2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Otolaryngology–Head and Neck Surgery 148(6S)

Table 8. Causes of thyroidectomy-related dysphonia. 70,248-255 Neural

Functional Consequence

Impact onVoice Character

1. Recurrent laryngeal nerve (RLN) injury (complete or partial, transient or permanent)

Immobile and laterally displaced fold

Breathy voice, vocal fatigue, hoarseness

Inadequate closure of vocal folds (VF) with phonation and swallowing Loss of VF bulk and tone Bowing of VF Physical findings are not good predictors but, if present, may include: •  Posterior laryngeal rotation toward the paretic side, or shift of the petiole 256 • Bowing of theVF on the weak side • Inferior displacement of the affectedVF

2. External branch of the superior laryngeal nerve (EBSLN) injury (complete or partial, transient or permanent)

Vocal fatigue, decreased ability to raise pitch, inability to project voice, decreased pitch flexibility and range

Non-Neural

Functional Consequence

Impact onVoice Character

3. Direct cricothyroid muscle injury— transient myositis or direct injury 4. Regional soft tissue injury (in the presence of intact neurological function)

As for EBSLN

As for ESBLN

Laryngotracheal regional scar with fixation Voice fatigue, decrease in vocal range, speech becomes more monotone, vocal pitch can be lower Strap muscles denervation or trauma Local hematoma and/or edema

5. Intubation-related injuries

VF trauma (ie, edema, hematoma, laceration) Hoarseness, odynophagia

General: 6%-13%

VF granuloma

Vocal fold paresis (VFP): .04%

Arytenoid dislocation

6. Voice change from unrelated intercurrent upper respiratory tract infection (URTI)

Typically viral-related laryngitis unrelated to surgery, rarely associated withVFP

Hoarseness, breathy voice if VFP

treatment, it may be prudent to avoid further incisions in the neck with or without placement of foreign materials in that location. As with most surgical decisions, recommendations are made based on an individual patient’s medical condition, needs, and desires, as well as a surgeon’s familiarity or exper- tise with a particular procedure. Bilateral VFP (from bilateral RLN injury) typically results in both VFs assuming a more midline position and attenuates the glottic airway. Typically, patients with this injury have voices with minimal deficit, but are more symptomatic with dyspnea. 237 Treatment is focused on either bypassing the glot- tic obstruction with a tracheostomy or by widening the glottis, potentially at the expense of voice quality and with risk of poor deglutition and aspiration. Procedures to rehabilitate this problem have also been described as either temporary or per- manent. Suture lateralization of a VF can be performed as a tem- porary measure to improve the airway during the period after injury where long-term outcome is uncertain. 238 Permanent treatments include posterior transverse cordotomy or aryte- noid reduction and removal procedures. 239 SLN paralysis and paresis are more difficult to both recog- nize and treat. 240 Typically, deficits that patients experience include difficulty in modulating their voice and transitions from modal to high-pitched voice. They may also describe vocal fatigue and poor vocal endurance. Treatment is often

small neck incision that may be separate from the incision of the thyroid operation. They are performed in the operating room, typically under monitored local anesthesia with seda- tion. Improved voice quality is near immediate after the operation. Laryngeal reinnervation is typically performed via an anas- tomosis between the donor ansa cervicalis and the recipient RLN. 231 Although less commonly performed than framework procedures and injection laryngoplasty, reinnervation is a commonly offered procedure that may potentially partially improve VF position and bulk and may avoid long-term denervation atrophy of the laryngeal muscles. 225,231 The heal- ing period after this operation is protracted for up to a year, which some patients may find unfavorable. Patients are typi- cally bridged during this healing period with an injection laryngoplasty using a temporary agent. Ansa to RLN anasto- mosis have also been offered as an intraoperative procedure during thyroidectomy when RLN resection is necessary and is associated with improved postoperative vocal outcomes. 232 All procedures to rehabilitate UVFP are considered safe and effective with very high success rates documented. 225,233-236 Few direct comparisons have suggested that one procedure is superior to another. 225 The surgeon must bear in mind that if there is concern regarding aggressive thyroid malignancy with possible or probable local recurrence requiring further

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