ORIGINAL ARTICLE

Laryngeal Complications After Thyroidectomy

Is It Always the Surgeon?
Matthias Echternach, MD; Christoph Maurer, MD; Thomas Mencke, MD;
Martin Schilling, MD; Thomas Verse, MD; Bernhard Richter, MD

Hypothesis: Laryngeal dysfunction after thyroidec- Results: The overall rate of laryngeal complications was
tomy is a common complication. However, few data are 42.0% (320 patients). Complications from an injury to
available to differentiate whether these complications re- the vocal folds occurred in 31.3% of patients. Weakness
sult from injury to the recurrent nerve or to the vocal or paresis of the recurrent nerve was initially present in
folds from intubation. 6.6% and was related to the nerves at risk. This rate was
higher in revision thyroidectomies than in primary sur-
Setting: University medical center. gical interventions (6.2% vs 11.6%; P=.04). The rate of
laryngeal injuries was higher in patients older than 65
Patients: Seven hundred sixty-one patients who years (39.8% vs 30.8%; P =.03).
underwent surgery to the thyroid gland from 1990 to
Conclusions: These data suggest that laryngeal compli-
2002. Of these patients, 8.4% underwent a revision
cations after thyroidectomies are primarily caused by in-
thyroidectomy. jury to the vocal folds from intubation and to a lesser ex-
tent by injury to the laryngeal nerve. We recommend
Intervention: Preoperative and postoperative laryngo-
documentation of informed consent, especially for pa-
stroboscopic examination. tients who use their voice professionally, such as sing-
ers, actors, or teachers.
Main Outcome Measure: Laryngostroboscopic evalu-
ation of laryngeal complications. Arch Surg. 2009;144(2):149-153

L
ARYNGEAL COMPLICATIONS AF- going thyroidectomy, the descriptions of
ter thyroidectomy are a com- vocal fold injury are missing. In smaller
mon problem.1-5 The leading groups of patients undergoing thyroidec-
cause of the problem is in- tomy, laryngeal dysfunction was noted by
jury to the recurrent nerve. Stojadinovic et al16 in 2 of 15 symptomatic
Studies performed on large groups of pa- and 2 of 30 asymptomatic patients and by
tients show a prevalence for permanent palsy de Pedro Netto et al17 in 28 of 100 patients.
of the recurrent nerve ranging from 0% In the present study, we sought to deter-
mine the incidence and characteristics of in-
tubation-related vocal fold injuries after thy-
Author Affiliations: Institute See Invited Critique roidectomy in a large group of patients.
for Musicians’ Medicine, at end of article
Freiburg University Medical
Center, Freiburg
METHODS
after primary surgery to 20% after revision
(Drs Echternach and Richter),
Department of Anaesthesiology,
surgery.1-5 Tracheal intubation can lead to A total of 1001 patients were included in the
Rostock University, Rostock hoarseness as well.6,7 The incidence of la- study between 1990 and 2002. All patients
(Dr Mencke), Department of ryngeal injuries caused by intubation is con- scheduled for thyroidectomy underwent pre-
Surgery, Saarland University sidered to be about 6% to 70% after surgi- operative evaluation of the vocal folds. Over-
Medical Center, Homburg cal procedures not adjacent to the larynx.6,8-13 all, 240 patients failed to appear for postop-
(Dr Schilling), and Department To date, there are few data concerning in- erative examination of the vocal folds at our
of Otorhinolaryngology, juries to the vocal folds after surgery in university medical center (reasons included re-
Asklepios Hospital Harburg, fusal of reexamination, subjective rejection of
Hamburg (Dr Verse), Germany;
close relationship to the larynx. Although reevaluation because of good vocal quality, or
and Department of Surgery, Musholt et al14 and Lombardi et al15 report reevaluation by an otolaryngologist at an-
Liestal Hospital, Liestal, that hoarseness is increased and videolaryn- other institution) and were excluded from the
Switzerland (Dr Maurer). goscopy was performed in patients under- analysis.

