent).1-3 Although unilateral injury can be associated with a change in voice, bilateral nerve injury can result in the most dreaded complication: need for temporary or permanent tracheostomy. To minimize this risk, preoperative laryngoscopy with assessment of vocal cord mobility has been advocated to allow for appropriate preoperative patient counseling and surgical planning. For this reason, many groups including ours have performed routine preoperative laryngoscopy in all patients before thyroid surgery.3-5 There is controversy, however, and recent trends in the Accepted for publication August 14, 2014. Reprint requests: Cortney Y. Lee, MD, UK Good Samaritan Surgical Specialties Clinic, 125 E. Maxwell St., Suite 302, Lexington, KY 40508. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.08.038
literature argue for the use of preoperative laryngoscopy only in select subsets of patients.6-8 Selective laryngoscopy guidelines limit laryngoscopy to patients with impaired voice, history of prior neck surgery, suspected locally advanced cancer, or large thyroid glands that would put the nerves at greater risk during surgery.7,8 Prior studies have reported the incidence of subjective patient voice and swallowing complaints to range from 11 to 14%.9,10 In our practice, we have performed laryngoscopy routinely on all patients before thyroid surgery. We have noted that a large portion of our patients present with complaints of voice changes, but few have corresponding abnormalities on laryngoscopy. Therefore, we hypothesized that a patient’s preoperative voice complaints do not correlate well with abnormalities on preoperative laryngoscopy. METHODS Using an institutional review board-approved protocol, a retrospective review of a single-surgeon experience was performed. Over a 3-year period from September 2010 through August 2013, all SURGERY 1477
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patients who underwent thyroid surgery or surgery for recurrent thyroid cancer were evaluated. Patients undergoing concomitant parathyroid surgery were also included. At the time of initial consultation, each patient was asked if he or she had noted any change in voice. If yes, the complaint was recorded as a subjective voice complaint. As part of the physical examination, the surgeon also recorded whether he noted any abnormality in voice quality. If the voice sounded abnormal during routine speech, it was recorded as such by the surgeon. Preoperative data, including patient demographics, history of prior neck surgery, and diagnoses, were recorded. Operative procedure, surgical pathology, and postoperative complications were also noted. All nerves at risk were identified by the operating surgeon and recurrent laryngeal nerve monitoring was used routinely. Postoperative flexible laryngoscopy was performed selectively. Preoperative laryngoscopy was performed either via indirect method using a hand-held mirror or flexible laryngoscopy using 1 of 3 laryngoscopes (Olympus P4, Olympus P2 and Welch Allen RL150). If indirect laryngoscopy was unsuccessful (cords not visualized) and the surgeon felt preoperative cord evaluation was necessary, flexible laryngoscopy was performed and recorded as such in our data. The primary goal of laryngoscopy was evaluation of vocal cord movement (abduction and adduction). Other pathology or abnormalities noted during laryngoscopy were also noted. Findings were recorded as normal or abnormal. Abnormalities were placed into 1 of 3 categories: Decreased vocal cord movement, complete vocal cord paralysis, or other abnormality. Statistical analysis was performed using Fisher’s exact or Chi-square tests for group comparisons of categorical variables and t tests for age comparisons. SPSS statistical software version 22 was used for all calculations (IBM Corp., Armonk, NY). RESULTS During our 3-year study period, 603 patients underwent thyroid surgery and most (95%) underwent preoperative laryngoscopy by the operating surgeon either via indirect method (303 patients) or via flexible laryngoscopy (270 patients). Laryngoscopy was either not performed or not recorded in 30 patients. Laryngoscopy was successful (cords visualized) in 489 patients. Of the 84 unsuccessful laryngoscopies (defined as ‘‘cords not visualized’’), almost all were indirect laryngoscopies (96%). Inability to see the cords was owing most commonly to gag reflex, but anatomy, such as
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Fig 1. Study population. We analyzed data from 464 patients who underwent successful laryngoscopy with complete voice data. Of these patients, 53% underwent indirect mirror laryngoscopy and the remainder underwent flexible laryngoscopy. *Almost all (81/84) of the patients without cord visualization underwent indirect mirror laryngoscopy only.
large epiglottis, occasionally contributed. Only 3 attempts at flexible laryngoscopy were unsuccessful, all owing to inability of the patient to tolerate the procedure. There were no complications from laryngoscopy. Of the 489 patients who underwent successful laryngoscopy, either the patient’s subjective voice complaint or the surgeon’s voice assessment was not recorded (25 patients) leaving 464 patients with complete data for analysis (Fig 1). The mean patient age was 51 years (range, 14– 83) and 82% were female. Sixty-eight patients (14%) had a history of previous neck surgery (56 thyroid, 6 parathyroid, 1 combined thyroid/parathyroid, 3 anterior approach cervical spine, 1 branchial cleft cyst, 1 tracheostomy). Preliminary preoperative diagnosis by the operating surgeon was benign in 48%, suspicious for neoplasm in 29%, and malignant in 20% of patients. Thyroid cancer was present in 40% of surgical specimens. The majority of patients underwent total thyroidectomy (67%); 3% underwent surgery for recurrent thyroid cancer (including modified radical neck dissection and resection of central neck
