These authors contributed equally to this work as first authors.
Voice change is a common complaint after thyroid surgery and has a significant impact on quality of life. The Korean Society of Laryngology, Phoniatrics and Logopedics assembled a task force to establish guideline recommendations on education, care, and management related to thyroid surgery. The guideline recommendations encompass preoperative voice education, management of anticipated voice change during surgery, and comprehensive voice care after thyroid surgery, and include in-depth information and up-to-date knowledge based on validated literature. The committee constructed 14 key questions (KQs) in three categories—preoperative (KQ 1–2), intraoperative (KQ 3–8), and postoperative (KQ 9–14) management—and developed 18 evidence-based recommendations. The Delphi survey reached an agreement on each recommendation. A detailed evidence profile is presented for each recommendation. The level of evidence for each recommendation was classified as high-quality, moderate-quality, or low-quality. The strength of each recommendation was designated as strong or weak considering the level of evidence supporting the recommendation. The guidelines are primarily targeted toward physicians who treat thyroid surgery patients and speech-language pathologists participating in patient care. These guidelines will also help primary care physicians, nurses, healthcare policymakers, and patients improve their understanding of voice changes and voice care after thyroid surgery.
Thyroid surgery is most often performed to treat thyroid cancer. Until 2014, thyroid cancer was the most common cancer in the Republic of Korea, ranking first in incidence among all cancers and ranking third among all malignant tumors in 2016. It is the second most common cancer in women and the most common cancer for both sexes in the 15–34 age group [
The extent of thyroidectomy remains debated due to potential complications, such as hypoparathyroidism and recurrent laryngeal nerve (RLN) injury, impairing quality of life (QOL), although total thyroidectomy (TT) has long been considered as the standard treatment for thyroid cancer. TT controls thyroid cancer with multiple tumor foci and facilitates the interpretation of serum thyroglobulin for predicting recurrence during the postoperative period. Radioactive iodine may be added after TT to ablate remnant thyroid tissues and potential residual lesions. Nevertheless, the American Thyroid Association (ATA) and Korean Thyroid Association (KTA) recommend a more conservative thyroid surgery approach, suggesting that thyroid lobectomy may be enough for differentiated thyroid cancer smaller than 4 cm without extrathyroidal extension [
Voice change is a common problem that patients encounter after thyroid surgery. Approximately 30% to 80% of patients complain of voice alteration after thyroid surgery [
Speech is a tool for sharing thoughts with others, communicating ideas, and achieving social activity; thus, voice alterations have a profound impact on QOL [
The guidelines are intended for all clinicians treating thyroid surgery and speech-language pathologists (SLPs) participating in patient care. These guidelines also aim to promote an improved understanding of voice change after thyroid surgery among policymakers, counselors, and patients scheduled to undergo thyroid surgery.
The committee was organized into advisory, operating, and working groups. The operating members included the committee chair and two executives appointed by the KSLPL. The advisory group consisted of 19 KSLPL board members with extensive clinical experience. The working group consisted of 19 KSLPL members. The advisory and operating groups identified the subject requiring CPG development as “voice care for patients undergoing thyroid surgery” and then confirmed the 14 key questions (KQ; consisting of two preoperative, six intraoperative, and six postoperative questions) (
A literature search of the OVID Medline, Embase, Cochrane Library, and KoreaMED databases was conducted on July 25, 2019, using search words selected by the committee. The retrieved articles were collected in Endnote X9 (Thomson Reuters, New York, NY, USA). After automatically removing duplicates, the committee members selected potentially relevant papers according to the title/abstract. The inclusion criteria were as follows: (1) human studies, (2) article publication type, and (3) English-language text. The committee members then conducted a full-text review to determine the final relevant papers. The search strategy, number of included/excluded articles, and search are presented in
We classified the literature as (1) randomized controlled trials (RCTs) or well-conducted systematic reviews or meta-analyses, (2) prospective cohort studies without randomization, (3) casecontrol studies with participants from multiple centers, (4) retrospective studies, and (5) expert opinions or case series. For quality assessment of studies, the Cochrane Risk of Bias for RCTs, the Risk of Bias Assessment Tool for Nonrandomized Studies v1.5 for non-critical control studies (non-RCTs and observational studies), and A Measurement Tool to Assess the Methodological Quality of Systematic Reviews for systematic reviews or meta-analysis were used [
Consensus on the recommendations for each KQ was reached through a Delphi survey. For the Delphi consensus, we sent e-mails to doctors specializing in thyroid surgery for more than 10 years in the KSLPL and executive director members of the KTA, Korean Association of Thyroid and Endocrine Surgeons, Korean Intraoperative Neural Monitoring Society, and Korean Academy of Speech-Language Pathology and Audiology. A total of 73 experts responded to the survey. The respondents were asked to choose one of the following responses: fully agree, agree, neither agree nor disagree, disagree, or fully disagree. A final agreement was reached for each survey item if more than twothirds of the panel members responded with “fully agree” or “agree.”
