HORMONES 2014, 13(1):5-15

Review

Hoarseness after thyroidectomy:

Blame the endocrine surgeon alone?
Demetrios Moris,1 Eleftherios Mantonakis,1 Marinos Makris,2
Adamantios Michalinos,1 Spiridon Vernadakis3

1
First Department of Surgery, “Laiko” General Hospital, National and Kapodistrian University of Athens, Athens,
Greece; 2Department of Surgery and Cancer, St Mary’s Hospital, Imperial College of London, London, United Kingdom;
3
Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany

Abstract
OBJECTIVE: Hoarseness is a postoperative complication of thyroidectomy, mostly due to
damage to the recurrent laryngeal nerve (RLN). Hoarseness may also be brought about via
vocal cord dysfunction (VCD) due to injury of the vocal cords from manipulations during
anesthesia, as well as from psychogenic disorders and respiratory and upper-GI related infec-
tions. We reviewed the literature aiming to explore these potential surgical and non-surgical
causes of hoarseness beyond thyroidectomy and the role of the endocrine surgeon. Is he/she
alone to blame? METHODS/MATERIAL: The MEDLINE/PubMed database was searched for
publications with the medical subject heading “hoarseness” and keywords “thyroidectomy”,
“RLN”, “VCD” or “intubation”. We restricted our search till up to May 2013. RESULTS: In
our final review we included 80 articles and abstracts that were accessible and available in
English. We demonstrated the incidence of hoarseness stemming from surgical and non-surgical
causes and also highlighted the role of intubation as a potential cause of injury-related VCD.
CONCLUSIONS: Hoarseness is a relatively common complication of thyroidectomy, which
can be attributed to many factors including surgeon’s error or injuries during intubation as
well as to other non-surgical causes. However, compared to procedures such as cervical spine
surgery, mediastinal surgery, esophagectomy and endarterectomy, thyroidectomy would seem
to be a procedure with a relatively low rate of recurrent laryngeal nerve palsies (RLNPs). It
is often difficult to determine whether the degree of hoarseness after thyroidectomy should
be attributed only the surgical procedure itself or to other causes, for example intubation and
extubation maneuvers. The differential diagnosis of postoperative hoarseness requires the
use of specific tools, such as stroboscopy and intra- and extralaryngeal electromyography,
while methods like acoustic voice analysis, with estimation of maximum phonation time and
phonation frequency range, can distinguish between objective and subjective deterioration in
the voice. The importance of medical history should be also emphasized.
Key words: Hoarseness, Intubation, Recurrent laryngeal nerve (RLN), Thyroidectomy, Vocal
cord dysfunction (VCD)

Address for correspondence:

Demetrios Moris, 56 Anastasiou Gennadiou Str., 11474, Athens, Greece; Tel.: +30 210-644059; E-mail: dimmoris@yahoo.com
Received: 14-05-2013, Accepted:13-01-2014
6 D. Moris ET AL