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recurrences) and 13% underwent combined thyroid/parathyroid surgery. Characteristics of patients with subjective voice complaints. In our patient population, 39% complained of change in voice. By far the most common complaint was hoarseness (61%), followed by ‘‘raspy’’ (8%), ‘‘deeper’’ (8%), and ‘‘weak’’ (5%). Additional complaints included ‘‘lower,’’ ‘‘scratchy,’’ change in pitch, and intermittent loss of voice. Women were more likely than men to complain of recent change in voice (42% vs 23%, respectively; P # .001). Mean age did not vary significantly by voice complaint. Fine needle aspiration results were more likely to be benign in those complaining of voice changes (41% vs 26%; P = .002). Likewise, patients with voice complaints were more likely to have a benign diagnosis on final pathology than those without voice complaints (66% vs 56%; P = .041). Patients presenting with voice complaints were less likely to have associated hyperparathyroidism requiring combined thyroid/parathyroid surgery than those without voice complaints (4% vs 19%; P # .001). Characteristics of patients with surgeondocumented voice abnormalities. Of all patients, only 4% were noted by the surgeon to have an abnormality in voice quality. Hoarseness was most often noted (7 patients) with other descriptions, including rough, raspy, breathy, nasal, and hollow. Patients with an abnormal voice per surgeon were more likely to have had prior neck surgery than those with a normal voice (33% vs 13%; P = .024). There were no differences between surgeon voice assessment and preoperative diagnosis or final surgical pathology. Preoperative laryngoscopy. Twenty-seven patients (6%) had an abnormality on laryngoscopy, including 11 patients with complete cord paralyses (2%), 13 patients with decreased cord movement (3%), and 3 patients with other abnormalities, including 1 laryngocele, 1 with bilateral cord edema, and 2 massive goiters with significant edema and distorted anatomy. Patients with abnormal laryngoscopy were more likely to have had prior neck surgery than those with normal laryngoscopy (33% vs 12%; P = .006). Patients with abnormal laryngoscopy were also more likely to have subjective voice complaints than those with normal laryngoscopy (67% vs 37%; P = .002). Abnormalities in laryngoscopy were noted in 3% of asymptomatic patients and in 3% of patients with a normal surgeon-documented voice. Complete cord paralysis. When we examine the subset of patients with complete cord paralysis (n = 11), 36% were male with an average age of
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60 years (range, 37–83), 6 patients had prior neck surgery, and 7 patients had a diagnosis of papillary thyroid cancer (average tumor size, 3.8 cm). Four nerves were paralyzed owing to direct involvement by cancer, 2 nerves had been resected previously for cancer, 2 nerves were presumably injured during prior neck surgery, 1 nerve was paralyzed owing to benign disease, and no obvious reason was found on the remaining 2 paralyses. Ten patients complained of voice changes, whereas the surgeon noted an abnormal voice in 8 patients. When evaluating the 5 patients with complete cord paralysis who had no prior neck surgery, all complained of change in voice; the surgeon noted a voice abnormality in all but 1 patient (Table). Comparing use of patient voice complaints. When the following 3 criteria are used for preoperative laryngoscopy---history of prior neck surgery, patient voice complaint, and surgeon-documented voice abnormality---48% of our study population (224 patients) would require preoperative laryngoscopy, and 100% of cord paralyses would be detected (sensitivity, 100%; specificity, 53%). In contrast, if patient voice complaints were excluded and only history of prior surgery and surgeondocumented voice abnormalities were used as criteria, only 16% of our study population (75 patients) would require preoperative laryngoscopy, and all but 1 cord paralyses would be detected (sensitivity, 91%; specificity, 86%; Fig 2). DISCUSSION New proposed guidelines use patients’ subjective voice complaints as 1 reason for proceeding with preoperative laryngoscopy in thyroid surgery. Preoperative voice complaints were much greater in our study population than reported elsewhere with 39% of patients reporting a change in voice. Unlike other studies that also included swallowing complaints within their quoted rates of 10–13%, in this study we only evaluated complaints specific to voice.9,10 The yield of routine laryngoscopy in our study population is quite low with abnormalities found in only 6% of patients undergoing laryngoscopy, compared with 18–36% found in other studies.6,11 Our rate of preoperative cord paralysis (2%) is in line with findings in other studies (1–7%).4-6,9-11 Not only is the yield of routine laryngoscopy low, but it is also associated with increased cost.12 In addition, although generally well-tolerated, there is associated patient discomfort.13,14 Many groups are evaluating the efficacy of less invasive means of screening for vocal cord dysfunction before and after thyroid surgery, including
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Table. Characteristics of 11 patients with complete cord paralysis on preoperative laryngoscopy Subjective voice complaints
Surgeon voice assessment
Prior neck surgery
56/F
Yes
Abnormal
Thyroidectomy
61/M
No
Abnormal
Thyroidectomy
83/F
Yes
Abnormal
Thyroidectomy
55/F 51/F
Yes Yes
Abnormal Normal
Thyroidectomy Thyroidectomy
71/M
Yes
Normal
Anterior cervical fusion
68/M
Yes
Abnormal
None
53/F
Yes
Normal
None
37/F
Yes
Abnormal
None
64/F
Yes
Abnormal
None
56/M
Yes
Abnormal
None
Age/ sex
Diagnosis PTC (2 cm recurrence) PTC (6.0 cm recurrence) PTC (1.0 cm recurrence) PTC Nodular adenomatous goiter Nodular adenomatous goiter PTC
Nodular adenomatous goiter Follicular adenoma PTC (3.4 cm primary) PTC (6.2 cm primary)
Operative procedure Central and MRND Tracheal resection Paratracheal dissection Central and MRND Completion thyroidectomy (ipsilateral to paralyzed cord) TT
TT, MRND, laryngectomy, upper sternectomy TT
Thyroid lobectomy (contralateral to paralyzed cord) TT, central, MRND, tracheal resection TT with MRND
Reason for nerve paralysis History of resection for cancer History of resection for cancer Complication of prior surgery Recurrent cancer Nerve incased by benign disease
Complication of prior surgery Cancer
Unknown (no cancer, no large goiter) Unknown (no cancer, no large goiter) Cancer Cancer
MRND, Modified radical neck dissection; PTC, papillary thyroid cancer; TT, total thyroidectomy.
