Laryngeal examination in thyroid and parathyroid surgery: AHNS Endocrine Surgery Guidelines

AHNS Endocrine Surgery Section
Guidelines
https://endocrine.ahns.info
Laryngeal Examination in
Thyroid and Parathyroid Surgery:
An American Head and Neck Society
Consensus Statement
Sinclair CF, Bumpous JM, Haugen BR, Chala A, Meltzer D,
Miller BS, Tolley NS, Shin JJ, Woodson G, Randolph GW

AHNS Endocrine Surgery Section - https://endocrine.ahns.info

• Consensus Author Panel
• National, multidisciplinary effort
• Members of AHNS Endocrine Surgery Section, endocrine
surgeons, head & neck surgeons, endocrinologists, radiologists
• Recommendations
• Authors with expertise for respective sections
• Evidence based literature - thyroid surgical publications &
recent AAO-HNS, AHNS & ATA guidelines
Consensus Development

• Intention
• To make recommendations regarding the optimal laryngeal
examination technique(s) to be used pre-thyroid and post-
thyroid surgery for adult patients
• To clarify limitations of different laryngeal examination
techniques using current best evidence
• To provide sound basic clinical guidance in the management
of thyroid surgical patients as it relates to voice and the larynx
• Statement includes discussion of:
• Laryngeal examination techniques stratified into primary and
secondary examination modalities
Thyroid and Parathyroid Surgery

• Postoperative voice changes are one of the most feared
complications of thyroid and parathyroid surgery
• There is a significant divergence between voice
symptoms and objective vocal cord function.
• Sensitivity of voice change in predicting objective vocal
fold function is low, between 33 – 68%
 Provides rationale for laryngeal examination in all
patients
Background
Randolph et al, Surgery 2006; 139(3): 357-362
Farrag et al, Laryngoscope 2006;116(2): 235-238

• Rates of recurrent laryngeal nerve (RLN) injury likely
approach 10%
• Have been significantly underreported due to:
• Variable postoperative laryngeal examination practices
• Reporting bias from expert units with lower rates of
complications because of higher caseload volume
Background

Pre-operative Laryngeal Examination
• Should be performed on 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 extension, or extensive cervical node
metastases)
Statement 1
Chandrasekhar et al, Otolaryngol Head Neck Surg 2013; 148(6 Suppl):S1-37
Haugen et al. Thyroid 2016; 26(1):1-37

• Symptoms that may suggest laryngeal pathology include
vocal fatigue, pain, increased effort, and decreased vocal
projection and range
• Rapidity of symptom onset plus timing and duration of
symptoms should be determined, as should coincident
swallowing abnormalities or respiratory difficulties
• Subjective patient-rated preoperative voice assessment
scales such as the GRBAS scale (Grade, Roughness,
Breathiness, Asthenia, Strain) and Voice Handicap Index
(VHI) may assist in comparing changes in pre and
postoperative vocal symptoms
Patient History

Post-operative Laryngeal Examination
• All patients should be considered for post-
operative laryngeal examination, particularly
where research regarding nerve paralysis is
being undertaken
• AAO-HNS and ATA guidelines recommend laryngeal
examination if postoperative voice abnormalities are
present
Statement 2
Chandrasekhar et al, Otolaryngol Head Neck Surg 2013; 148(6 Suppl):S1-37
Haugen et al. Thyroid 2016; 26(1):1-37

• Easily performed in the office setting with or without the
use of topical nasal anesthesia
• The patient is examined in the sitting position. The scope
is inserted into the nasal cavity and directed into either the
inferior meatus or middle meatus of the nose, depending
on patency
• The examiner must note normal and abnormal findings in
the nasal cavity, nasopharynx, oropharynx, larynx and
hypopharynx
Flexible Transnasal Laryngoscopy

• Anatomic and physiological function should be
observed including
• Palatal elevation
• Dynamic tension of the vocal cords on phonation
• Laryngeal elevation with phonation and swallowing
• Vocal cord mobility
• Laryngeal penetration and aspiration
• Subglottic patency
• Presence of lesions or masses
• Tracheal or laryngeal invasion by malignancy

• Dysfunction of the external branch of the superior
laryngeal nerve is difficult to diagnose
• Subtle laryngeal findings may include:
• Diminished laryngeal elevation
• Decreased ipsilateral longitudinal tension on the vocal cords
• and hemilarynx
• Laryngeal rotation to the side of involved nerve dysfunction

• Flexible transnasal laryngoscopy is the optimal
method for laryngeal examination on the basis
of widespread availability, patient tolerance,
and assessment of both RLN and EBSLN
function
Statement 3

• Performed using a warmed dental mirror inserted into
the oral cavity during manual tongue protrusion
• Swallowing cannot be assessed by mirror examination
as it is not possible to swallow with an open mouth
• Contraindications include a brisk gag reflex, trismus,
palatal obturators or poor mouth opening combined
with dental considerations
• Advantages include cost and convenience
Indirect (Mirror) Laryngoscopy

Indirect (Mirror) Laryngoscopy
• Mirror examination of the larynx can
adequately document vocal fold movement
abnormalities and is a useful tool in settings
where transnasal laryngoscopy is unavailable
Statement 4

Fiberoptic Vs. Mirror Laryngoscopy

Laryngeal Ultrasound
• Laryngeal ultrasound may be useful for
documenting gross vocal fold movement
abnormalities, especially in the pediatric
population where use of transnasal
laryngoscopy may be limited
Statement 5

Laryngeal Ultrasound

• Utilized to obtain a detailed evaluation of true vocal
fold vibration
• Uses synchronized flashing light to create a pseudo-
slow motion examination of the mucosal wave and
vocal fold vibrations
• Can be performed using a rigid scope trans-orally or by
flexible transnasal laryngoscopy
• Beneficial to diagnose mucosal vocal fold abnormalities
such as nodules, polyps, cysts, scar/sulcus, atrophy,
subtle epithelial neoplasms, glottic gaps
Laryngeal Stroboscopy

• In regard to thyroid surgery, stroboscopy may be
helpful in diagnosing hypomobility (paresis) of the true
vocal fold
• Paresis findings may include:
• Vocal fold bowing (70%)
• Incomplete closure (62%)
• Increased vibratory amplitude (38%)
Simpson et al, J Voice 2009; 23(3): 396-398

• Laryngeal stroboscopy should be considered
for people with documented postoperative
hoarseness who do not have vocal fold
movement abnormalities.
Statement 6

• Flexible transnasal fiber-optic laryngoscopy, by virtue
of its availability, rapid learning curve, patient
tolerability, and laryngeal diagnostic capabilities is
currently the gold standard technique for laryngeal
examination pre and post thyroid surgery
• Adjunctive laryngeal examination techniques
(electromyography, stroboscopy) may be required for
patients who exhibit laryngeal symptomatology
unaccounted for by findings on fiber-optic nasal
endoscopy
Conclusions

Thyroid and Parathyroid Surgery:
An American Head and Neck Society
Consensus Statement
Sinclair CF, Bumpous JM, Haugen BR, Chala A, Meltzer D,
Miller BS, Tolley NS, Shin JJ, Woodson G, Randolph GW

Laryngeal examination in thyroid and parathyroid surgery: AHNS Endocrine Surgery Guidelines

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Laryngeal examination in thyroid and parathyroid surgery: AHNS Endocrine Surgery Guidelines