Introduction has with time declined and is presently estimated to be

Hoarseness is one of the most common complica- less than 2%,6 the morbidity and mortality associated
tions following an operative procedure of the thyroid with this complication make it the most frequent source
gland. The recurrent laryngeal nerve (RLN) can be of malpractice lawsuits in thyroid surgery.7 While this
damaged by retraction, since it lies within the tra- problem may not exist to a great extent in units with
cheoesophageal groove, as well as by thermal injury only specialists in endocrine surgery operating, it still
or dissection. These injuries can be the most devas- occurs at a frequency of 0.2–0.8% in academic or edu-
tating to the patient. Clinical manifestations range cational hospitals with a high admission of patients.8
from mild symptoms of hoarseness, loss of effective Numerous studies, with sometimes conflicting results,
cough mechanism and upper pharyngeal dysphagia can be found in the literature regarding RLN injury
with aspiration in cases of ipsilateral injury causing in thyroidectomy. Steurer et al9 showed that surgical
ipsilateral vocal cord dysfunction (VCD), to life- dissection of the RLN did not increase the total risk
threatening airway obstruction from bilateral RLN of temporary and permanent palsy. A RLN paralysis
injury. It is well known among endocrine surgeons rate of less than 2.5% was reported among patients
that after thyroidectomy most patients complain of who underwent more extensive thyroid operations
some voice and swallowing disturbances, even in the for benign10-14 and malignant15,16 thyroid conditions
absence of objective laryngeal nerve injuries, diag- and during thyroid reoperations.10,17-19 Though there
nosed with videostrobolaryngoscopy (VSL).1-4 This are numerous reports quoting high levels of safety
functional, “subjective” postthyroidectomy syndrome, during more extensive thyroid operations and rein-
which includes a broad spectrum of symptoms among terventions by experienced surgeons, thyroid cancer
patients, is of great concern since severe thyroid sur- operations and secondary thyroidectomy are still
gery complications may be connected with profound associated with a higher complication rate and an
medicolegal implications.1-5 increased risk of RLN injury.20,21 In postoperative
RLNP, recovery may be anticipated at a rate ranging
The aim of our study was to establish, via a search from 50% to 88%,6,20,22 the rates depending on the
of the literature, whether hoarseness after thyroid- type of surgery (primary vs redo), thyroid disease
ectomy should be mostly attributed to surgical error (benign vs malignant), extent of surgery (lobectomy
rather than to other causes such as intubation ma- vs subtotal resection), formal identification of the
neuvers or to the patient’s surgical and non-surgical RLN and surgical volume (high vs low).23-25
medical history.
In another study,26 it was found that the kind of
dissection (total dissection, partial dissection or no
Methods dissection) had no significant influence on the rate
Studies were identified by performing an electronic of RLNP (P=0.10).26 Only revision surgery was as-
search of MEDLINE up till May 2013 with the key sociated with higher rate of impairment of the RLN
words “hoarseness”, “thyroidectomy”, “recurrent (6.2% vs 11.6%; P=0.04).26 About 40% of these
laryngeal nerve (RLN)”, “vocal cord paresis dysfunc- patients had impairment of vocal function that was
tion (VCD)” or “intubation”. more often attributed to vocal folds injury rather
than to RLNP.26 Studies with a large number of
In this review we included 80 articles and abstracts patients show prevalence for permanent paresis to
that were accessible and available in English. We be between 0% after primary surgery and 20% after
demonstrated the incidence of hoarseness in other revision surgery.6,27
surgical and non-surgical causes while also highlighting
the role of intubation as a potential cause of VCD. The extent of RLN injury may vary in severity
from neuropraxia to neurotmesis. In neuropraxia,
spontaneous recovery of dysphonia after a period of
Results time varying from 1 to 6 months should be expected.25
Hoarseness due to RLN injury after thyroidectomy After neurotmesis, there would be no such recov-
Although the incidence of permanent RLN palsy ery. Therefore, most studies agree that a minimum
Hoarseness after thyroidectomy: Blame the endocrine surgeon alone? 7