voice questionnaires and ultrasonographic evaluation of cord function.13,15-18 The majority of thyroid surgeons likely either lack time or choose not to use formal voice assessment methods preoperatively. We are strong proponents of surgeon-performed, in-office ultrasonography. We recognize that ultrasonography may prove to be an excellent, noninvasive screening measure to detect cord paralyses in the future, but many thyroid surgeons do not have access to ultrasonography in the office. Therefore, our results should be applicable to the practice of most thyroid surgeons. If the new recommended guidelines for determining need for selective laryngoscopy are applied to our patient population (including patients with voice complaints, voice abnormalities noted by the surgeon, and history of prior neck surgery), almost one half of our patient population (48%) meet the criteria for preoperative laryngoscopy. When evaluating this subset of patients, the yield of preoperative laryngoscopy was quite low, with abnormalities noted in only 9% of patients with a 5% rate of complete cord paralyses (all 11 cord
paralyses captured). In contrast, if patients’ subjective complaints are excluded and only history of prior surgery and surgeon-noted voice abnormalities are used as criteria, only 16% of our population would need preoperative laryngoscopy and the yield is much greater revealing abnormalities in laryngoscopy twice as often (22%) with a 14% rate of complete cord paralyses (10 of 11 cord paralyses captured). Surgeon voice assessment is extremely specific, and when combined with a history of prior neck surgery, the surgeon’s assessment captured all but 1 cord palsy in our study. The 1 patient with complete cord paralysis preoperatively that was ‘‘missed’’ by this group was noted to have normal intraoperative nerve monitoring and normal function of the cord postoperatively. This finding may explain why the voice sounded normal to the surgeon preoperatively. One of the stated benefits of detecting cord paralyses preoperatively is the ability to counsel effectively patients on the small risk of bilateral nerve injury preoperatively. In our population, the findings on laryngoscopy only
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Fig 2. Comparison of criteria for preoperative laryngoscopy in detecting vocal cord paralyses before thyroid surgery. Elimination of patient voice complaints from criteria maintains sensitivity and significantly improves specificity, and drastically decreasing the number of patients requiring preoperative laryngoscopy. (A) Including patient voice complaints (48% of patients require laryngoscopy). (B) Excluding patient voice complaints (16% of patients require laryngoscopy).
changed the operative plan in 1 patient (a laryngocele was addressed at the time of thyroidectomy). Only 1 of the 11 cord paralyses was noted to be contralateral to the nerve at risk, but the surgical plan was not altered. Our data show a significant correlation between preoperative voice complaints and benign thyroid disease, which we suspect may be owing to selection bias. All patients in our study underwent operation. By definition, resection of benign thyroid disease is indicated if symptomatic, which includes changes in voice, pressure, dysphagia, and tracheal irritation. If both surgical and nonsurgical patients presenting with benign disease were evaluated, this difference may disappear. Although other authors have reported a high rate of laryngeal abnormalities (18–36%) found on preoperative laryngoscopy, we did not find a significant number of abnormalities in our study population.6,11 Only 6% of preoperative laryngoscopic evaluations were abnormal, including 11 cord paralyses (2%). Subtle changes such as mild edema or erythema seen frequently with reflux
disease were not documented as abnormalities, which could explain our lesser rate. Although our overall rate of abnormalities was less, our prevalence of cord paralyses was similar to many other reported studies.4-6,9-11 Although other abnormalities found on laryngoscopy may need attention, one could argue that cord paralyses are the only abnormality that directly relates to the feared risk of bilateral nerve injury in thyroid surgery. Along with most thyroid surgeons, we advocate for intraoperative visualization of every nerve at risk. In this study, 1,001 nerves were at risk, and all were identified visually at the time of operation with no permanent nerve palsies other than encased nerves requiring resection for oncologic purposes. Based on recent publications and the results of our study, we have changed our practice from routine use of preoperative laryngoscopy in all patients undergoing thyroid surgery to selective use in those with history of prior neck surgery and voice abnormalities noted by the surgeon. Using these 2 criteria, we would have missed only 1 patient with preoperative cord paralysis (0.2%) and would have performed 84% fewer laryngoscopies while maintaining an acceptable sensitivity (91%) and specificity (86%). Although we do not seek to minimize the utility of a thorough history or dismiss patients’ concerns about changes in voice, we maintain that patient voice complaint is not a useful indicator of risk of cord palsy before thyroid surgery. Owing to low yield, increased cost, and associated patient discomfort with routine laryngoscopy before thyroid surgery, we support selective use in patients with a history of prior neck surgery or surgeon-documented voice abnormality while minimizing the utility of patient’s subjective voice complaints.
REFERENCES 1. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract 2009;63:624-9. 2. Sheahan P, O’Connor A, Murphy MS. Risk factors for recurrent laryngeal nerve neuropraxia postthyroidectomy. Otolaryngol Head Neck Surg 2012;146:900-5. 3. Hayward NJ, Grodski S, Yeung M, Johnson WR, Serpell J. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg 2013;83:15-21. 4. Farrag TY, Samlan RA, Lin FR, Tufano RP. The utility of evaluating true vocal fold motion before thyroid surgery. Laryngoscope 2006;116:235-8. 5. Randolph GW, Kaman D. The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery 2006;139:357-62. 6. Nam IC, Bae JS, Shim MR, Hwang YS, Kim MS, Sun DI. The importance of preoperative laryngeal examination before
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thyroidectomy and the usefulness of a voice questionnaire in screening. World J Surg 2012;36:303-9. Chandrasekhar SS, Randolph GW, Sideman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg 2013;148(6 Suppl):S1-37. Hodin R, Clark O, Doherty G, Grant C, Heller K, Weigel R. Voice issues and laryngoscopy in thyroid surgery patients. Surgery 2013;154:46-7. Lang BH, Chu KK, Tsang RK, Wong KP, Wong BY. Evaluating the incidence, clinical significance and predictors for vocal cord palsy and incidental laryngopharyngeal conditions before elective thyroidectomy: is there a case for routine laryngoscopic examination? World J Surg 2014;38: 385-91. Schlosser K, Zeuner M, Wagner M, Slater P, Fernandez ED, Rothmund M. Laryngoscopy in thyroid surgery: essential standard or unnecessary routine? Surgery 2007;142:858-64. Echternach M, Maurer CA, Mencke T, Schilling M, Verse T, Richter B. Laryngeal complications after thyroidectomy: Is it always the surgeon? Arch Surg 2009;144:149-50. Park JO, Bae JS, Chae BJ, Kim CS, Nam IC, Chun BJ, et al. How can we screen voice problems effectively in patients undergoing thyroid surgery? Thyroid 2013;23:1437-44. Young VN, Smith LJ, Rosen CA. Comparison of tolerance and cost-effectiveness of two nasal anesthesia techniques for transnasal flexible laryngoscopy. Otolaryngol Head Neck Surg 2014;150:582-6. Sharma A, Price T, Mierzwa K, Montgomery P, Qayyum A, Bradnam T. Transnasal flexible laryngo-oesophagoscopy: an evaluation of the patient’s experience. J Laryngol Otol 2006;120:24-31. Stojadinovic A, Henry LR, Howard RS, Gurevich-Uvena J, Makashay MJ, Coppit GL, et al. Prospective trial of voice outcomes after thyroidectomy: evaluation of patientreported and clinician-determined voice assessments in identifying postthyroidectomy dysphonia. Surgery 2008; 143:732-42. Solomon NP, Helou LB, Henry LR, Howard RS, Coppit G, Shaha AR, et al. Utility of the voice handicap index as an indicator of postthyroidectomy. J Voice 2013;27:348-54. Wong KP, Lang BH, Ng SH, Cheung CY, Chan CT, Lo CY. A prospective, assessor-blind evaluation of surgeonperformed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy. Surgery 2013;154:1158-64. Cheng SP, Lee JJ, Liu TP, Lee KS, Liu CL. Preoperative ultrasonography assessment of vocal cord movement during thyroid and parathyroid surgery. World J Surg 2012; 36:2509-15.
