84th Annual Meeting of the American Thyroid Association:

Thyroid Surgery Guidelines for Voice Preservation

As part of  the Clinical: Voice Symposium, Surgically Related session, David J. Terris, MD presented Getting the Most Out of the New Guidelines (American Thyroid Association (ATA) and American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF)) during the ATA’s annual meeting. The ATA guidelines are very similar to the AAO-HNSF guidelines, although the ATA guidelines are not yet finalized.

Thyroid surgery is laryngeal nerve and parathyroid gland preservation surgery. It is critical to remember that many people in different professions (eg, country western singers, teachers, lawyers) rely on well-functioning vocal cords to achieve success in their careers.

Preoperative: Examine and assess larynx function.

  • Dr. Terris commented, “What's the harm in just asking the patient how is your voice? … and it turns out that information can be very helpful in achieving the optimal, eventual physiologic, and functional outcomes.”
  • Vocal cord paralysis cannot always be determined by listening to the patient’s voice.

Furthermore, Dr. Terris indicated, “We know that 8% of thyroid cancer patients,  and up to 1% of patients with benign thyroid disease will have a vocal cord paralysis. And, this turns out to be predictive of invasive disease. So 70% of patients with invasive thyroid cancer will have a vocal cord paralysis. This is changing our management algorithm, and it affects how we approach these patients with known cancer.”

Intraoperative: Find the laryngeal nerve and protect it.
“More recent data suggests it is important to see the nerve and sufficiently dissect it to protect it. The laryngeal nerve must be competently dissected before safely removing the thyroid,” stated Dr. Terris.

  • Stimulation of the laryngeal nerve may be helpful to prevent bilateral paralysis. Dr. Terris pointed out, “there is one prospective, randomized trial, which showed no benefit with nerve monitoring in reducing the rate of a permanent nerve injury. There was a reduced rate of temporary injury … another paper shows a reduced rate of permanent paralysis only in a reoperative setting.” Could these findings be justification for surgeons who are reluctant to utilize nerve monitoring during the [first] surgery because the incidence of laryngeal nerve injury is low?
  • “I consider the principle benefit of nerve monitoring—having knowledge of not just the anatomic integrity, but the electrophysiologic integrity of one nerve before going to the other side and operate on the other nerve. This is valuable information when doing bilateral thyroid surgery,” explained Dr. Terris.

Postoperative: Assess larynx function.
Assess the function of the larynx because early intervention (eg, vocal cord injection) may reduce the need for a more invasive procedure in the future.

January 27, 2015

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