2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy
S.-K.
Baek et
al.
/ Auris
Nasus
Larynx
44
(2017)
583 – 589
minimal
neural
damage,
such
as
traction
or
thermal
damage
careful
capsular dissection was performed
identified. However,
lead
to
these
voice
changes. Even
if
some
damage may
be
prevent
injury
to
the
EBSLNs
on
the
superior
pole
of
the
may
to
the
use
of
IONM
can
reduce
the
minor
neural
In particular,
the branches of
superior
thyroid artery were
inevitable,
gland.
and
ligated
separately.
damage.
identified
the
objective
of
this
study
is
to
identify
any
integrity
monitor
(NIM)
electromyogram system, Medtronic Florida, USA) was
(EMG) Xomed
Nerve
Therefore,
difference
tracheal Surgical laryngeal
of
voice
outcome
according
to
the and
use
of
IONM
tube
(NIM-Response
2.0
thyroid
surgery
by
performing
pre-
post-operative
Products,
Jacksonville,
used
for
during
voice
analysis
in
the
patients
without
any
nerve
monitoring.
The
endotracheal
tube
in
sizes
multi-parametric
of
neural
damages.
or
8.0
was
placed
in
contact
with
the
true
vocal
cords. probe
evidence
7.0 For was
identification
of
the RLN,
a monopolar
stimulator
used event
with
an
initial
stimulation
level
of
1.0 mA,
and
Materials & methods
2.
threshold
was
set
at
100 m V.
Before
nerve strap
the
the
stimulator
probe
was
tested pulse
on
identification,
Subjects
2.1.
muscles
to
confirm
whether
the
probe
and
generator neuromus- intubation
working blocking
properly.
Furthermore,
additional following
were cular
retrospective
review
was
performed
with
a
total
of
A
agents
were
not
used
469 of Anam Hospital, Korea University, Seoul, South Korea between October 2012 and November 2014. Among these patients, 284 patients were excluded due to young age before 18 years, insufficient medical records, previous vocal cord paralysis or vocal fold lesion, planned recurrent laryngeal nerve sacrifice during operation, completion thyroidectomy, or combined lateral neck dissection. In addition, patients showing post- thyroidectomy evidence of RLN or EBSLN palsy and patients with anaplastic or medullary carcinoma of the thyroid were also excluded. Overall, 185 female patients met the inclusion criteria. The study group consisted of 68 retrospectively selected, consecutive patients who had undergone IONM thyroid surgery for papillary thyroid carcinoma between January 2014 and November 2014. A historical group of 117 similar patients who had not received IONM thyroid surgery for papillary thyroid carcinoma between October 2012 and December 2013 was used as an external control group. Based on the extent of thyroid surgery, all the patients were divided into four groups: hemi-thyroidectomy with IONM (Group A, n = 37) or without IONM (Group B, n = 41) and total thyroidectomy with IONM (Group C, n = 31) or without IONM (Group D, n = 76) ( Fig. 1 ). female patients who were referred to the thyroid center
the
operation.
during
2.3.
Voice
analysis
Pre-and post-operative evaluation of vocal cord motility was performed via 70-degree rigid endoscope in all cases. Subjects were assessed four times: before surgery and at 1 week, 1 month, and 3 months after surgery. The following were undertaken: acoustic analysis (measuring fundamental frequency, jitter, shimmer and noise to harmonic ratio), aerodynamic analysis (measuring mean flow rate, maximum phonation time and subglottic pressure), voice range profile (VRP) analysis, vocal assessment using the grade-roughness-breathiness-asthenia- strain scale, and assessment of the Voice Handicap Index. Acoustic variables were measured using the Multi- Dimensional Voice Program software application from the Computerized Speech Lab system (model 4500; KayPentax, Lincoln Park, New Jersey, USA), assessing a few seconds of sustained phonation of the vowel/a/. VRPs, including vocal pitch (frequency) range and vocal intensity range, were assessed to identify the maximum and minimum intensity (decibel, dB) and frequency (hertz, Hz) of the voiced sound. Subjective assessment of voice quality was performed using the grade-roughness-breathiness-asthenia-strain scale designed by De Bodt et al., [6] with additional assessment of aphonia. This assessment was performed by an experienced phonetician with no knowledge of the study design. The Voice Handicap Index (VHI) consists of 30 questions divided by content into 3 subscales covering functional, physical and emotional parameters. All patients completed a Voice Handicap Index questionnaire, using a five-point rating scale to indicate their response. The scale was ordinal and scored from 0 (meaning never) to 4 (meaning always) for each of the questions, with a minimum total score of 0 and a maximum total score of 120. Higher scores indicated worse perceived disability due to the patient ’ s voice problem.
Surgical
techniques
2.2.
open
thyroid
surgery,
a
standard
5 – 6
cm
transverse
In
incision was
performed
two
fingerbreadths
above
the
cervical sternal muscles
notch. Subplatysmal
skin
flaps were made
and
the
strap
were
divided
at
the
midline
and
retracted
laterally. capsular peripheral
identification
of
the
thyroid
gland,
careful
After
close
to
the
thyroid
was
performed
and
dissection
of
the
superior,
middle,
and
inferior
thyroid
vessels
ligation
performed
individually,
just
on
the
thyroid
capsule,
using
was
harmonic
shear.
In
endoscopic
or
robotic
thyroid
surgery,
a
a
cm
skin
incision
was
performed
on
the
axilla
for the
5 – 6
approach
and
a
7 – 8
cm
skin
incision
along
transaxillary
hairline
from
the
earlobe was
performed
for
the
retroauricular
skin
flap was
extended
to
the
anterior
neck
until
approach. The
2.4.
Statistics
contralateral
lobe
of
the
thyroid
was
exposed.
Harmonic
the
for vessel preserved
control.
In
all operations, RLNs were
results
of
voice
analysis
were
compared
between
The
shear was used
and
but
EBSLNs
were
not
routinely
with
and
without
IONM.
Statistical
analysis
was
identified
patients
112
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