follow-up period of 12 months is needed to assess patients.37 In another study, Rahman et al38 found
voice function after thyroidectomy if dysphonia is that respiratory complications after thyroidectomy
detected.25 In summary, the incidence of RLN palsy concern up to 7.6% of cases. Among these, 10% of
varies from less than 1% to as high as 20%, depend- them were attributed to difficult intubation, while
ing on the type of disease (benign or malignant), the 15% were due to RLNP.38
type of thyroid resection (first-time or reoperation)
Risk factors for vocal fold injury caused by intuba-
and the extent (subtotal or total thyroidectomy), the
tion are cuff pressure,39 size of the tube, movement of
surgical technique (with or without routine RLN
the tube, physical trauma, intubation environment,
identification) and surgeon experience.28
duration of intubation, gastroesophageal reflux and
Anesthesiologic causes of hoarseness mucociliary mechanism.35 Kikura et al40 demonstrated
that the risk of VCD due to intubation increases
Hoarseness due to intubation three-fold in patients 50 years old or above, twice in
Although the literature is much more oriented patients intubated for 3-6 h, fifteen times in patients
to describing the risk of damaging the RLN during intubated for more than 6 h and twice in patients
thyroidectomy, vocal cords can be injured during the with a history of diabetes mellitus or hypertension.
intubation-extubation procedures as well. The end
result of this injury-related vocal cord dysfunction is It is thus not unreasonable to assume that in many
the same: hoarseness. In fact, it is fairly difficult to cases of thyroidectomy, a large number of these risk
differentiate between the damage done by thyroid factors are dealt with. In these cases, the contribu-
surgery and anesthesia in most cases. Injury to the tion of the intubation procedure to hoarseness after
vocal folds attributed to intubation or extubation was thyroidectomy should be always taken into account.
identified in 31% of the patients recruited into a re- As far as the drug used for relaxation is concerned,
cent study.26 Compared with findings in older studies no significant influence has been detected in rapid-
that found laryngeal injuries in 6.2% to 16.3% of the sequence induction nor in reduction in vocal fold
patients who underwent thyroid surgery, later data injury using neuromuscular monitoring.35,36 When
suggest a much higher rate for these complications.29 intraoperative neuromonitoring (IONM) is applied,
However, another study demonstrated the frequency no increase in the incidence of laryngeal side effects
of intubation-related RLN palsy as a cause of hoarse- and lesions was observed.41 Meanwhile, inadequate
ness to be 1.4% transiently and 0.5% permanently.30 muscle relaxation at the moment of tracheal intuba-
Furthermore, when investigated one to two days after tion is another possible cause leading to laryngeal
surgery, an even higher rate of complications (73%) injuries,42 while movement of the tube in the trachea
was ascertained in the form of increased amount of was found to be related to an increased incidence of
visible blood vessels, bleeding into the vocal cords hoarseness.43
or the trachea and bruises at the vocal processes or
the arytenoid cartilages.31 The differential diagnosis The results of intubation in other surgical
of postoperative hoarseness requires the use of spe- approaches beyond thyroidectomy
cific tools apart from simple laryngoscopy, including General principles/mechanisms
stroboscopy as well as intra- and extralaryngeal elec-
tromyography.32,33 A partial palsy of the RLN due to Εxtensive data are available concerning the preva-
intubation would be associated with severe dyspho- lence of hoarseness after thyroidectomy, as mentioned
nia or aphonia and not with dyspnea because of the earlier.36-46 On the other hand, there is a lack in the
typical intermediate position of the paralyzed vocal literature of sufficient data as to the correlation of
folds with a normal electromyographic function of the intubation and hoarseness in other surgical approaches
cricothyroid muscle.32 This rate of laryngeal injuries not in the head and neck. This information would be
led Mencke et al34-36 to conclude that thyroidectomy of great importance, since it could help identify the
represents a minor risk to the larynx as compared exact effect of intubation on the vocal cords and the
with the intubation or extubation procedure, while mechanism by which intubation itself could cause
similar findings were reported in a smaller group of hoarseness.
8 D. Moris ET AL

Nuutinen et al37 demonstrated a bilateral VCD in a et al48 concluded that prolonged intubation led to
non-head and -neck-related surgery which was attrib- longer postoperative hoarseness. By contrast, Col-
uted to overextension of the neck during intubation. ton House et al46 found that duration of intubation,
One possible pathophysiological explanation regarding type of endotracheal tube and size of endotracheal
this clinical presentation could be the compression of tube do not significantly correlate to the incidence
the nerve, specifically the anterior branch of RLN,45 of vocal fold mobility and degree of laryngeal injury
between an inflated endotracheal tube cuff and the noted after prolonged intubation. Intubation-related
overlying thyroid cartilage, especially at the junction laryngeal injuries were seen to be present in up to 12%
of the vocal process of the arytenoid cartilage and the of patients with the use of neuromuscular blockade
membranous true vocal cord, 6 to 10 mm below the drugs for tracheal intubation35,42,45 but have also been
level of the cord.31 Another suggested mechanism observed in 42% of patients without them.35 In a study
includes a slipped upward endotracheal tube which of Mencke et al,36 the incidence of VCD, caused by
brings the inflated cuff to rest against the vocal cords.46 bilateral thickening of the vocal folds (86%) reached
Additionally, a similar presentation can occur due to 27%. More vocal fold injuries are detected in older
an overinflated cuff which has kept the vocal cords patients, presumably due to a decrease in flexibility
under constant pressure.46 Both these conditions may and atrophy of the vocal tissues.26 Similarly to other
also cause damage to the anterior branch of the RLN studies,35,36 the most common finding was thickening
that innervates the lateral cricoarytenoid muscle.46 of the mucosa in the posterior parts of the vocal folds,
Moreover, the nasogastric tube can be implicated followed by hematoma. Whether these alterations are
in RLN palsy if positioned in the midline, a posi- caused by laceration or by gastroesophageal reflux
tion which may lead to postcricoid inflammation, remains unclear, but alterations in the posterior part
which in turn results in vocal cord immobility.43 The of the vocal folds have been attributed to the tube
underlying pathophysiological mechanism seems to or to adduction reaction of the vocal folds caused
be neuropraxia of the posterior branch of the RLN by anesthesia.26 Laryngologic complications due to
that innervates the posterior cricoarytenoid and in- hematomas were most commonly located on the left
terarytenoid muscles, or inflammatory spasm of the side, very probably because the anesthesiologist was
interarytenoid muscles themselves.43 right-handed.42 Granulations and thickening were
primarily found bilaterally in the posterior part of
Operation type and duration the vocal folds, most likely as a result of chronic ir-
ritation by the endotracheal tube.
A recent study showed a statistically significant
difference in the incidence of sore throat among Hoarseness in non-thyroid surgery
patients who underwent cesarean section and other
Complications after cervical spine procedures
gynecological patients, particularly when endotracheal
demonstrated a rate of RLNP of nearly 25%, with
tubes of sizes larger than 7.5mm ID (p < 0.03) were
8% being clinically symptomatic and 15.9% detected
used.47 This study indicates that the CO2 pneumop-
via laryngoscopy.49 Recently, Jung et al50 demon-
eritoneum and Trendelenburg position used during
strated in a prospective study a significant decrease
laparoscopy increase endotracheal cuff pressure and
in hoarseness incidence in anterior cervical spine
may lead to discomfort during the postoperative
surgery, with a total rate of persisting symptomatic
phase. Measurement of endotracheal cuff pressure
and asymptomatic RLN palsy of 1.3%.
is a simple and inexpensive procedure and should
be applied in patients undergoing laparoscopic sur- The morbidity of RLN palsy is high during some
gery.30 As regards the effect of duration of surgery thoracic operations.51 The incidence is around 31%
on the incidence of hoarseness, study results in the among patients undergoing left lung resection for
literature are controversial. Jones et al38 stated that cancer52 and, as reported in Japan, can be as high as
increased duration of surgery led to an increased 80% among those undergoing esophagectomy with
incidence of hoarseness, mainly because of mucosal three-fold lymph node dissection for carcinoma.53 In a
damage caused by the endotracheal tube.38 Yamanaka recent study concerning esophagectomy with cervical
Hoarseness after thyroidectomy: Blame the endocrine surgeon alone? 9

