Estudio de prevalencia de lesiones laríngeas y disfagia en pacientes críticos traqueostomizados por COVID-19 / A Study on the Prevalence of Laryngeal Injuries and Dysphagia in Critically Ill Tracheostomized Patients due to COVID-19

El trabajo original que publica en esta edición el equipo multidisciplinario del Hospital Fernández merece la siguiente reflexión: La pandemia por SARS-CoV-2 puso a nuestro sistema de salud ante un desafío inédito. La falta de previsión de las autoridades ante este evento que se extendió primero por el hemisferio norte se sumó a una infraestructura deteriorada e insuficiente. Frente a semejante reto, el personal de salud en su conjunto respondió con su capacidad de trabajo, intelectual y, en muchos casos, con su propia vida para poder salvar a la mayor cantidad posible de enfermos. Nunca será reconocido suficientemente este esfuerzo

Application value of intraoperative neuromonitoring plus "classification of EBSLN" to protect the external branch of the superior laryngeal nerve / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the application efficacy of the "classification of external branch of superior laryngeal nerve (EBSLN)" combined with intraoperative neuromonitoring (IONM) in the dissection of EBSLN for protecting the nerve from injuery, compared with ligation of branches of the superior thyroid vessels without attempts to visually identify the nerve. Methods: A prospective randomized controled study was performed in our center. Patients subjected to thyroidectomy from January 2017 to June 2019 were randomly divided into 2 groups, patients in experimental group underwent thyroidectomy and "classification of EBSLN" with IONM to dissect EBSLN, and patients in control group received synchronous surgery without attempts to visually identify the nerve. The anatomical subtypes of EBSLN in experimental group were recorded. The voice handicap index 10 (VHI-10) score was evaluated and the movement of bilateral vocal cords was examined by laryngoscope before surgery, 1 month, 3 months, and 6 months after surgery, respectively. SPSS 26.0 statistical software was used for statistical analysis. Results: Among the 1 377 EBSLN from 827 patients (317 males and 510 females, aged 24-58 years old), 691 EBSLNs in experimental group and 686 EBSLNs in control group. Totally 98.3% of EBSLNs in experimental group were identified by IONM including 16.4% (113/691) for type Ⅰ, 21.3% (147/691) for type Ⅱa, 31.4% (217/691) for type Ⅱb, 10.4% (72/691) for type Ⅲa, 3.9% (27/691) for type Ⅲb, 16.6% (115/691) for type Ⅲc. There was no statistical significance difference in baseline data between 2 groups (all P>0.05). All patients were followed up for more than 6 months. The postoperative nerve injury rate of experimental group was significantly lower than that of control group (1.2% vs. 7.5%, χ²=12.659, P<0.001), and the VHI-10 scores and laryngoscope results of experimental group were better than those of control group in three follow-up visits (P<0.001). With postoperative laryngoscope examination, 3 patients in the experimental group and 23 patients in the control group showed vocal cord relaxation, bilateral oblique asymmetry and other phenomena, which were considered as the results of permanent injury. Other patients with symptoms were relieved to varying degrees during the follow-up, and their symptoms were considered as the results of temporary injury. Conclusion: IONM combined with "classification of EBSLN" can reduce significantly the risk of EBSLN injury in thyroidectomy, which is better than direct ligation of branches without attempts to visually identify the nerve.

Laryngeal and vocal alterations after thyroidectomy / Alterações laríngeas e vocais após tireoidectomia

