Comparison of efficacy and complications between radiofrequency ablation and repeat surgery in the treatment of locally recurrent thyroid cancers: a single-center propensity score matching study.

PURPOSE: To compare the efficacy and complication rates of radiofrequency ablation (RFA) and repeat surgery in the treatment of locally recurrent thyroid cancers. MATERIALS AND METHODS: A total of 221 patients with locally recurrent thyroid cancers who underwent either RFA (n = 96) or repeat surgery (n = 125) between March 2008 and March 2017 were retrospectively enrolled (range of follow-up, 1-10 years). Each cohort consisted of 70 patients after propensity score adjustment. Patients with more than three recurrent lesions were excluded. The primary and secondary end points were recurrence-free survival and complication rates, respectively. Recurrence-free survival curves were compared via the log-rank test. The complications-voice changes, hypocalcemia, and immediate procedural complications-were compared between the groups. In addition, pretreatment serum thyroglobulin (Tg) levels and those at the last follow-up were also compared between the two groups to examine therapeutic efficacy. RESULTS: After propensity score matching, both groups showed no significant differences in baseline characteristics. The recurrence-free survival rates were comparable between the RFA and surgery groups (p = .2). There were no significant differences in mean serum Tg levels and their mean decrease after treatment between the groups (p = .891 and p = .963, respectively). Immediate procedural complications and voice changes also showed no significant between-group differences (p = .316, p = .084, respectively). Hypocalcemia occurred only in the repeat surgery group (n = 18). Overall complications were significantly more frequent in the repeat surgery group (RFA, n = 7; surgery, n = 27; p < .001). CONCLUSION: RFA may be an effective and safe alternative to repeat surgery in the treatment of a small number of locally recurrent thyroid cancers.

Long-Lasting Voice-Related Symptoms in Patients Without Vocal Cord Palsy After Thyroidectomy.

BACKGROUND: Some patients complain of long-lasting voice symptoms after thyroid surgery without objective vocal fold pathology. We assessed the factors that may influence voice symptoms more than 12 months after thyroidectomy. METHODS: We performed a retrospective analysis of 68 patients from July 2010 to May 2012. The voices of all patients were analyzed before and after thyroid surgery (2 weeks and 2, 4, 6, 8, 10, and 12 months after surgery). According to the recovery of postoperative voice symptoms, patients were divided into two groups: the non-recovery group and the recovery group. Voice symptoms were measured using a thyroidectomy-related voice questionnaire (TVQ). We compared voice analysis data for each group and investigated the factors related to long-lasting postoperative voice symptoms. RESULTS: Forty-nine patients were included in the recovery group, and 19 patients were included in the non-recovery group. No differences in sex ratio, tumor size, and surgical extent were found between the groups. However, the proportion of professional voice users (odds ratio 4.121; 95% confidence interval 0.983-17.267; p < 0.043) was significantly higher in the non-recovery group. The cutoff score of the TVQ, at 2 months after thyroid surgery, for the differentiation of the recovery and non-recovery groups was 25, and the sensitivity and specificity values were 84.2 and 87.8%, respectively. CONCLUSIONS: Professional voice users may be presented long-lasting voice symptoms after thyroid surgery. The cutoff TVQ score of 25, at 2 months after thyroid surgery, may be a guideline for counseling patients who have voice symptoms.

The Long-Term Prognosis of Voice Pitch Change in Female Patients After Thyroid Surgery.

BACKGROUND: Relatively large numbers of patients complain of lower-pitched voices after thyroidectomy. However, little is known about the risk factors for, prognosis of, or progression over time of, such changes, in female patients. METHODS: We analyzed the data of 217 patients who underwent thyroid surgery and postoperative (2 weeks, and 3, 6, and 12 months after surgery) voice work-ups. To identify patients with lower-pitched voices, speaking fundamental frequencies (SFFs) were compared before and after surgery. The change was calculated for all patients (postoperative change in SFF, ΔSFF). RESULTS: The mean ΔSFF was 8.35 ± 17.06 Hz and significant changes in voice pitch (ΔSFF ≥12 Hz) were evident in 93 (42.85 %) patients after surgery, mostly within 6 months, and only 18.4 % of patients had lower-pitched voices 1 year after surgery. On multivariate analysis, age (≥52 vs. <52 years) and extent of surgery remained significant predictors of lower-pitched voice after surgery. The ΔSFFs of older patients (≥52) were significantly greater than those of younger patients (<52) at the 2-week follow-up, but not at the 3-, 6-, or 12-month follow-ups. The ΔSFFs of patients who underwent total thyroidectomy were significantly higher than those who underwent lobectomy at the postoperative 2-week follow-up, but did not differ at the 3-, 6-, and 12-month follow-ups. CONCLUSIONS: Patients frequently experience a lower-pitched voice after thyroid surgery. Such problems develop more frequently in the early postoperative period, in aged patients, and in those who had undergone total thyroidectomy. However, over time, the changes usually decrease to levels similar to those of patients without these risk factors.