anastomosis,54 the overall incidence of postoperative RLNP, 8 (8.9%) of whom had previously undergone a
unilateral RLNP (URLNP) was 50% with 28.6% surgical procedure with a nerve at risk (thyroid gland
categorized as transient, 10.7% as permanent and the or transcervical approach to the spinal cord). The
remaining 17.9% as of unknown clinical outcome due incidence of patients with recurrent carotid stenosis
to absence of follow-up. Hoarseness is the most com- who require reoperation appears to be approximately
mon postoperative complication of extended radical 2% to 10%.60,61
esophagectomy for thoracic esophageal cancer, with
Table 1 depicts the incidence of hoarseness in
a rate of 45%, as reported by Nishimaki.55 The rate
surgical procedures beyond thyroidectomy.
of hoarseness after mediastinoscopy has been gen-
erally reported at less than 1%.56 Widstrom57 found Hoarseness due to non-surgical causes
that laryngoscopy before and after mediastinoscopy
revealed VCD in 6% of patients. Psychogenic hoarseness
Psychogenic hoarseness is a condition described
As far as coronary bypass is concerned, transient
in the literature variably by such terms as “hysteric
hoarseness following open-heart surgery may be an
croup” and “emotional laryngeal wheezing”, suggest-
ominous sign of RLN injury. Since this hoarseness
ing psychological disorders as the cause for vocal cord
cannot be attributed to intralaryngeal edema, several
adduction.62,63 and can be as high as 80% among those
mechanisms of injury to RLN have been suggested:
undergoing esophagectomy with 3-fold lymph node
a) through central venous catheterization; b) by
dissection for carcinoma in Japan. Other disorders
traction on the esophagus; c) by direct vocal cord
such as depression, factitious disorder, conversion
damage or palsy from a traumatic endotracheal in-
disorder and somatoform disorder are referred to as
tubation; d) trauma by compression of the RLN or
being associated with hoarseness.64-66 The common
its anterior branch at the tracheoesophageal groove
by an inappropriately sized endotracheal tube cuff; denominator in all these diagnoses was the presence of
e) by a faulty insertion of a nasogastric tube; f) due significant emotional stress. Husein et al67 found that
to median sternotomy and/or sternal traction pulling emotional stress was the inciting factor in the absence
laterally on both subclavian arteries; g) due to direct of any obvious psychiatric disorder. Depression has
manipulation and retraction of the heart during open- been a common underlying psychiatric diagnosis in
heart procedures; h) from hypothermic injury with many patients with hoarseness affecting up to 33%
ice/slush. The incidence of hoarseness in open-heart to 40% of patients with VCD.64 Neri et al68 in a ret-
surgery is 1-2%.58 rospective research observed that out of 15 thyroid-
ectomized patients with postoperative hoarseness, 7
AbuRahma and Choueiri59 studied the incidence of (46.6%) had a nerve lesion, while 8 (55.3%) did not,
hoarseness after carotid endarterectomy. Twenty-five a result that was attributed to psychogenic causes.
cranial and/or cervical nerve injuries were identified Baker69 described a case of psychogenic dysphonia
in 19 out of 89 patients (21%), of which 6 involved the following a modified thyroplasty for a unilateral vo-
RLN (7%).59 Of these injuries, 88% were transient cal fold paresis.
with a complete healing time ranging from 2 weeks
to 28 months, while the remaining 12% were per- One interesting manifestation that should be
manent.59 When the permanent nerve injuries were highlighted is postthyroidectomy bilateral abductor
excluded, the average recovery time was 13.5 months vocal cord paralysis (BAVCP), which is a potentially
for the RLN,59 a longer healing time than other cranial life-threatening syndrome strongly connected with
nerve injuries. Fifteen patients (16.8%) experienced serious psychiatric manifestations as well as by voice,
postoperative hoarseness or voice changes,59 but dur- airway, hypothyroid and hypoparathyroid symptoms.
ing comprehensive examination, including fiberoptic Around one third of the patients (35.2%) with the
laryngoscopy, only 11 (12.3%) of these were found to syndrome had psychiatric complications, with 16.4%
have injury to the vagal nerve or its branches. Four having pre-existing psychiatric symptoms exacerbated
injuries (4.4%) were attributed to endotracheal in- by the syndrome, 12.5% presenting with psychiatric
tubation. Fourteen patients (15.7%) had preexisting symptoms initiated by the syndrome and 4.7% of them
10 D. Moris ET AL

