Postoperative Voice Changes Research Articles

A Prospective Comparative Analysis to Study the Impact on Voice Changes Following Endoscopic Thyroidectomy.

Endoscopic approach has come up as a safe and feasible procedure for thyroidectomy with better cosmetic outcomes. However, concerns over its safety in terms of nerve injury and postoperative voice changes remain. This prospective study evaluated the role of vocal cord function assessment using laryngeal examination and voice analysis in patients who underwent endoscopic hemithyroidectomy either by the trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) or the bilateral axillobreast approach (BABA). Thirty-nine consecutive patients were randomly allocated to either of the 2 groups of endoscopic hemithyroidectomy; 19 in TOETVA and 20 in the BABA groups. Vocal cord function was assessed subjectively using the GRBAS scale and objectively by acoustic analysis of parameters such as jitter, shimmer, mean frequency (F 0 ), noise-to-harmonic ratio (NHR), and maximum phonatory time (MPT) at baseline, postoperative day 10, and 3 months after surgery. There were no significant differences in mean GRBAS scores and values of mean frequency, jitter and shimmer between the 2 groups and on postoperative day 10 and at 3 months compared with baseline. The mean NHR and MPT showed no differences between the 2 procedures. However, there was a significant decrease in their values on day 10 postsurgery, compared with baseline. These values returned to their baseline at 3 months. The other operative parameters were comparable between the 2 groups, except for the shorter mean operative time in the TOETVA group. Perioperative quantitative voice parameters were comparable with no statistically significant difference between the 2 techniques of endoscopic thyroidectomy.

Outcome Analysis of Total Thyroidectomy: Conventional Suture Ligation Technique vs Sutureless Technique.

Total thyroidectomy is a common surgical procedure in endocrine surgery. However, it carries potential complications such as damage to the recurrent laryngeal nerve, permanent hypoparathyroidism, and bleeding. Methods: A prospective study was conducted at the Professorial Surgical Unit, Jaffna Teaching Hospital, involving consecutive patients who underwent total thyroidectomy. Patients with certain conditions were excluded from the study. The data collected were analyzed using IBMSPSSStatistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). This study included 59 patients who had total thyroidectomy from January 2018 to January 2021 at the Professorial Surgical Unit, Jaffna Teaching Hospital. Of these, 45 underwent conventional suture ligation (CSL), and 17 had a sutureless (SL) technique. Mean ages were 44±12.47 years (range: 23 to 68) for CSL and 47.63±13.37 years (range: 27 to 73) for SL. Operative time was 2.16 ± 0.32 hours for CSL and 1.56 ± 0.49 hours for SL. Intraoperative and postoperative bleeding occurred in 2.38% of CSL cases but not in SL. Postoperative hypocalcemia was 7.14% for CSL and 5.88% for SL. Postoperative stays averaged 3.83 ± 1.56 days for CSL and 3.41 ± 1.62 days for SL. The study found that the operative time differed significantly between the suture and SL techniques. However, there was no statistically significant difference in postoperative drainage volume or postoperative complications. The SL technique was shown to be superior to the conventional suture ligation technique for total thyroidectomy. It resulted in shorter operative time, reduced intraoperative bleeding, lower incidence of postoperative drainage, fewer postoperative voice changes, and shorter hospital stays. Therefore, the SL technique was deemed safe, efficient, and effective for total thyroidectomy compared to the conventional suture ligation technique.

The Underreported Postoperative Suffering after Thyroid Surgery: Dysphagia, Dysphonia, and Neck Pain-A Cross-Sectional Study.

