Vocal cord paresis and paralysis after thyroid and parathyroid surgery

BACKGROUND. Vocal cord paresis in 59% of cases is a result of surgical interventions on the organs of the neck and chest. However, thyroid surgery is the main cause of them (up to 49% of cases). Unfortunately, the most tragic complication — bilateral recurrent laryngeal nerve injury in 80% is associated with thyroidectomy.

AIM. To determine the risk factors and causes of vocal cord paresis in patients after thyroid and parathyroid surgery. To analyze the clinical picture, catamnesis of postoperative vocal cord paresis.

MATERIALS AND METHODS. The study included patients who underwent thyroid and parathyroid surgery. Laryngeal mobility was assessed in all patients before and after surgery (transcutaneous ultrasound, videolaryngoscopy). Surgical interventions were performed by 8 endocrine surgeons with mandatory visualization of the recurrent laryngeal nerve. In the late postoperative period videolaryngoscopy was performed in patients with vocal cord paresis every month. Patients monitoring was discontinued upon recovery of laryngeal mobility.

RESULTS. In the study identified 2682 (100%) recurrent laryngeal nerves and diagnosed 169 (6.3%) unilateral vocal cord paresis. Preoperative vocal cord paresis (type A) was found in 0.5% of patients. Postoperative vocal cord paresis due to carcinoma invasion (type B) were noted in 0.5% of cases. Type “C” included inadvertent postoperative vocal cord paresis, occurring in 5.3% of cases.

Factors such as sex, age, disease, chronic thyroiditis, increasing surgery, retrosternal location, and increased volume of the thyroid lobe did not elevate the level of postoperative vocal cord paresis (p>0.05). However, reoperation, progression of malignant processes and surgical technique influence the number of postoperative vocal cord paresis (p < 0.05).

Vocal cord paresis was characterized by the following clinical properties: negative Valsalva test — 68.1%, choke on liquid — 46.0%, breathlessness — 7.4%, and the voice did not change in 24.5% of patients. Recovery of laryngeal mobility was observed in 67.2% of patients. In 97.1% of cases complete recovery of motor function was noted within the first 3 months after surgery.

CONCLUSION. The clinical picture of vocal cord paresis in the early postoperative period ranging from asymptomatic forms to dysphagia and respiratory failure. Moreover, the symptoms and laryngoscopic findings are nonspecific (independent of the cause of recurrent laryngeal nerve injury), thus, not determining the prognosis for recovery of laryngeal mobility. However, in the long-term postoperative period indicators such as frequency of recovery, timing of recovery and volume of vocal cord mobility reflect three types of nerve damage — neurotmesis, neuropraxia, and axonotmesis.

1. Pisanu A, Porceddu G, Podda M, et al. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014; 188(1):152-61. doi: 10.1016/j.jss.2013.12.022.

2. Dhillon VK, Rettig E, Noureldine SI, et al. The incidence of vocal fold motion impairment after primary thyroid and parathyroid surgery for a single high-volume academic surgeon determined by pre- and immediate post-operative fiberoptic laryngoscopy. Int J Surg. 2018;56:73-78. doi: 10.1016/j.ijsu.2018.06.014.

3. Hayward NJ, Grodski S, Yeung M, et al. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg. 2013;83(1-2):15-21. doi: 10.1111/j.1445-2197.2012.06247.x.

4. Chen HC, Jen YM, Wang CH, et al. Etiology of vocal cord paralysis. ORL J Otorhinolaryngol Relat Spec. 2007;69(3):167-71. doi: 10.1159/000099226.

5. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007;117(10):1864-70. doi: 10.1097/MLG.0b013e3180de4d49.

6. Spataro EA, Grindler DJ, Paniello RC. Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis. Otolaryngol Head Neck Surg. 2014;151(2):286-93. doi: 10.1177/0194599814531733.

7. Takano S, Nito T, Tamaruya N, et al. Single institutional analysis of trends over 45 years in etiology of vocal fold paralysis. Auris Nasus Larynx. 2012;39(6):597-600. doi: 10.1016/j.anl.2012.02.001.

8. Дайхес Н.А., Кокорина В.Э., Нажмудинов И.И. и др. Клинические рекомендации. Парезы и параличи гортани. М.: НМАО МЗ РФ; 2014. Daykhes NA, Kokorina VE, Nazhmudinov II, et al. Klinicheskie rekomendatsii. Parezy i paralichi gortani. M.: NMAO MZ RF; 2014. (In Russ.).

9. Dhillon VK, Randolph GW, Stack BC, et al. Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment. Head Neck. 2020;42(12):3779-3794.

10. Chandrasekhar SS, Randolph GW, Seidman MD, et al. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148(6 Suppl):S1-S37.

11. Jeannon JP, Orabi AA, Bruch GA, et. al. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract. 2009;63:624–62910.

12. Chadwick D, Kinsman R, Walton P. Fifth national audit report of the British association of endocrine and thyroid surgeons. 2017.

13. Mahvi DA, Saadat LV, Knell J, et al. Recurrent Nerve Injury After Total Thyroidectomy: Risk Factor Analysis of a Targeted NSQIP Data Set. Am Surg. 2023;89(5):1396-1404. doi: 10.1177/00031348211054701.

14. Weiss A, Parina RP, Tang JA, et al. Outcomes of thyroidectomy from a large California state database. Am J Surg. 2015 Dec;210(6):1170-6; discussion 1176-7. doi: 10.1016/j.amjsurg.2015.08.011.

15. Davey MG, Cleere EF, Lowery AJ, et al. Intraoperative recurrent laryngeal nerve monitoring versus visualisation alone - A systematic review and meta-analysis of randomized controlled trials. Am J Surg. 2022;224(3):836-841. doi: 10.1016/j.amjsurg.2022.03.036.