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 Table 1. General Data for 761 Study Patients Table 3. Preoperative and Postoperative
Laryngostroboscopic Findings in 761 Patients
Variable No. (%)
Diagnosis No. (%)
Sex
Female 528 (69.4) Preoperative findings a
Male 233 (30.6) Laryngitis 52 (6.8)
Age, y Edema 21 (2.8)
Median 51 Cyst 1 (0.1)
Range 7-87 Granuloma 1 (0.1)
ⱕ64 600 (78.8) Polyp 6 (0.8)
ⱖ65 161 (21.2) Leukoplakia 2 (0.3)
Lateralization of surgery Sulcus vocalis 1 (0.1)
Total bilateral 46 (6.0) Hyperfunction 15 (2.0)
Total unilateral 70 (9.2) Hypofunction 21 (2.8)
Subtotal bilateral 413 (54.3) Hyperplasia of ventricular folds 5 (0.7)
Subtotal unilateral 77 (10.1) Palsy of recurrent nerve 14 (1.8)
Total on one side, subtotal on the other side 115 (15.1) Postoperative findings b
Bilateral node extirpation 32 (4.2) Hematoma 70 (9.2)
Unilateral node extirpation 6 (0.8) Granuloma 68 (8.9)
Resection at the isthmus 2 (0.3) Thickening of mucosa 104 (13.7)
First thyroidectomy 697 (91.6) Edema 29 (3.8)
Revision thyroidectomy 64 (8.4) Subluxation of arytenoid cartilage 1 (0.1)
Recurrent nerve palsy 84 (11.0)

a Two patients had 2 different kinds of laryngeal changes.

b Three hundred fifty-six alterations were noted in 320 patients.

Table 2. Histopathologic Findings at Thyroidectomy

ralysis of the recurrent nerve were considered separately because
Finding No. (%) a their origin after thyroidectomy (because of the surgical pro-
Malignant lesion 59 (7.8)
cedure or intubation) is still unclear.
Follicular 21 (35.5)
In all patients, age, sex, histopathologic diagnosis, and re-
Papillary 19 (32.2) port of the surgical procedure were analyzed (Table 1 and
Lindsay tumor b 6 (10.2) Table 2). For comparison between groups, the ␹2 test and Ken-
Anaplastic 1 (1.7) dall ␶-b rank correlation were used. Statistical significance was
Medullary 9 (15.3) defined with a 95% confidence interval (P⬍.05).
Paraganglioma 1 (1.7)
Metastasis 2 (3.4)
RESULTS
Benign lesion 702 (92.2)
Nodular goiter and adenoma 576 (82.1)
Thyroiditis 70 (10.0) At preoperative stroboscopic examination, we found 139
Hyperparathyroidism 54 (7.7) alterations of the vocal folds in 137 patients (18.0%;
Oncocytoma 2 (0.3) Table 3). Fourteen patients (1.8%) had preexisting palsy
a The percentages for the main categories “Malignant lesion” and “Benign
of the recurrent nerve. Eight of these patients had pre-
lesion” are based on the entire cohort of 761 patients; the percentages for
viously undergone a surgical procedure with a nerve at
the subcategories are based on 59 and 702 patients, respectively. risk (thyroid gland [n=7] or transcervical approach to
b Also known as follicular differentiated papillary thyroid carcinoma.
the spinal cord [n = 1]). In 2 patients, the paresis was
caused by a malignant lesion and, in 4 patients, the cause
was unknown.
In each of the remaining 761 patients (Table 1), preop- The total number of nerves at risk was 1365. In 2 pa-
erative and postoperative endoscopic laryngostroboscopy
tients, only resection in the area of the thyroid isthmus
(Timcke Elektromedizinische Geräte, Hamburg, Germany) was
performed by an experienced otolaryngologist. Compared with was performed, without any risk of damage to the laryn-
laryngoscopy, laryngostroboscopy provides more detailed in- geal recurrent nerve.
formation about vocal fold oscillations such as amplitudes and The histopathologic findings revealed a malignant le-
mucosa waves and the glottic closure18 and is more sensitive sion in 59 patients (7.8%) (Table 2). Two patients had
for detection of even small alterations. The postoperative ex- thyroid metastasis from primary tumors in a kidney and
amination was performed on day 3 or 4 after surgery. in the stomach. In 21 patients (2.8%), surgical compli-
Laryngeal complications were defined as newly discovered cations during or after thyroidectomy were cited in the
findings at the vocal folds after surgery compared with the pre- surgical reports, with the most prevalent complication
operative status. Specific attention was placed on findings de- being bleeding in the surgical area in 10 patients (47.6%
scribed in the literature6,9-14,16,19 such as edema, granulations,
of surgical complications). No descriptions of injury to
hematomas, dislocation of the arytenoid cartilage, and fibrin-
ous laryngitis or thickening of the vocal folds. All of these con- the recurrent nerve were noted in the surgical reports.
ditions resulted in incomplete closure of the rima glottidis or The overall rate of postoperative laryngeal complica-
changes in the amplitude of the vocal fold vibration or move- tions after surgery was 42.0%. Thirty-six patients exhib-
ments of the mucosa wave and, therefore, caused hoarse- ited 2 different kinds of laryngeal complications. The rate
ness.6,9-14,16,19 Apart from these complications, weakness and pa- of vocal fold injury was estimated at 31.3% (Table 3). Only