Abstract Introduction: Dysphonia is a common symptom after thyroidectomy. Objective: To analyze the vocal symptoms, auditory-perceptual and acoustic vocal, videolaryngoscopy, the surgical procedures and histopathological findings in patients undergoing thyroidectomy. Methods: Prospective study. Patients submitted to thyroidectomy were evaluated as follows: anamnesis, laryngoscopy, and acoustic vocal assessments. Moments: pre-operative, 1st post (15 days), 2nd post (1 month), 3rd post (3 months), and 4th post (6 months). Results: Among the 151 patients (130 women; 21 men). Type of surgery: lobectomy + isthmectomy n = 40, total thyroidectomy n = 88, thyroidectomy + lymph node dissection n = 23. Vocal symptoms were reported by 42 patients in the 1st post (27.8%) decreasing to 7.2% after 6 months. In the acoustic analysis, f0 and APQ were decreased in women. Videolaryngoscopies showed that 144 patients (95.3%) had normal exams in the preoperative moment. Vocal fold palsies were diagnosed in 34 paralyzes at the 1st post, 32 recurrent laryngeal nerve (lobectomy + isthmectomy n = 6; total thyroidectomy n = 17; thyroidectomy + lymph node dissection n = 9) and 2 superior laryngeal nerve (lobectomy + isthmectomy n = 1; Total thyroidectomy + lymph node dissection n = 1). After 6 months, 10 patients persisted with paralysis of the recurrent laryngeal nerve (6.6%). Histopathology and correlation with vocal fold palsy: colloid nodular goiter (n = 76; palsy n = 13), thyroiditis (n = 8; palsy n = 0), and carcinoma (n = 67; palsy n = 21). Conclusion: Vocal symptoms, reported by 27.8% of the patients on the 1st post decreased to 7% in 6 months. In the acoustic analysis, f0 and APQ were decreased. Transient paralysis of the vocal folds secondary to recurrent and superior laryngeal nerve injury occurred in, respectively, 21% and 1.3% of the patients, decreasing to 6.6% and 0% after 6 months.

Resumo Introdução: A disfonia é um sintoma comum após a tireoidectomia. Objetivo: Analisar os sintomas vocais, auditivo-perceptivos e acústica vocal, videolaringoscopia, procedimento cirúrgico e achados histopatológicos em pacientes submetidos à tireoidectomia. Método: Estudo prospectivo. Pacientes submetidos à tireoidectomia foram avaliados da seguinte forma: anamnese, laringoscopia e avaliações vocais acústicas. Momentos: pré-operatório, 1ª avaliação pós (15 dias), 2ª avaliação pós (1 mês), 3ª avaliação pós (3 meses) e 4ª avaliação pós-operatória (6 meses). Resultados: Dos 151 pacientes, 130 eram mulheres e 21, homens. Tipos de cirurgia: lobectomia + istmectomia n = 40, tireoidectomia total n = 88, tireoidectomia + dissecção de linfonodo n = 23. Sintomas vocais foram relatados por 42 pacientes na 1ª avaliação pós-operatória (27,8%), reduzidos para 7,2% após 6 meses. Na análise acústica, f0 e APQ estavam diminuídos nas mulheres. As videolaringoscopias mostraram que 144 pacientes (95,3%) tiveram exames normais no momento pré-operatório. Paralisia das cordas vocais foi diagnosticada em 34 pacientes na 1ª avaliação pós-operatória, 32 do nervo laríngeo recorrente (lobectomia + istmectomia - n = 6; tireoidectomia total - n = 17; tireoidectomia total + dissecção de linfonodos - n = 9) e 2 do nervo laríngeo superior (lobectomia + istmectomia - n = 1; tireoidectomia total + dissecção de linfonodos - n = 1). Após 6 meses, 10 pacientes persistiram com paralisia do nervo laríngeo recorrente (6,6%). Histopatologia e correlação com paralisia das cordas vocais: bócio coloide nodular (n = 76; paralisia n = 13), tireoidite (n = 8; paralisia n = 0) e carcinoma (n = 67; paralisia n = 21). Conclusão: Os sintomas vocais, relatados por 27,8% dos pacientes na 1ª avaliação pós-operatória, diminuíram para 7% em 6 meses. Na análise acústica, f0 e APQ diminuíram. A paralisia transitória de cordas vocais secundária à lesão do nervo laríngeo recorrente e nervo laríngeo superior ocorreu, respectivamente, em 21% e 1,3% dos pacientes, reduziu-se para 6,6% e 0% após 6 meses.