Table 1. Incidence of hoarseness in surgical procedures beyond thyroidectomy

Incidence of Method of identification
Procedure Author hoarseness Mechanism of injury of hoarseness Study category
Carotid AbuRahma et al 59
7% Local trauma to the nerve Clinical examination Prospective
endarterectomy Ballotta et al60 2-10% in by means of retraction, and direct laryngoscopy LOE II-2
Schauber et al61 restenosis stretching, clamping and
Morris64 surgery transection. However, most
of the clinical injuries occur
during retraction
Open heart surgery Hamdan et al58 1-2% Several mechanisms Direct laryngoscopy Review article
LOE III
Lung cancer Filaire et al52 31% Surgical injury, Fiber optic laryngeal Prospective
Zhao et al36 tumor invasion examination LOE II-2
Esophagectomy Isono et al53 45-80% Cervical access and Clinical examination Prospective
Nishimaki et al55 lymphadenectomy and direct laryngoscopy LOE II-2
Pertl et al54
Cervical spine Jung et al49,50 1,3-25% Endotracheal cuff Indirect laryngoscopy Prospective
surgery pressure, retraction LOE II-2
Intubation or Kambic et al42 6.2-31% Arytenoid trauma, surgical Videoendoscopy and Randomized
extubation Zimmert et al29 trauma, modification of the videostrobolaryngoscopy controlled trial
Mencke et al35,36 vascular supply and venous LOE I
Echternach et al26 drainage of the larynx, etc.
Mediastinoscopy Roberts et al40 1-6% Traction in the anterior Intraoperative Prospective
mediastinum neuromonitoring LOE II-2
LOE= Level of evidence according to US Preventive Services Task Force (USPSTF).

