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Triological Best Practice: Should Bedside Laryngoscopy Be Routinely Performed Following Thyroidectomy?

LARYNGOSCOPE(2022)

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Abstract
Vocal fold motion impairment (VFMI) is a well-recognized complication following thyroidectomy. The incidence of recurrent laryngeal nerve (RLN) injury varies from 1.8% to 13.3%.1 VFMI can be very debilitating to patients, resulting in dysphonia, dysphagia/aspiration, dyspnea, and decreased cough strength. Although bedside laryngoscopy (BL) remains the gold standard for evaluation of vocal fold motion, there is no universally accepted consensus on the timing of and threshold for performing BL following surgery. Furthermore, using vocal quality alone has been shown to underestimate the true incidence of VFMI.1 Postoperative evaluation by BL may facilitate closed-loop communication with patients – which should follow a careful and detailed preoperative discussion of surgical risks and benefits –, validate patients' postoperative concerns, and may provide valuable technical feedback to the surgical team. As most patients with VFMI will be symptomatic, and a significant percentage will be left with permanent paralysis, frank and open recognition of the complication and development of an appropriate post-discharge mitigation strategy for symptomatic patients that upholds the principles of beneficence and non-maleficence should be implemented. Herein, we review five published studies (Table I) to investigate the question of timing and necessity of laryngoscopy following thyroidectomy. Given the important prognostic and therapeutic implications of identifying VFMI early in the post-operative course, should BL be routinely performed following thyroidectomy? Based on the 2015 American Thyroid Association (ATA)'s management guidelines published by Haugen et al.,2 there is a strong recommendation in support of post-operative voice assessment based on the patient's subjective report and physician's objective assessment of voice. Although there is a strong recommendation in support of a formal laryngeal exam pre-operatively in cases of dysphonia, history of head and neck surgery or radiation, gross extrathyroidal extension of cancer, or extensive nodal involvement, there is no formal recommendation for post-operative laryngoscopy. Instead, the ATA recommends that voice assessment be performed at 2 weeks to 2 months following surgery and encourages interventions including early vocal fold medialization and voice therapy for those identified with VFMI. Dhillon et al.3 performed a retrospective cohort study of 1,547 patients undergoing thyroid and parathyroid surgery (n = 1580 procedures for a total of 2,527 nerves) by a single high-volume surgeon at an academic tertiary care center. BL was performed preoperatively and immediately post-operatively. The study sought to identify risk factors for VFMI, as well as assess the utility of immediate post-operative BL in the early diagnosis of VFMI. The authors found an incidence of postoperative VFMI of 2.9 percent, and the factors most predictive of VFMI included larger primary tumor size and performance of a central neck dissection. These authors recommend immediate postoperative BL. Patient sedation, airway secretions, and post-intubation laryngeal edema after extubation had no significant impact on the sensitivity and negative predictive value of BL. The authors suggest that VFMI detection allows for early patient counseling to set expectations and plan for interventions that may improve voice and swallowing outcomes, including intervention by a Speech-Language Pathologist and laryngologist for early vocal fold augmentation and rehabilitation. Furthermore, they believe immediate post-operative BL provides timely feedback regarding surgical technique that is useful for the surgeon in identifying surgical nuances that affect RLN function. Dionigi et al.4 performed a prospective study on 453 consecutive patients undergoing thyroidectomy in a single referral center in an attempt to identify the proper timing to detect VFMI. All patients underwent BL before operation (T0), at day 0 in the recovery room (T1), post-operative day (POD) 2 prior to hospital discharge (T2), and finally at 2+ weeks follow-up (T3). The incidence of RLN palsy was 6.4%, 6.7%, and 4.8% for T1, T2, and T3, respectively. There was no significant difference between T1 and T2, however, T2 observation was significantly superior to that at T3 in terms of VFMI diagnosis, likely due to RLN neuropraxia that recovered between the POD 2 and two-week post-operative visit. Based on these results, the authors recommend routine BL post-operatively at POD 2 (prior to hospital discharge) to best diagnose VFMI. They cite POD 2 as having slightly superior sensitivity compared to POD 0 likely due to patient's poor compliance and difficulty following commands early after extubation in the recovery room. Schlosser et al.5 prospectively evaluated 763 patients undergoing thyroid surgery who underwent laryngoscopy both pre-operatively and on POD 2 or 3. The vast majority of patients with VFMI (81%) were symptomatic. They found that post-operative VFMI was transient in all of the asymptomatic patients, and all eventually recovered normal vocal fold function. Therefore, these authors do not recommend performing routine laryngoscopy in patients with no obvious or perceptible symptoms, as spontaneous recovery of mobility is likely. de Pedro Netto et al. conducted a prospective, nonrandomized study of 100 patients undergoing thyroid surgery and compared the results with a control group with similar demographic, clinical, and surgical variables undergoing breast surgery. All subjects underwent BL, a subjective and objective (acoustic) voice analysis, and a Voice Handicap Index questionnaire before and after surgery. Post-operative BL showed VFMI in 12 percent and overall laryngeal abnormalities including laryngeal edema in 28 percent of the thyroid group, whereas there were no laryngeal abnormalities in the control group. Excluding patients with post-operative vocal fold paralysis, 29.7 percent of patients reported voice changes at two weeks following thyroid surgery, whereas zero patients reported dysphonia following breast surgery. These authors thus recommend routine post-operative BL to aid in early diagnosis and initiation of multidisciplinary management of subjects with vocal disturbances following thyroidectomy. The role and timing of routine BL following thyroidectomy remains controversial. Post-operative VFMI may be a source of considerable distress to patients, and results in symptoms including dysphonia, dysphagia/aspiration, dyspnea, and decreased cough strength. Early recognition and multidisciplinary management with vocal fold augmentation, voice and swallowing therapy, and/or involvement of a Speech Language pathologist may be important in improving outcomes in these patients, such as a more rapid return to work. Given the low risk, cost, and morbidity of a laryngeal examination – and the potential significant harm to patients when VFMI is missed – routine laryngoscopy should be performed as early as possible in all patients following thyroid surgery. These recommendations are based on one evidence-based clinical practice guideline (level 1 evidence), three prospective studies (level 1 evidence), one retrospective study (level 2 evidence).
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Key words
bedside laryngoscopy,thyroidectomy,triological best practice
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