喉返神经麻痹的管理及效果

Cl R aly p ev o Jo aD So Na of 14 showing voice changes. RLNP was detected in 9 of 291 (3.1%) patients without documented thy the cau bra cri inc ran 000 doi The American Journal of Surgery (2009) 197, 459–465 nerve injury; 8 recovered. Nine of 15 patients with RLN section had poor vocal function, which improved in 8 patients after medialization of the unilateral vocal fold. CONCLUSIONS: Patients with PTC may have vocal dysfunction from cancer or surgery-related RLNP. Vocal evaluation and management may help improve their vocal function, thus enhancing their quality of life. © 2009 Published by Elsevier Inc. Voice alteration is a morbidity associated with invasive roid malignancies and thyroid surgery. Surgical injury to recurrent laryngeal nerve (RLN) is regarded as the main se of voice changes,1–3 but surgical injury to the external nch of the superior laryngeal nerve (EBSLN) or the cothyroid muscle also may cause voice changes.4,5 The idence of laryngeal nerve paralysis has been reported to ge from 0% to 30%.4,6 Laryngeal nerve paralysis has important implications, especially for patients in voice-re- lated professions, and is associated with most reports of complications of thyroid surgery.7 Voice changes after thy- roidectomy, however, may not be related to impaired func- tion of the RLN or EBSLN.8–11 By using objective voice measurements, the incidence of voice changes has been found to be as high as 84%.10 Although most patients without doc- umented nerve damage recover from the RLN paralysis ng-Lyel Roh, M.D., Ph.D.a,*, Yeo-Hoon Yoon, M.D.b, Chan Il Park, M.D., Ph.D.b epartment of Otolaryngology, Asan Medical Centre, University of Ulsan, College of Medicine, 388–1, Pungnap-dong, ngpa-gu, Seoul 138-736, the Republic of Korea; bDepartment of Otolaryngology-Head and Neck Surgery, Chungnam tional University, College of Medicine, Daejeon, the Republic of Korea Abstract BACKGROUND: Recurrent laryngeal nerve paralysis (RLNP) occurs in patients with thyroid ma- lignancy. This study prospectively evaluated vocal function and management outcomes of patients with papillary thyroid carcinomas (PTCs) and RLNP. METHODS: Of 319 PTC patients, 256 underwent total thyroidectomy with or without neck dissec- tion, 42 underwent lobectomy, and 21 underwent reoperation for recurrent cancers. All patients underwent laryngoscopy and vocal function measurements before and after surgery. Patients with RLNP and poor vocal function underwent voice surgery. RESULTS: Temporary and permanent RLNP rates were 2.8% and .9% at nerve-at-risk–based analysis, respectively. Of 28 patients with tumor invasion of RLN, 14 had preoperative RLNP, with 9 KEYWORDS: Papillary thyroid carcinoma; Thyroid surgery; Recurrent laryngeal nerve; Paralysis; Voice management inical Surgery-International ecurrent laryngeal nerve par apillary thyroid carcinomas: f resulting vocal dysfunction (R RL wa me * Corresponding author: Tel.: �82-2-3010-3965; fax: �82-2-489-2773. E-mail address: rohjl@amc.ac.kr Manuscript received April 18, 2008; revised manuscript April 22, 2008 2-9610/$ - see front matter © 2009 Published by Elsevier Inc. :10.1016/j.amjsurg.2008.04.017 sis in patients with aluation and management LNP) that occurs after thyroid surgery,6,11 patients with N sections may have impaired vocal, swallowing, and air- y functions, suggesting that they require further manage- nt. tat ner hav age pro com car Pa Pa fer tia inv PT ph sur 20 an sch the tio mo Ins inf Su ind the sur inc mi hu art cap tio av dis co car tie wa lou pre roi wa wi fin thy the tie cra lob rot ifie wi pa inf pe RN As glo pa aft we ba tes rap an on glo Pa RL ary lar bil glo Vo dex sca exa nai and is tot vo we ph lar rec (K wi Th tim an wi ob eo sco 460 The American Journal of Surgery, Vol 197, No 4, April 2009 Although the incidence, causes, natural history, and preven- ive measures associated with voice changes and laryngeal ve paralysis have been examined