Advertisement

Hormones

, Volume 13, Issue 1, pp 5–15 | Cite as

Hoarseness after thyroidectomy: Blame the endocrine surgeon alone?

  • Demetrios Moris
  • Eleftherios Mantonakis
  • Marinos Makris
  • Adamantios Michalinos
  • Spiridon Vernadakis
Review

Abstract

OBJECTIVE

Hoarseness is a postoperative complication of thyroidectomy, mostly due to damage to the recurrent laryngeal nerve (RLN). Hoarseness may also be brought about via vocal cord dysfunction (VCD) due to injury of the vocal cords from manipulations during anesthesia, as well as from psychogenic disorders and respiratory and upper-GI related infections. We reviewed the literature aiming to explore these potential surgical and non-surgical causes of hoarseness beyond thyroidectomy and the role of the endocrine surgeon. Is he/she alone to blame?

METHODs/MATERIAL

The MEDLINE/PubMed database was searched for publications with the medical subject heading “hoarseness” and keywords “thyroidectomy”, “RLN”, “VCD” or “intubation”. We restricted our search till up to May 2013.

RESULTS

In our final review we included 80 articles and abstracts that were accessible and available in English. We demonstrated the incidence of hoarseness stemming from surgical and non-surgical causes and also highlighted the role of intubation as a potential cause of injury-related VCD.

CONCLUSIONS

Hoarseness is a relatively common complication of thyroidectomy, which can be attributed to many factors including surgeon’s error or injuries during intubation as well as to other non-surgical causes. However, compared to procedures such as cervical spine surgery, mediastinal surgery, esophagectomy and endarterectomy, thyroidectomy would seem to be a procedure with a relatively low rate of recurrent laryngeal nerve palsies (RLNPs). It is often difficult to determine whether the degree of hoarseness after thyroidectomy should be attributed only the surgical procedure itself or to other causes, for example intubation and extubation maneuvers. The differential diagnosis of postoperative hoarseness requires the use of specific tools, such as stroboscopy and intra- and extralaryngeal electromyography, while methods like acoustic voice analysis, with estimation of maximum phonation time and phonation frequency range, can distinguish between objective and subjective deterioration in the voice. The importance of medical history should be also emphasized.