Female sex, central lymph node metastasis and dissection are causes of globus symptom after thyroidectomy.

Globus symptoms are not uncommon after an uncomplicated thyroidectomy. However, their associated factors and etiology have not been investigated. We investigated the etiology and factors related to globus symptoms after thyroidectomy. The medical records of 289 patients who underwent thyroidectomy and completed a voice analysis, psychiatric screening, and voice-related questionnaires before and 1 month after the surgery were reviewed. Patients were excluded if they had globus symptoms before surgery or scored high on the psychiatric questionnaire. The selected patients were divided into two groups according to development of globus symptoms after surgery. Clinicopathological parameters and results of the voice analysis and voice-related questionnaires were compared between the two groups. A total of 157 patients were enrolled, and more than half (80/155, 51 %) showed development of globus symptoms 1 month after thyroidectomy. Female patients [hazard ratio (HR), 2.605; P = 0.010], patients who had central lymph node metastasis (HR, 3.533; P = 0.001), and patients who underwent central neck dissection (HR, 3.652; P = 0.014) had a higher probability of developing globus symptoms. Patients who developed globus symptoms scored higher on the voice-related questionnaire, and had a greater decrease in speaking fundamental frequency (P < 0.001). Globus symptoms developed after 1 month in more than half of patients who underwent thyroidectomy. Female sex and central lymph node metastasis and dissection increased the possibility of developing the symptoms.

A prospective randomized controlled trial of the laryngeal mask airway versus the endotracheal intubation in the thyroid surgery: evaluation of postoperative voice, and laryngopharyngeal symptom.

BACKGROUND: The present study was performed to determine whether thyroidectomy patients undergoing general anesthesia provided with a laryngeal mask airway (LMA) have a lower risk of voice-related complications and laryngopharyngeal symptoms than those undergoing endotracheal intubation (ETI). MATERIALS AND METHODS: In a prospective, double-blinded, randomized clinical trial, we studied 64 patients undergoing elective thyroid lobectomy between July 2013 and February 2014. Acoustic analyses were performed preoperatively and at 48 h and 2 weeks postoperatively. The voice handicap index (VHI), M.D. Anderson dysphagia index (MDADI), and laryngopharyngeal symptom score (LPS) were determined preoperatively and at 24 h, 48 h, 1 week, and 2 weeks post-thyroidectomy. RESULTS: In acoustic analysis, jitter, shimmer and noise-to-harmonic ratio showed significantly better results in the LMA group than the ETI group 48 h after surgery, but there was no difference at 2 weeks. The incidence of postoperative lower-pitched voice in the LMA group was also significantly lower than that in the ETI group. In the LMA group, the VHI, MDADI, and LPS were better compared to those in the ETI group at 24 h postoperatively, and improved to the preoperative state within 1 week. However, those in the ETI group remained poorer than the preoperative values 1 week after surgery. CONCLUSIONS: Use of the LMA in general anesthesia for thyroid surgery has advantages over the ETI in decreasing patients' subjective and objective voice symptoms, reducing the duration of symptoms, and relieving the laryngopharyngeal symptoms.

The therapeutic decision making of the unilateral vocal cord palsy after thyroidectomy using thyroidectomy-related voice questionnaire (TVQ).