DISCUSSION Dr Jacob Moalem (Rochester, NY): I am curious if you looked at the indication for thyroidectomy and if, in the setting of a known thyroid cancer, a patient complaint of hoarseness might be taken differently than in the setting of a benign nodular disease. Dr Kristin L. Long (Lexington, KY): We did look at that patient population within our study. However, we did not extrapolate the 2 together. The majority of the patients who actually complained, that had subjective voice complaints, had benign
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disease on their final pathology. But it would be interesting to go back and make that comparison. Dr Ashok Shaha (New York, NY): In your graph, you did laryngoscopy on some 500 patients. In 84, you could not see the vocal cords or you could not tell. That is a little surprising. If you put the scope down, you should be able to see it in 100% of the patients. So I am just curious why you could not see that. I just want to go back to yesterday’s discussion again. I am done with my question, but more of a comment. I think it is important to realize that it is a good and standard practice to know the status of the vocal cords before thyroid surgery. That is my personal comment. You may not agree with me. The Society may not agree with me. I think it is a good practice because we need to know what the status of the vocal cords is today. At the time of surgery, you may find some surprises. We have seen time again and again a normal voice with a normal vocal cord function, both preoperatively and postoperatively. If we are going to analyze our own data, our own complications, we need to know what was before and what was after. Keep in mind---I am going to repeat it---mirror examination is a simple test. The entire paraphernalia costs $200 to the institution and absolutely nothing to the surgeon and patient. Keep that in mind. Dr Kristin L. Long: Over one half of the laryngoscopies in our study were indirect (mirror) laryngoscopies. Regarding the 84 patients that we were not able to visualize the cords, almost all were indirect laryngoscopies with the inherent difficulties owing to gag reflex or patient’s inability to tolerate the procedure. Dr Gregory Randolph (Boston, MA): This brings added attention to the group of patients who may benefit most from laryngoscopy. I would certainly agree with you that voice complaints are prevalent in the normal population. But your assessment of voice was really just looking at the chart and sorting out did they complain of a voice abnormality or not? Were those data present? There are more sensitive measures, like the Voice Handicap Index and Cap V, and other instruments that track more robustly subjective assessments with vocal cord pathology. I would be hesitant to just throw out subjective complaints of the patient off the table in making these decisions, and a more sensitive analysis of symptoms might help you to really get to the more important symptoms that track with legitimate vocal cord pathology. Dr Kristin L. Long: I think the important thing for us, and what we were attempting to focus on, is what I think the majority of the operating surgeons
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in this room would do, simply ask the patient if you have had a change in voice. Dr Gregory Randolph: Right. And you may have suggested that that assessment is not sufficient. But better to make it more sensitive than to not ask the patient symptoms. Dr Bradford Carter (Baltimore, MD): Sometimes, trying to do a little bit more assessment about what the symptoms may be can help. For example, if they have a history of reflux or sinus problems, et cetera, and the duration of their symptoms and whether they are progressive can help to narrow subjectively the patients that you may refer or scope. I think that might be something that would be worth part of the evaluation, instead of just are there symptoms, but is there some etiology that would be more of a benign process? Also, a lot of people complain of hoarseness but may not have true dysphonia or evidence of dysphonia, which is not that hard to try to assess right there at the time that you are discussing the symptoms. I was wondering if those could be included in your evaluation before you throw out the laryngoscopy for symptoms.
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Dr Kristin L. Long: We certainly do ask our patients other questions in relation to their symptomatology not strictly just related to their voice. I think our approach to this was simply using only the patient’s subjective voice complaints as a criterion was not going to be enough. Generally, the patients who had subjective complaints also had surgeon-documented voice complaints if they were going to have an abnormality that we would find on laryngoscopy. Dr Richard A. Prinz (Evanston, IL): You just limited the prior operations to thyroid and parathyroid, and I think that can be a little misleading because anywhere the recurrent nerve and vagus nerve are at, and there is an operation, it is at risk. So if there is a prior operation, carotid, chest, or so forth, I think we should still be getting the laryngoscopy. Dr Kristin L. Long: We agree. Actually, all neck surgeries were considered in this. Our sixth patient who was listed in that chart had undergone an anterior cervical fusion. We did include everyone, including thyroid and parathyroid, but other neck surgeries as well.