Analysis of Voice and Swallowing Symptoms after Thyroidectomy in Patients without Recurrent Laryngeal Nerve Injury in Early Postoperative Period

BACKGROUND AND OBJECTIVES: After thyroidectomy, many patients experience problems report such things as reduced voice range and vocal fatigue, swallowing problems without superior and recurrent laryngeal nerve injury. The purpose of this study was to evaluate voice and swallowing problems before and after thyroid surgery without laryngeal nerve injury. MATERIALS AND METHODS: Ninety-three patients who underwent thyroidectomy without laryngeal nerve injury and completed the follow-up evaluations were studied between June 2013 and December 2015. Each evaluation was performed preoperatively, as well as 1 week, 1 month postoperatively. Analysis was performed including voice handicap index (VHI), dysphagia handicap index (DHI), and acoustic voice analysis. RESULTS: Patients show significant variation of parameters in the fundamental frequency (F), maximal phonation time (MPT), shimmer, jitter and soft phonation index (SPI) early after operation, and most of them showed recovery of parameters after 1month of operation. Perceptive complaint of voice and swallowing also showed significant decreased after operation (p<0.005). After 1 month of operation, MPT, highest frequency and frequency ranges still showed significant decreased parameters. Comparing acoustic and perceptive parameters of total thyroidectomy and lobectomy, there was no significant changes between them except highest frequency (p=0.042). CONCLUSION: The results from both subjective and objective evaluations show voice and swallowing disturbance after thyroidectomy even in the absence of laryngeal nerve and provide patients information about the recovery process after surgery. Highest frequency parameter showed most significant changes after operation.

The Effect of Total Thyroidectomy on the Speech Production

OBJECTIVES: Voice and speech alternations that can occur after total thyroidectomy are usually due to recurrent or superior laryngeal nerve injury. These alterations may also be associated with other extralaryngeal factors, such as neck muscle dysfunction and scar contracture of the neck. We performed a prospective acoustic analysis on speech changes after surgery, in the absence of laryngeal nerve injury. METHODS: Patients aged 19 to 58 years undergoing total thyroidectomy, in the absence of laryngeal/pulmonary disease, previous neck surgery, or other malignant diseases, were recruited prospectively. For the running speech analysis, the speaking fundamental frequencies (SFo), range of SFo and speaking intensity were evaluated before surgery, 7 days, and 1 and 3 months after surgery. For consonant analysis, the acoustic distinctions of stop consonant, the voice onset time (VOT), vowel duration and closure duration were evaluated at the same periods. RESULTS: SFo and range of SFo were specifically diminished after surgery, while speaking intensities were not changed significantly after surgery. The thyroidectomized speakers displayed systematically varied VOT for the consonant production, which was phonetically representative. However, VOT after surgery could be longer in the strong aspirated and glottalized stops, but not in the lax stop than before surgery. The vowel and closure durations were not affected before and after surgery. CONCLUSION: Patients with thyroidectomy have some difficulty of pitch control and consonant articulation during speaking. VOT is also one of the meaningful acoustic parameters and provide a reference for comparing acoustic measures before and after thyroidectomy.

Post-Thyroidectomy Syndrome / 대한이비인후과학회지

Phonatory and swallowing symptoms after thyroidectomy are well-known implications of laryngeal nerve injuries. The laryngeal nerve injuries, superior and inferior, are major complication that results in changes both to voice quality and production of high-pitched sounds, which is of utmost importance for voice professionals. However, these functional and subjective voice and swallowing symptoms were often neglected by clinicians. Most voice and swallowing alterations after thyroidectomy are self limited and are not related to demonstrable impaired nerves function. Several causes have been supposed to interpret these symptoms. They have been attributed to arytenoid trauma after endotracheal intubation, surgical trauma, modification of the vascular supply of the larynx, local pain in the neck, cricothyroid dysfunction, strap muscle mal-function, laryngotracheal fixation with impairment of vertical movement, and psychologic reaction to the operation. Because of the impact of patient's perception on postoperative outcome in recent years, some groups have extensively investigated this functional post-thyroidectomy syndrome. All the published studies demonstrate that most patients who undergo thyroidectomy have at least some subjective vocal and/or swallowing complaints early after the opera-tion. Despite increasing interest, prospective data about the long-term outcomes of functional postthyroidectomy syndrome are lacking. This paper is to review the long-term trend and evolution of voice and swallowing symptoms after thyroidectomy in the absence of laryngeal nerve injury.