extensively,2–6,8–11 there e been few reports on the systematic evaluation and man- ment of RLNP in thyroid cancer patients. We therefore spectively evaluated vocal function and management out- es of patients with well-differentiated papillary thyroid cinomas (PTCs) and cancer- or surgery-related RLNP. tients and Methods tients and study design This was a prospective study of patients with well-dif- entiated PTC scheduled for thyroid surgery and at poten- l risk for RLNP because of the surgery or tumor RLN asion. All patients were diagnosed preoperatively with C after fine-needle aspiration cytology and ultrasonogra- y and underwent thyroidectomy or reoperative thyroid gery of the central neck compartment between March 03 and June 2006. Patients with poorly differentiated, aplastic, or other thyroid malignancies, and patients not eduled for thyroid surgery on the central compartment of neck, were excluded. All patients underwent vocal func- n and laryngoscopic examination before and for at least 6 nths after thyroidectomy. The study was approved by the titutional Review Board of our institution, and written ormed consent was obtained from each patient. rgical procedure Patients underwent lobectomy or total thyroidectomy, as icated by their primary pathology, under general anes- sia. Patients with recurrent tumors underwent reoperative gery of the central neck. After a lower transverse cervical ision, the strap muscles were retracted laterally from the dline or sometimes divided for adequate exposure of ge or infiltrative thyroid lesions. The superior thyroid ery and vein were ligated individually on the thyroid sule to avoid injury to the EBSLN. Routine identifica- n of the EBSLN was not performed during surgery to oid inadvertent nerve injury. The cricothyroid muscle was sected carefully from the thyroid gland without electro- agulation or manual retraction. The RLN was identified efully and dissected unilaterally or bilaterally in all pa- nts. When tumors directly invaded the RLN, the nerve s meticulously shaved off the tumors using surgical pes under magnification. When the RLN was paralyzed operatively or infiltrated extensively by malignant thy- d tumors and not easily shaved off the tumors, the nerve s sacrificed. Neck dissection was performed in selected patients. Patients th macroscopically involved or ultrasonography-guided e-needle aspiration cytology–positive nodes underwent total roidectomy and therapeutic neck dissection. Prophylactic or ser rapeutic central neck dissection was performed in 179 pa- nts. Node clearance of the central neck was performed nially by both superior thyroid arteries and the pyramidal e, caudally by the innominate vein, laterally by the ca- id sheaths, and dorsally by the prevertebral fascia. Mod- d radical neck dissection was performed on 70 patients th clinically positive lateral neck nodes. The lateral com- rtment was delimited superiorly by the hypoglossal nerve, eriorly by the subclavian vein, and laterally by the tra- zius muscle. Intraoperative neurologic monitoring of the L was not performed. sessment and management of RLNP Vocal quality, along with vocal fold mobility and the ttal gap between both vocal folds, was assessed in each tient before, 1 week after, and 1, 3, 6, and 12 months er, thyroid surgery. If any abnormalities on laryngoscopy re found, objective vocal function was assessed using a ttery of acoustic, aerodynamic, and videostroboscopic ts. Patients with RLNP also underwent computed tomog- hy scanning to determine the association between RLNP d thyroid tumors. The decision to perform voice surgery each patient was based on each patient’s vocal function, ttal gap, and the recovery potential of the injured RLN. tients with poor voice quality and a wide glottal gap after N section were indicated for voice surgery, consisting of tenoid adduction, medialization thyroplasty, or injection yngoplasty. Patients with a narrow glottal