Postoperative voice change, difficulty of swallowing, throat pain, and neck pain are the most commonly complaint after thyroid surgery. However, little emphasis is given to the problem, especially a place where the surgical and anesthesia services' unmet need is highly observed, i.e., the problem gets little attention especially in the countries where the gaps of surgery and anesthesia services are observed. Hence, this study aims to determine the magnitude and associated factors of voice change and related complaints after thyroid surgery. A cross-sectional study was conducted on 151 patients who had had thyroid surgery from June 1 to December 30, 2021. Data were retrieved during the postoperative period after the patient regains consciousness. Out of 151 participants, 98 (64.9%) patients complained of either voice change or difficulty of swallowing and neck pain after thyroid surgery within 24 hours. Majority (58.3%) of the participants aged more than 30 years with a mean age of 33.7 ± 8.3 years and females 102 (67.5%). Neck pain is the most (52.3%) complained suffering after thyroid surgery, followed by voice change 38.4% and difficulty in swallowing 37.7%. Difficulty in swallowing after thyroid surgery significantly associated with a patient who frequently experience intraoperative hypotension (AOR = 23.24, 95% CI 4.6-116.7, and p = 0.01), type of surgical procedure (total thyroidectomy) (AOR = 8.62, 95% CI 1.21-61.50, and p = 0.03), and larger ETT size (AOR = 4.92, 95% CI 1.34-18.01, and p = 0.02). Postoperative voice change is associated with larger endotracheal tube (AOR = 15.47, 95% CI 3.4-69.5, and p ≤ 0.001), surgery lasting more than 2 hours (AOR = 7.34, 95% CI 1.5-35.1, and p = 0.01), and intraoperative hypotension (AOR = 23.24, 95% CI 4.6-116.7, and p ≤ 0.001). The complaint of postthyroidectomy neck pain and throat discomfort is higher than 64.9%. Intraoperative hypotension, blood loss, higher ETT size utilization, and duration of surgical procedure are the identified possible risk factors and have to be minimized as much as possible. Patient reassurance has to be considered during the postoperative time.

VOICE CONDITION FOLLOWING SHORT-TERM ENDOTRACHEAL INTUBATION IN HEAD AND NECK SURGERY: STUDY PROTOCOL FOR CLINICAL TRIAL.

Endotracheal intubation is an airway management procedure commonly performed under general anesthesia. It is linked with postoperative voice changes. The incidence and reasons of hoarseness and vocal cord injury are not very well investigated, especially after short-term anesthesia and intubation in head and neck surgery. The aim of the study is to identify the causes of voice changes after short endotracheal anesthesia in head and neck surgery. The study will include patients scheduled for head and neck surgery under general anesthesia with endotracheal intubation up to 3 hours. There will be 3 groups of patients, as follows: thyroid surgery, non-thyroid surgery, and control group undergoing surgery outside head and neck. Videostroboscopy will be recorded before and after surgery. Further diagnostic workup will include voice status; subjective voice self-analysis; perceptive and objective acoustic voice analysis at 4 time points (preoperatively, postoperative day 2, 2 weeks and 1 month after surgery). Endotracheal intubation is a safe method of airway management although it can temporarily alter a patient's voice quality. It is not known how much of this is the result of anesthesia, general condition of the patient, or surgery. This trial is expected to shed some light on this issue.

Prevalence and Predictors of Post-Thyroidectomy Voice Dysfunction in a Nigerian Cohort.

Advances in surgical techniques have significantly improved the safety of thyroidectomy. Quality of life issues, such as voice changes, however continue to be important considerations. This study evaluated the prevalence and determinants of voice changes following thyroidectomies for non-malignant goiters in a Nigerian Hospital. Consecutive adults who had thyroidectomy for non-malignant goiters were evaluated. Preoperatively, each participant had laryngoscopy and voice assessment using the Voice Handicap Index-10. At surgery, the intubation difficulty score, size of endotracheal tubes, and duration of operation were recorded. Laryngoscopy and VHI-10 assessments were repeated 1week, 1month, and 3months after surgery. Pre and postoperative assessments were compared. Fifty-four patients completed the study. Subtotal thyroidectomy was the commonest operation performed in 17 patients (31.48%), with 14 (25.93%) having total thyroidectomy. Baseline median VHI-10 score was 6.5(IQR-10). Five patients had abnormal preoperative laryngoscopy findings (benign vocal cord lesions). Postoperatively, seven patients had endoscopic evidence of vocal cord paralysis, six were unilateral while one was bilateral. Ten patients (18.5%) had early voice changes. Median VHI-10 score at one week was significantly higher than baseline (10 vs. 6.5, p = 0.01). At 3months, VHI-10 reverted back to baseline in five of the ten patients while five patients (9.3%) had persistent voice changes. Abnormal endoscopic findings predicted the occurrence of early postoperative voice changes. Thyroidectomy for non-malignant goiters is associated with transient voice changes, many of which revert to normal over time. Abnormal endoscopic findings predict its occurrence.

The Advantages of Robotic Over Open Thyroidectomy in Thyroid Diseases: A Systematic Review.