The objective of this study was to investigate the efficacy of early management of post-thyroidectomy unilateral vocal cord palsy (UVCP) and the clinical utility of the thyroidectomy-related voice questionnaire (TVQ) when planning UVCP treatment. The study group comprised 48 consecutive patients diagnosed with UVCP after thyroidectomy. Laryngoscopic examination and voice analysis were conducted, and the TVQ was administered pre-thyroidectomy and at 2 weeks and 1, 3, 6, and 12 months post-thyroidectomy. Twenty-five patients with aspiration symptoms and severe vocal difficulties received injection laryngoplasty, and 23 with no aspiration symptoms and relatively mild vocal difficulties underwent voice therapy. We performed a video fluoroscopic swallowing study on each patient 2 weeks after thyroidectomy and 1 month following the procedure. The average total TVQ scores 2 weeks post-thyroidectomy were 51.92 ± 11.42 in the injection laryngoplasty group and 35.78 ± 12.99 in the voice therapy group. Both subjective and objective parameters improved significantly at 1 month after treatment and continued to improve slowly over the next 12 months (p < 0.01) in both groups. TVQ scores were significantly lower in the injection laryngoplasty group than in the voice therapy group 1 month post-intervention (p < 0.01). At the study end point, the greatest improvement in subjective symptoms occurred in temporary VCP patients who underwent injection laryngoplasty. The optimal TVQ score cut-off distinguishing the two groups was 45 (68.0 % sensitivity, 78.3 % specificity). In conclusion, early management following timely diagnosis of post-thyroidectomy UVCP can improve symptoms within 1 month. Moreover, application of TVQ will aid clinicians to plan treatment for postoperative VCP patients.

Therapeutic approach to patients with a lower-pitched voice after thyroidectomy.

BACKGROUND: A lower-pitched voice is one of the most common voice alterations after thyroidectomy without laryngeal nerve injury. The aim of this study was to evaluate the acoustic and stroboscopic changes and the treatment outcomes in patients with a lower-pitched voice with the goal of eventually establishing a therapeutic guideline. METHODS: Patients with a lower-pitched voice were selected according to the results of acoustic analysis among thyroidectomized patients. According to their pitch-gliding ability, patients were classified into a "gliding group" and "nongliding group," and direct voice therapy was performed. For those who did not respond, indirect voice therapy with subsequent identical direct voice therapy was performed. Video-stroboscopy, acoustic and perceptual analysis, and subjective analysis using a questionnaire were performed before and after treatment. The results of the two groups were compared. RESULTS: Fifty patients were enrolled. Decreased vocal cord tension was the most common stroboscopic finding in these patients. After direct voice therapy, 87 % of patients in the gliding group showed restoration of pitch 2 months after thyroidectomy. None of the patients in the nongliding group showed improvement. After indirect voice therapy and subsequent direct voice therapy, these nonresponders finally showed improvement 4.5 months after thyroidectomy. Several characteristic stroboscopic findings of the nongliding group were identified. CONCLUSIONS: The pitch-gliding ability and several specific stroboscopic findings were predictive of a response to direct voice therapy. Based on these findings, an individualized therapeutic approach could be applied, and the pitch of patients with a lower-pitched voice after thyroidectomy was restored earlier than expected.

Early postoperative vocal function evaluation after thyroidectomy using thyroidectomy related voice questionnaire.

BACKGROUND: The objectives of this study were to evaluate a screening method for detecting postoperative vocal cord palsy and lower-pitched voice and to identify how a pre-thyroidectomy laryngeal disorder affects post-thyroidectomy voice change by using our subjective voice questionnaire. METHODS: We examined 300 consecutive patients scheduled to undergo thyroidectomies between November 2010 and August 2011. Laryngoscopic examination, thyroidectomy-related voice questionnaire (TVQ) administration, and acoustic and perceptual analyses were performed preoperatively and 2 weeks after thyroidectomy. RESULTS: Ninety-eight (32.6 %) patients had a preoperative laryngeal disorder. Postoperatively, 31 (10.3 %) patients had vocal cord palsy and 54 (18 %) had a lower-pitched voice 2 weeks after thyroidectomy. Postoperative TVQs classified 25 (8.4 %) patients as normal and 275 (91.6 %) patients as abnormal, including 79 (26.3 %) mild, 131 (43.6 %) moderate, and 65 (21.6 %) severe cases. Of the patients with vocal cord palsy, 80.6 % belonged to the severe group, and 92.6 % of patients with lower-pitched voices belonged to the moderate and severe groups. Fundamental frequency and speaking fundamental frequency were decreased significantly in women. The most efficient TVQ cutoff values for detecting post-thyroidectomy vocal cord palsy and postoperative lower-pitched voice were 35 (87.1 % sensitivity, 79.9 % specificity) and 25 (75.9 % sensitivity, 56.5 % specificity), respectively. Total TVQ scores increased more in the nonlaryngeal than in the laryngeal disorder group. CONCLUSIONS: During the early postoperative period, 28.3 % of patients had vocal cord palsy or lower-pitched voices, which could be evaluated using a simple questionnaire. Therefore, early postoperative voice evaluation is important. Patients with nonlaryngeal disorders may be more sensitive than those with laryngeal disorders to laryngeal symptoms.

