In a patient with new‑onset dysphonia, a solid hypoechoic thyroid nodule with irregular margins, a history of melanoma, and prior radioactive iodine treatment for Graves disease, what is the appropriate work‑up and management for incomplete vocal‑cord closure due to suspected unilateral recurrent laryngeal nerve palsy?

Management of Incomplete Vocal Cord Closure with Suspected Unilateral Recurrent Laryngeal Nerve Palsy

In a patient with new-onset dysphonia and incomplete vocal cord closure, immediate flexible laryngoscopy is mandatory to confirm unilateral recurrent laryngeal nerve palsy, followed by urgent evaluation of the thyroid nodule for malignancy given the high-risk features (solid, hypoechoic, irregular margins) and concerning history of melanoma. 1, 2

Immediate Diagnostic Work-Up

Laryngoscopic Evaluation

• Perform flexible laryngoscopy immediately in any patient with suspected laryngeal malfunction to obtain early diagnosis of vocal cord palsy 1
• Laryngoscopy will reveal the affected vocal cord paralyzed in a paramedian position if RLN injury is present 2
• Document baseline vocal cord function, as this is essential for medicolegal purposes and clinical management 1, 3

Thyroid Nodule Assessment

• The combination of preoperative RLN palsy with a thyroid mass is strongly suggestive of malignancy (94% incidence) 4
• Solid hypoechoic nodules with irregular margins require ultrasound-guided fine needle aspiration cytology immediately 5
• CT imaging should be obtained to assess for extrathyroidal invasion, as 93% of malignant thyroid tumors presenting with preoperative RLN palsy demonstrate extrathyroidal extension 4
• Given the history of melanoma, metastatic disease to the thyroid must be considered alongside primary thyroid malignancy 4

Critical Clinical Context

Understanding the Mechanism

The RLN innervates all intrinsic laryngeal muscles except the cricothyroid, controlling vocal fold movement crucial for both phonation and swallowing 6, 2. When the nerve is compromised by tumor invasion or compression, the vocal cord becomes paralyzed in a paramedian position, resulting in incomplete glottic closure during phonation 2.

Distinguishing Benign from Malignant Causes

• While RLN palsy with benign multinodular goiter is extremely rare, it does occur 5
• However, preoperative RLN palsy in the setting of a suspicious thyroid nodule carries a 94% probability of malignancy 4
• The irregular margins and solid hypoechoic appearance further elevate malignancy risk 4, 5

Surgical Management Algorithm

If Malignancy is Confirmed

• Surgery should be performed by an experienced thyroid surgeon, as these cases often require complex procedures beyond total thyroidectomy 4
• The RLN should be preserved if it can be dissected free from the tumor, even if currently paralyzed, because functional recovery occurs in approximately 67% of cases when the nerve is preserved 4
• Expect to perform more extensive surgery than standard total thyroidectomy, including potential central compartment dissection and management of upper aerodigestive tract invasion 4
• Use intraoperative nerve monitoring to confirm nerve integrity at the end of the procedure 1, 7

If Benign Disease is Confirmed

• Total or completion thyroidectomy should still be performed to remove the compressive mass and preserve the affected nerve 5
• There is a significant chance (40%) of nerve function recovery after surgical decompression in benign disease 5
• The nerve should be carefully dissected and preserved, as recovery can occur even years after initial injury 8

Postoperative Management and Rehabilitation

Immediate Postoperative Care

• Initiate a short course of corticosteroids to reduce nerve inflammation 3
• Prescribe voice rest and ensure adequate hydration 3
• Refer to speech therapy for compensatory techniques 1, 3

Multidisciplinary Team Approach

• A cohesive team including an otolaryngologist and speech therapist plays a central role in postoperative rehabilitation 1
• Follow-up laryngoscopy at 4-6 weeks to assess recovery 3
• Continue voice therapy with focus on compensatory techniques for breathy voice quality, reduced volume, and voice fatigue 2, 3

Monitoring for Recovery

• Most unilateral RLN injuries show compensation from the opposite vocal cord over time 6, 2
• Recovery from temporary RLN injury typically occurs within 1-3 months 2
• Serial laryngoscopies should be performed until recovery or definitive RLN palsy is demonstrated 7

Management of Aspiration Risk

Swallowing Assessment

• RLN injury impairs vocal cord function, compromising airway protection during swallowing and leading to potential aspiration 6
• Assess for dysphagia and aspiration risk, not just voice symptoms 3
• Patients experience impaired ability to cough effectively in the early post-injury period 6

Interventions for Persistent Dysfunction

• For persistent dysphagia beyond 6 months, consider interventions such as thyroplasty or vocal cord injections, though these are rarely required 6
• In cases of significant aspiration risk, tracheostomy may be considered to protect the airway 6

Special Considerations for This Patient

Prior Radioactive Iodine Treatment

• Previous RAI treatment for Graves disease does not increase the baseline risk of RLN injury during surgery 1
• However, document this history as it may affect tissue planes during dissection 1

Melanoma History

• Metastatic melanoma to the thyroid is rare but must be excluded 4
• Ensure cytology and eventual histopathology specifically address this possibility 4

Common Pitfalls to Avoid

• Delayed laryngoscopy leads to delayed treatment and poorer outcomes 3
• Assuming all preoperative RLN palsy is due to malignancy without tissue diagnosis 5
• Inadequate follow-up—patients require regular laryngoscopic examinations to monitor recovery 3
• Sacrificing the RLN when it can be dissected free, as this eliminates the 67% chance of functional recovery 4
• Performing bilateral thyroidectomy when intraoperative nerve monitoring shows loss of signal on the first side, which risks bilateral palsy 7