New York Otology, New York, New York 10028, USA.
Otolaryngol Head Neck Surg. 2013 Jun;148(6 Suppl):S1-37. doi: 10.1177/0194599813487301.
Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient's voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.
The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.
The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient's voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient's voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.
甲状腺切除术可用于临床指征，包括恶性肿瘤、良性结节或囊肿、细针穿刺活检可疑发现、颈段食管受压引起的吞咽困难、气道受压引起的呼吸困难。约 10%的患者在手术后会出现暂时性喉返神经损伤，多达 1/25 的患者会出现持续的声音问题。甲状腺手术后生活质量下降是多因素的，可能包括终身药物治疗、甲状腺抑制、放射性扫描/治疗、暂时性和永久性甲状旁腺功能减退、术后暂时性或永久性发声困难以及吞咽困难。本临床实践指南提供了在甲状腺手术术前、术中、术后期间管理患者声音的循证建议。
本指南的目的是优化成年患者（18 岁及以上）甲状腺手术后的声音结果。目标受众是任何参与管理此类患者的临床医生，包括但不限于耳鼻喉科医生、普通外科医生、内分泌科医生、内科医生、言语语言病理学家、家庭医生和其他初级保健提供者、麻醉师、护士以及其他管理甲状腺/声音问题患者的人员。本指南适用于临床医生在甲状腺手术前后可能与之互动的任何环境。特别排除 18 岁以下的儿童；然而，专家组了解到，许多发现可能适用于这一人群。同时切除喉的患者也被排除在外。虽然本指南仅限于甲状腺切除术，但一些建议也可能适用于甲状旁腺切除术。
指南制定小组强烈建议外科医生在甲状腺手术期间识别喉返神经。专家组提出了以下建议：（1）一旦决定进行甲状腺手术，临床医生或外科医生应记录对患者声音的评估；（2）如果患者的声音受损且决定进行甲状腺手术，应检查声带活动度，或将患者转介给能够检查声带活动度的临床医生；（3）如果患者的声音正常且有以下情况之一，应在决定进行甲状腺手术时检查声带活动度，或将患者转介给能够检查声带活动度的临床医生：（a）甲状腺癌伴甲状腺外侵犯的可疑证据，或（b）先前增加喉返神经损伤风险的颈部手术（颈动脉内膜切除术、颈椎前路、颈段食管切除术和先前的甲状腺或甲状旁腺手术），或（c）两者都有；（4）一旦决定进行甲状腺手术，应向患者介绍甲状腺手术对声音的潜在影响；（5）在有术前喉镜检查的患者中，将异常术前喉评估的结果告知麻醉师；（6）在进行甲状腺手术时采取措施保护上喉神经的外支；（7）记录甲状腺手术后 2 周到 2 个月之间声音是否有变化；（8）如果甲状腺手术后声音发生变化，应检查声带活动度，或将患者转介进行声带活动度检查；（9）如果在甲状腺手术后发现声带活动异常，应将患者转介给耳鼻喉科医生；（10）对甲状腺手术后声音改变或声带活动异常的患者进行咨询，提供嗓音康复选择。专家组提出了一个选择，即外科医生或其指定代表可以在甲状腺手术期间监测喉肌电图。专家组没有对甲状腺手术中单次静脉内皮质类固醇剂量对声音结果的影响提出建议。