space and ateral RLNP were indicated for tracheostomy or posterior ttic cordotomy to widen the glottic airway. cal function assessment Voice quality was assessed using the vocal handicap in- ,12 the grade, rough, breathy, asthenic, strained (GRBAS) le,13 acoustic and aerodynamic methods, and stroboscopic mination. The vocal handicap index is a 30-item question- re consisting of 3 subscales measuring functional, physical, emotional handicaps in verbal communication. Each item scored from 0 to 4, each subscale from 0 to 40, and the al score is from 0 to 120; higher scores indicate greater cal disability. Acoustic parameters and aerodynamic data re analyzed by Computerized Speech Lab and Aero- one II (Kay Elemetrics, Corp., Lincoln Park, NJ). The ynxes of the subjects were examined, and images were orded using rigid and rhino-larynx videostroboscopy ay Elemetrics, Corp.). Scores were between 0 and 10, th higher scores indicating higher levels of abnormality. e GRBAS scale measurements, maximum phonation e, and laryngoscopy assessments were performed before d after thyroid surgery, as described previously. Patients th voice or laryngeal abnormalities underwent further jective assessments with acoustic, aerodynamic, and vid- stroboscopic tests. The GRBAS scale and videostrobo- pic results were assessed blindly by 2 independent ob- vers. St use use tes va pa co Re Pa ex aft lar rat Pa sho 22 dia eso (11 28 un ser wa RL pa pa tie inv pe pa tiv inc tha 54 dif thy we sec sha Th RL inj 8 r me pa Vo tio an wi inv the the bil pa do Fig pap cus pre pre RL and sid thy com iza late T V S M P S M p 461J.-L. Roh et al. Papillary thyroid carcinoma and vocal dysfunction atistical analysis SPSS 12.0 for Windows (SPSS, Inc., Chicago, IL) was d for statistical analysis. The Mann–Whitney U test was d to compare continuous variables and the Fisher exact t was used to investigate differences between categoric riables. The Wilcoxon signed-rank test was used to com- re intragroup results at different times. Differences were nsidered significant when the P value was less than .05. sults tients, pathology, and treatment characteristics A total of 327 patients were enrolled. Eight patients were cluded because they were lost to follow-up evaluation er surgery without proper assessment of their voices and ynxes, leaving 319 eligible patients. The male:female io was 1:4.4, and the median patient age was 46 years. tient demographic, clinical, and pathologic data are wn in Table 1. The median tumor size was 1.5 cm and 6 patients (70.8%) had tumors larger than 1.0 cm in meter. Local tumor invasion of the RLN, larynx, trachea, phagus, or great vessels was observed in 35 patients .0%), with 28 (8.8%) showing RLN invasion. Of these patients, 15 underwent unilateral RLN section and 13 derwent a RLN shaving procedure. EBSLN was not ob- ved in 277 patients (86.8%), and their strap musculature s preserved. The median MACIS score was 5.1. NP and voice surgery A total of 29 patients had postoperative RLNP, with 1 tient having bilateral RLNP (Fig. 1). Fourteen of these 29 tients had unilateral RLNP preoperatively. Fifteen pa- able 1 Patient demographics and clinical characteristics ariable No. of patients % of total ex, male/female 59/260 18.5/81.5 edian age (range), y 46 (16–85) rimary tumor Median tumor size (range), cm 1.5 (.2–5.5) Local invasion (T4 tumor) 35 11.0 RLN invasion 28 8.8 urgery Reoperative surgery 21 6.6 Lobectomy 42 13.2 Total thyroidectomy 256 80.2 Central neck dissection 179 56.1 Lateral neck dissection 70 21.9 edian MACIS score (range) 5.1 (3.1–11.1) The demographic, clinical, and pathologic data of the 319 study atients are shown. tio nts underwent unilateral RLN section because of tumor asion. After excluding these 15 patients, temporary and rmanent RLN paralysis occurred in 4.6% and 1.3% of tients, respectively, and in 2.8% and .9% of cases, respec- ely, using nerve-at-risk–based analysis (Table 2). The