Over a hundred thousand thyroid surgeries are performed per year in the United States. Although conventional thyroidectomy has successful surgical outcomes, robotic minimally invasive procedures, known for their scar free (regarding the neck, no collar incision) surgical outcomes gained popularity through the years. Furthermore, these techniques are new and still debatable. The purpose is to know the advantages of robotic over open thyroidectomy in thyroid diseases. Note that we didn't aim to compare different robotic techniques due to the lack of data.We performed a systematic review comparing surgical approaches for thyroidectomy, open vs robotic techniques, from January 2017 to December 2021, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. All papers with no full free article access and not in the English language were excluded. The outcomes of interest were superior cosmetics outcome, cost-effectiveness, limitations, operation time, length of hospital stay and postoperative pain or complications, and future outcomes.A literature search was carried out in electronic databases (PubMed, Google Scholar) in order to retrieve all papers comparing the effectiveness of robotic vs open thyroidectomy. An initial reference search yielded 433 articles. Finally, we chose nine studies covering different robotic thyroidectomy techniques compared to the open thyroidectomy approach. Promising results were seen in these studies, especially with superior cosmetic results, less post-operative pain, swallowing discomfort, and voice changes. In addition, the risk of recurrent laryngeal nerve injury is almost the same as the open approach. Multiple types of biases were caused by the selection of the population and the limitation of the studies to certain regions associated with the low numbers of robotic thyroidectomy approaches in Europe and the United States of America and the lack of randomized trials and long-term follow-up respectively. All studies discussed the importance of the surgeon's skills and the patient decision in choosing the appropriate approach for the thyroidectomy depending on the risk factors, a larger number of patients, and longer follow-up from multiple hospitals.

Voice analysis before and after thyroid surgery

Voice change after thyroidectomy is one of the most common complaints and have a significant impact on patients quality of life. Postoperative voice change may occur due to vocal cord paralysis after recurrent laryngeal nerve injury during surgery, but recently, voice change without nerve injury is getting a lot of attention, and many studies are being performed on it. Pre-operative voice evaluation is necessary for the purpose of detecting pre-existing voice abnormalities and securing a baseline data to counsel patients about their impaired voice or provide appropriate postoperative voice therapy. Post-operative voice evaluation is also important to accurately evaluate voice abnormalities and provide appropriate treatment. Techniques of voice evaluation vary from subjective measurement using questionnaires to professional analysis including acoustic and aerodynamic studies. Among various methods, it is important to properly select and implement a method available for the conditions of each institution, and refer to a specialist if it is difficult to perform professional analysis and treatment.

Nasal resonance changes after endoscopic endonasal transsphenoidal skull base surgery: Analysis of voice quality.

ObjectivesTo study the effect of endoscopic endonasal transsphenoidal surgery on voice quality in patients with pituitary lesions.MethodsAn observational study comparing voice quality before and after surgery was conducted between September 2015 and September 2017 at Srinagarind Hospital, Khon Kaen University, Thailand. Pituitary tumor patients who underwent endoscopic endonasal transsphenoidal surgery were recruited. The nasal corridors were created with a type I (preserving both middle turbinates with a rescue flap) or type II (cutting one middle turbinate with a raised nasoseptal flap) for the binostril with four‐hand technique. All patients were evaluated for nasal resonance, acoustic parameters, acoustic perception, and self‐assessment of their satisfaction with postoperative voice changes with a visual analog scale (VAS). The patients were evaluated 1 day before surgery and at 1 and 3 months after surgery.ResultsForty‐four patients, including 19 males and 25 females with a mean age of 50.0 ± 15.6 years, were enrolled. Mean scores for nasal resonance and all acoustic parameters were not significantly changed after surgery for either nasal corridor type (p > .05). Regarding acoustic perception, word and sentence and GIRBAS scores showed no significant difference before and after surgery (p > .09) in either type of nasal corridor. There was no incidence of hypernasality voice after surgery. Patients' self‐satisfaction ratings (i.e., VAS) with voice quality were high and showed no significant change 1 and 3 months postsurgery (p > .05).ConclusionsThese endoscopic endonasal transsphenoidal approaches are minimally invasive skull base surgery techniques that have minimal effects on postsurgery voice quality.Trial RegistrationThis trial was registered at ClinicalTrial.gov (NCT02828514).Level of Evidence4.

Impact of Thyroid surgery on Voice: A prospective study.

