What is the management approach for hoarseness after a thyroid Fine Needle Aspiration (FNA)?

Management of Hoarseness After Thyroid Fine Needle Aspiration (FNA)

Hoarseness after thyroid FNA should be managed with reassurance, voice rest for 1-2 weeks, adequate hydration, and monitoring, as most cases resolve spontaneously within 6 months. 1

Causes of Post-FNA Hoarseness

• Recurrent Laryngeal Nerve (RLN) Injury: Though rare, FNA can cause transient vocal cord paralysis with an incidence of approximately 0.036% 2
• External/Superior Laryngeal Nerve (ELN/SLN) Injury: Affects voice quality while preserving gross vocal cord movement 1
• Local Trauma: Needle trauma causing edema or small hematoma formation

Initial Assessment and Management

Immediate Evaluation

1. Assess severity of symptoms:

   • Degree of hoarseness
   • Presence of stridor or respiratory distress (emergency)
   • Timing of onset (typically 1-2 days after FNA) 2

2. Laryngoscopic examination:

   • Indicated for persistent symptoms beyond 2 weeks
   • Evaluates for vocal cord mobility and position
   • Distinguishes between RLN injury (visible paralysis) vs. ELN injury (normal appearance but voice changes) 1

First-Line Management

• Voice rest for 1-2 weeks 1
• Adequate hydration to maintain vocal cord lubrication
• Reassurance that most cases resolve spontaneously within 4-6 months 2
• Anti-inflammatory medication if significant discomfort

Follow-up Care

2-4 Week Follow-up

• If symptoms persist beyond 2-4 weeks, refer to otolaryngology for:
  • Video-stroboscopy for detailed assessment 1
  • Evaluation of vocal fold mobility
  • Assessment for hematoma or other complications

Referral to Speech-Language Pathology

• Indicated for:
  • Persistent symptoms beyond 4 weeks
  • Professional voice users (singers, teachers, public speakers)
  • Significant impact on quality of life 3, 1

Long-term Management

For Persistent Symptoms (>3 months)

• Voice therapy: Can significantly improve outcomes even with permanent injury 1
• Surgical options (if no improvement after 6 months):
  • Injection laryngoplasty for RLN injury
  • Cricothyroid approximation for ELN injury 1

Prognosis

• Excellent: Most cases (>90%) resolve spontaneously within 6 months 2
• Variable recovery time: Average recovery period is approximately 4 months 4
• Permanent changes: Rare after FNA (much more common after thyroid surgery)

Special Considerations

Professional Voice Users

• More aggressive early intervention may be warranted
• Earlier referral to speech therapy and otolaryngology
• More frequent follow-up evaluations

Warning Signs Requiring Immediate Attention

• Progressive worsening of hoarseness
• Development of stridor or respiratory distress
• Expanding neck hematoma (requires emergency management per SCOOP protocol) 3

Key Pitfalls to Avoid

• Delayed diagnosis: Failing to recognize potential nerve injury
• Inadequate follow-up: Not monitoring for resolution
• Overlooking other causes: Post-FNA hoarseness may coincide with other causes of voice changes (upper respiratory infections, reflux, etc.) 5

Remember that while thyroid surgery has a well-documented risk of vocal cord paralysis (up to 2.1% for thyroidectomy), FNA-related vocal cord paralysis is much rarer but should still be considered in the differential diagnosis of post-procedure hoarseness 3, 2.