What is the management plan for hoarseness after thyroidectomy?

Management of Hoarseness After Thyroidectomy

Patients with hoarseness after thyroidectomy should be referred to an otolaryngologist for evaluation and management of potential vocal fold abnormalities. 1

Initial Assessment and Referral

• Immediate recognition: Any voice change persisting beyond 2 weeks post-thyroidectomy warrants attention and referral 1
• Causes of post-thyroidectomy hoarseness:
  • Recurrent laryngeal nerve (RLN) injury (up to 2.1% of thyroidectomies) 1, 2
  • External/superior laryngeal nerve (ELN/SLN) injury 2
  • Vocal cord dysfunction from intubation trauma 3
  • Laryngeal edema from venous/lymphatic drainage disruption 4
  • Psychogenic factors or respiratory infections 3

Diagnostic Evaluation

• Laryngoscopy: Essential to visualize vocal fold mobility and determine the cause of hoarseness 1
• Video-stroboscopy: For detailed assessment of vocal fold function, especially in cases where standard laryngoscopy shows normal-appearing vocal cords but voice changes persist 2
• Voice assessment: Evaluate parameters such as breathiness, weakness, difficulty with volume/pitch adjustment 1

Management Algorithm

1. Immediate Management (0-2 weeks)

• Voice rest for 1-2 weeks
• Adequate hydration
• Reassurance that many cases improve spontaneously
• Review medications that may worsen hoarseness (antihistamines, diuretics, anticholinergics) 1

2. Early Intervention (2-4 weeks)

• Refer to otolaryngologist if hoarseness persists beyond 2 weeks 1
• Laryngoscopic examination to determine:
  • Vocal fold mobility status
  • Presence of edema or other abnormalities
  • Type of nerve injury (RLN vs. SLN)

3. Rehabilitation Phase (1-6 months)

• Voice therapy with a speech-language pathologist 1, 2
  • Compensatory techniques
  • Vocal exercises to improve strength and control
  • Prevention of maladaptive compensatory behaviors

4. Surgical Interventions (if needed)

For persistent vocal fold paralysis or significant voice impairment after 6 months:

• Injection laryngoplasty 1

  • Temporary restoration of vocal fold position and bulk
  • Can be performed in office or operating room
  • May need to be repeated as material resorbs

• Framework procedures 1

  • Permanent restoration of vocal fold position
  • Requires neck incision and operating room
  • Near immediate voice improvement

• Reinnervation procedures 1

  • For permanent improvement
  • Takes up to a year for full effect
  • Often combined with temporary injection

• Cricothyroid approximation surgery 2

  • Specifically for SLN injury to improve pitch

Patient Counseling Points

Patients should be informed that:

1. Voice changes are significant complications of thyroidectomy
2. Symptoms may include hoarseness, breathiness, vocal fatigue, or difficulty projecting voice
3. Recovery timeline varies - nerves may take over a year to heal completely
4. Early intervention improves long-term outcomes
5. Treatment options range from non-invasive voice therapy to surgical procedures
6. Even with permanent nerve injury, significant voice improvement is possible with proper rehabilitation 1

Prognosis

• Many patients experience spontaneous improvement within 3-6 months 2
• Transient voice changes from manipulation or edema typically resolve within 1 month 4
• Permanent nerve injuries may require long-term management
• Voice therapy can significantly improve outcomes even with permanent injury 2

Special Considerations

• Professional voice users require more aggressive and earlier intervention 2
• Bilateral vocal cord paresis requires special attention due to potential airway compromise 5
• Post-thyroidectomy syndrome may cause voice symptoms even without nerve injury 6