The guideline will be updated every 5 years to reflect new clinical data and the latest trends.
KQ 1. Is preoperative laryngeal visual examination necessary?
Population: patients undergoing thyroid surgery
Intervention: performing a preoperative laryngeal visual examination
Comparison: not performing a preoperative laryngeal visual examination
Outcome: detecting the rate of laryngeal abnormalities
The clinician should perform preoperative laryngeal visualization in all patients undergoing thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=57): fully agree (40, 70.2%), agree (8, 14.0%), neither agree nor disagree (2, 3.5%), disagree (7, 12.3%), fully disagree (0)
Preoperative laryngeal visualization is recommended because it can (1) assess vocal fold mobility as well as vocal fold mucosal lesions in patients with vocal symptoms, (2) identify normal-voiced patients with pre-existing vocal fold paralysis (VFP), (3) predict the possibility of extrathyroidal extension of thyroid cancers and establish a proper surgical plan, and (4) evaluate the baseline status of preoperative laryngeal function for postoperative voice care.
Farrag et al. [
The presence of VFP before thyroid surgery implies the invasive nature of thyroid cancer because gross invasion of the RLN by thyroid cancer is correlated with a high recurrence rate and mortality rate [
Vocal fold mobility can be assessed using various instruments, including a mirror, flexible or rigid laryngeal endoscopy, stroboscopy, ultrasonography, and electromyography. The approach used is usually dependent on the institutional facilities. Among them, the flexible laryngoscope has several advantages over other laryngeal instruments. It enables laryngeal visualization with less gag reflex and enables the observation of the vocal fold status in the anteriorly displaced arytenoid and during compensatory supraglottic movement [
Rigid laryngeal endoscopy is commonly conducted to visualize laryngeal diseases. Still, it may be challenging to observe vocal fold lesions using the rigid laryngeal endoscopy when the gag reflex is provoked or there is anterior displacement of the arytenoid cartilage due to VFP. Laryngeal stroboscopy is the gold standard for assessing mucosal wave propagation during phonation. It also enables a detailed evaluation of vibratory patterns, such as the regularity and symmetry of vibrations, and facilitates the diagnosis of incomplete VFP or combined laryngeal mucosal lesions [
Most otolaryngologists use laryngeal endoscopy (rigid or flexible) to assess vocal fold mobility, and endocrine surgeons usually refer to otolaryngologists to evaluate the vocal fold movement of patients with voice change in Korea. The British Thyroid Association recommends a laryngeal status examination for all patients with thyroid cancer or voice change undergoing thyroid surgery [
The economic burden of rising medical expenses is another consideration. One reason why preoperative laryngeal examinations are performed only in selected patients may be attributed to the cost-to-benefit ratio, especially in low-risk thyroid cancer patients without voice change [
KQ 2. Is a preoperative voice assessment necessary?