Thyroidectomy is one of the most common neck surgery done worldwide. It is associated with debilitating post-operative voice changes even without recurrent laryngeal nerve (RLN) injury. Aims and Objectives: To study the impact of thyroidectomy on voice parameters in the absence of Recurrent Laryngeal Nerve and External Branch of Superior Laryngeal Nerve injury and comparison between the pre and post-operative changes in the subjective and objective voice parameters. Methodology: Patients fulfilling the inclusion criteria underwent thyroidectomy. The Subjective voice assessment was done using Voice Impairment Score (VIS) and objective parameters were analyzed using Multi-Dimensional Voice Program (MDVP) pre-operatively and post-operatively at 1week, 1month and 3months interval. Results: On MDVP analysis of patients, a fall in Mean F0 (Hz), Minimum F0 (Hz) and Maximum F0 (Hz) values was noted at 1week after surgery. But a trend toward the pre-operative values was observed at 3months post-operatively.

English

BACKGROUND Thyroidectomy is a surgical procedure which is commonly performed by surgeons worldwide, but the outcome and complication rates were mainly dependent on the surgeon’s skill and experience, indication and the extent of surgery and the number of thyroid surgeries performed at that particular centre. The aim of this study was to assess the frequency of the postoperative complications after thyroid surgery in Sri Venkateswara Ramnaraian Ruiya Government General Hospital, Tirupati. METHODS A prospective study conducted on 100 patients with thyroid swelling who attended the Sri Venkateshwara Ramnaraian Ruya Government General Hospital, Tirupati. Patient age, sex, rural/urban origin, history, diagnosis, type of surgery, laboratory investigation such as complete blood, serum calcium, thyroid function test, us culture and sensitivity test in wound infections and indirect laryngoscopy for all pre-operative patients and postoperative voice change patients. Outcomes recorded as a complication of thyroid surgery within one week. RESULTS Totally 100 patients were enrolled in the study. Thyroid enlargement was more common in females (F: M =5.6:1) presenting in 3rd and 4th decades mostly with the mean age and standard deviation were 42.92 years and 13.097 years respectively. Total thyroidectomy was the most common procedure performed (44 %) followed by hemithyroidectomy (31 %), subtotal thyroidectomies (29 %) and near total thyroidectomy (5 %). On histopathological examination most common finding was multinodular goiter (54 %) followed by nodular goiter (33 %) and malignancies (10 %). The overall postoperative complication rate was 47 %. The most common postoperative complications after thyroidectomies were seroma formation in wound complication (27 %), followed by hypocalcemia (11 %), recurrent laryngeal nerve (RLN) injury (3 %), and surgical site infection (2 %). Majority of these complications were found to be associated with total thyroidectomy, female population, and in patients with age more than 30 years. CONCLUSIONS Seroma formation in wound complication is the commonest post thyroidectomy complication. Female gender, old age, and extensive thyroid surgery were associated with increased complication rate. KEYWORDS Post-Operative Complications, Thyroid Surgery

Study on changes of voice characteristics after adenotonsillectomy or adenoidectomy in children

Objective: To study voice changes in children after adenotonsillectomy or adenoidectomy and the relationship with the vocal tract structure. Methods: Fifty patients were recruited in this study prospectively, aged from 4 to 12 years old with the median age of 6. They were underwent adenotonsillectomy or adenoidectomy in Beijing Tongren Hospital, Capital Medical University from July 2019 to August 2020. In the cases, there are 31 males and 19 females. Thirty-six patients underwent adenotonsillectomy and 14 patients underwent adenoidectomy alone. Twenty-two children (13 males, 9 females) with Ⅰ degree of bilateral tonsils without adenoid hypertrophy and no snoring were selected as normal controls. Adenoid and tonsil sizes were evaluated. Subjective changes of voice were recorded after surgery. Moreover, voice data including fundamental frequency(F0), jitter, shimmer, noise to harmonic ratio(NHR), maximum phonation time(MPT), formant frequencies(F1-F5) and bandwidths(B1-B5) of vowel/a/and/i/were analyzed before, 3 days and 1 month after surgery respectively.SPSS 23.0 was used for statistical analysis. Results: Thirty-six patients(72.0%,36/50) complained of postoperative voice changes. The incidence was inversely correlated with age. In children aged 4-6, 7-9, and 10-12, the incidence was 83.3%(25/30), 63.6%(7/11) and 44.4%(4/9) respectively. Voice changes appeared more common in children underwent adenotonsillectomy(77.8%,28/36) than in those underwent adenoidectomy alone(57.1%,8/14), but there was no statistical difference. After operation, for vowel/a/, MPT(Z=2.18,P=0.041) and F2(t=2.13,P=0.040) increased, B2(Z=2.04,P=0.041) and B4(Z=2.00,P=0.046) decreased. For vowel/i/, F2(t=2.035,P=0.050) and F4(t=4.44,P=0.0001) increased, B2(Z=2.36,P=0.019) decreased. Other acoustic parameters were not significantly different from those before surgery. The F2(r=-0.392, P =0.032) of vowel/a/and F2(r=-0.279, P=0.048) and F4 (r=-0.401, P =0.028) of vowel/i/after adenotonsillectomy were significantly higher than those of adenoidectomy alone. Half of patients with postopertive voice changes can recover spontaneously 1 month after surgery. Conclusions: Voice changes in children underwent adenotonsillectomy or adenoidectomy might be related to their changes in formants and bandwidths. The effect of adenotonsillectomy on voice was more significant compared with that of adenoidectomy alone. The acoustic parameters did not change significantly after surgery except MPT.

