ENT Referral for Thyroidectomy Patients
Patients scheduled for thyroidectomy are referred to ENT (Ear, Nose, and Throat) specialists primarily for preoperative vocal cord assessment to establish baseline laryngeal function and identify any pre-existing recurrent laryngeal nerve (RLN) injury, which is critical for surgical planning and medicolegal documentation.
Primary Reasons for ENT Consultation
Preoperative Laryngeal Examination
Baseline vocal cord function assessment is essential before thyroid surgery, particularly for patients undergoing revision thyroidectomy where the risk of RLN injury is substantially higher 1.
High-volume thyroid surgeons (>100 cases/year) perform preoperative vocal fold examination significantly more often than lower-volume surgeons, especially before second surgeries, recognizing its importance in surgical planning 1.
Pre-existing RLN palsy is a significant risk factor that must be documented before surgery, as it affects surgical approach and increases the risk of postoperative respiratory complications requiring tracheostomy 2.
Airway Risk Assessment
ENT evaluation helps identify patients at high risk for postoperative airway complications, including those with large goiters, tracheal deviation/narrowing, retrosternal extension, or predicted difficult intubation 2.
Patients with multiple risk factors (≥4 of 6 predictive factors) have substantially higher rates of requiring tracheostomy (9 of 13 patients requiring tracheostomy vs. 2 of 90 who did not) 2.
Preoperative assessment of tracheal anatomy and potential tracheomalacia is crucial, as tracheomalacia is the most common indication for postoperative tracheostomy following thyroidectomy 2.
Multidisciplinary Collaboration Framework
Joint Guideline Development
The British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK) collaborated with the Difficult Airway Society and British Association of Endocrine and Thyroid Surgeons to develop comprehensive guidelines for managing thyroidectomy complications, emphasizing the critical role of ENT specialists 3.
ENT involvement is recommended for complex cases requiring potential emergency airway management, including front-of-neck airway procedures if postoperative haematoma causes airway compromise 3.
Medicolegal and Documentation Considerations
Informed Consent Requirements
Documentation of baseline vocal cord function protects both patient and surgeon, as voice changes and RLN injury are recognized complications that must be disclosed preoperatively 1.
Only 79.7% of surgeons discuss possible voice changes and 36.7% discuss pitch changes, despite nearly universal disclosure of hoarseness risk, highlighting gaps in preoperative counseling 1.
The risk of RLN injury is 3-3.4%, making preoperative laryngeal examination a standard of care for documentation purposes 4.
Postoperative Management Planning
Emergency Airway Preparedness
ENT specialists provide expertise in managing postoperative airway emergencies, including haematoma evacuation and emergency tracheostomy if needed 3.
Postoperative respiratory complications occur in approximately 31% of patients with large goiters, with 13% requiring tracheostomy 2.
The DESATS protocol (Difficulty swallowing, EWS elevation, Swelling, Anxiety, Tachypnoea, Stridor) requires immediate senior review, which may include ENT consultation for airway assessment 3.
Common Pitfalls to Avoid
Failing to perform preoperative laryngeal examination in revision cases significantly increases medicolegal risk and compromises surgical planning 1.
Underestimating airway risk in patients with large goiters or multiple risk factors can lead to preventable emergency situations requiring urgent tracheostomy 2.
Not discussing the possibility of postoperative tracheostomy (only 53.7% of surgeons do so) leaves patients unprepared for this potential outcome 1.