idence of RLNP was higher after reoperative surgery n after initial thyroid surgery (4 of 31 [12.9%] vs 12 of 2 [2.2%]; P � .008). The incidence of RLNP did not fer between patients who underwent lobectomy or total roidectomy (P � .999) or between patients who under- nt total thyroidectomy with or without central neck dis- tion (P � .744). Of the 13 patients who underwent RLN ving procedures, 5 had postoperative unilateral RLNP. ree of these patients showed complete recovery of the NP within 6 months (Fig. 2). Of the 291 patients without ury to the RLN, 9 had temporary unilateral RLNP, with ecovering within 3 months after thyroidectomy. Eight patients with unilateral RLN injuries underwent dialization procedures of the unilateral vocal fold, 5 tients at initial surgery and 3 patients 2 to 10 months later. ice surgery was not randomized in patients with inten- nal RLN section; only patients with poor vocal quality d wide glottal gaps underwent voice surgery. One patient th preoperative unilateral RLNP showed bilateral RLN asion of the PTC; this patient underwent sectioning of unilateral RLN and shaving of the contralateral RLN off tumors. Laryngoscopy in the recovery room showed ateral RLNP requiring urgent airway management. This tient, who immediately underwent posterior glottic cor- tomy, showed no further symptoms of airway obstruc- ure 1 Flow chart showing the study cohort of patients with illary thyroid carcinomas who underwent thyroid surgery, fo- ing on their vocal function and RLNP. All patients underwent operative laryngoscopic examination. Fourteen patients had operative RLNP because of tumor invasion. Postoperative NP was found in 15 of 305 patients without preoperative RLNP in 1 of 14 patients with preoperative RLNP on the contralateral e. RLNP recovered in 11 of 16 patients within 6 months after roid surgery. AA � arytenoids adduction; B/L � bilateral; CT � puted tomography; IL � injection laryngoplasty; MT � medial- tion thyroplasty; PGC � posterior glottic cordotomy; U/L � uni- ral. n. Re RL vo mo 7 u un RL rel Th sur tiv 14 (38 an da for sur de sur som thy gro Co op pe rat pa ne an rel T reoper s T S R % and . w .008). f tumor Fig out RL inv sur RL 462 The American Journal of Surgery, Vol 197, No 4, April 2009 covery of vocal function in patients with RLNP Of 15 patients with intentional sections of the unilateral N, 9 had poor vocal function preoperatively, 5 had good ice quality, and 1 had normal vocal function and vocal cord bility (Fig. 1). Of the 9 patients with poor vocal function, nderwent medialization of the unilateral vocal cord, 1 derwent posterior glottic cordectomy because of bilateral NP, and 1 refused voice surgery. The 5 patients with atively good voice quality did not undergo voice surgery. e 8 patients with poor voice quality who underwent voice gery showed improvement in their subjective and objec- e vocal functions (Table 3). Despite the preserved RLN, patients had postoperative unilateral RLNP: 5 of the 13 .5%) patients who underwent RLN shaving procedures d 9 of the 291 (3.1%) patients without documented nerve mage. Recovery of the RLNP was observed in 2 of the able 2 Incidence of RLNP according to surgical procedure and No. of patients No. of nerve at risk otal 319 573 urgery Lobectomy 42 42 Total thyroidectomy 256 500 No CND 77 154 CND 109 215 CND � LND 70 131 eoperation† 21 31 The incidence of postoperative temporary and permanent RLNP was 2.8 as higher after reoperative surgery than after initial thyroid surgery (P � CND � central neck dissection; LND � lateral neck dissection. *Calculated after excluding patients with preoperative RLNP because o †All patients had recurrent papillary thyroid carcinomas. ure 2 Recovery of postoperative RLNP in 14 patients with- preoperative RLNP. These patients experienced postoperative NP after a procedure in which the RLN was shaved off the asive papillary thyroid carcinoma (n � 5) or after thyroid gery with no