Correlation of Voice Hoarseness and Vocal Cord Palsy: A Prospective Assessment of Recurrent Laryngeal Nerve Injury Following Anterior Cervical Discectomy and Fusion.

Injury to the recurrent laryngeal nerve (RLN) has been implicated as a common complication following anterior cervical discectomy and fusion (ACDF) surgery. The purpose of this study is to determine the true incidence of voice hoarseness and RLN palsy following ACDF surgery, to determine the reliability of symptoms in the diagnosis of RLN injury, and to evaluate factors related to the development of these symptoms. All patients undergoing elective (primary or secondary) ACDF surgery at a single institution consented to and enrolled in the present study. All approaches were through the left side. Enrolled patients received both preoperative and postoperative (within 1 month following surgery) laryngoscopy by a fellowship-trained ENT physician for evaluation of RLN function. Patients also responded as to whether they were experiencing postoperative symptoms of dysphagia, aspiration, and voice changes. In total, 108 patients were included in this study. Mean age of the population was 59.2 ± 10.7 years and mean body mass index was 31.2 ± 7.1 kg/m2. Three patients had previously undergone a thyroidectomy, whereas 20 patients had undergone a previous ACDF. Average intubation time for ACDF surgery was 121.6 ± 38.5 minutes. After surgery and excluding patients who were experiencing preoperative symptoms, 19 patients (20.4%) complained of dysphagia, 2 patients (1.9%) complained of aspiration symptoms, and 5 patients (4.6%) complained of voice hoarseness. There was no incidence of vocal cord palsy from postoperative laryngoscopy. From multivariate analysis, endotracheal cuff pressure after retractor placement was correlated to postoperative voice hoarseness, dysphagia, and aspiration symptoms. From the results of this prospective study, the RLN remained functional even a month after surgery despite several cases of postoperative dysphagia, aspiration, and voice changes. Endotracheal cuff pressure, number of vertebral levels, body mass index, and intubation time were important variables related to postoperative symptoms. Voice hoarseness does not necessarily indicate recurrent laryngeal nerve injury after ACDF but may be caused by compressive forces on laryngeal tissue during retraction or intubation. Laryngoscopy should be performed in cases with high clinical suspicion. 2.

Evaluation of one-year incidence of vocal dysfunction and associated demographic factors in thyroidectomy patients: A descriptive analytical study

BackgroundVoice changes are common complaint following thyroidectomy that might or might not be associated with laryngeal nerve damage. Objective: The aim of this study is to evaluate the effect thyroidectomy on voice alteration and its association with gender and age. MethodsIn this descriptive analytical study, patients who underwent thyroidectomy at (XXX) without laryngeal nerve damage were included. These patients were evaluated based on subjective (self-reported) and objective (videostroboscopy) voice assessment. The data was collected immediately after the surgery and 6 months after the surgery during the follow-up. ResultsOf 76 patients included, the mean age of patients was 46.3 year. 25 (43.4%) were males and 51 (56.6%) were female. 28.9% patients were presented with apparent damage to the vocal cords, of which 8 (10.5) had voice changes. There was no statistically significant difference between sex and postoperative vocal cord dysfunction (P = 0.592). However, in male gender, late postoperative voice changes were significantly more, p = 0.013. The age was also not associated with immediate or late postoperative changes and damage to vocal cords, p > 0.05. ConclusionOur study reported that male gender can be an important factor in deterring voice changes after thyroidectomy nonetheless, it can not predict the risk of vocal cord damage. Furthermore, age might not a risk factor either. Studies with greater sample size are required to confirm these findings.