Population: patients undergoing thyroidectomy
Intervention: preoperative voice assessment
Comparison: no preoperative voice assessment
Outcome: usefulness of the assessment
1. The clinician should check the voice status of all patients undergoing thyroid surgery (strong recommendation, moderate-quality evidence)
Expert opinion (n=73): fully agree (47, 64.4%), agree (15, 20.5%), neither agree nor disagree (7, 9.6%), disagree (3, 4.1%), fully disagree (0), no answer (1, 1.4%)
2. In the following cases, a preoperative voice assessment is indicated (strong recommendation, moderate quality of evidence)
- Patients with voice problems before surgery
- Patients with abnormal findings on a laryngeal visual examination before surgery
- Patients at high risk of voice change after surgery
Expert opinion (n=73): fully agree (52, 71.2%), agree (18, 24.7%), neither agree nor disagree (2, 2.7%), disagree (1, 1.4%), fully disagree (0)
Approximately 33% of patients scheduled for thyroidectomy demonstrate preoperative voice symptoms [
A Voice Handicap Index (VHI; VAS) can be used to describe patients’ voice status in two aspects: the quality of the voice and the degree to which voice symptoms (if any) affect daily life. The patient assigns a score between 0 and 100 points; a score of 0 means normal, while a higher value indicates abnormal findings [
There are several ways to evaluate a patient’s voice before surgery, including patient self-assessment, psychosomatic assessment by an experienced SLP, and acoustic analysis of a voice recording using computer software. The former two methods are easy, simple, and highly reproducible methods that do not need specialized assessment equipment. First, for the self-assessment method, patients are asked to report whether they have noticed changes in their vocal pitch, loudness, quality, or endurance. Among various self-assessment questionnaires, the VHI developed by Jacobson in 1997 has been widely used. In 2002, the Agency for Healthcare Research and Quality recognized that, among various voice disorder questionnaires, only the VHI met reliability and validity criteria. Its usefulness has been verified through many studies [
Patients may also undergo an auditory perceptual assessment, wherein evaluators subjectively evaluate the patient’s voice. The most representative tests are the Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Two or more experts (a doctor or SLP) listen to samples of the patient’s voice (/a/ or /i/ or predefined sentence) and assess their voice status. GRBAS evaluates the voice in terms of the overall grade, roughness, breathiness, asthenia, and strain [
KQ 3. Is perioperative counseling about the impact of surgery on voice and vocal hygiene necessary for thyroid surgery patients?
Population: patients undergoing thyroid surgery
Intervention: perioperative patient counseling on voice outcomes
Comparison: no perioperative patient counseling on voice outcomes
Outcome: voice outcomes and patients’ satisfaction
1. The clinicians or SLP should counsel all patients undergoing thyroid surgery about the potential voice impact of thyroid surgery (strong recommendation, low-quality evidence).
Expert opinion (n=73): fully agree (42, 57.5%), agree (27, 37.0%), neither agree nor disagree (2, 2.7%), disagree (1, 1.4%), strongly disagree (0), no response (1, 1.4%)
2. Clinicians or SLPs should provide education on vocal hygiene to improve voice quality in patients with voice changes after surgery (strong recommendation, low-quality evidence).
Expert opinion (n=73): fully agree (42, 57.5%), agree (27, 37.0%), neither agree nor disagree (2, 2.7%), disagree (1, 1.4%), strongly disagree (0), no response (1, 1.4%)
Clinicians should educate patients about the potential risks of voice change, voice hygiene, and possible management of postoperative voice change prior to surgery. The cooperation of patients and their family members is vital for the optimal treatment of voice changes after surgery [
The following should be included in the patient’s education [
Several types of patient education information forms can be used. In a randomized study of 125 patients undergoing thyroid surgery, patients who were provide written educational materials, such as pamphlets (50.3%), showed higher recall rates for risk factors than those who were not (29.5%) [
Vocal hygiene education helps produce a normal voice during phonation, forestalling undesirable postural and lifestyle habits (
Vocal hygiene education after thyroid surgery is frequently implemented as part of voice therapy programs. SLPs should monitor patients’ compensatory vocal habits and encourage them to maintain vocal hygiene and receive voice therapy [
Although all patients undergoing surgery should receive voicerelated patient education before/after surgery, it is especially important for professional voice users with high vocal demands or patients with a high risk of voice change due to surgery [
KQ 4. Does perioperative systemic corticosteroid administration benefit voice quality after thyroid surgery?
Population: patients undergoing thyroid surgery
Intervention: systemic corticosteroid administration
Comparison: no administration of systemic steroid
Outcome: improvement of postoperative voice quality
Systemic corticosteroid administration is not recommended to improve voice quality after thyroid surgery (strong recommendation, high-quality evidence).
Expert opinion (n=57): fully agree (27, 47.4%), agree (17, 29.8%), neither agree nor disagree (8, 14.0%), disagree (8, 14.0%), fully disagree (5, 8.8%)
Corticosteroid administration for facial nerve paralysis and idiopathic sudden sensory neural hearing loss has been reported to decrease the symptom duration and improve the prognosis [
Wang et al. [
KQ 5. What are the surgical techniques to preserve the EBSLN for voice preservation during thyroidectomy?
