EndocrineComplete and incomplete recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Characterizing paralysis and paresis
Introduction
Paralysis of the recurrent laryngeal nerve (RLN) is a typical and occasionally permanent complication after thyroid surgery affecting patient’s quality of life. The incidence of temporary (rehabilitation within 6 months) and permanent paralysis ranges from 1.4 to 38 and 0.3 to 3 percent respectively.1, 2, 3, 4, 5, 6, 7, 8 Immobility of the vocal fold (VF) is defined as the absence of purposeful motion and is categorized as VF paralysis.9, 10 Recently a reduced but still visible mobility of the VF (in contrast to paralysis) gained attention in laryngological research owing to improved methods of diagnosis.11, 12 This entity was first described by Koufman et al in 50 patients with symptoms such as dysphonia, vocal fatigue, and diplophonia.13
Hypomobility of the VF after thyroidectomy has still not been defined as an outcome parameter and has not been implemented in early routine postoperative evaluation, yet VF hypomobility was mentioned in a previous manuscript of our institution.14 However, for patients and for surgeons it is of major importance to distinguish between complete immobility (paralysis), incomplete or reduced mobility (paresis), and regular movement of the VF. The aim of the present study was to prospectively investigate the, incidence, rate of recovery of VF paresis in comparison to VF paralysis after thyroid and parathyroid surgery and to evaluate contributing risks factors for these complications. Furthermore, intraoperative neuromonitoring data of surgeries and symptoms of VF paresis patients were compared with those with VF paralysis.
Section snippets
Methods
Data were prospectively collected and analyzed in a single high-volume thyroid center with the focus on postoperative VF function distinguishing paralysis, paresis, and regular mobility. These entities were recorded as separate outcome parameter in our database. Ethical approval was granted by the KAV review board (EK 15-128-VK). In the study, 4,715 patients (female and male) were prospectively included. All patients underwent thyroid and parathyroid surgery between January 2012 until December
Results
In the study, 4,707 patients were surgically treated for thyroid and parathyroid disease with 7,992 NAR; 3,495 were women and 1,212 men. Patients received bilateral surgery (n = 3,302) or unilateral surgery (n = 1,388), and 17 were sole resections of thyroid isthmus or pyramidal lobe.
Diagnoses were distributed as follows: malignant diagnosis in 641 patients (14.85%), Graves disease in 374 (9.12%), recurrent disease in 301 (5.18%), and hyperparathyroidism in 245 (4.09%) patients. The remaining
Discussion
The aim of this study was to investigate incidence and prognosis of VF hypomobility (ie, paresis) versus complete VF immobility (ie, paralysis) after thyroid and parathyroid surgery in routine postoperative laryngoscopy. The discrepancy between these 2 diagnoses has not been evaluated as an independent parameter after thyroid surgery to the best of our knowledge. There was a significant difference between the 2 groups in the rate of recovery, time to restitution, and IONM vagal nerve amplitude
Funding/Support
The authors have indicated that they have no conflicts of interest (or funding) regarding the content of this article.
Conflict of interest/Disclosure
All authors declare no conflict of interest.
Acknowledgments
We thank Paul Haller and Nikolaus Pfisterer for their contribution to the statistical analysis as well as Malwina Jarosz for data acquisition.
References (34)
Recurrent laryngeal nerve paralysis: Anatomy and etiology
Otolaryngol Clin North Am
(2004)- et al.
Vocal Fold Paresis and Paralysis
Otolaryngologic Clinics of North America
(2007) - et al.
Determining the etiology of mild vocal fold hypomobility
J Voice
(2003) - et al.
Vocal fold paresis
Otolaryngol Neck Surg
(2000) - et al.
Surgery for thyroid cancer
Surg Oncol Clin N Am
(2008) - et al.
Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery
Surgery
(2004) - et al.
Vocal fold paresis and paralysis: What the thyroid surgeon should know
Surg Oncol Clin N Am
(2008) - et al.
The prevalence of undiagnosed thyroid disease in patients with symptomatic vocal fold paresis
J Voice
(2011) - et al.
Evaluation of vocal fold motion abnormalities: Are we all seeing the same thing?
J Voice
(2017) - et al.
Mild vocal fold paresis: Understanding clinical presentation and electromyographic findings
J Voice
(2006)
Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: Asystematic review
Int J Clin Pract
Recurrent laryngeal nerve injury in thyroid surgery: A review
ANZ J Surg
Quality of life measures and predictors for adults with unilateral vocal cord paralysis
Laryngoscope
Late-onset palsy of the recurrent laryngeal nerve after thyroid surgery
Br J Surg
Guidelines for complications after thyroid surgery: Pitfalls in diagnosis and advices for continuous quality improvement
Eur Surg Acta Chir Austriaca
Risk of recurrent laryngeal nerve palsy in patients undergoing thyroidectomy with and without intraoperative nerve monitoring
Br J Surg
Postoperative vocal fold palsy in patients undergoing thyroid surgery with continuous or intermittent nerve monitoring
Br J Surg
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