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 1 patient experienced subluxation of the arytenoid car-
A
tilage, which was repositioned in a subsequent surgical
procedure that resulted in good improvement in vocal
function. No statistically significant occurrence of later-
alization of granulomas occurred (P = .63) (Figure, A).
Although edema was more unilateral than bilateral (n=20
vs n=9; P=.04), there was no dominance of one side over
the other (P=.37). Only hematomas (Figure, B) were more
prevalent unilaterally (left side, n = 46; right side, n=20;
bilateral, n=4; P ⬍.001).
Patients with preoperative alteration of the vocal folds
did not demonstrate a statistically significant higher rate
of postoperative vocal fold injury compared with pa-
tients without any alterations (P=.06). Patients with pre-
operative superficial laryngitis, characterized by injec-
tion of vessels, did not have a statistically significant higher
rate of postoperative hematoma (P= .31). There was no
significant difference associated with the patients’ sex B
(P=.15). Older patients (ⱖ65 years) exhibited more al-
terations in the vocal folds than did younger patients
(39.8% vs 30.8%; P = .03).
Overall weakness or paralysis of the recurrent nerve
was noted in 78 patients unilaterally and in 6 patients
bilaterally. There was no injury to the superior laryn-
geal nerve. For the 1365 nerves at risk, the rate of recur-
rent nerve palsy was 6.6%. No significant difference was
noted in the rate of recurrent nerve palsy associated with
malignant lesions (P = .13) or age (P= .23). According to
the surgical reports, there were descriptions of prepara-
tion of the recurrent nerves in 1345 nerves at risk (98.5%).
In our data, the kind of dissection (total dissection, par-
tial dissection, or no dissection) compared with the nerves
at risk had no significant influence on the rate of recur-
rent nerve palsy (P = .10). Only revision surgery was as- Figure. Indirect laryngoscopic views of a granuloma on the left vocal fold at
sociated with higher rate of impairment of the recurrent the vocal process (A) and a hematoma on the right vocal fold (B).
nerve (6.2% vs 11.6%; P = .04).
The reason for this might be the earlier performance of
laryngostroboscopy. Compared with recent prospective
COMMENT
studies in smaller patient groups, our data reflect a simi-
lar frequency of intubation-related laryngeal inju-
To our knowledge, in the present study, we demon- ries.10,12 However, these studies excluded patients who
strated for the first time in a large group of patients that underwent an operation performed close to the larynx.
damage to the recurrent nerve is not the most prevalent The comparable number of laryngeal injuries led the au-
cause of laryngeal complications after thyroidectomy. Ap- thors to believe that, compared with intubation and ex-
proximately 40% of our patients had impairment in vo- tubation, thyroidectomy causes minor risk to the lar-
cal function overall; however, 3 to 4 days after surgery, ynx.10-12 Similar findings were reported in a smaller group
injury to the vocal folds was noted about 3 times more of patients undergoing thyroidectomy.17
often than palsy of the recurrent nerve. Among many risk factors for injury to the vocal folds
We found injury to the vocal folds, presumably caused caused by intubation are cuff pressure, size of the tube,
by intubation or extubation, in 31% of our patients. Com- movement of the tube, physical trauma, intubation envi-
pared with findings in older studies that found laryn- ronment, duration of intubation, gastroesophageal reflux,
geal injuries of 6.2% to 16.3%, our data suggest a much and mucociliary mechanism.10,21 However, previous stud-
higher rate for these complications.9,13,20 Previous au- ies found no significant influence of the drug used for re-
thors who examined intubation-related complications laxation after rapid-sequence induction and no reduction
chose a longer interval after surgery and used laryngos- in vocal fold injury using neuromuscular monitoring.11,12
copy or mirror stroboscopy rather than endoscopic laryn- In contrast to our findings, Weymuller22 found higher rates
gostroboscopy. Endoscopic laryngostroboscopy is a more of hoarseness in women. Other authors were unable to con-
sensitive method for detecting small alterations in the vo- firm a relationship between the size of the tube and changes
cal folds. Pröschel and Eysholdt,6 who investigated short- in the acoustic signal.23 We found more vocal fold injuries
term alterations of the larynx after intubation, exam- in older patients, presumably due to a decrease in flexibil-
ined the vocal folds 1 to 2 days after surgery and found ity and atrophy of the vocal tissues.24 In this study, other
an even higher rate of complications (73%) than we did. potential risk factors such as nicotine use, ethanol abuse,