Population: patients undergoing thyroid surgery
Intervention: identification of the EBSLN
Comparison: no identification of the EBSLN
Outcome: preservation of voice
The surgeon should carefully dissect through the avascular plane between the superior pole of the thyroid glands and the cricothyroid muscle and ligate the vessel pedicles near the thyroid capsule to preserve the EBSLN (strong recommendation, moderate-quality evidence).
Expert opinion (n=57): fully agree (48, 84.2%), agree (8, 14.0%), neither agree nor disagree (0), disagree (0), fully disagree (0), no response (1, 1.8%)
The EBSLN, a branch of the vagus nerve, is the motor nerve to the cricothyroid muscle, an essential tensor of the vocal folds. EBSLN injury results in an inability to reach high pitches, loss of ability to project the voice, and vocal fatigue during prolonged speech [
KQ 6. What are the surgical techniques to preserve the RLN for voice preservation during thyroidectomy?
Population: patients undergoing thyroid surgery
Intervention: identification of the RLN
Comparison: no identification of the RLN
Outcome: preservation of voice
1. The surgeon should identify the nerve by direct visualization during thyroid surgery to preserve the RLN (strong recommendation, moderate-quality evidence).
Expert opinion (n=57): fully agree (46, 80.7%), agree (9, 15.8%), neither agree nor disagree (2, 3.5%), disagree (0), fully disagree (0)
2. The surgeon should perform capsular dissection of the thyroid gland to preserve the RLN during thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=57): fully agree (12, 21.1%), agree (30, 52.6%), neither agree nor disagree (9, 15.8%), disagree (5, 8.8%), fully disagree (0), no response (1, 1.8%)
Visual identification of the RLN during thyroid surgery decreases the rate of permanent nerve injury [
KQ 7. Is intraoperative neuromonitoring necessary to preserve voice quality during thyroid surgery?
Population: patients undergoing thyroid surgery
Intervention: intraoperative neuromonitoring
Comparison: no intraoperative neuromonitoring
Outcome: voice preservation
Intraoperative neuromonitoring is useful for reducing RLN injury during thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=66): fully agree (47, 71.2%), agree (17, 25.8%), neither agree nor disagree (2, 3.0%), disagree (0), fully disagree (0)
No consensus has been reached on whether the use of intraoperative neuromonitoring (IONM) always lowers the risk of VFP in thyroid surgery. A recent meta-analysis suggested that IONM reduces the risk of postoperative nerve damage, although a consistent conclusion was not reached in some case series [
In particular, when TT is performed, bilateral VFP can cause serious side effects, such as dyspnea; therefore, IONM is helpful [
In Korea, IONM during thyroid surgery is allowed and covered by national insurance for the following conditions: recurrent thyroid cancer in the central compartment region; patients with unilateral vocal cord paralysis before surgery; thyroid cancer with definite central compartment lymph node metastasis; lesions caused by extracapsular involvement of the thyroid gland (T4); and high-risk thyroid and parathyroid surgery, such as advanced thyroid cancer, and Graves’ disease, or prominent goiter. IONM in thyroid surgery is recommended for identifying the RLN status and predicting the presence of RLN damage, especially for high-risk patients or when performed by inexperienced surgeons because it is thought that IONM could lower the risk of RLN palsy after thyroid surgery.
KQ 8. Does intraoperative RLN reinnervation improve the postoperative voice quality?
Population: patients with unilateral RLN injury during thyroidectomy
Intervention: re-innervation of RLN
Comparison: no re-innervation
Outcome: voice quality
The surgeon should consider RLN reinnervation if the RLN is transected during surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=57): fully agree (29, 40.4%), agree (24, 42.1%), neither agree nor disagree (10, 17.5%), disagree (0), fully disagree (0)
Apparent unilateral RLN injury may occur during thyroid surgery when the RLN is retracted or sacrificed due to abutting or invasive cancer. In those cases, the surgeon should consider additional surgery for voice improvement, including intraoperative RLN reinnervation and/or intra- or postoperative medialization laryngoplasty, such as IL, medialization thyroplasty (MT), or arytenoid adduction (AA) (see KQ 11) [
A combination of medialization laryngoplasty and reinnervation may be required for better voice improvement [
RLN reinnervation techniques include primary anastomosis, nerve graft (ansa cervicalis, hypoglossal nerve, or vagus nerve to RLN), and neuromuscular pedicle graft [
KQ 9. Is a postoperative laryngeal visual examination necessary?
