2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Chandrasekhar et al

Two randomized controlled studies have been performed in which corticosteroids were administered before induction with anesthesia for thyroid surgery. One randomized, double- blind, controlled study administered a single preoperative dose of dexamethasone (8 mg) intravenously to 1 of 2 cohorts (n = 51) and compared the rate of postoperative nausea and vomiting (primary outcome measure), pain, and subjective vocal function (voice visual analog scale 0-100) to a second cohort (n = 51) after total thyroidectomy or lobectomy for benign disease. 203 Potential adverse events associated with corticosteroid use including hyperglycemia, infection, delayed wound healing, and cardiovascular abnormalities were also collected, but not reported. Dexamethasone-treated patients had significantly less nausea and vomiting ( P = .0001) and less pain ( P = .008); however, no differences were noted in subjective voice analyses ( P = .693). In another double-blind, controlled thyroidectomy study, the effect of dexamethasone (8 mg) administered preopera- tively before induction with anesthesia was assessed in 72 patients after randomization into control group (n = 35) and a dexamethasone group (n = 37) and evaluated with respect to nausea, pain, and voice alteration. 81 Voice function was assessed by fundamental voice frequency, the mean funda- mental frequency of a sustained “a,” as well as by subjective voice function using a modified VHI and by a voice visual analog scale. Dexamethasone significantly reduced the inci- dence and severity of the postoperative nausea and/or vomit- ing ( P = .001) and significantly reduced postoperative pain ( P = .009). In the first postoperative day, all patients assessed for vocal function experienced a reduced ability for lengthen- ing their vocal folds, which was more pronounced in the con- trol group versus the dexamethasone group when reading a standardized text and when pronouncing a sustained “a” ( P = .018 and .015, respectively). No significant differences were noted between groups on the voice disturbance index; how- ever, significant differences were noted in subjective voice analysis with a nonvalidated outcome measure ( P < .003). Of note, significant differences between groups were no longer apparent by 24 hours after surgery and no steroid-related com- plications were observed. Evidence available in the literature supports using cortico- steroids when compared to placebo in the perioperative period to reduce postoperative nausea and vomiting and pain without increased adverse effects associated with corticosteroids. While the effect of corticosteroids on changes in voice after thyroid surgery appear to have their greatest impact on those that are temporary and early, methodological limitations in 2 relevant studies reduce the certainty regarding the clinical sig- nificance of the observed effects. Additional studies are needed to evaluate corticosteroid use to improve voice. More detailed assessments of potential adverse effects of corticoste- roids in patients undergoing thyroidectomy are necessary to allow a risk versus benefit determination.

has been a change in voice between 2 weeks and 2 months following thyroid surgery. Recommendation based on systematic reviews, clinical practice guidelines, and prospective, observational studies with a preponder- ance of benefit over harm. Action Statement Profile • • Aggregate evidence quality: Grade C, cohort stud- ies on the prevalence and duration of voice changes after thyroid surgery and the underreporting of voice changes if not specifically sought • • Benefit: Identification of significant voice impair- ment and early institution of counseling and/or voice rehabilitation; avoidance of patient anxiety • • Risk, harm, cost: Cost of assessment tools/examina- tions • • Benefit-harm assessment: Preponderance of benefit • • Value judgments: The Guideline Development Group believes that postoperative voice assessment is not being performed universally, in the identified time frame. • • Intentional vagueness: The documentation time is stated as between 2 weeks and 2 months because there is no evidence on the optimal time, but the GDG suggests that the evaluation should be late enough to overcome transient postoperative changes but early enough to allow effective intervention. • • Role of patient preferences: No role in documenting the outcome, but a significant role in the choice and extent of outcome assessment • • Exclusions: None • • Policy level: Recommendation Supporting text. The purpose of this statement is to improve quality of care by making explicit an important aspect of outcome assessment that may or may not be routinely included in the care of patients after surgery. The result of this outcome assessment (change in voice vs no change in voice) is used subsequently (Statement 10) to prioritize patients for laryngeal examination after surgery. Inherent in this approach is the assumption that early detection of voice change and potential nerve injury after surgery allows early intervention and management that may improve outcomes. The surgeon can document whether or not there has been a voice change by simply making a note in the patient’s medical record to this effect. The actual determination of voice change, or assessment of voice if done, does not need to be performed by the surgeon, but may be done by any clinician responsible for routine ongoing care, which includes the operating sur- geon or his or her designee, the endocrinologist, the primary care provider (internist, family physician, gynecologist), nurse practitioner, or physician’s assistant. The surgeon’s obligation is to ensure that the results of this assessment or screening process are documented in the medical record and refer as necessary.

STATEMENT 9. POSTOPERATIVE VOICE ASSESS- MENT: The surgeon should document whether there

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