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 and gastroesophageal reflux were not evaluated. It is pos- we preoperatively found idiopathic recurrent nerve
sible that these potential risk factors increase the risk of in- palsy. It is presumed that recurrent nerve palsy would
tubation-related complications. be considered a surgical complication after thyroidec-
Similar to other studies,6,10,12 the most common find- tomy without any preoperative laryngologic examina-
ing in our study was thickening of the mucosa in the pos- tion. This emphasizes the need for preoperative laryn-
terior parts of the vocal folds, followed by hematoma. goscopy before thyroidectomy, at least for medicolegal
Whether these alterations are caused by laceration or by reasons.
gastroesophageal reflux remains unclear. However, al- Our data suggest that laryngeal complications caused
terations in the posterior part of the vocal folds have been by injury to the vocal folds occur much more frequently
thought to be induced by the tube or by an adduction than impairment of the recurrent nerve function, thus
reaction of the vocal folds caused by superficial anesthe- confirming findings in smaller patient groups. We rec-
sia.6 Subluxation of the arytenoid cartilage was found in ommend documentation of informed consent, espe-
only 1 patient, and only rarely has dislocation of the ary- cially for patients who use their voice professionally, such
tenoid cartilage been reported.25 Similar to our findings, as singers, actors, or teachers.
Kambic and Radsel9 found such dislocation in only 1 of
1000 patients. To avoid ankylosis of the cricoarytenoid
joint, early surgical mobilization is recommended.19 Accepted for Publication: February 1, 2008.
Our data confirm findings in the subgroup of hema- Correspondence: Matthias Echternach, MD, Institute for
tomas in which a higher rate of laryngologic complica- Musicians’ Medicine, Freiburg University Medical
tions was found on the left side, presumably due to the Center, Breisacher Str 60, 79106 Freiburg, Germany
anesthesiologist being right-handed.9,13 Granulations and ([email protected]).
thickening were primarily found bilaterally in the pos- Author Contributions: Dr Echternach had full access to
terior part of the vocal folds, presumably more the re- all of the data in the study and takes responsibility for
sult of chronic irritation by the endotracheal tube. the integrity of the data and the accuracy of the data analy-
It has been suggested that vocal fold injuries are fre- sis. Study concept and design: Echternach, Maurer, and
quently noted in the first days after surgery but that they Mencke. Acquisition of data: Echternach and Schilling.
heal quickly.6,8 Peppard and Dickens13 described heal- Analysis and interpretation of data: Echternach, Maurer,
ing of glottal hematomas within 4 weeks in 21 of 22 pa- Mencke, Verse, and Richter. Drafting of the manuscript:
tients. Analysis of hoarseness with acoustic or percep- Echternach, Verse, and Mencke. Critical revision of the
tive measurements14-17 cannot be offered because of the manuscript for important intellectual content: Echternach,
large number of patients. However, because of the risk Maurer, Mencke, Schilling, Verse, and Richter. Statisti-
of persisting alterations with long-term impairment of the cal analysis: Echternach, Mencke, and Verse. Adminis-
voice, we recommend laryngologic follow-up examina- trative, technical, and material support: Echternach, Maurer,
tions for patients who use their voice professionally (eg, Verse, and Richter. Study supervision: Maurer, Mencke,
professional singers, actors, or teachers). Schilling, Verse, and Richter.
There is comprehensive literature about the preva- Financial Disclosure: None reported.
lence of recurrent nerve palsy after thyroidectomy. Stud- Additional Information: This study was performed at the
ies with a large number of patients show prevalence for Departments of Otolaryngology (Drs Echternach and
permanent paresis to be between 0% after primary sur- Verse), Surgery (Drs Maurer and Schilling), and Anes-
gery and 20% after revision surgery.1-5 Our findings are thesiology (Dr Mencke) at Saarland University Medical
within this range. Center, Homburg, Germany.
In the present study, no intraoperative monitoring of Additional Contributions: Volker Barth, MD, acquired
the laryngeal recurrent nerve was performed. There is still data and examined patients; Thomas Fuchs-Buder, MD,
controversy about the use of intraoperative recurrent nerve supervised the study; and Kenan Demiroglu performed
monitoring. Despite some publications recommending statistical analysis and acquired data.
monitoring, recent studies could not show lower inci-
dences of postoperative recurrent nerve palsy with moni- REFERENCES
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INVITED CRITIQUE