Background. Although routine preoperative laryngoscopy has been standard practice for many thyroid surgeons, there is recent literature that supports selective laryngoscopy. We hypothesize that patients’ preoperative voice complaints do not correlate well with abnormalities seen on preoperative laryngoscopy. Methods. A retrospective chart review of a 3-year, single-surgeon experience was performed. Records of patients undergoing thyroid surgery were reviewed for patient voice complaints, prior neck surgery, surgeon-documented voice quality, and results of laryngoscopy. Results. Of 464 patients, 6% had abnormal laryngoscopy findings, including 11 cord paralyses (2%). Preoperatively, 39% of patients had voice complaints, but only 10% had a corresponding abnormality on laryngoscopy. Only 4% of patients had a surgeon-documented voice abnormality with 72% corresponding abnormalities on laryngoscopy, including 8 cord paralyses. When eliminating patient voice complaints and using only history of prior neck surgery and surgeon-documented voice abnormality as criteria for preoperative laryngoscopy, only 1 cord paralysis is missed and sensitivity (91%) and specificity (86%) were high. Also, when compared with routine laryngoscopy, 84% fewer laryngoscopies are performed. Conclusion. When using patients’ voice complaints as criteria for preoperative laryngoscopy, the yield is low. We recommend using surgeon-documented voice abnormalities and history of prior neck surgery as criteria for preoperative laryngoscopy. (Surgery 2014;156:1477-83.) From the University of Kentucky, Lexington, KY
RECURRENT LARYNGEAL NERVE INJURY is a serious complication of thyroid surgery occurring in a small percentage of patients (1.2–10.2% transient, 0.3–5.8% permanent).1-3 Although unilateral injury can be associated with a change in voice, bilateral nerve injury can result in the most dreaded complication: need for temporary or permanent tracheostomy. To minimize this risk, preoperative laryngoscopy with assessment of vocal cord mobility has been advocated to allow for appropriate preoperative patient counseling and surgical planning. For this reason, many groups including ours have performed routine preoperative laryngoscopy in all patients before thyroid surgery.3-5 There is controversy, however, and recent trends in the Accepted for publication August 14, 2014. Reprint requests: Cortney Y. Lee, MD, UK Good Samaritan Surgical Specialties Clinic, 125 E. Maxwell St., Suite 302, Lexington, KY 40508. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.08.038
literature argue for the use of preoperative laryngoscopy only in select subsets of patients.6-8 Selective laryngoscopy guidelines limit laryngoscopy to patients with impaired voice, history of prior neck surgery, suspected locally advanced cancer, or large thyroid glands that would put the nerves at greater risk during surgery.7,8 Prior studies have reported the incidence of subjective patient voice and swallowing complaints to range from 11 to 14%.9,10 In our practice, we have performed laryngoscopy routinely on all patients before thyroid surgery. We have noted that a large portion of our patients present with complaints of voice changes, but few have corresponding abnormalities on laryngoscopy. Therefore, we hypothesized that a patient’s preoperative voice complaints do not correlate well with abnormalities on preoperative laryngoscopy. METHODS Using an institutional review board-approved protocol, a retrospective review of a single-surgeon experience was performed. Over a 3-year period from September 2010 through August 2013, all SURGERY 1477
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patients who underwent thyroid surgery or surgery for recurrent thyroid cancer were evaluated. Patients undergoing concomitant parathyroid surgery were also included. At the time of initial consultation, each patient was asked if he or she had noted any change in voice. If yes, the complaint was recorded as a subjective voice complaint. As part of the physical examination, the surgeon also recorded whether he noted any abnormality in voice quality. If the voice sounded abnormal during routine speech, it was recorded as such by the surgeon. Preoperative data, including patient demographics, history of prior neck surgery, and diagnoses, were recorded. Operative procedure, surgical pathology, and postoperative complications were also noted. All nerves at risk were identified by the operating surgeon and recurrent laryngeal nerve monitoring was used routinely. Postoperative flexible laryngoscopy was performed selectively. Preoperative laryngoscopy was performed either via indirect method using a hand-held mirror or flexible laryngoscopy using 1 of 3 laryngoscopes (Olympus P4, Olympus P2 and Welch Allen RL150). If indirect laryngoscopy was unsuccessful (cords not visualized) and the surgeon felt preoperative cord evaluation was necessary, flexible laryngoscopy was performed and recorded as such in our data. The primary goal of laryngoscopy was evaluation of vocal cord movement (abduction and adduction). Other pathology or abnormalities noted during laryngoscopy were also noted. Findings were recorded as normal or abnormal. Abnormalities were placed into 1 of 3 categories: Decreased vocal cord movement, complete vocal cord paralysis, or other abnormality. Statistical analysis was performed using Fisher’s exact or Chi-square tests for group comparisons of categorical variables and t tests for age comparisons. SPSS statistical software version 22 was used for all calculations (IBM Corp., Armonk, NY). RESULTS During our 3-year study period, 603 patients underwent thyroid surgery and most (95%) underwent preoperative laryngoscopy by the operating surgeon either via indirect method (303 patients) or via flexible laryngoscopy (270 patients). Laryngoscopy was either not performed or not recorded in 30 patients. Laryngoscopy was successful (cords visualized) in 489 patients. Of the 84 unsuccessful laryngoscopies (defined as ‘‘cords not visualized’’), almost all were indirect laryngoscopies (96%). Inability to see the cords was owing most commonly to gag reflex, but anatomy, such as
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Fig 1. Study population. We analyzed data from 464 patients who underwent successful laryngoscopy with complete voice data. Of these patients, 53% underwent indirect mirror laryngoscopy and the remainder underwent flexible laryngoscopy. *Almost all (81/84) of the patients without cord visualization underwent indirect mirror laryngoscopy only.