Population: patients undergoing thyroid surgery
Intervention: preoperative laryngeal examination
Comparison: no preoperative laryngeal examination
Outcome: detection rates of preoperative laryngeal abnormalities
1. The clinician should check patients’ voice after thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=73): fully agree (41, 56.2%), agree (22, 30.1%), neither agree nor disagree (5, 6.8%), disagree (4, 5.5%), fully disagree (0), no response (1, 1.4%)
2. The clinician should examine the vocal fold status of patients with voice change after thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=57): fully agree (43, 75.4%), agree (11, 19.3%), neither agree nor disagree (2, 3.5%), disagree (1, 1.8%), fully disagree (0)
Approximately 30%–80% of patients experience voice changes immediately after surgery. Symptoms range from non-specific, including weakened vocal strength or difficulty maintaining long utterances, to severe hoarseness [
According to a systematic review of 27 articles investigating 25,000 patients after thyroid surgery, the incidence of temporary and permanent RLN palsy was 9.8% (1.4%–38.4%) and 2.3% (0%–18.6%), respectively. The RLN palsy rate varied widely according to the method of larynx examination [
Early recognition of postoperative VFP may enable an early intervention and improve long-term clinical efficacy by reducing muscle atrophy of the vocal folds or secondary compensatory dysfunction, which will decrease voice and swallowing complications, thereby improving patients’ QOL [
KQ 10. Is a multidimensional voice assessment necessary after thyroid surgery?
Population: patients who underwent thyroid surgery
Intervention: postoperative voice assessment
Comparison: no postoperative voice assessment
Outcome: usefulness of the assessment
The clinician or SLP should consider a multidimensional voice assessment for patients with voice problems after thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=73): fully agree (45, 61.6%), agree (20, 27.4%), neither agree nor disagree (7, 9.6%), disagree (1, 1.4%), fully disagree (0)
If any abnormalities are detected immediately after surgery on voice screening and laryngeal visual inspection, an objective voice assessment is required [
Even though various time points have been suggested, postoperative voice assessment is most likely within 2 weeks to 2 months after surgery [
When the patient shows difficulty producing short utterances, MPT is a useful measure [
KQ 11. Are vocal fold medialization procedures necessary for patients with unilateral VFP after thyroid surgery?
Population: patients with unilateral VFP after thyroid surgery
Intervention: vocal fold medialization
Comparison: not performing vocal fold medialization
Outcome: improvement of postoperative voice quality
1. Close observation for 6–12 months is feasible for patients with unilateral VFP with low vocal demands and no risk of aspiration after thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=66): fully agree (23, 34.8%), agree (39, 59.1%), neither agree nor disagree (1, 1.5%), disagree (2, 3.0%), fully disagree (0), no response (1, 1.5%)
2. Vocal fold medialization is recommended to improve voice quality and reduce aspiration for patients with unilateral VFP after thyroid surgery (strong recommendation, moderate-quality evidence).