16. Патент РФ на изобретение №2787835/09.06.22. Бюл. №2. Куприн А.А. «Способ диагностики нарушений подвижности голосовых складок»)

17. Патент РФ на изобретение №2800313/02.08.22. Бюл. №20. Куприн А.А. «Способ хирургического лечения рака ЩЖ с метастазами в лимфатические узлы центральной клетчатки шеи»

18. Lang BH, Chu KK, Tsang RK et al. Evaluating the incidence, clinical significance and predictors for vocal cord palsy and incidental laryngopharyngeal conditions before elective thyroidectomy: Is there a case for routine laryngoscopic examination? World J Surg. 2014;38:385–391. doi: 10.1007/s00268-013-2259-3.

19. Kay-Rivest E, Mitmaker E, Payne RJ, et al. Preoperative vocal cord paralysis and its association with malignant thyroid disease and other pathological features. J Otolaryngol Head Neck Surg. 2015;11;44(1):35. doi: 10.1186/s40463-015-0087-1.

20. Heikkinen M, Mäkinen K, Penttilä E, et al. Incidence, Risk Factors, and Natural Outcome of Vocal Fold Paresis in 920 Thyroid Operations with Routine Pre- and Postoperative Laryngoscopic Evaluation. World J Surg. 2019;43(9):2228-2234. doi: 10.1007/s00268-019-05021-y.

21. Joliat GR, Guarnero V, Demartines N, et al. Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Incidence and postoperative evolution assessment. Medicine (Baltimore). 2017;96(17):e6674. doi: 10.1097/MD.0000000000006674.

22. Roh JL, Yoon YH, Park CI. Recurrent laryngeal nerve paralysis in patients with papillary thyroid carcinomas: evaluation and management of resulting vocal dysfunction. Am J Surg. 2009;197(4):459-65. doi: 10.1016/j.amjsurg.2008.04.017.

23. Roh JL, Park JY, Park CI. Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone. Ann Surg. 2007;245(4):604-10. doi: 10.1097/01.sla.0000250451.59685.67.

24. Rowe-Jones JM, Rosswick RP, Leighton SE. Benign thyroid disease and vocal cord palsy. Ann R Coll Surg Engl. 1993;75(4):241-4.

25. Chen HC, Pei YC, Fang TJ. Risk factors for thyroid surgery-related unilateral vocal fold paralysis. Laryngoscope. 2019;129(1):275-283. doi: 10.1002/lary.27336.

26. Liu N, Chen B, Li L, et al. Mechanisms of recurrent laryngeal nerve injury near the nerve entry point during thyroid surgery: A retrospective cohort study. Int J Surg. 2020;83:125-130. doi: 10.1016/j.ijsu.2020.08.058.

27. Gunn A, Oyekunle T, Stang M, et al. Recurrent Laryngeal Nerve Injury After Thyroid Surgery: An Analysis of 11,370 Patients. J Surg Res. 2020;255:42-49. doi: 10.1016/j.jss.2020.05.017.

28. Leonard-Murali S, Ivanics T, Nasser H, et al. Intraoperative Nerve Monitoring in Thyroidectomies for Malignancy: Does It Matter? Am Surg. 2022;88(6):1187-1194. doi: 10.1177/0003134821991967.

29. Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136:1310–1322. doi: 10.1016/j.surg.2004.07.01815657592.

30. Kim H, Liu X, Sun H. Medico-Legal Issues of Intraoperative Neuromonitoring in Thyroid Surgery J Endocr Surg. 2017;17(2):42-56. doi.org/10.16956/jes.2017.17.2.42.

31. Готовяхина Т. В. Патология гортани в раннем послеоперационном периоде при хирургических вмешательствах на щитовидной железе. // Российская оториноларингология. - 2016. - №2 - С.25-30. [Gotovyakhina TV. Laryngeal pathology in the early postoperative period after thyroid surgery. Rossijskaya otorinolaringologiya. 2016;2:25-30. (In Russ.)] doi.org/10.18692/1810-4800-2016-2-25-30.

32. Mantalovas S, Sapalidis K, Manaki V, et al. Surgical Significance of Berry's Posterolateral Ligament and Frequency of Recurrent Laryngeal Nerve Injury into the Last 2 cm of Its Caudal Extralaryngeal Part(P1) during Thyroidectomy. Medicina (Kaunas). 2022;1;58(6):755. doi: 10.3390/medicina58060755.

33. Henry BM, Pękala PA, Sanna B, et al. The Anastomoses of the Recurrent Laryngeal Nerve in the Larynx: A Meta-Analysis and Systematic Review.J Voice. 2017;31(4):495-503. doi: https://doi.org/10.1016/j.jvoice.2016.11.004.

34. Naidu L, Lazarus L, Partab P, et al. Laryngeal nerve «anastomoses». Folia Morphol (Warsz). 2014;73(1):30-36. doi: https://doi.org/10.5603/FM.2014.0005.

35. Enomoto K, Uchino S, Watanabe S, et al. Recurrent laryngeal nerve palsy during surgery for benign thyroid diseases: risk factors and outcome analysis. Surgery. 2014;155(3):522-8. doi: 10.1016/j.surg.2013.11.005.

36. Chiang FY, Wang LF, Huang YF, et al. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery. 2005;137(3):342-7. doi: 10.1016/j.surg.2004.09.008.

37. Dionigi G, Wu CW, Kim HY, et al. Severity of Recurrent Laryngeal Nerve Injuries in Thyroid Surgery. World J Surg. 2016;40(6):1373-81. doi: 10.1007/s00268-016-3415-3.