H oarseness is a dreaded complication after thy-

roidectomy. Even in the most experienced
hands, significant postoperative voice changes
occur in more than 5% to 10% of patients. Echternach
et al report that 42% of patients undergoing thyroidec-
of the gland? Is the incidence of vocal fold trauma in pa-
tients undergoing operations on the outside of the neck
similar? A control group such as this would have pro-
vided this information. Third, there are no data in this
article to suggest that recognizing laryngeal dysfunc-
tomy at their institution experienced a laryngeal com- tion preoperatively or postoperatively affects patient out-
plication. Most of these complications were unrelated to comes. Fourth, because only 23.8% of patients with la-
injury to the recurrent nerve by the surgeon but caused ryngeal injuries received long-term follow-up, we do not
by trauma to the vocal folds after intubation. While these know the long-term implications of these injuries. It is
finding are enlightening (and relieving!) to those of us hoped that additional data from this group and others
who perform thyroid operations, there are still unre- will shed light on these important issues.
solved issues and questions about the data in this study.
First, there are no data about patient symptoms associ- Herbert Chen, MD
ated with the laryngeal complications. If most patients
did not have symptoms, what is the clinical importance Correspondence: Dr Chen, Department of Surgery, Uni-
of the findings? Second, do we know for certain that most versity of Wisconsin Medical School, H4/750 Clinical Sci-
of the vocal fold injuries were caused by endotracheal ence Center, 600 Highland Ave, Madison, WI 53792 (chen
intubation rather than intraoperative abrasions or trauma @surgery.wisc.edu).
from pulling on the thyroid and trachea during removal Financial Disclosure: None reported.

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 of air via the colonoscope to test the anastomosis, data though the data presented did not comment on details
supporting its use as a method of ensuring anastomotic such as the circumferential nature of the initial leak, the
integrity is, at best, inconclusive. This large study of left- percentage of the anastomosis that had to be primarily
sided colorectal anastomoses reveals that, indeed, anas- repaired (perhaps number of 3-0 silks used), or the pre-
tomotic leak testing is beneficial and that an airtight anas- existing comorbidities of these patients related to risk of
tomosis may be a reliable indicator of anastomotic an anastomotic leak, the data from this article proposes
integrity. Three very important conclusions are brought an algorithmic approach to the results of the intraopera-
to the forefront. First, an airtight anastomosis does not tive anastomotic leak testing following colorectal resec-
guarantee that anastomotic disruption will not occur post- tion and directs the surgeon to the need to repair, re-
operatively. Second, primary repair of a colorectal anas- resect, or divert.
tomosis that does not subsequently leak on testing also
does not guarantee a subsequent postoperative anasto- Walter E. Longo, MD
motic leak. Third, these data seem to suggest that an ini-
tial positive anastomotic leak test that either repair with Correspondence: Dr Longo, Yale School of Medicine, De-
fecal diversion or resecting the initial anastomosis and partment of Surgery, PO Box 208062, New Haven, CT
performing a new colorectal anastomosis will offer the 06520-8062 ([email protected]).
best chance of not encountering a postoperative leak. Al- Financial Disclosure: None reported.

Correction

Middle Initial Missing From Author Name. In the ar-

ticle titled “Laryngeal Complications After Thyroidec-
tomy: Is It Always the Surgeon?” by Echternach et al,
published in the February issue of the Archives (2009;
144[2]:149-153), the second author’s middle initial was
omitted from the byline on page 149. It should have read
as follows: Christoph A. Maurer, MD.

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