Expert opinion (n=66): fully agree (18, 27.3%), agree (28, 42.4%), neither agree nor disagree (16, 24.2%), disagree (2, 3.0%), fully disagree (0), no response (2, 3.0%)
The management of patients with unilateral VFP after thyroid surgery is similar to the general protocols for unilateral VFP management. If the cause of nerve damage following thyroid surgery is clear, the initial plan should be established accordingly. Clinicians could choose to “wait-and-see” in patients with low vocal demand, few VFP complications, and no apparent RLN injury [
Various treatment options exist in the presence of a clear nerve section, such as tumor invasion during surgery. The surgeon could choose among nerve grafts (see KQ 8), IL, laryngeal framework surgery (LFS), such as MT and AA, and combinations of these treatments. Although some procedures, such as IL, and MT, could be performed in conjunction with surgery, it is usually recommended to wait a couple of months before performing LFS because the precise vocal fold position will be obvious after mucosal swelling has subsided and muscular atrophy has progressed. However, IL can be performed using temporary injection materials to improve voice quality during the early period of VFP before choosing permanent treatment [
Injection materials for IL are divided into short- and long-acting materials. Short-acting materials include gelatin, collagen-based products, carboxymethylcellulose, and hyaluronic acid (HA). Those materials have been reported to last up to 2 to 6 months. Long-acting materials include calcium hydroxyapatite (CaHA) and polymethylmethacrylate microspheres in bovine collagen. They can be maintained for more than 2 years [
The technique for vocal fold injection following thyroid surgery is similar to that of unilateral VFP from any other cause. The initial injection starts with the posterior glottis and proceeds into the middle portion of the vocal fold. The ideal injection location is slightly lower than the vocal fold’s free margin and into the thyroarytenoid muscle. Superficial injection into the lamina propria may interfere with the vibration of the vocal folds and worsen the voice quality. Over-injection by 15%–30% is recommended, considering the extent of subsequent absorption. Following thyroid surgery, surgical field fibrosis and adhesion may hinder the identification of surgical landmarks for IL, resulting in difficulty finding the exact injection site. For those cases, it is helpful to perform IL under general anesthesia rather than local anesthesia or to use the trans-thyroid cartilage or trans-thyrohyoid membrane approach under local anesthesia. When choosing the cricothyroid approach, several trial injections from the thyroid cartilage to the cricoid cartilage may be needed. The clinician may identify the proper injection site with a step-down injection by visualizing the needle tip sticking out under the mucosa below the glottis with the laryngoscope.
LFS is used to treat permanent unilateral VFP [
AA induces a neutral position of the paralyzed vocal fold by manipulating the arytenoid cartilage’s muscular process [
KQ 12. Is surgical treatment necessary for patients with bilateral VFP after thyroid surgery?
Population: patients with bilateral VFP after thyroid surgery
Intervention: surgical treatment
Comparison: no surgical treatment
Outcome: maintenance of airway patency
Clinicians should provide appropriate management to maintain respiratory function for patients with bilateral VFP (strong recommendation, moderate-quality evidence).
Delphi consensus (n=66): fully agree (44, 66.7%), agree (20, 30.3%), neither agree nor disagree (2, 3.0%), disagree (2, 3.0%), fully disagree (0)
With the development of surgical skills (see KQs 5–7), the incidence of bilateral VFP after thyroid surgery has decreased. Symptoms vary depending on the degree of gap between the paralyzed vocal folds, ranging from voice changes to shortness of breath, wheezing, and swallowing difficulty. Patients may present with only airway symptoms with a normal voice. Postoperative laryngoscopy confirms the presence of bilateral vocal fold immobility. CT and laryngeal electromyography help distinguish immobility from nerve injury [
Bilateral VFP treatment aims to maintain a patent upper respiratory tract and make daily activities possible. The treatment modality and timing of surgery for bilateral VFP following thyroid surgery are determined according to the possibility of nerve recovery, accompanying symptoms, and the degree of the objectively evaluated vocal fold gap. If the patients’ vocal fold gaps are sufficient to maintain breathing and mild airway symptoms, conservative treatment (e.g., close observation, oxygen supply, and humidity maintenance) is possible. Clinicians may inject botulinum toxin into the vocal folds to widen the gap and control airway problems [
As alternative methods for widening the airway, laser cordotomy or arytenoidectomy can be conducted for reducing respiratory compromise in patients with bilateral VFP [
KQ 13. Is postoperative neck exercise needed to improve neck discomfort in patients who undergo thyroid surgery?
Population: thyroidectomy patients
Intervention: neck exercise
Comparison: no neck exercise
Outcome: improvement of neck discomfort
Neck exercise may help to reduce postoperative neck discomfort after thyroid surgery (weak recommendation, low-quality evidence).
Expert opinion (n=57): fully agree (16, 28.1%), agree (31, 54.4%), neither agree nor disagree (10, 17.5%), disagree (0), fully disagree (0)
Approximately 80% of patients who receive thyroidectomy complain of posterior neck pain and experience a decreased range of neck flexion and extension. They have significantly more trigger points in the neck muscles, such as the scalene, sternocleidomastoid, trapezius, and levator scapulae [
Another study compared neck pain, disability score, and neck sensitivity a week and a month postoperatively between a group that did not perform neck stretching exercises and a group in which neck stretching exercises were initiated the day after surgery. A week after the operation, the stretching neck group showed a significant improvement in neck pain, disability score, and neck sensitivity. However, there was no significant difference between the two groups a month after surgery [
KQ 14. Is voice therapy necessary for optimizing voice outcomes and improving voice-related QOL after thyroid surgery?