having psychiatric symptoms etiologically distinct ing GERD.64 Twenty-two adolescent patients with
from the syndrome.70 VCD had posterior laryngeal changes of arytenoid
and interarytenoid edema with pachyderma typically
VCD and asthma seen in GERD.74 Cases of patients with VCD when
Differentiating asthma and VCD can sometimes GERD symptoms are present should prompt evalu-
be difficult.71 The literature reports cases of hoarse- ation and consideration for treatment with proton
ness misdiagnosed as asthma for extended periods pump inhibitors.64
of time.72 Approximately one third of patients with
VCD were diagnosed with asthma prior to the correct Hoarseness and environmental exposure
diagnosis of VCD.71 Morris et al64 found that, of 11% Studies indicate that many persons present hoarse-
of patients with VCD who had bronchoprovocation ness caused by environmental factors. Perkner et al75
testing, only 29% were reactive. O’Connell et al73 found that patients exposed to smoke, dust, fumes, gas
reported coexistent asthma in 35% of patients with or vapors had VCD symptoms within 24 h of a single
VCD. The current literature lacks prospective stud- exposure. Moreover, Andrianopoulos et al76 reported
ies that adequately define the relationship between that hoarseness was triggered in patients by stimuli
VCD and asthma or uses multiple measures to define including foods, perfumed products, air pollutants
airway hyperreactivity.64 and chemical agents. Chlorine gas inhalation can
also exert a wide array of effects on the entire airway,
VCD and Gastroesophageal Reflux Disease ranging from mucous membrane irritation to acute
(GERD) respiratory distress syndrome (ARDS).77 The extent
Although not implicated as a causative factor, 18% and location of damage is determined mainly by the
of patients with VCD are reported to have underly- duration of exposure and quantity of gas released.77
Hoarseness after thyroidectomy: Blame the endocrine surgeon alone? 11

Reactive airways dysfunction and nonspecific bron- ously absent: 7% were due to RLN damage (3% cord
chial hyper-responsiveness are commonly reported hypomobility, 4% monoplegia), 6% were due to a
as sequelae to chlorine exposure.77 deficit of the superior laryngeal nerve (SLN) (hypo-
tonia) and 21% were due to scarring and adhesion
Discussion formation.78 Several causes have been proposed to
interpret these symptoms. They have been attributed
It is presumed that hoarseness is a surgical com- to arytenoid trauma after endotracheal intubation,3
plication after thyroidectomy when no preoperative surgical trauma, modification of the vascular supply
laryngologic examination is undertaken. This empha- and venous drainage of the larynx,1 local pain in the
sizes the need for preoperative laryngoscopy before neck, cricothyroid dysfunction,1-3 strap muscle mal-
thyroidectomy, at least for medicolegal reasons, espe- function or lesion of the perithyroidal neural plexus,4
cially since laryngeal complications caused by injury intra-operative injury of the fine anastomotic branches
to the vocal folds occur much more frequently than connecting the inferior laryngeal nerve (ILN) and the
impairment of the RLN.2,3,78 Discordance between ob- external branch of superior laryngeal nerve (EBSLN)
jective and subjective deterioration of voice is observed and/or one of their anastomosis with the sympathetic
in about one third of symptomatic patients.2,3 With cervical chain,1 laryngotracheal fixation with impair-
regard to objective alterations, it has been demon- ment of vertical movement2,4 and psychologic reaction
strated that patients who undergo total thyroidectomy to the operation.1
may show significant objective variations of acoustic In a large study of 1333 patients, only 8 (0.6%)
voice analysis (AVA), with decrease in maximum demonstrated preoperative unilateral VCP, which
phonation time (MPT)3,5 and phonational frequency was found in 4 of the 1219 patients (0.3%) who
range2,3 in the absence of any laryngeal nerves injury. underwent a primary thyroid operation and in 4 of
On the other hand, it is shown1,4 that most patients the 114 patients with recurrent disease (3.5%).26
complain of vocal symptoms in the absence of any Unilateral VCP was due to compression of the nerve
objective alteration of AVA.1,4 Caregivers should be by an enlarged thyroid gland or to surgical injury
aware of these subjective discomforts that commonly during the first thyroid operation in all patients with
occur after thyroid surgery. Furthermore, patients recurrent disease. The rate of vocal fold injury was
should be fully informed pre-operatively about these estimated at 31.3%.26 It was not clear whether these
symptoms that can persist after thyroidectomy. They rates of complications should be attributed to surgi-
should also be reassured about the complete revers- cal maneuvers alone. For the 1365 nerves at risk, the
ibility of such symptoms, in the absence of any objec- rate of recurrent nerve palsy was 6.6%. No significant
tive nerve injury, as for example the slow decline in difference was noted in the rate of RLNP associated
pre-operative compressive symptoms after surgery.79 with malignant lesions (P=0.13) or age (P=0.23).
Most studies agree that a minimum follow-up period
of 12 months is needed to assess voice function after As stated, a partial palsy of the recurrent laryngeal
thyroidectomy if dysphonia is detected.25 nerve due to intubation would be associated with
severe dysphonia or aphonia and not with dyspnea
Several studies in the literature report symptoms of because of the typical intermediate position of the
hoarseness that precede thyroidectomy. Rosato et al78 paralyzed vocal folds with a normal electromyographic
emphasize that, preoperatively, more than one third function of the cricothyroid muscle. The use of these
of patients already show phonation and deglutition methods to identify the nature of postoperative hoarse-
problems: 8% are due to damage to the RLN (6% ness is recommended in cases of regular IONM but
cord hypomobility, 2% monoplegia), 3% are due to postoperatively impaired function of the vocal cords.32
deficit of the superior laryngeal nerve (hypotonia) and Even endotracheal intubation could be considered
16% are associated with problems in the physiology safe in operations under general anesthesia; rarely, it
of swallowing. In their study, postoperatively, around could cause hoarseness as a complication. As recorded
one third of patients complained about the onset of in the literature, a possible reason for hoarseness is
phonation and swallowing problems that were previ- compression of anterior branches of the RLN in the
12 D. Moris ET AL