Impact of adenotonsillectomy on acoustic parameters of voice using GRBAS scale in children

Adenoids and tonsils are pharyngeal lymphoid tissue aggregation. Adenotonsillar hypertrophy is usually seen in children. Enlarged adenoid and tonsillar tissue in children causes snoring, sleeping disorders, failure to thrive, frequent upper respiratory tract infections and abnormalities in maxillofacial development. Surgical treatment performed for their removal is termed as adenotonsillectomy. This is one of the most commonly performed surgical procedures in children. The present study was conducted to compare the voice change using the GRBAS scale before and after adenotonsillectomy. This is a prospective study conducted for three months at the Department of Otorhinolaryngology in our tertiary care center. Voice of 35 children with adenotonsillar hypertrophy is analyzed by GRBAS scale in three stages before the surgery, three weeks after surgery and six weeks after surgery. The resulting voice quality improvement is noted in these children after adenotonsillectomy. This study showed that surgical procedures of adenotonsillectomy do not induce drastic adjustments in sound quality and can be performed safely in children. Post-operative voice changes are a significant concern issue among the parents of the children.

Changes in Acoustic Aspects of Vocal Function in Children After Adenotonsillectomy

Adenotonsillectomy is one of the most common pediatric surgical procedures. Postoperative voice changes are a very common concern among patient's parents. Therefore, the aim of this study is to analyze acoustic voice parameters after adenotonsillectomy, tonsillectomy, and adenoidectomy in pediatric patients in a tertiary referral academic center. All pediatric patients undergoing an adenotonsillectomy, tonsillectomy or adenoidectomy in a single center from 2002 to 2018 were included in the study. Change of fundamental frequency, jitter, shimmer, and harmonic-noise ratio at first, seventh and 30th postoperative day compared to preoperative values were the primary outcome parameters. Statistical analysis was performed using repeated measures analysis of variance model. A total of 1258 patients were included in the study. The mean age of patients at the time of surgery was 8.3 years (range 3.0-18.0 years). Around 698 were male (55.5%) and 560 female (44.5%). The values of fundamental frequency increased significantly after the first and seventh postoperative day (P=0.001 both) but normalized 1 month after surgery (P=0.962). At the first postoperative month, values of jitter and shimmer decreased significantly (P=0.005 and P=0.002, respectively). Measurements of harmonic-noise ratio revealed a significant increase 30 days after surgery (P=0.004). Statistically significant differences in objective voice parameters within the first postoperative month after tonsillectomy, adenoidectomy, and adenotonsillectomy were observed. The fundamental frequency returned to normal 1 month after surgery. These findings can contribute in soothing the concerns of parents regarding postoperative voice changes.

Lever-elevating vs. liquid-isolating maneuvers during microwave ablation of high-risk benign thyroid nodules: a prospective single-center study

Aim: To compare the effects of the liquid-isolating maneuver and the lever-elevating maneuver in protecting cervical structures during microwave ablation for treating high-risk benign thyroid nodules.Methods: This prospectively study was approved by the Medical Ethics Committee of Panzhihua Central Hospital. A total of 174 patients were enrolled and randomly assigned to a liquid-isolating maneuver group (LIM, n = 87) or a lever-elevating maneuver group (LEM, n = 87). Operation time, postoperative voice change, time to recovery of baseline voice, peri-thyroid hematoma, neck tension, and intraoperative vasovagal reaction were assessed.Results: Operation time was greater in the LIM group than in the LEM group (44.75 ± 13.14 vs. 32.87 ± 10.84 min; p = .017).Voice changes were observed in 6 patients in the LIM group and 2 in the LEM group (6.9% vs. 2.3%, p = .278). The time to recovery of baseline voice was significantly greater in the LIM group compared with the LEM group (36.15 ± 10.24 vs. 24.48 ± 11.53 days, p = .014). The incidences of peri-thyroid hematoma and neck tension were higher in the LIM than in the LEM group (11.5% vs. 3.4%, 10.3% vs. 2.3%, p = .044 and p = .029). One patient (1.1%) in the LEM group and none of the patients in the LIM group experienced a vasovagal response (p = 1.000).Conclusion: The lever-elevating method is feasible and effective for the microwave ablation of benign thyroid nodules, with better protection of neck structures than observed with the liquid-isolating method.