Key words

Hoarseness Intubation Recurrent laryngeal nerve (RLN) Thyroidectomy Vocal cord dysfunction (VCD) 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Lombardi CP, Raffaelli M, D’Alatri L, et al, 2006 Voice and swallowing changes after thyroidectomy in patients without inferior laryngeal nerve injuries. Surgery 140: 1026–1032.CrossRefGoogle Scholar
  2. 2.
    Sinagra DL, Montesinos MR, Tacchi VA, et al, 2004 Voice changes after thyroidectomy without recurrent laryngeal nerve injury. J Am Coll Surg 199: 556–560.CrossRefGoogle Scholar
  3. 3.
    Stojadinovic A, Shaha AR, Orlikoff RF, et al, 2002 Prospective functional voice assessment in patients undergoing thyroid surgery. Ann Surg 236: 823–832.CrossRefGoogle Scholar
  4. 4.
    Henry LR, Solomon NP, Howard R, et al, 2008 The functional impact on voice of sternothyroid muscle division during thyroidectomy. Ann Surg Oncol 15: 2027–2033.CrossRefGoogle Scholar
  5. 5.
    Soylu L, Ozbas S, Uslu HY, Kocak S, 2007 The evaluation of the causes of subjective voice disturbances after thyroid surgery. Am J Surg 194: 317–322.CrossRefGoogle Scholar
  6. 6.
    Wagner HE, Seiler C, 1994 Recurrent laryngeal nerve palsy after thyroid gland surgery. Br J Surg 81: 226–228.CrossRefGoogle Scholar
  7. 7.
    Schulte KM, Roher HD, 1999 Medico-legal aspects of thyroid surgery. Chirurg 70: 1131–1138.CrossRefGoogle Scholar
  8. 8.
    Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A, 2008 Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg 32: 1358–1366.CrossRefGoogle Scholar
  9. 9.
    Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W, 2002 Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 112: 124–133.CrossRefGoogle Scholar
  10. 10.
    Reeve TS, Delbridge L, Brady P, Crummer P, Smyth C, 1988 Secondary thyroidectomy: a twenty-year experience. World J Surg 12: 449–453.CrossRefGoogle Scholar
  11. 11.
    Bellantone R, Lombardi CP, Bossola M, et al, 2002 Total thyroidectomy for management of benign thyroid disease: review of 526 cases. World J Surg 26: 1468–1471.CrossRefGoogle Scholar
  12. 12.
    Bron LP, O’Brien CJ, 2004 Total thyroidectomy for clinically benign disease of the thyroid gland. Br J Surg 91: 569–574.CrossRefGoogle Scholar
  13. 13.
    Efremidou EI, Papageorgiou MS, Liratzopoulos N, Manolas KJ, 2009 The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: a review of 932 cases. Can J Surg 52: 39–44.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Liu Q, Djuricin G, Prinz RA, 1998 Total thyroidectomy for benign thyroid disease. Surgery 123: 2–7.CrossRefGoogle Scholar
  15. 15.
    Flynn MB, Lyons KJ, Tarter JW, Ragsdale TL, 1994 Local complications after surgical resection for thyroid carcinoma. Am J Surg 168: 404–407.CrossRefGoogle Scholar
  16. 16.
    Hay ID, Hutchinson ME, Gonzalez-Losada T, et al, 2008 Papillary thyroid microcarcinoma: a study of 900 cases observed in a 60-year period. Surgery 144: 980–987.CrossRefGoogle Scholar
  17. 17.
    Chao TC, Jeng LB, Lin JD, Chen MF, 1997 Reoperative thyroid surgery. World J Surg 21: 644–647.CrossRefGoogle Scholar
  18. 18.
    Lefevre JH, Tresallet C, Leenhardt L, Jublanc C, Chigot JP, Menegaux F, 2007 Reoperative surgery for thyroid disease. Langenbecks Arch Surg 392: 685–691.CrossRefGoogle Scholar
  19. 19.
    Terris DJ, Khichi S, Anderson SK, Seybt MW, 2010 Reoperative thyroidectomy for benign thyroid disease. Head Neck 32: 285–289.PubMedGoogle Scholar
  20. 20.
    Jatzko GR, Lisborg PH, Muller MG, Wette VM, 1994 Recurrent nerve palsy after thyroid operations—principal nerve identification and a literature review. Surgery 115: 139–144.PubMedGoogle Scholar
  21. 21.
    Chiang FY, Wang LF, Huang YF, Lee KW, Kuo WR, 2005 Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery 137: 342–347.CrossRefGoogle Scholar
  22. 22.