large epiglottis, occasionally contributed. Only 3 attempts at flexible laryngoscopy were unsuccessful, all owing to inability of the patient to tolerate the procedure. There were no complications from laryngoscopy. Of the 489 patients who underwent successful laryngoscopy, either the patient’s subjective voice complaint or the surgeon’s voice assessment was not recorded (25 patients) leaving 464 patients with complete data for analysis (Fig 1). The mean patient age was 51 years (range, 14– 83) and 82% were female. Sixty-eight patients (14%) had a history of previous neck surgery (56 thyroid, 6 parathyroid, 1 combined thyroid/parathyroid, 3 anterior approach cervical spine, 1 branchial cleft cyst, 1 tracheostomy). Preliminary preoperative diagnosis by the operating surgeon was benign in 48%, suspicious for neoplasm in 29%, and malignant in 20% of patients. Thyroid cancer was present in 40% of surgical specimens. The majority of patients underwent total thyroidectomy (67%); 3% underwent surgery for recurrent thyroid cancer (including modified radical neck dissection and resection of central neck
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recurrences) and 13% underwent combined thyroid/parathyroid surgery. Characteristics of patients with subjective voice complaints. In our patient population, 39% complained of change in voice. By far the most common complaint was hoarseness (61%), followed by ‘‘raspy’’ (8%), ‘‘deeper’’ (8%), and ‘‘weak’’ (5%). Additional complaints included ‘‘lower,’’ ‘‘scratchy,’’ change in pitch, and intermittent loss of voice. Women were more likely than men to complain of recent change in voice (42% vs 23%, respectively; P # .001). Mean age did not vary significantly by voice complaint. Fine needle aspiration results were more likely to be benign in those complaining of voice changes (41% vs 26%; P = .002). Likewise, patients with voice complaints were more likely to have a benign diagnosis on final pathology than those without voice complaints (66% vs 56%; P = .041). Patients presenting with voice complaints were less likely to have associated hyperparathyroidism requiring combined thyroid/parathyroid surgery than those without voice complaints (4% vs 19%; P # .001). Characteristics of patients with surgeondocumented voice abnormalities. Of all patients, only 4% were noted by the surgeon to have an abnormality in voice quality. Hoarseness was most often noted (7 patients) with other descriptions, including rough, raspy, breathy, nasal, and hollow. Patients with an abnormal voice per surgeon were more likely to have had prior neck surgery than those with a normal voice (33% vs 13%; P = .024). There were no differences between surgeon voice assessment and preoperative diagnosis or final surgical pathology. Preoperative laryngoscopy. Twenty-seven patients (6%) had an abnormality on laryngoscopy, including 11 patients with complete cord paralyses (2%), 13 patients with decreased cord movement (3%), and 3 patients with other abnormalities, including 1 laryngocele, 1 with bilateral cord edema, and 2 massive goiters with significant edema and distorted anatomy. Patients with abnormal laryngoscopy were more likely to have had prior neck surgery than those with normal laryngoscopy (33% vs 12%; P = .006). Patients with abnormal laryngoscopy were also more likely to have subjective voice complaints than those with normal laryngoscopy (67% vs 37%; P = .002). Abnormalities in laryngoscopy were noted in 3% of asymptomatic patients and in 3% of patients with a normal surgeon-documented voice. Complete cord paralysis. When we examine the subset of patients with complete cord paralysis (n = 11), 36% were male with an average age of
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60 years (range, 37–83), 6 patients had prior neck surgery, and 7 patients had a diagnosis of papillary thyroid cancer (average tumor size, 3.8 cm). Four nerves were paralyzed owing to direct involvement by cancer, 2 nerves had been resected previously for cancer, 2 nerves were presumably injured during prior neck surgery, 1 nerve was paralyzed owing to benign disease, and no obvious reason was found on the remaining 2 paralyses. Ten patients complained of voice changes, whereas the surgeon noted an abnormal voice in 8 patients. When evaluating the 5 patients with complete cord paralysis who had no prior neck surgery, all complained of change in voice; the surgeon noted a voice abnormality in all but 1 patient (Table). Comparing use of patient voice complaints. When the following 3 criteria are used for preoperative laryngoscopy---history of prior neck surgery, patient voice complaint, and surgeon-documented voice abnormality---48% of our study population (224 patients) would require preoperative laryngoscopy, and 100% of cord paralyses would be detected (sensitivity, 100%; specificity, 53%). In contrast, if patient voice complaints were excluded and only history of prior surgery and surgeondocumented voice abnormalities were used as criteria, only 16% of our study population (75 patients) would require preoperative laryngoscopy, and all but 1 cord paralyses would be detected (sensitivity, 91%; specificity, 86%; Fig 2). DISCUSSION New proposed guidelines use patients’ subjective voice complaints as 1 reason for proceeding with preoperative laryngoscopy in thyroid surgery. Preoperative voice complaints were much greater in our study population than reported elsewhere with 39% of patients reporting a change in voice. Unlike other studies that also included swallowing complaints within their quoted rates of 10–13%, in this study we only evaluated complaints specific to voice.9,10 The yield of routine laryngoscopy in our study population is quite low with abnormalities found in only 6% of patients undergoing laryngoscopy, compared with 18–36% found in other studies.6,11 Our rate of preoperative cord paralysis (2%) is in line with findings in other studies (1–7%).4-6,9-11 Not only is the yield of routine laryngoscopy low, but it is also associated with increased cost.12 In addition, although generally well-tolerated, there is associated patient discomfort.13,14 Many groups are evaluating the efficacy of less invasive means of screening for vocal cord dysfunction before and after thyroid surgery, including
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Table. Characteristics of 11 patients with complete cord paralysis on preoperative laryngoscopy Subjective voice complaints
Surgeon voice assessment
Prior neck surgery
56/F
Yes
Abnormal
Thyroidectomy
61/M
No
Abnormal
Thyroidectomy
83/F
Yes
Abnormal
Thyroidectomy
55/F 51/F
Yes Yes
Abnormal Normal
Thyroidectomy Thyroidectomy
71/M
Yes
Normal
Anterior cervical fusion
68/M
Yes
Abnormal
None
53/F
Yes
Normal
None
37/F
Yes
Abnormal
None
64/F
Yes
Abnormal
None
56/M
Yes
Abnormal
None
Age/ sex
Diagnosis PTC (2 cm recurrence) PTC (6.0 cm recurrence) PTC (1.0 cm recurrence) PTC Nodular adenomatous goiter Nodular adenomatous goiter PTC
Nodular adenomatous goiter Follicular adenoma PTC (3.4 cm primary) PTC (6.2 cm primary)
Operative procedure Central and MRND Tracheal resection Paratracheal dissection Central and MRND Completion thyroidectomy (ipsilateral to paralyzed cord) TT
TT, MRND, laryngectomy, upper sternectomy TT
Thyroid lobectomy (contralateral to paralyzed cord) TT, central, MRND, tracheal resection TT with MRND
Reason for nerve paralysis History of resection for cancer History of resection for cancer Complication of prior surgery Recurrent cancer Nerve incased by benign disease
Complication of prior surgery Cancer
Unknown (no cancer, no large goiter) Unknown (no cancer, no large goiter) Cancer Cancer
MRND, Modified radical neck dissection; PTC, papillary thyroid cancer; TT, total thyroidectomy.