The evolution and progress of standard procedures for intraoperative nerve monitoring

The close proximity of the recurrent and external superior laryngeal nerves to the thyroid bed places them at risk of injury during neck endocrine procedures. Intra-operative nerve visual identification with structural preservation does not equate with the preservation of nerve functional integrity and the morbidity of neural injury resulting in post-operative vocal fold paralysis or voice change can be significant. As such, intraoperative neuromonitoring strategies for the recurrent laryngeal and, more recently, the external branch of the superior laryngeal nerve have evolved and have gained increasing attention from surgeons performing neck endocrine procedures worldwide. Currently, many head and neck and general surgeons use neural monitoring in at least some of their surgical cases. The support for intraoperative nerve monitoring (IONM) continues to grow at both an individual and organization level as the guidelines for standardization are published, prospective randomized controlled trials are reported, and structured training courses are established. This article will discuss the evolution and recent progress of standard procedures for intraoperative neuromonitoring of laryngeal nerves in thyroid and parathyroid surgeries.

Voice Disorders after Intubation: The Importance of Intra-Operative Monitoring and Controlling of Endo-Tracheal Tube Cuff Pressure in Reducing Intubation-Related Complications

AbstractBackground: The importance of monitoring and controlling endotracheal tube cuff (ETTc) pressure in reducing larynge-otracheal injuries and intubation-related respiratory compli-cations has been previously investigated by several authors. However, little is known about the role of controlling ETT cuff pressure in minimizing transient voice changes following endotracheal intubation.Aim of the Study: The aim of this study was to investigate the importance of monitoring and controlling ETTc pressure in reducing voice disorders after endotracheal intubation.Patients and Methods: Fifty patients in the age between 18-50 years, undergoing middle ear surgery were enrolled into the study. Patients were randomized by means of individ-ually prepared envelopes to either the control group (n=25), without measuring ETTc pressure, or the study group (n=25), with ETTc pressure measurement. All patients were examined pre-operatively to determine baseline values, 24 hours after surgery and 1 week post-operatively. Phoniatric examination included auditory perceptual assessment, videolaryngoscopy and acoustic analysis of voice. Statistical analysis included the arithmetic mean, Standard Deviation (SD), standard error, hypothesis student's t and Spearman's rank-order correlation tests. p-values <0.05 were chosen as the level of significance.Results: Auditory perceptual assessment of voice per-formed one day after extubation indicated the presence of post-intubation dysphonia which was of a mild to moderate grade, an irregular quality, a low pitch and fluctuating loudness. These changes were more pronounced and occurred more frequently in patients of the control group in whom the cuff pressure was adjusted by pilot balloon palpation according to the experience of the anaesthesiologist. One week after surgery, all patients belonging to the study group, in whom a hand-held cuff pressure monitor was used to adjust the cuff pressure, showed improvement in all the perceived parameters, whereas persistent dysphonia was still perceived in two patients of the control group. Videolaryngoscopy performed before intubation showed that all patients were free from any laryngeal lesions. One day after extubation, there was evidence of traumatic laryngeal lesions in the form of vocal fold congestion in 5 patients (20%) of the control group and 3 patients (12%) of the study group. One week after extubation, residual lesions were still present in 3 patients (12%) of the control group in the form of mild vocal fold edema in one patient and vocal fold congestion in two other patients. Acoustic analysis of voice performed 24 hours after extubation showed a highly significant increase in fundamental frequency F0 in both male and female patients of the control group. These changes were accompanied by a significant increase in jitter in only the female patients. By contrast, acoustic analysis of voice recorded both 24 hours and one week after extubation in patients belonging to the study group did not show any significant changes in any of the measured parameters when compared to their corresponding baseline values. An inter-group com-parison of the post-operative parameters recorded by acoustic analysis of voice one day after extubation showed a statistically highly significant (p=0.013) reduction in fundamental fre-quency F0 by 75% among male patients, and a statistically significant (p=0.05) reduction in jitter by 74% in females belonging to the study group when compared to those of the control group. Shimmer and NHR increased to 78% and 47%, respectively, in male patients belonging to the study group, and decreased in females, but these changes were statistically not significant.Correlation performed between the changes in parameters obtained by acoustic analysis of voice and the duration of intubation showed a statistically significant (p-value=0.023) positive correlation between the changes in fundamental frequency F0 and the duration of intubation. Likewise, a significant (p-value=0.016) positive correlation was found between the changes in jitter and the duration of intubation.Conclusion and Future Recommendations: General an-aesthesia has multisystem effects, some of which can disturb the fine harmony necessary for voice production. Even short-term intubation is usually followed by a period of dysphonia that may extend after extubation anywhere from 12 hours to more than five days. Proper control of endotracheal tube cuff (ETTc) pressure by a manometer helps reduce ETT-related postprocedural complications. Acoustic analysis may be used to identify and monitor even minor laryngeal trauma resulting from the procedure. Jitter and shimmer are the best indicators of post-intubation phonation changes. For medicolegal reasons, patients scheduled for general anesthesia should be informed about the possible post-operative voice changes that could last longer than one day. We further recommend routine intraoperative monitoring of endotracheal tube cuff pressure, in additition to post-operative phoniatric assessment and follow-up of the patients for early post-operative diagnosis and treatment of dysphonia.