    Lamade W, Renz K, Willeke F, Klar E, Herfarth C, 1999 Effect of training on the incidence of nerve damage in thyroid surgery. Br J Surg 86: 388–391.CrossRefGoogle Scholar
  23. 23.
    Dralle H, Sekulla C, Haerting J, Timmermann W, et al, 2004 Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 136: 1310–1322.CrossRefGoogle Scholar
  24. 24.
    Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R, 1998 The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 228: 320–330.CrossRefGoogle Scholar
  25. 25.
    Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R, 2009 Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract 63: 624–629.CrossRefGoogle Scholar
  26. 26.
    Echternach M, Maurer CA, Mencke T, Schilling M, Verse T, Richter B, 2009 Laryngeal complications after thyroidectomy: is it always the surgeon? Arch Surg 144: 149–153.CrossRefGoogle Scholar
  27. 27.
    Thomusch O, Machens A, Sekulla C, et al, 2000 Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg 24: 1335–1341.CrossRefGoogle Scholar
  28. 28.
    Barczynski M, Konturek A, Cichon S, 2009 Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 96: 240–246.CrossRefGoogle Scholar
  29. 29.
    Zimmert M, Zwirner P, Kruse E, Braun U, 1999 Effects on vocal function and incidence of laryngeal disorder when using a laryngeal mask airway in comparison with an endotracheal tube. Eur J Anaesthesiol 16: 511–515.CrossRefGoogle Scholar
  30. 30.
    Yildirim ZB, Uzunkoy A, Cigdem A, Ganidagli S, Ozgonul A, 2012 Changes in cuff pressure of endotracheal tube during laparoscopic and open abdominal surgery. Surg Endosc 26: 398–401.CrossRefGoogle Scholar
  31. 31.
    Cavo JW Jr, 1985 True vocal cord paralysis following intubation. Laryngoscope 95: 1352–1359.CrossRefGoogle Scholar
  32. 32.
    Dralle H, Kruse E, Hamelmann WH, et al, 2004 Not all vocal cord failure following thyroid surgery is recurrent paresis due to damage during operation. Statement of the German Interdisciplinary Study Group on Intraoperative Neuromonitoring of Thyroid Surgery concerning recurring paresis due to intubation. Chirurg 75: 810–822.PubMedGoogle Scholar
  33. 33.
    Colton House J, Noordzij JP, Murgia B, Langmore S, 2011 Laryngeal injury from prolonged intubation: a prospective analysis of contributing factors. Laryngoscope 121: 596–600.CrossRefGoogle Scholar
  34. 34.
    Watanabe K, Hagiya K, Inomata S, Miyabe M, Tanaka M, Mizutani T, 2010 Bilateral vocal cord paralysis in a patient with chronic renal failure associated with Alport syndrome. J Anesth 24: 472–475.CrossRefGoogle Scholar
  35. 35.
    Mencke T, Echternach M, Kleinschmidt S, et al, 2003 Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology 98: 1049–1056.CrossRefGoogle Scholar
  36. 36.
    Mencke T, Echternach M, Plinkert PK, et al, 2006 Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial. Anesth Analg 102: 306–312.CrossRefGoogle Scholar
  37. 37.
    Nuutinen J, Karja J, 1981 Bilateral vocal cord paralysis following general anesthesia. Laryngoscope 91: 83–86.CrossRefGoogle Scholar
  38. 38.
    Rahman GA, 2009 Possible risk factors for respiratory complications after thyroidectomy: an observational study. Ear Nose Throat J 88: 890–892.PubMedGoogle Scholar
  39. 39.
    Liu J, Zhang X, Gong W, et al, 2010. Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multicenter study. Anesth Analg 111: 1133–1137.CrossRefGoogle Scholar
  40. 40.
    Kikura M, Suzuki K, Itagaki T, Takada T, Sato S, 2007 Age and comorbidity as risk factors for vocal cord paralysis associated with tracheal intubation. Br J Anaesth 98: 524–530.CrossRefGoogle Scholar
  41. 41.
    Birkholz T, Irouschek A, Saalfrank-Schardt C, Klein P, Schmidt J, 2012 Laryngeal morbidity after intubation with or without neuromuscular block in thyroid surgery using recurrent laryngeal nerve monitoring. Auris Nasus Larynx 39: 288–293CrossRefGoogle Scholar
  42. 42.
    Kambic V, Radsel Z, 1978 Intubation lesions of the larynx. Br J Anaesth 50: 587–590.CrossRefGoogle Scholar