voice questionnaires and ultrasonographic evaluation of cord function.13,15-18 The majority of thyroid surgeons likely either lack time or choose not to use formal voice assessment methods preoperatively. We are strong proponents of surgeon-performed, in-office ultrasonography. We recognize that ultrasonography may prove to be an excellent, noninvasive screening measure to detect cord paralyses in the future, but many thyroid surgeons do not have access to ultrasonography in the office. Therefore, our results should be applicable to the practice of most thyroid surgeons. If the new recommended guidelines for determining need for selective laryngoscopy are applied to our patient population (including patients with voice complaints, voice abnormalities noted by the surgeon, and history of prior neck surgery), almost one half of our patient population (48%) meet the criteria for preoperative laryngoscopy. When evaluating this subset of patients, the yield of preoperative laryngoscopy was quite low, with abnormalities noted in only 9% of patients with a 5% rate of complete cord paralyses (all 11 cord
paralyses captured). In contrast, if patients’ subjective complaints are excluded and only history of prior surgery and surgeon-noted voice abnormalities are used as criteria, only 16% of our population would need preoperative laryngoscopy and the yield is much greater revealing abnormalities in laryngoscopy twice as often (22%) with a 14% rate of complete cord paralyses (10 of 11 cord paralyses captured). Surgeon voice assessment is extremely specific, and when combined with a history of prior neck surgery, the surgeon’s assessment captured all but 1 cord palsy in our study. The 1 patient with complete cord paralysis preoperatively that was ‘‘missed’’ by this group was noted to have normal intraoperative nerve monitoring and normal function of the cord postoperatively. This finding may explain why the voice sounded normal to the surgeon preoperatively. One of the stated benefits of detecting cord paralyses preoperatively is the ability to counsel effectively patients on the small risk of bilateral nerve injury preoperatively. In our population, the findings on laryngoscopy only
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Fig 2. Comparison of criteria for preoperative laryngoscopy in detecting vocal cord paralyses before thyroid surgery. Elimination of patient voice complaints from criteria maintains sensitivity and significantly improves specificity, and drastically decreasing the number of patients requiring preoperative laryngoscopy. (A) Including patient voice complaints (48% of patients require laryngoscopy). (B) Excluding patient voice complaints (16% of patients require laryngoscopy).
changed the operative plan in 1 patient (a laryngocele was addressed at the time of thyroidectomy). Only 1 of the 11 cord paralyses was noted to be contralateral to the nerve at risk, but the surgical plan was not altered. Our data show a significant correlation between preoperative voice complaints and benign thyroid disease, which we suspect may be owing to selection bias. All patients in our study underwent operation. By definition, resection of benign thyroid disease is indicated if symptomatic, which includes changes in voice, pressure, dysphagia, and tracheal irritation. If both surgical and nonsurgical patients presenting with benign disease were evaluated, this difference may disappear. Although other authors have reported a high rate of laryngeal abnormalities (18–36%) found on preoperative laryngoscopy, we did not find a significant number of abnormalities in our study population.6,11 Only 6% of preoperative laryngoscopic evaluations were abnormal, including 11 cord paralyses (2%). Subtle changes such as mild edema or erythema seen frequently with reflux
disease were not documented as abnormalities, which could explain our lesser rate. Although our overall rate of abnormalities was less, our prevalence of cord paralyses was similar to many other reported studies.4-6,9-11 Although other abnormalities found on laryngoscopy may need attention, one could argue that cord paralyses are the only abnormality that directly relates to the feared risk of bilateral nerve injury in thyroid surgery. Along with most thyroid surgeons, we advocate for intraoperative visualization of every nerve at risk. In this study, 1,001 nerves were at risk, and all were identified visually at the time of operation with no permanent nerve palsies other than encased nerves requiring resection for oncologic purposes. Based on recent publications and the results of our study, we have changed our practice from routine use of preoperative laryngoscopy in all patients undergoing thyroid surgery to selective use in those with history of prior neck surgery and voice abnormalities noted by the surgeon. Using these 2 criteria, we would have missed only 1 patient with preoperative cord paralysis (0.2%) and would have performed 84% fewer laryngoscopies while maintaining an acceptable sensitivity (91%) and specificity (86%). Although we do not seek to minimize the utility of a thorough history or dismiss patients’ concerns about changes in voice, we maintain that patient voice complaint is not a useful indicator of risk of cord palsy before thyroid surgery. Owing to low yield, increased cost, and associated patient discomfort with routine laryngoscopy before thyroid surgery, we support selective use in patients with a history of prior neck surgery or surgeon-documented voice abnormality while minimizing the utility of patient’s subjective voice complaints.