larynx between the posteromedial part of the thyroid intubation maneuvers, which are additionally a proven
cartilage and the cuff of the tube. In the literature, and well established cause. The connection of intuba-
unilateral VCD due to endotracheal intubation is tion with the clinical outcome of hoarseness should
mentioned as occurring more frequently in compari- be reconsidered due to interesting and constantly
son to bilateral VCD. These types of palsies usually increasing literature establishing and explaining the
totally resolve in approximately 6 months.80 pathophysiology and incidence of laryngeal injury
Table 2 summarizes the clinical presentation of during and after endotracheal intubation as well
both unilateral and bilateral VCD. as in other surgical procedures not in the head and
neck region.

Conclusions Currently available data justify the assumption

that not every case of RNL palsy following thyroid
Hoarseness is a common complication of thyroid- surgery should be attributed to the operation itself.
ectomy which can be attributed to many factors includ- Nevertheless, the damage caused by intubation may
ing surgical error, intubation injury and non-surgical only account for a minority of these cases. The differ-
causes, such as psychological reasons. Furthermore, ential diagnosis of postoperative hoarseness requires
many patients have pre-existing hoarseness that may the use of specific tools which go beyond simple laryn-
either improve or persist after surgery. As compared goscopy and include stroboscopy as well as intra- and
with procedures such as cervical spine surgery, medi- extralaryngeal electromyography. Finally, we should
astinum surgery, esophagectomy and endarterectomy, highlight the value of an extensive and adequate
thyroidectomy appears to be a procedure with a medical history in order to disclose previous surgical
relatively low risk for hoarseness. procedures that may result in subclinical forms of
It is difficult to determine whether the full per- RLN injuries or non-surgical causes (psychological
centage of hoarseness after thyroidectomy should or environmental causes) that can lead to VCD and
be attributed to surgical procedures alone or also to hoarseness post-thyroidectomy.

Table 2. Clinical presentation of VCD

Unilateral VCD Bilateral VCD
Presentation of symptoms 6-80
Days Hours to days
Time of diagnosis 6-80
Days following extubation Hours following extubation
Voice characters 32
Breathy, hoarse, weak Normal or weak. Both cords generally lie within 2 to 3 mm of the
midline, and the voice is of good quality but of limited intensity
Cough32 Usually inefficient Inefficient (paramedian position)
Efficient (median position)
Breathing32 Normal Insufficient
Choking 32
Present Present (paramedian)
Absent (median)
Laryngoscopic examination Hematomas, mucosal Mucosal thickening, granulations
after intubation35-36 thickening
Frequency6 About 85% of the cases Less frequent. Almost 15% of the cases.
Swallowing dysfunction6 Especially noticeable when Much more noisy presentation. Correlated with insufficient
drinking liquids breathing
Airway32 Airway is usually not obstructed The airway is inadequate, resulting in stridor and dyspnea with
because the normal cord abducts moderate exertion as each cord is drawn to the midline glottis by
sufficiently an inspiratory Bernoulli effect. Aspiration is also a danger
Hoarseness after thyroidectomy: Blame the endocrine surgeon alone? 13

Financial disclosure/Conflict 15. Flynn MB, Lyons KJ, Tarter JW, Ragsdale TL,1994
of interest Local complications after surgical resection for thyroid
carcinoma. Am J Surg 168: 404-407.
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