  43. 43.
    Friedman M, Toriumi DM, 1989 Esophageal stethoscope. Another possible cause of vocal cord paralysis. Arch Otolaryngol Head Neck Surg 115: 95–98.CrossRefGoogle Scholar
  44. 44.
    Paulsen FP, Rudert HH, Tillmann BN, 1999 New insights into the pathomechanism of postintubation arytenoid subluxation. Anesthesiology 91: 659–666.CrossRefGoogle Scholar
  45. 45.
    Wason R, Gupta P, Gogia AR, 2004 Bilateral adductor vocal cord paresis following endotracheal intubation for general anaesthesia. Anaesth intensive Care 32: 417–418.PubMedGoogle Scholar
  46. 46.
    Lu YH, Hsieh MW, Tong YH, 1999 Unilateral vocal cord paralysis following endotracheal intubation—a case report. Acta Anaesthesiol Sin 37: 221–224.PubMedGoogle Scholar
  47. 47.
    Kolawole IK, Ishaq MS, 2008 Post-anaesthetic respiratory complaints following endotracheal anaesthesia in lower abdominal obstetric and gynaecology surgery. Niger J Clin Pract 11: 225–230.PubMedGoogle Scholar
  48. 48.
    Yamanaka H, Hayashi Y, Watanabe Y, Uematu H, Mashimo T, 2009 Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation. Br J Anaesth 103: 452–455.CrossRefGoogle Scholar
  49. 49.
    Jung A, Schramm J, Lehnerdt K, Herberhold C, 2005 Recurrent laryngeal nerve palsy during anterior cervical spine surgery: a prospective study. J Neurosurg Spine 2: 123–127.CrossRefGoogle Scholar
  50. 50.
    Jung A, Schramm J, 2010 How to reduce recurrent laryngeal nerve palsy in anterior cervical spine surgery: a prospective observational study. Neurosurgery 67: 10–15.CrossRefGoogle Scholar
  51. 51.
    Zhao J, Xu H, Li W, Chen L, Zhong D, Zhou Y, 2010 Intraoperative recurrent laryngeal nerve monitoring during surgery for left lung cancer. J Thorac Cardiovasc Surg 140: 578–582.CrossRefGoogle Scholar
  52. 52.
    Filaire M, Mom T, Laurent S, et al, 2001 Vocal cord dysfunction after left lung resection for cancer. Eur J Cardiothorac Surg 20: 705–711.CrossRefGoogle Scholar
  53. 53.
    Isono K, Sato H, Nakayama K, 1991 Results of a nationwide study on the three-field lymph node dissection of esophageal cancer. Oncology 48: 411–420.CrossRefGoogle Scholar
  54. 54.
    Pertl L, Zacherl J, Mancusi G, et al, 2011 High risk of unilateral recurrent laryngeal nerve paralysis after esophagectomy using cervical anastomosis. Eur Arch Otorhinolaryngol 268: 1605–1610.CrossRefGoogle Scholar
  55. 55.
    Nishimaki T, Suzuki T, Suzuki S, Kuwabara S, Hatakeyama K, 1998 Outcomes of extended radical esophagectomy for thoracic esophageal cancer. J Am Coll Surg 186: 306–312.CrossRefGoogle Scholar
  56. 56.
    Roberts JR, Wadsworth J, 2007 Recurrent laryngeal nerve monitoring during mediastinoscopy: predictors of injury. Ann Thorac Surg 83: 388–391.CrossRefGoogle Scholar
  57. 57.
    Widstrom A, 1975 Palsy of the recurrent nerve following mediastinoscopy. Chest 67: 365–366.CrossRefGoogle Scholar
  58. 58.
    Hamdan AL, Moukarbel RV, Farhat F, Obeid M, 2002 Vocal cord paralysis after open-heart surgery. Eur J Cardiothorac Surg 21: 671–674.CrossRefGoogle Scholar
  59. 59.
    Aburahma AF, Choueiri MA, 2000 Cranial and cervical nerve injuries after repeat carotid endarterectomy. J Vasc Surg 32: 649–654.CrossRefGoogle Scholar
  60. 60.
    Ballotta E, Da Giau G, Renon L, et al, 1999 Cranial and cervical nerve injuries after carotid endarterectomy: a prospective study. Surgery 125: 85–91.CrossRefGoogle Scholar
  61. 61.
    Schauber MD, Fontenelle LJ, Solomon JW, Hanson TL, 1997 Cranial/cervical nerve dysfunction after carotid endarterectomy. J Vasc Surg 25: 481–487.CrossRefGoogle Scholar
  62. 62.
    Collett PW, Brancatisano T, Engel LA, 1983 Spasmodic croup in the adult. Am Rev Respir Dis 127: 500–504.CrossRefGoogle Scholar
  63. 63.
    Rodenstein DO, Francis C, Stanescu DC, 1983 Emotional laryngeal wheezing: a new syndrome. Am Rev Respir Dis 127: 354–356.PubMedGoogle Scholar