Comparison of Postoperative Neck Pain and Discomfort, Swallowing Difficulty, and Voice Change After Conventional Open, Endoscopic, and Robotic Thyroidectomy: A Single-Center Cohort Study

Background: The objective of this study was to compare the postoperative neck pain and discomfort, swallowing difficulty, and voice change after conventional open thyroidectomy (COT), endoscopic thyroidectomy (ET), or robotic thyroidectomy (RT) performed by a single surgeon.Methods: From January 2013 to December 2017, 254 patients underwent COT, ET, or RT performed by a single surgeon and completed a postoperative symptom survey conducted in the outpatient clinic by three nurses. The survey collected information on postoperative neck pain and discomfort, swallowing difficulty, and voice change.Results: Of the 254 patients, 169 underwent COT, 32 underwent ET, and 53 underwent RT. The mean age in the COT, ET, and RT groups was 50.1, 44.5, and 41.6 years, respectively. The mean interval between thyroidectomy and survey in the COT, ET, and RT groups was 42.7, 50.2, and 9.2 months, respectively. Postoperative neck pain was significantly higher in the ET and RT groups than in the COT group (p = 0.026). The average neck impairment index score in the RT group was significantly higher than that in the COT group (p < 0.001). There were no significant differences in pain scale scores, swallowing difficulty, swallowing impairment index, voice change, and voice hand index among the three groups.Conclusions: There were no significant differences in postoperative voice change or swallowing difficulty among the COT, ET, and RT groups, whereas neck pain and discomfort were more common after ET and RT than COT.

Comparison Between Patient-Perceived Voice Changes and Quantitative Voice Measures in the First Postoperative Year After Thyroidectomy

Voice changes after thyroidectomy are typically attributed to recurrent laryngeal nerve injury. However, most postoperative voice changes occur in the absence of clinically evident vocal fold paralysis. To date, no study has compared the prevalence, duration, and consequences of voice-related disability from the patient perspective with use of quantitative vocal measures. To assess the quality-of-life consequences of postthyroidectomy voice change from the perspective of patients with thyroid cancer and to compare patient-perceived voice changes with changes in quantitative vocal variables at 5 time points in the first postoperative year. This prospective mixed methods observational study within a randomized clinical trial occurred at the University of Wisconsin Hospital and Clinics. Participants were 42 patients with clinically node-negative papillary thyroid cancer without a preexisting vocal cord paralysis who were recruited and enrolled from outpatient clinics between June 6, 2014, and March 6, 2017, as part of the ongoing randomized clinical trial. Total thyroidectomy. Semistructured interviews, symptom prevalence, and instrumental voice evaluations (laryngoscopy, phonation threshold pressure, Dysphonia Severity Index, and Voice Handicap Index) occurred at baseline (n = 42) and 2-week (n = 42), 6-week (n = 39), 6-month (n = 35), and 1-year (n = 30) postoperative time points. Participants had a mean age of 48 years (interquartile range, 38-58 years; age range, 22-70 years) and were mostly female (74% [31 of 42]) and of white race/ethnicity (98% [41 of 42]). Impaired communication was the primary theme derived from patient interviews from before thyroidectomy to after thyroidectomy. Voice changes were perceived by 24 participants at 2 weeks after thyroidectomy. After surgery, voice symptoms were prevalent and persisted for 50% (21 of 42) of participants out to at least 1 year of follow-up. Quantitative vocal perturbations were detected in the Dysphonia Severity Index and Voice Handicap Index at the 2-week follow-up but returned to baseline levels by the 6-week follow-up visit. Voice changes are common after surgery for papillary thyroid cancer and affect quality of life for many patients out to 1 year of follow-up. Directly querying patients about postoperative voice changes and questioning whether commonly used aerodynamic and acoustic variables detect meaningful voice changes are important in identifying patients whose quality of life has been affected by postthyroidectomy dysphonia. ClinicalTrials.gov Identifier: NCT02138214.