The importance of preoperative laryngeal examination before thyroidectomy and the usefulness of a voice questionnaire in screening.

BACKGROUND: The objectives of this study were to emphasize the importance of preoperative laryngeal examination before thyroidectomy by investigating the incidence of coincident abnormal laryngeal conditions that impair the quality of voice, and evaluate the usefulness of the "thyroidectomy-related voice questionnaire" as a screening tool. METHODS: Five hundred consecutive patients scheduled to undergo thyroidectomy underwent preoperative laryngeal examination and voice analysis and completed the questionnaire. According to the laryngeal examination results, patients were classified into normal and abnormal groups. Acoustic-analysis results and questionnaire scores were compared between the two groups, and correlations between acoustic parameters and questionnaire scores were evaluated. The cutoff score of the questionnaire that can effectively discriminate between the two groups was also determined. RESULTS: The incidence of abnormal laryngeal conditions was 35.8%. The most common finding was laryngopharyngeal reflux (27.2%) followed by vocal nodule (4.8%), vocal polyp (1.8%), vocal cord palsy (1.2%), Reinke's edema (0.4%), vocal cyst (0.2%), and vocal sulcus (0.2%). The perceptual grade of voice quality (0.33 ± 0.49 for normal group vs. 0.65 ± 0.62 for abnormal group, P = 0.000) and the questionnaire scores (3.21 ± 5.47 for normal group vs. 13.41 ± 11.67 for abnormal group, P = 0.000) of the two groups were significantly different, and there was a significant correlation between objective voice parameters and questionnaire scores. A questionnaire score of 5 showed the best sensitivity (74%) and specificity (71%) in discriminating between the two groups. CONCLUSIONS: The incidence of coincident abnormal laryngeal conditions is relatively high; therefore, voice screening before thyroidectomy is important. The "thyroidectomy-related voice questionnaire" is a simple and effective screening tool to detect preexisting laryngeal disorders that can affect the quality of voice.

Development and Validation of the Thyroidectomy-Related Voice and Symptom Questionnaire (TVSQ).

OBJECTIVES: Common symptoms after thyroidectomy include voice change and throat and neck discomfort. But no common questionnaire has been developed. This study was performed to evaluate the reliability and validity of the Thyroidectomy-related Voice and Symptom Questionnaire (TVSQ). METHODS: Fourty items of the TVSQ were divided into 20 items related to the "voice change" and "throat and neck discomfort" subcategories, using item generation. Through a reduction process, 20 items were removed and 20 items were used. For the patients after thyroidectomy, we evaluated the reliability and validity of each of the 20 items through item discrimination, test-retest reliability, concurrent validity, and external validity by comparing normal group and laryngeal disease patients. Also, the patients were compared before as well as 2 and 4 weeks after thyroidectomy. RESULTS: Item discrimination assessment showed a significant correlation between TVSQ total score and both the TVSQ "voice change" score (r = 0.908**) and TVSQ "throat and neck discomfort" score (r = 0.862**). Test-retest reliability assessment showed a significant correlation between TVSQ total scores at 2 and 4 weeks postoperatively (r = 0.764**). Concurrent validity assessment revealed that the TVSQ showed high correlations with other voice questionnaires (Voice Handicap Index, Reflux Finding Index, and Vocal Track Discomfort Scale; r = 0.538**-0.830**). External validity assessment revealed that the TVSQ was suitable for patients after thyroidectomy (P < 0.000**). CONCLUSIONS: Validity and reliability tests revealed that the TVSQ was suitable for assessment of the subjective feelings of patients with voice change and throat and neck discomfort after thyroidectomy.

Multivariate Analysis of Risk Factors in the Development of a Lower-Pitched Voice After Thyroidectomy.

OBJECTIVES: Thyroid surgeons frequently encounter outpatients with mobile vocal cords complaining of lower-pitched voices following thyroidectomy. This study investigated the clinical and pathological parameters affecting voice pitch following thyroid surgery. METHODS: We analyzed the data of 393 patients with mobile vocal cords and who also underwent thyroid surgery. Speaking fundamental frequency (SFF) and fundamental frequency (F0) were compared before and after surgery. RESULTS: Approximately 26.7% of patients had significantly lowered SFFs (ΔSFF ≥ 12 Hz), and 30.2% exhibited significantly lower sustained vowel F0s (ΔF0 ≥ 12 Hz) following thyroid surgery. On multivariate analysis, only gender: female remained a significant predictor of a clinically significant change in SFF following thyroid surgery ( P < .001). Gender: female and extent of surgery: total remained significant predictors of a clinically significant change in F0 after surgery ( P = .006 and P = .007, respectively). CONCLUSIONS: Appreciable proportions of patients experience lower-pitched voice and related vocal symptoms early after thyroid surgery. Such problems develop more frequently in females who underwent total thyroidectomy.