  64. 64.
    Morris MJ, Christopher KL, 2010 Diagnostic criteria for the classification of vocal cord dysfunction. Chest 138: 1213–1223.CrossRefGoogle Scholar
  65. 65.
    Gavin LA, Wamboldt M, Brugman S, Roesler TA, Wamboldt F, 1998 Psychological and family characteristics of adolescents with vocal cord dysfunction. J Asthma 35: 409–417CrossRefGoogle Scholar
  66. 66.
    Lacy TJ, McManis SE, 1994 Psychogenic stridor. Gen Hosp Psychiatry 16: 213–223.CrossRefGoogle Scholar
  67. 67.
    Husein OF, Husein TN, Gardner R, et al, 2008 Formal psychological testing in patients with paradoxical vocal fold dysfunction. Laryngoscope 118: 740–747.CrossRefGoogle Scholar
  68. 68.
    Neri G, Castiello F, Vitullo F, DE Rosa M, Ciammetti G, Croce A, 2011 Post-thyroidectomy dysphonia in patients with bilateral resection of the superior laryngeal nerve: a comparative spectrographic study. Acta Otorhinolaryngol Ital 31: 228–234.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Baker J, 2003 Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports. J Voice 17: 308–318.CrossRefGoogle Scholar
  70. 70.
    Holinger PC, Holinger LD, Holinger SW, Seibel J, Holinger PH, 1980 Psychiatric manifestations of the post-thyroidectomy bilateral abductor vocal cord paralysis syndrome. Cases and theoretical issues. J Nerv Ment Dis 168: 46–49.CrossRefGoogle Scholar
  71. 71.
    Morris MJ, Christopher KL, 2012 Difficult-to-treat asthma or vocal cord dysfunction? Am J Respir Crit Care Med 185: 340; author reply 340–341.CrossRefGoogle Scholar
  72. 72.
    Rogers JH, Stell PM, 1978 Paradoxical movement of the vocal cords as a cause of stridor. J Laryngol Otol 92: 157–158.CrossRefGoogle Scholar
  73. 73.
    O’Connell MA, Sklarew PR, Goodman DL, 1995 Spectrum of presentation of paradoxical vocal cord motion in ambulatory patients. Ann Allergy Asthma Immunol 74: 341–344.PubMedGoogle Scholar
  74. 74.
    Powell DM, Karanfilov BI, Beechler KB, Treole K, Trudeau MD, Forrest LA, 2000 Paradoxical vocal cord dysfunction in juveniles. Arch Otolaryngol Head Neck Surg 126: 29–34.CrossRefGoogle Scholar
  75. 75.
    Perkner JJ, Fennelly KP, Balkissoon R, et al, 1998 Irritant-associated vocal cord dysfunction. J Occup Environ Med 40: 136–143.CrossRefGoogle Scholar
  76. 76.
    Andrianopoulos MV, Gallivan GJ, Gallivan KH, 2000 PVCM, PVCD, EPL, and irritable larynx syndrome: what are we talking about and how do we treat it? J Voice 14: 607–618.CrossRefGoogle Scholar
  77. 77.
    Allan PF, Abouchahine S, Harvis L, Morris MJ, 2006 Progressive vocal cord dysfunction subsequent to a chlorine gas exposure. J Voice 20: 291–296.CrossRefGoogle Scholar
  78. 78.
    Rosato L, Carlevato MT, De Toma G, Avenia N, 2005 Recurrent laryngeal nerve damage and phonetic modifications after total thyroidectomy: surgical malpractice only or predictable sequence? World J Surg 29: 780–784.CrossRefGoogle Scholar
  79. 79.
    Lombardi CP, Raffaelli M, De Crea C, et al, 2009 Long-term outcome of functional post-thyroidectomy voice and swallowing symptoms. Surgery 146: 1174–1181.CrossRefGoogle Scholar
  80. 80.
    Tekin M, Acar GO, Kaytaz A, Savrun FK, Celik M, Cam OH, 2012 Bilateral vocal cord paralysis secondary to head and neck surgery. J Craniofac Surg 23: 135–137.CrossRefGoogle Scholar

Copyright information

© Hellenic Endocrine Society 2014

Authors and Affiliations

  • Demetrios Moris
    • 1
    • 4
  • Eleftherios Mantonakis
    • 1
  • Marinos Makris
    • 2
  • Adamantios Michalinos
    • 1
  • Spiridon Vernadakis
    • 3
  1. 1.First Department of Surgery, “Laiko” General HospitalNational and Kapodistrian University of AthensAthensGreece
  2. 2.Department of Surgery and Cancer, St Mary’s HospitalImperial College of LondonLondonUK
  3. 3.Department of General, Visceral, and Transplantation SurgeryUniversity Hospital EssenEssenGermany
  4. 4.AthensGreece

Personalised recommendations