Population: patients with thyroid surgery
Intervention: voice therapy
Comparison: no voice therapy
Outcome: improvement in voice and QOL
Voice therapy is helpful to improve voice quality and QOL for patients with voice problems after thyroid surgery (weak recommendation, moderate-quality evidence).
Expert opinion (n=57): fully agree (18, 31.6%), agree (31, 54.4%), neither agree nor disagree (7, 12.3%), disagree (0), fully disagree (0)
In the postoperative period, patients’ responses to voice changes vary, ranging from not being aware of or ignoring the problem to requiring treatment, considering the QOL [
Even without RLN injury, patients frequently present a wide variety of symptoms as a result of adhesions in the surgical field. Typical characteristics include voice change, vocal fatigue, vocal effort, changes in habitual vocal pitch, decreased vocal range, muscle cramps, and cervical stiffness such as muscle tension dysphonia [
Voice abnormalities due to RLN damage can be significantly improved by voice therapy alone. Even if VF medialization injection procedures or thyroplasty are planned, the effectiveness of voice improvement can be enhanced through preoperative or postoperative voice treatment [
EBSLN damage causes paralysis of the cricothyroid muscle, causing problems with the stretching, stiffening, or thinning of the vocal cords. Patients may experience hoarseness, vocal fatigue, decreased vocal loudness and pitch range, difficulty in controlling vocal intensity and pitch, and transitions from modal to highpitched falsetto [
Voice change is one of the main complaints after thyroid surgery, resulting in a decrease in QOL. The clinician should check the voice status and perform laryngeal visualization for all patients before thyroid surgery. Further voice assessments are indicated for patients with any abnormalities on voice screening and laryngeal examination, and for patients at a high risk of voice change after surgery. The clinician or SLP should educate patients before surgery about the potential risk of voice change, voice hygiene, and possible management of postoperative voice change. The effects of steroids on the prevention of voice change patients are still unclear; thus, systematic steroids are not recommended. For optimal voice outcomes, the surgeon should pay close attention to preserving the EBSLN and RLN during thyroid surgery. IONM helps identify the RLN status and predict the presence of RLN damage, especially in high-risk patients. After thyroid surgery, the clinician should check the patients’ voice status. A postoperative laryngeal examination and multidimensional voice assessment are indicated for patients with voice change.
The management of RLN injuries should be tailored to the clinical circumstances. During surgery, the surgeon should consider laryngeal reinnervation if the RLN is transected and the distal stump of the RLN is available. Close observation for 6–12 months or less-invasive treatment, including voice therapy and IL, is feasible for unilateral VFP patients with low vocal demands and no risk of aspiration after thyroid surgery. However, vocal fold medialization is recommended for patients with high vocal demand and/or aspiration. The clinician should monitor respiratory function for patients with bilateral VFP. Neck exercise is recommended to reduce postoperative neck discomfort after thyroid surgery. A flowchart for the care and management of voice change after thyroid surgery is depicted in
▪ This guideline provides recommendations on voice management related to thyroid surgery.
▪ Fourteen key questions related to preoperative, intraoperative, and postoperative management were identified.
▪ Based on these key questions, 18 evidence-based recommendations were developed.
No potential conflict of interest relevant to this article was reported.
Conceptualization: CHR, BJL, JYL. Data curation: all authors. Formal analysis: all authors. Methodology: CHR, SJL, JYL. Project administration: CHR, SJL, JYL. Visualization: CHR, SJL, JYL. Writing–original document: all authors. Writing–review & editing: CHR, SJL, BJL, JYL.
We would like to express our special thanks to the Creative Media Service of the National Cancer Center, Korea, for providing superb figures.
Supplementary materials can be found via
Care and management of voice change for thyroid surgery: Korean Society of Laryngology, Phoniatrics and Logopedics Clinical Practice Guideline
Search strategy for voice care in thyroid surgery
Search strategy along the key question
Flow diagram for the literature search. KQ, key question; SLN, superior laryngeal nerve; RLN, recurrent laryngeal nerve; IONM, intraoperative neuromonitoring; VFP, vocal fold paralysis.
Voice education after thyroid surgery.
(A-D) Neck exercise after thyroid surgery.