injury to the RLN (n � 9). �, RLN shaved; e, weN not injured. mer and 8 of the latter within 6 months after thyroid gery (Fig. 2). Subjective and objective vocal functions creased in both groups during the first few weeks after gery, although the patients without RLN damage showed ewhat greater improvement (Table 4). Six months after roidectomy, however, vocal function was similar in the 2 ups (P � .1). mments We have shown here that, of PTC patients without pre- erative RLNP, 4.6% and 1.3% experience temporary and rmanent RLNP, respectively, after thyroid surgery. These es were similar to those reported previously.2,3,6 If the 15 tients with intentional nerve section because of tumor rve invasion were included, the overall rates of temporary d permanent RLNP increased to 9.1% and 5.6%. The atively high RLNP rate in our patients may have been cause of the relatively high proportion of patients with asive PTC (11.0%) involving the upper aerodigestive ct and the RLN, and the relatively high rate of reoperative roid surgery (6.6%). Surgeries for thyroid cancer have en associated with high RLNP rates.3,6 This study pro- ctively evaluated vocal function and RLNP in a single up of patients with PTC. In agreement with earlier studies, we found that periop- tive laryngoscopic examination was essential for the de- tion of RLNP.14,15 RLNP was detected preoperatively in of 28 (50%) patients and voice change was detected in ly 9 of 14 (64.3%). In comparison, preoperative RLNP s present in 70% of patients with invasive thyroid dis- e; of these, two-thirds presented with normal voice and ee-fourths had no suspicion of RLNP on preoperative mputed tomography.14 These findings indicated that ptomatic voice assessment and radiographic evaluation ation Preoperative RLNP, n Postoperative RLNP* Temporary, % Permanent, % 14 16 (2.8) 5 (.9) 0 1 (2.4) 0 12 11 (2.2) 2 (.4) 0 4 (2.6) 0 3 5 (2.3) 2 (.9) 9 2 (1.5) 0 2 4 (12.9) 3 (9.7) 9% of cases, respectively, using nerve-at-risk–based analysis, which invasion. be inv tra thy be spe gro era tec 14 on wa eas thr co sym re insufficient to detect preoperative RLNP and sug- ge tie co pe thu era co lar op the pa RL thy wa rec Ou 29 co (88 we (38 rec T tients V † V P A A V erwent v fu 463J.-L. Roh et al. Papillary thyroid carcinoma and vocal dysfunction sted the need for laryngoscopic examination of all pa- nts undergoing thyroid surgery.14 In addition, laryngos- py and voice examination during the early postoperative riod provided accurate information on complications, s guiding further management. One patient with postop- tive bilateral RLNP underwent prompt posterior glottic rdotomy because of acute airway obstruction detected by yngoscopy in the recovery room. Therefore, routine peri- erative laryngoscopy and voice examination can assist in proper management of these patients, improving im- ired vocal or airway function. Postoperative laryngoscopy also can detect unrecognized NP in patients who do not suffer nerve damage during roid surgery. In a study by Lo et al,6 unrecognized RLNP s detected in 28 of 500 (5.6%) patients, with complete overy of vocal cord function documented in 26 (92.9%). r findings were similar in that we observed RLNP in 9 of 1 (3.1%) patients without documented RLN damage, with mplete recovery of vocal cord function documented in 8 .9%). We also observed recovery in patients who under- nt RLN shaving procedures; of these 13 patients, 5 .5%) experienced postoperative unilateral RLNP, with able 3 Preoperative and postoperative vocal function in 13 pa ariable Voice surgery (n � 7)* Preoperative† Postoperative oice handicap index Functional 11.2 (5.4) 3.1 (2.4) Physical 12.9 (5.6) 3.4 (3.4) Emotional 14.2 (6.2) 4.6 (4.2) Total 38.3 (16.6) 11.1 (9.8) erceptual§ Overall grade 4.3 (3.4) 1.1 (1.1) Roughness 4.1 (3.2) 1.3 (1.2) Breathiness 4.7 (3.0) 1.3 (1.1) Strain 3.6 (2.8) 1.5 (1.1) coustic F0, Hz 178.6 (59.4) 172.4 (54.2) Jitter, % 3.1 (2.1) .9 (.