2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

OTO XXX10.1177/0194599813487301Otola

ryngology–Head andNeckSurgeryChandrasekhar et al 2013©TheAuthor(s) 2010

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Reprinted by permission of Otolaryngol Head Neck Surg. 2013; 148(6 Suppl):S1-S37.

Clinical Practice Guideline Supplement

Otolaryngology– Head and Neck Surgery 148(6S) S1–S37 © American Academy of Otolaryngology—Head and Neck

Clinical Practice Guideline: ImprovingVoice Outcomes afterThyroid Surgery

Surgery Foundation 2013 Reprints and permission:

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Sujana S. Chandrasekhar, MD 1 , GregoryW. Randolph, MD 2 , Michael D. Seidman, MD 3 , Richard M. Rosenfeld, MD, MPH 4 , Peter Angelos, MD, PhD 5 , Julie Barkmeier-Kraemer, PhD, CCC-SLP 6 , Michael S. Benninger, MD 7 , Joel H. Blumin, MD 8 , Gregory Dennis, MD 9 , John Hanks, MD 10 , Megan R. Haymart, MD 11 , RichardT. Kloos, MD 12 , Brenda Seals, PhD, MPH 13 , Jerry M. Schreibstein, MD 14 , Mack A.Thomas, MD 15 , CarolynWaddington, MS, FNP 16 , BarbaraWarren, PsyD, Med 17 , and Peter J. Robertson, MPA 18

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Results. The guideline development group made a strong rec- ommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery.The group made rec- ommendations that the clinician or surgeon should (1) docu- ment assessment of the patient’s voice once a decision has been made to proceed with thyroid surgery; (2) examine vo- cal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient’s voice is impaired and a decision has been made to proceed with thyroid sur- gery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient’s voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid end- arterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiolo- gist of the results of abnormal preoperative laryngeal assess- ment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid sur- gery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an oto- laryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on op- tions for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery.The group made no recommendation regarding the impact of a single intraopera- tive dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

Abstract Objective. Thyroidectomy may be performed for clinical indica- tions that include malignancy, benign nodules or cysts, suspi- cious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treat- ment, temporary and permanent hypoparathyroidism, tempo- rary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based rec- ommendations for management of the patient’s voice when undergoing thyroid surgery during the preoperative, intraop- erative, and postoperative period. Purpose. The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thy- roid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be lim- ited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recom- mendations may extrapolate to parathyroidectomy as well.

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