How can we screen voice problems effectively in patients undergoing thyroid surgery?

BACKGROUND: Voice problems following thyroid surgery are well known, and perioperative voice analysis in patients undergoing thyroidectomy no longer seems optional. However, multiple means of assessing vocal function are time-consuming, require specific instruments and specialists, and increase costs. Therefore, we designed this study to develop an efficient and cost-effective screening tool for detecting voice disorders following thyroidectomy. METHODS: We developed the Perioperative Voice-Screening Protocol for Thyroid Surgery (PVST) using the Thyroidectomy-Related Voice Questionnaire (TVQ) to provide a cost-effective diagnostic flow chart for patients following thyroidectomy. The TVQ is a simple questionnaire that was developed at our institution and has already demonstrated its effectiveness in detecting pre- and postthyroidectomy voice-related disorders in our previous studies. To investigate the PVST, we enrolled 242 subjects who underwent thyroidectomy and let them follow the PVST. All subjects underwent a voice work-up by a voice specialist to verify the predictive value of the protocol. RESULTS: Using PVST, we could effectively screen for abnormal preoperative laryngeal findings with sensitivity and specificity of 82.1% and 50.5%, respectively, especially laryngeal benign mucosal disease with sensitivity and specificity of 100% and 45.6%, respectively. We could also screen for postoperative voice-related problems with sensitivity and specificity of 100% and 50.4% for detecting vocal-cord palsy, and 66.7% and 51.2% for detecting a low-pitched voice, respectively. If all 242 patients followed the protocol, US $42,768 would be saved, and the PVST was estimated to decrease costs by 43.5%. CONCLUSIONS: The PVST is a reliable and cost-effective perioperative screening tool that enables thyroid surgeons to detect patients with voice problems in their routine outpatient clinic for early and appropriate referral to voice specialists.

Histopathologic findings related to the indeterminate or inadequate results of fine-needle aspiration biopsy and correlation with ultrasonographic findings in papillary thyroid carcinomas.

OBJECTIVE: To determine histopathologic findings related to the indeterminate or inadequate result of fine-needle aspiration biopsy (FNAB) in papillary thyroid carcinomas (PTCs) and to correlate histopathological findings with ultrasonographic features of tumors. MATERIALS AND METHODS: We retrospectively reviewed the medical records of FNAB, histopathologic characteristics, and sonographic findings of the solid portion of 95 PTCs in 95 patients. All cases were pathologically confirmed by surgery. Histopathologic characteristics were analyzed for tumor distribution, microcystic changes, fibrosis, and tumor component. We assumed several histopathologic conditions to be the cause of indeterminate or inadequate results of FNAB, including: 1) an uneven tumor distribution, 2) > 30% microcystic changes, 3) > 30% fibrosis, and 4) < 30% tumor component. Ultrasonographic findings of each PTC were evaluated for echotexture (homogeneous or heterogeneous), echogenicity (markedly hypoechoic, hypoechoic, isoechoic, or hyperechoic), and volume of the nodule. We correlated histopathologic characteristics of the PTC with results of the FNAB and ultrasonographic findings. RESULTS: From 95 FNABs, 71 cases (74%) were confirmed with malignancy or suspicious malignancy (PTCs), 21 (22%) had indeterminate results (atypical cells), and three (4%) were negative for malignancy. None of the assumed variables influenced the diagnostic accuracy of FNAB. Tumor distribution and fibrosis were statistically correlated with ultrasonographic findings of the PTCs (p < 0.05). Uneven tumor distribution was related with small tumor volume, and fibrosis over 30% was correlated with homogeneous echotexture, markedly hypoechoic and hypoechoic echogenicity, and small tumor volume (p < 0.05). CONCLUSION: No histopathologic component was found to correlate with improper results of FNAB in PTCs. In contrast, two histopathologic characteristics, uneven distribution and fibrosis, were correlated with ultrasonographic findings.