What are the preoperative preparations for thyroplasty?

Preoperative Preparation for Thyroplasty

Thyroplasty requires comprehensive preoperative laryngeal assessment, patient education about voice outcomes, careful management of anticoagulation therapy, and risk stratification for airway complications, particularly in patients with chronic pulmonary disease or those requiring complex procedures.

Preoperative Laryngeal Assessment

All patients must undergo preoperative laryngoscopy to document baseline vocal fold position and function before thyroplasty. 1 This assessment serves multiple critical purposes:

• Document baseline laryngeal anatomy and vocal fold mobility to establish a reference point for postoperative comparison and medico-legal documentation 1
• Identify any preexisting voice abnormalities that may affect surgical planning and patient expectations 1
• Communicate abnormal findings to the anesthesiologist prior to surgery to optimize airway management and tube selection 1

The laryngeal examination should specifically evaluate for vocal fold position, degree of glottal gap, presence of atrophy, and any anatomical variations that may influence surgical approach. 1

Patient Education and Informed Consent

Patients must receive explicit education about the potential impact of thyroplasty on voice outcomes once the decision to proceed with surgery has been made. 1 This discussion should include:

• Risk of voice changes following the procedure, including both temporary and permanent alterations 1
• Potential for dysphagia related to the surgical intervention 1
• Rare but serious complications including airway obstruction (2.03% overall complication rate) and the possibility of tracheostomy or reintubation 2
• Risk of prosthesis extrusion (8.6% in historical series), which may occur 1 week to 5 months postoperatively 3

Written consent should document these discussions in accordance with informed consent principles. 1

Anticoagulation and Antiplatelet Management

Antiplatelet and anticoagulant therapy requires careful preoperative planning, as continuation increases airway complication risk. The evidence presents a nuanced picture:

• Aspirin continuation in thyroid surgery (a related neck procedure) does not significantly increase intraoperative blood loss (2.5 mL increase; 95% CI, -0.4 to 5.3) but may increase hematoma formation (3.3% absolute increase) 4
• For thyroplasty specifically, continuous antiplatelet use is associated with a clinically meaningful 3.5-fold increased risk of airway complications (adjusted RR 3.49; 95% CI, 1.28-9.54) 2
• Resumption of antiplatelets on postoperative day 1 carries a 2.9-fold increased risk (adjusted RR 2.86; 95% CI, 0.89-9.19) 2
• Resumption of anticoagulants on postoperative day 1 carries a 3.2-fold increased risk (adjusted RR 3.20; 95% CI, 0.77-13.25) 2

The decision to continue or hold anticoagulation must balance cardiac risk against bleeding risk, with consideration for delaying resumption beyond postoperative day 1 in high-risk patients. 2

Risk Stratification for Airway Complications

Identify high-risk patients who require enhanced perioperative monitoring and airway management planning. 2 Risk factors include:

• Advanced age - associated with increased complication risk 2
• Complex surgical procedures - arytenoid adduction combined with thyroplasty, or type III/IV thyroplasty carry higher risk than simple type I procedures 2
• Chronic obstructive pulmonary disease - significantly increases airway complication risk and requires preoperative optimization 2
• Metastatic cancer - associated with increased perioperative complications 2
• Female sex - may be more prone to prosthesis extrusion and movement due to smaller laryngeal size 3
• Previous radiation to the operative field - historically considered a contraindication, though recent evidence suggests it may be feasible with careful selection 5

Preoperative Medical Optimization

Patients with chronic pulmonary disease require preoperative pulmonary optimization to minimize airway complication risk. 2 This includes:

• Pulmonary function assessment in patients with known chronic obstructive pulmonary disease 2
• Optimization of bronchodilator therapy prior to surgery 2
• Smoking cessation if applicable, though active smoking was not identified as a significant risk factor in available studies 5

Diabetic patients should have glucose control optimized, though diabetes was not identified as a significant independent risk factor for complications in thyroplasty. 5

Anesthetic Planning and Communication

The surgeon must inform the anesthesiologist of any abnormal preoperative laryngeal findings to allow for:

• Appropriate endotracheal tube selection based on laryngeal anatomy 1
• Optimization of airway management strategy for intubation and extubation 1
• Planning for postoperative monitoring based on identified risk factors 1

Local anesthesia is the preferred technique for thyroplasty as it allows intraoperative voice assessment and fine adjustment of prosthesis placement. 6 This should be discussed during preoperative planning.

Special Considerations for Previously Irradiated Patients

Previous external beam radiation to the neck is not an absolute contraindication to thyroplasty, though careful patient selection is warranted. 5 When considering thyroplasty in previously irradiated patients:

• Plan for postoperative antibiotic prophylaxis in all cases 5
• Assess for other risk factors including diabetes, active smoking, and immunosuppression 5
• Counsel patients about theoretical increased risk of infection and implant extrusion, though short-term outcomes show no increased complications with appropriate selection 5

Preoperative Testing and Documentation

Standard preoperative assessment should include:

• Videolaryngoscopy with documentation of vocal fold position and glottal gap 1
• Voice assessment including subjective patient-reported outcomes 1
• Review of cardiac risk factors and anticoagulation needs 2
• Pulmonary assessment in patients with chronic lung disease 2