Identifying the non-recurrent laryngeal nerve: preventing a major risk of morbidity during thyroidectomy

Non-recurrent laryngeal nerve [NRLN] is a rare anomaly which is reported in 0.3%-0.8% of people on the right side and in 0.004% [extremely rare] on the left side. Damage to this nerve during the surgical procedure may lead to severe iatrogenic morbidity and should therefore be prevented from being damaged. The best way to avoid this damage to the nerve is to identify the nerve with a systematic diligent dissection based on usual anatomical landmarks and awareness about the possibility of their existence. Hereby, we are going to present a 26-year-old woman, a case of NRLN on the right side which was identified during thyroidectomy. The nervous anomaly was accompanied with vascular abnormality which was confirmed by computerized tomography [CT] angiography, post-operatively

Voice-related Outcome after Thyroidectomy / 대한내분비외과학회지

PURPOSE: Vocal symptoms have been reported after thyroidectomy and even in the absence of injury to the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve. The aim of this prospective study was to evaluate the subjective and objective voice changes in patients without laryngeal nerve injury after thyroidectomy. METHODS: The subjects had undergone total thyroidectomy for differentiated thyroid carcinoma from November 2007 to December 2008. Twenty-eight subjects (males: 8, females: 20) were selected for this study. Voice analysis was prospectively evaluated in the subjects at the time of preoperation and postoperation (10.8 months for the males and 11.7 months for the females). A subjective analysis was done using the visual analogue scale (VAS, 0: no symptom, 10: severe symptoms) and objective analyses were determined by several parameters such as the fundamental frequency (Fo), jitter, shimmer and the noise to harmonic ratio (NHR) using the multi-dimensional voice program. Maximum phonation time (MPT)was performed as an aerodynamic test. RESULTS: 3 patients (37.5%) among the males and 14 patients (70%) among the females had subjective postoperative voice change. The VAS showed a significant difference for the females (0 to 1.25±0.97, P0.05). The vocal parameters (Fo, jitter, shimmer, NHR) and MPT showed no significant changes for both the males and females (P>0.05). CONCLUSION: Subjective voice changes may occur after thyroidectomy without laryngeal nerve injury. Surgeons should take possible voice changes into consideration when informing patients before thyroidectomy.

Frequency of early post operative complications of thyroidectomy

To determine the frequency of early post operative complications after thyroid gland. Descriptive case series study. This study was carried out in all four surgical units, Liaquat University Hospital Jamshoro, from September 2009 to July 2010. This study consisted of 100. Detailed Hisotry was taken from all the patients with special regard to the swelling infront of neck, moving up with deglutition and pressure symptoms like dyspnea, dysphagia, engorged neck veins. Detailed Clinical examination of the patient was done and recorded in proforma. Systemic review was also done to see any co-morbidity. All patients underwent for base line and specific investigations especially TSH, T3 and T4 as diagnostic modality and for assessment of thyroid disease. Inclusion criteria were that all patients after counseling for study and taking voluntary consent were included in this study above 15 year of age and irrespective of their sex admitted in surgical units through outpatient department and diagnosed as case of thyroid disease on the basis of history, clinical examination and investigations. Exclusion criteria included unfit patients for general anesthesia, previous thyroid surgery, pre-operative recurrent laryngeal or superior laryngeal nerve involment and traumatic thyroid injury. Follow up of all these patients was done for period of 6 months. Results were prepared with help of tables and graphs. Data was analyzed through SPSS software version 16.0. 100 cases of thyroid were operated. Out of 100 patients including in this study 84 were women [84%] and 16 were male [16%]; with male to female ratio of 1:52. There was wide variation of age ranging from a minimum of 10 years to 70 years with the mean age was 31.78 years. Symptoms of patients were an enlarged painless lump infront of neck in 99 [99%], Discomfort during swallowing in 42 [45%], Tachycardia in 55[55%], Tremors in 41 [41%], heat Intolerance 43[43%] and cold Intolerance in 20[20%] [Table 1]. Clinical examination of patients revealed that thyroid gland was enlarged in 99 [99%] patients, out of whom 59 [59%] patients had Multinodular goiter, while 30 [30%] patients had Solitary Nodule [Solid/ Cystic], 7 [7%] patients had thyroid cancer and 4 [4%] patients had a thyrotoxicosis. The commonest surgical procedure done was subtotal thyroidectomy in 62 patients [62%], near total thyroidectomy in 28 patients [28%] and lobectomy with isthmusectomy in 10 patients [10%]. The common early postoperative complications seen in this study were haematoma formation 9% patients, hypoparathyroidism 3% patients, wound infection 6% patients, laryngeal nerve injury 5% patients and thyrotoxicosis storm in 2% patients [Chart No.2]. We conclude that patients who undergo thyroidectomy an increased risk of developing postoperative hypoparathyroidism. Despite the fact that total thyroidectomy is a more involved procedure that exposes more parathyroid glands and recurrent laryngeal nerves to surgical risk than unilateral thyroid lobectomy, it is an inherently safe procedure