REFERENCES 1. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract 2009;63:624-9. 2. Sheahan P, O’Connor A, Murphy MS. Risk factors for recurrent laryngeal nerve neuropraxia postthyroidectomy. Otolaryngol Head Neck Surg 2012;146:900-5. 3. Hayward NJ, Grodski S, Yeung M, Johnson WR, Serpell J. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg 2013;83:15-21. 4. Farrag TY, Samlan RA, Lin FR, Tufano RP. The utility of evaluating true vocal fold motion before thyroid surgery. Laryngoscope 2006;116:235-8. 5. Randolph GW, Kaman D. The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery 2006;139:357-62. 6. Nam IC, Bae JS, Shim MR, Hwang YS, Kim MS, Sun DI. The importance of preoperative laryngeal examination before
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thyroidectomy and the usefulness of a voice questionnaire in screening. World J Surg 2012;36:303-9. Chandrasekhar SS, Randolph GW, Sideman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg 2013;148(6 Suppl):S1-37. Hodin R, Clark O, Doherty G, Grant C, Heller K, Weigel R. Voice issues and laryngoscopy in thyroid surgery patients. Surgery 2013;154:46-7. Lang BH, Chu KK, Tsang RK, Wong KP, Wong BY. Evaluating the incidence, clinical significance and predictors for vocal cord palsy and incidental laryngopharyngeal conditions before elective thyroidectomy: is there a case for routine laryngoscopic examination? World J Surg 2014;38: 385-91. Schlosser K, Zeuner M, Wagner M, Slater P, Fernandez ED, Rothmund M. Laryngoscopy in thyroid surgery: essential standard or unnecessary routine? Surgery 2007;142:858-64. Echternach M, Maurer CA, Mencke T, Schilling M, Verse T, Richter B. Laryngeal complications after thyroidectomy: Is it always the surgeon? Arch Surg 2009;144:149-50. Park JO, Bae JS, Chae BJ, Kim CS, Nam IC, Chun BJ, et al. How can we screen voice problems effectively in patients undergoing thyroid surgery? Thyroid 2013;23:1437-44. Young VN, Smith LJ, Rosen CA. Comparison of tolerance and cost-effectiveness of two nasal anesthesia techniques for transnasal flexible laryngoscopy. Otolaryngol Head Neck Surg 2014;150:582-6. Sharma A, Price T, Mierzwa K, Montgomery P, Qayyum A, Bradnam T. Transnasal flexible laryngo-oesophagoscopy: an evaluation of the patient’s experience. J Laryngol Otol 2006;120:24-31. Stojadinovic A, Henry LR, Howard RS, Gurevich-Uvena J, Makashay MJ, Coppit GL, et al. Prospective trial of voice outcomes after thyroidectomy: evaluation of patientreported and clinician-determined voice assessments in identifying postthyroidectomy dysphonia. Surgery 2008; 143:732-42. Solomon NP, Helou LB, Henry LR, Howard RS, Coppit G, Shaha AR, et al. Utility of the voice handicap index as an indicator of postthyroidectomy. J Voice 2013;27:348-54. Wong KP, Lang BH, Ng SH, Cheung CY, Chan CT, Lo CY. A prospective, assessor-blind evaluation of surgeonperformed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy. Surgery 2013;154:1158-64. Cheng SP, Lee JJ, Liu TP, Lee KS, Liu CL. Preoperative ultrasonography assessment of vocal cord movement during thyroid and parathyroid surgery. World J Surg 2012; 36:2509-15.
DISCUSSION Dr Jacob Moalem (Rochester, NY): I am curious if you looked at the indication for thyroidectomy and if, in the setting of a known thyroid cancer, a patient complaint of hoarseness might be taken differently than in the setting of a benign nodular disease. Dr Kristin L. Long (Lexington, KY): We did look at that patient population within our study. However, we did not extrapolate the 2 together. The majority of the patients who actually complained, that had subjective voice complaints, had benign
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disease on their final pathology. But it would be interesting to go back and make that comparison. Dr Ashok Shaha (New York, NY): In your graph, you did laryngoscopy on some 500 patients. In 84, you could not see the vocal cords or you could not tell. That is a little surprising. If you put the scope down, you should be able to see it in 100% of the patients. So I am just curious why you could not see that. I just want to go back to yesterday’s discussion again. I am done with my question, but more of a comment. I think it is important to realize that it is a good and standard practice to know the status of the vocal cords before thyroid surgery. That is my personal comment. You may not agree with me. The Society may not agree with me. I think it is a good practice because we need to know what the status of the vocal cords is today. At the time of surgery, you may find some surprises. We have seen time again and again a normal voice with a normal vocal cord function, both preoperatively and postoperatively. If we are going to analyze our own data, our own complications, we need to know what was before and what was after. Keep in mind---I am going to repeat it---mirror examination is a simple test. The entire paraphernalia costs $200 to the institution and absolutely nothing to the surgeon and patient. Keep that in mind. Dr Kristin L. Long: Over one half of the laryngoscopies in our study were indirect (mirror) laryngoscopies. Regarding the 84 patients that we were not able to visualize the cords, almost all were indirect laryngoscopies with the inherent difficulties owing to gag reflex or patient’s inability to tolerate the procedure. Dr Gregory Randolph (Boston, MA): This brings added attention to the group of patients who may benefit most from laryngoscopy. I would certainly agree with you that voice complaints are prevalent in the normal population. But your assessment of voice was really just looking at the chart and sorting out did they complain of a voice abnormality or not? Were those data present? There are more sensitive measures, like the Voice Handicap Index and Cap V, and other instruments that track more robustly subjective assessments with vocal cord pathology. I would be hesitant to just throw out subjective complaints of the patient off the table in making these decisions, and a more sensitive analysis of symptoms might help you to really get to the more important symptoms that track with legitimate vocal cord pathology. Dr Kristin L. Long: I think the important thing for us, and what we were attempting to focus on, is what I think the majority of the operating surgeons
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in this room would do, simply ask the patient if you have had a change in voice. Dr Gregory Randolph: Right. And you may have suggested that that assessment is not sufficient. But better to make it more sensitive than to not ask the patient symptoms. Dr Bradford Carter (Baltimore, MD): Sometimes, trying to do a little bit more assessment about what the symptoms may be can help. For example, if they have a history of reflux or sinus problems, et cetera, and the duration of their symptoms and whether they are progressive can help to narrow subjectively the patients that you may refer or scope. I think that might be something that would be worth part of the evaluation, instead of just are there symptoms, but is there some etiology that would be more of a benign process? Also, a lot of people complain of hoarseness but may not have true dysphonia or evidence of dysphonia, which is not that hard to try to assess right there at the time that you are discussing the symptoms. I was wondering if those could be included in your evaluation before you throw out the laryngoscopy for symptoms.
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Dr Kristin L. Long: We certainly do ask our patients other questions in relation to their symptomatology not strictly just related to their voice. I think our approach to this was simply using only the patient’s subjective voice complaints as a criterion was not going to be enough. Generally, the patients who had subjective complaints also had surgeon-documented voice complaints if they were going to have an abnormality that we would find on laryngoscopy. Dr Richard A. Prinz (Evanston, IL): You just limited the prior operations to thyroid and parathyroid, and I think that can be a little misleading because anywhere the recurrent nerve and vagus nerve are at, and there is an operation, it is at risk. So if there is a prior operation, carotid, chest, or so forth, I think we should still be getting the laryngoscopy. Dr Kristin L. Long: We agree. Actually, all neck surgeries were considered in this. Our sixth patient who was listed in that chart had undergone an anterior cervical fusion. We did include everyone, including thyroid and parathyroid, but other neck surgeries as well.