2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

S INCLAIR ET AL .

thyroid surgery. 9–11 Only recently has increased awareness of the importance of voice outcomes for thyroid surgical patients led to the publication of a number of articles on this topic, with several large surgical and medical societies, including the American Academy of Otolaryngology Head and Neck Surgery (AAO/HNS), the American Thyroid Association (ATA), and the American Head and Neck Society (AHNS), publishing best practice guidelines relat- ing to voice, laryngeal function, and laryngeal examination in patients undergoing thyroid surgery. 12–14 Although these guidelines predominantly address thyroid surgery, they are also relevant to parathyroid surgery by virtue of the prox- imity of the larynx and RLN to the parathyroidectomy operative field. A recent AAO/HNS clinical practice guide- line recommends preoperative laryngoscopy in all patients undergoing thyroid surgery when the voice is abnormal, if there is preoperative suggestion of malignancy with extra- thyroidal extension, or if there is a history of surgery in which the vagus or RLN was at risk. 12 The ATA clinical guidelines from 2009 on thyroid nodules and differentiated thyroid cancer made no reference to laryngeal examination, however, the recently published 2015 guidelines recom- mend laryngeal examination for all patients undergoing thyroid surgery who are at high risk for nerve injury (pre- operative voice abnormalities, history of cervical or upper chest surgery, thyroid cancer with known posterior exten- sion, or extensive cervical node metastases) in accordance with the AAO/HNS clinical practice guidelines. 14 The AHNS recommends laryngeal examination for all patients with thyroid malignancy. 13 Similarly, the British Thyroid Association recommends the larynx be examined in patients with preoperative voice changes and for those undergoing thyroid cancer surgery, and the National Com- prehensive Cancer Network guidelines recommend a pre- operative laryngeal examination for all patients with papillary, follicular, Hurthle cell, and medullary cancers (www.NCCN.org). The German Association of Endocrine Surgeons 15 and a consensus statement of the British Asso- ciation of Endocrine and Thyroid Surgeons (www.baets. org, 2010) both recommend that all patients undergoing thyroid surgery should have preoperative and postoperative laryngeal examinations. ATA guidelines for anaplastic thy- roid carcinoma strongly recommend every patient undergo initial evaluation of the vocal folds. 16 PURPOSE This AHNS consensus statement focuses on the techni- ques of laryngeal examination for patients undergoing thyroidectomy and parathyroidectomy. This document describes the procedure and results of the consensus panel of the AHNS, which is the principal United States profes- sional organization dedicated to head and neck surgical cancer with substantial expertise in management of thy- roid and parathyroid surgical disorders as well as defini- tive expertise in the examination, evaluation, and surgical management of the larynx. This document is intended to help guide all clinicians who diagnose or manage adult patients with thyroid disease for whom surgery is indi- cated, contemplated, or has been performed. Clinicians may be from varied specialties, including otolaryngology, general surgery, endocrinology, radiation oncology,

nuclear medicine, internal medicine, speech-language pathology, family medicine, anesthesiology, and nursing. The purpose of this article was to make recommenda- tions regarding the optimal laryngeal examination techni- que(s) to be used prethyroid and postthyroid surgery for adult patients. Through this work, we seek to reduce the unnecessary variation in the management of patients undergoing thyroid surgery, to clarify limitations of dif- ferent laryngeal examination techniques using current best evidence, and to help identify those areas where addi- tional research is necessary. Ultimately, we endeavor to provide sound basic clinical guidance in the management of thyroid surgical patients as it relates to voice and the larynx. Although modifications of the techniques described may be required for pediatric patients, many techniques are also useful in this population. The recom- mendations in this article are not intended to limit or restrict care provided by clinicians based on the assess- ment of individual patients but instead to help guide clini- cians with their decision-making for any given patient. Members of the author panel were selected in part from the membership of the AHNS and its Endocrine Surgical Committee. Both otolaryngologists and general surgeons with expertise in head and neck endocrine surgery were included as well as representation from medical endocrinol- ogy and radiology. Each author was assigned a laryngeal examination technique based on his or her particular spe- cialty. Literature searches were performed to identify relevant articles in multiple databases, including the Cochrane Library, EMBASE, PubMed, Infobase, the Cochrane Central Register of Controlled Trials (CENTRAL), and MEDLINE. Search terms included thyroidectomy, voice, larynx, vocal fold paralysis, recurrent laryngeal nerve, superior laryngeal nerve, flexible laryngoscopy, transcutaneous laryngeal ultra- sound, and thyroid carcinoma. After each author had submit- ted their contribution, the final article was collated and consensus recommendations made regarding optimal laryn- geal examination technique(s) to be used prethyroid and post- thyroid surgery. The manuscript was then distributed to members of the AHNS Endocrine Committee and governing counsel for further feedback. RESULTS Recommendations Preoperative laryngeal examination. Preoperative laryngeal examination should be performed on all patients undergoing thyroid surgery who are at high risk for nerve injury (preoperative voice abnormal- ities, history of cervical or upper chest surgery, thyroid cancer with known posterior extension, or extensive cer- vical node metastases). All patients should be considered for postoperative laryngeal examination, par- ticularly where research regarding nerve paralysis is being undertaken. AAO-HNS and ATA guidelines recommend laryngeal examination if postoperative voice abnormalities are present. Postoperative laryngeal examination.

HEAD & NECK—DOI 10.1002/HED JUNE 2016

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