(A, B) Laryngeal massage after thyroid surgery.
(A-C) Neck posture adjustments after thyroid surgery.
Flowchart for the care and management of voice change after thyroid surgery. KQ, key question; VAS, visual analog scale; GRBAS, Grade, Roughness, Breathiness, Asthenia, and Strain; VHI, Voice Handicap Index; IONM, intraoperative neuromonitoring; EBSLN, external branch of the superior laryngeal nerve; RLN, recurrent laryngeal nerve; MPT, maximum phona- tion time; MDVP, Multi-Dimensional Voice Program; VRP, voice range profile; CPP, cepstral peak prominence; VFP, vocal fold paralysis.
Organization of the KSLPL guidelines of voice care and management in the treatment of voice change after thyroid surgery
Location key | |
---|---|
[A] Preoperative management | |
[Key question 1] Is preoperative laryngeal visual examination necessary? | |
[Key question 2] Is preoperative voice assessment necessary? | |
[B] Intraoperative management | |
[Key question 3] Is perioperative counseling about the impact of surgery on voice and vocal hygiene necessary for thyroid surgery patients? | |
[Key question 4] Does perioperative systemic corticosteroid administration benefit voice quality after thyroid surgery? | |
[Key question 5] What are the surgical techniques to preserve the external branch of the superior laryngeal nerve for voice preservation during thyroidectomy? | |
[Key question 6] What are the surgical techniques to preserve the recurrent laryngeal nerve for voice preservation during thyroidectomy? | |
[Key question 7] Is intraoperative neuromonitoring necessary to preserve voice quality during thyroid surgery? | |
[Key question 8] Does intraoperative recurrent laryngeal nerve reinnervation improve the postoperative voice quality ? | |
[C] Postoperative management | |
[Key question 9] Is postoperative laryngeal visual examination necessary? | |
[Key question 10] Is comprehensive voice assessment necessary after thyroid surgery? | |
[Key question 11] Are vocal fold medialization procedures necessary for patients with unilateral vocal fold paralysis after thyroid surgery? | |
[Key question 12] Is surgical treatment necessary for patients with bilateral VFP after thyroid surgery? | |
[Key question 13] Is postoperative neck exercise needed to improve neck discomfort in patients with thyroid surgery? | |
[Key question 14] Is voice therapy necessary for optimizing voice outcome and improving voice-related quality of life after thyroid surgery? |
KSLPL, Korean Society of Laryngology, Phoniatrics and Logopedics; VFP, vocal fold paralysis.
Level of evidence
Term | Definition |
---|---|
High-quality of evidence | RCT without important limitations or overwhelming evidence from observational study |
Moderate-quality of evidence | RCT with important limitations or strong evidence from observational studies |
Low-quality of evidence | Observational studies/case studies |
RCT, randomized controlled trial.
Interpretation of American College of Physicians grading system
Grade of recommendation | Benefit vs. risks and burdens | Interpretation | Implication | |
---|---|---|---|---|
Strong recommendation | ||||
High-quality of evidence | Benefits clearly outweigh risks and burden or vice versa. | Strong recommendation––can apply to most patients in most circumstances without reservation. | For patients: most would want the recommended course and only a small proportion would not. | |
Moderate-quality of evidence | Strong recommendation––but may change when higher-quality evidence becomes available. | For clinicians: most patients should receive the recommended course of action. | ||
Low-quality of evidence | ||||
Weak recommendation | ||||
High-quality of evidence | Benefits closely balanced with risk and burden. | Weak recommendation, best action may differ depending on circumstances or patients’ or societal values. | For patients: most would want the recommended course of action, but some would not. A decision may depend on an individual’s circumstances. | |
Moderate-quality of evidence | Uncertainty in the estimates of benefits, risks, and burden; benefits, risks, and burden may be closely balanced. | Very weak recommendation, other alternatives may be reasonable. | For clinicians: different choices will be appropriate for different patients, and a management decision consistent with a patient’s values, preferences, and circumstances should be reached. | |
Low-quality of evidence | ||||
No recommendation | ||||
Insufficient evidence | Balance of benefits and risks cannot be determined. | Insufficient evidence to recommend for or against routinely providing the service | For patients: decisions based on evidence from scientific studies cannot be made. | |
For clinicians: decisions based on evidence from scientific studies cannot be made |