2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Chandrasekhar et al

Patient aged 18 years or older undergoing thyroid surgery

Document baseline assessment of patient’s voice

No

A. Thyroid cancer with suspected extrathyroidal extension B. A history of prior neck surgery

Is the patient’s voice impaired?

Does the patient have: A AND/ORB

Yes

Examine the patient’s vocal fold motion or refer for examination

No

Educate patient about the potential impact of thyroid surgery on the voice

Inform the anesthesiologist of abnormal preoperative laryngeal assessment

Identify the recurrent laryngeal nerve during thyroid surgery

Optional

Monitor laryngeal electromyography (EMG) during surgery

Take steps to preserve the external branch of the superior laryngeal nerve

Any change in the patient’s voice between 2 weeks and 2 months following surgery?

No

Yes

Document voice changes in the patient’s medical record

Examine vocal fold mobility or refer for examination

No

Abnormal vocal fold mobility?

Yes

Refer to an otolaryngologist

Counsel patient on options for voice rehabilitation

Patient transitions to adjuvant therapy or surveillance as indicated by the underlying disease

Figure 5. Algorithm of guideline’s key action statements.

provided. The diagrams identify the location of the thyroid gland and the position of both the SLN and the RLN. Research Needs This guideline was based on the current body of evidence regarding voice outcomes during thyroid surgery. As deter- mined by the GDG’s review of the literature, assessment of current clinical practices, and determination of evidence gaps, research needs were determined as follows: 1. Investigate methods to avoid unnecessarily extensive or bilateral thyroid surgery, including methods to increase accuracy of FNAB in predicting malignancy.

2. Investigate what patient subgroups are at highest risk for RLN paralysis at thyroidectomy. 3. Determine how surgeons can learn maximally from their own surgical cases and complications. 4. Develop learning tools for both patients and physi- cians to optimize shared decision making around the time of thyroidectomy. 5. Further research on endotracheal tube size, shape, and cuff dynamics to optimize voice around the time of thyroidectomy or other general anesthetic requir- ing intubation. 6. Further research on the current practices of surgeons during thyroidectomy including the number of cases where the nerve is not identified.

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