The Effect on Voice by Strap Muscle Cutting in Thyroidectomy / 대한내분비외과학회지

PURPOSE: Voice change after thyroidectomy has generally been the result of damage to the recurrent or superior laryngeal nerve. But many patients complain voice alteration without laryngeal nerve injury after thyroidectomy. The purpose of this study is to investigate whether strap muscle division results in any subjective or objective functional sequelae in voice, through long-term follow-up prospectively. METHODS: Twenty-two female patients who had undergone thyroid surgery between July 1998 and December 1999, were studied. The patients who were planned for neck dissection, who had benign laryngeal disease or vocal cord paresis, and whose vocal cord paresis were developed after thyroid surgery, were excluded from this study. Twelve patients had undergone thyroidectomy via retraction of strap muscle and ten patients had undergone thyroidectomy via cutting of strap muscle. For evaluation of voice, questionnaires for changes of voice, acoustics (fundamental frequency, jitter, shimmer, signal to noise ratio, noise to harmonic ratio, voice range), and aerodynamic (maximal phonation time) analyses were done. RESULTS: The subjective voice symptoms after thyroidectomy were disturbances of high pitch, singing, loud voice, and easy fatigue at phonation. There were no significant differences in voice parameters on acoustic and aerodynamic analyses between the strap muscle retraction group and the cutting group through long-term follow-up. CONCLUSION: We conclude that strap muscle division does not result in any subjective or objective functional problems in voice. We suggest that surgical division and reconstruction of these muscles should be employed routinely when operating on large, toxic or neoplastic glands.

Voice Comparison between Strap Muscle Retraction and Cutting Technique in Thyroidectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: A voice analysis was carried out before and after thyroid surgeries without laryngeal nerve injury, between strap muscle retraction and cutting group in thyroid surgery. The study was done by means of questionaires, acoustics and aerodynamic analysis. MATERIALS AND METHODS: A total of fourty-two patients of whom thirty-eight are females and four are males were analyzed; hemithyroidectomy (19 cases) and total thyroidectomy (23 cases). Twenty-seven patients had undergone thyroidectomy via retraction of strap muscle and 15 patients had undergone thyroidectomy via cutting of strap muscle. For evaluation of voice, questionaires for changes of voice, acoustics (fundamental frequency, jitter, shimmer, noise to harmonic ratio, voice intensity, vocal range), and aerodynamic (maximal phonation time, mean flow rate and subglottal pressure) analyses were done. RESULTS: The subjective voice symptoms after thyroidectomy were disturbances of high pitch, loud voice and singing voice, and easy fatigue at phonation. These voice symptoms were related to the extent of surgery. Vocal range was the only diminished parameter in acoustic and aerodynamic analyses after thyroidectomy. There were significant differences in jitter on acoustic and aerodynamic analyses between the strap muscle retraction group and the cutting group. CONCLUSION:Voice alteration after thyroidectomy without laryngeal nerve injury may be associated with the disturbance of the extralaryngeal skeleton- laryngotracheal fixation with impairment of vertical movement or by temporal malfunction of the strap muscles. These voice problems were related to the extent of surgery and cutting of strap muscles.