Research

JAMA Otolaryngology–Head & Neck Surgery | Original Investigation

Patient-Reported Dysphagia After Thyroidectomy

A Qualitative Study
Brittany N. Krekeler, MS; Elizabeth Wendt, MPH; Cameron Macdonald, PhD; Jason Orne, PhD;
David O. Francis, MD, MS; Rebecca Sippel, MD; Nadine P. Connor, PhD

Supplemental content
IMPORTANCE It is important that clinicians understand consequences of thyoridectomy on
swallowing from the patient perspective to better care for this population.

OBJECTIVE Using rigorous qualitative methodology, this study set out to characterize the
effect of swallowing-related symptoms after thyroidectomy on patient quality of life and
swallowing-related outcomes.

DESIGN, SETTING, AND PARTICIPANTS Prospective, grounded theory analysis of interviews

with 26 patients at 3 time points after thyroidectomy (2 weeks, 6 weeks, and 6 months). Data
were collected from an ongoing clinical trial (NCT02138214), and outpatient interviews were
conducted at the University of Wisconsin Hospital and Clinics. All participants were age 21 to
73 years with a diagnosis of papillary thyroid cancer without cervical or distant metastases
and had undergone total thyroidectomy. Exclusion criteria were preexisting vocal fold
abnormalities (eg, polyps, nodules), neurological conditions affecting the voice or swallowing
ability, and/or development of new-onset vocal fold paresis or paralysis (lasting longer than
6 months) after total thyroidectomy.

INTERVENTIONS Total thyroidectomy.

MAIN OUTCOMES AND MEASURES Symptoms of dysphagia and related effects on quality of
life elicited through grounded theory analysis of semistructured interviews with patients after
thyroidectomy designed to foster an open-ended, patient-driven discussion.

RESULTS Of the 26 patients included, 69% were women (n = 18); mean (SD) age, 46.4 (14.1)
years; mean (SD) tumor diameter 2.2 (1.4) cm. Two weeks after thyroidectomy, 80% of
participants (n = 20) reported at least 1 swallowing-related symptom when prompted by
the interview cards; during the open interview, 53% of participants (n = 14) volunteered
Author Affiliations: Department of
discussion of swallowing-related symptoms unprompted. However, only 8% of participants
Communication Sciences and
in this study (n = 2) qualified for a follow-up dysphagia evaluation, indicating that the Disorders, University of Wisconsin,
majority of reported symptoms were subjective in nature. Six weeks and 6 months after Madison (Krekeler, Connor);
thyroidectomy, 42% (n = 11) and 17% (n = 4) of participants, respectively, reported continued Department of Surgery, Division of
Otolaryngology–Head and Neck
swallowing symptoms using the prompts; 12% (n = 3) discussed symptoms without Surgery, University of Wisconsin,
prompting cards at both time points. Madison (Krekeler, Francis, Connor);
University of Wisconsin School of
Medicine and Public Health, Madison
CONCLUSIONS AND RELEVANCE Swallowing symptoms after thyroidectomy are
(Wendt); Qualitative Health Research
underreported in the literature. This study revealed that as many as 80% of patients who Consultants, Madison, Wisconsin
have thyroidectomy may experience swallowing-related symptoms after surgery, and many (Macdonald); Department of
develop compensatory strategies to manage or reduce the burden of these symptoms. Sociology, Drexel University,
Philadelphia, Pennsylvania (Orne);
Considering the large number of individuals who may experience subjective dysphagia,
Wisconsin Surgical Outcomes
preoperative counseling should include education and management of such symptoms. Research Program, Madison (Francis,
Sippel); Department of Surgery,
Division of General Surgery,
University of Wisconsin, Madison
(Francis).
Corresponding Author: Brittany N.
Krekeler, MS, University of Wisconsin
Medical Sciences Center, 1300
University Ave, Room 483, Madison,
JAMA Otolaryngol Head Neck Surg. 2018;144(4):342-348. doi:10.1001/jamaoto.2017.3378 WI 53706 (brittany.krekeler@wisc
Published online March 8, 2018. .edu).

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 Patient-Reported Dysphagia After Thyroidectomy
T
hyroid cancer rates have increased at least 3-fold across
the last few decades,1,2 with over 63 000 incident cases
diagnosed annually.3 The primary treatment modality
for thyroid cancer is total thyroidectomy.4-8 Swallowing com-
plaints are common after surgery, but patients are generally
counseled that symptoms should spontaneously resolve within
the immediate 2-week postoperative period.9 Mechanisti-
cally, postoperative swallowing dysfunction can affect the oro-
pharyngeal and pharyngoesophageal phases,5,10 often result-
ing in globus sensation, choking, psychological stress, and
reduced quality of life.5,8,10,11
Informed consent prior to thyroidectomy tends to focus
on cancer extirpation, surgical healing, and potential
complications.4,12 The most common adverse effects and com-
plications cited during this process are vocal fold paralysis and
hypocalcemia.12 Dysphagia complaints may be discussed, but
they are typically considered transient and thus are often mini-
mized during preoperative counseling.6,8 Nonetheless, post-
thyroidectomy dysphagia has been documented.7,10,11,13 Ob-
jective dysphagia can be managed with swallow therapy and,
in select circumstances, surgical intervention (eg, laryngo-
plasty). Dysphagia complaints despite normal findings on ob-
jective instrumental swallowing evaluation (ie, subjective dys-
phagia) have few management options beyond reassurance and
compensatory (or management) strategies but can have sub-
stantial quality-of-life consequences.
Previous attempts to assess the nature and prevalence of sub-
jective dysphagia have used dysphagia-related patient-reported
outcome (PRO) measures, the content of which should derive di-
rectly from the patients.14,15 Unfortunately, a thematic deficiency
in dysphagia PRO measures is lack of patient involvement in con-
tent development.14 In fact, to our knowledge, no study has char-
acterized subjective postthyroidectomy dysphagia from the pa-
tients’ perspective or emphasized how it affects their quality of
life. A rigorous qualitative approach is required to understand
postthyroidectomy subjective dysphagia. The present study in-
vestigates this gap in knowledge using grounded theory analy-
sis of semistructured interviews with patients who underwent
total thyroidectomy for papillary thyroid cancer.
Methods
Each patient signed a consent form prior to any study-related
procedures. The qualitative data reported herein were derived
from a clinical trial approved by the University of Wisconsin
Health Sciences institutional review board (NCT02138214). All
participants also provided written informed consent to
participate in the present interview study and to have their
responses recorded and published.
Patient Population and Inclusion Criteria
Participants were recruited from an ongoing randomized clini-
cal trial concerning surgical management of thyroid cancer. In-
clusion criteria were (1) age 21 to 73 years, (2) a diagnosis of pap-
illary thyroid cancer without cervical or distant metastases,
(3) having undergone total thyroidectomy with recurrent
laryngeal nerve monitoring, and (4) the ability to read and write
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Original Investigation Research
Key Points
Question How common is postthyroidectomy dysphagia, and
how is it characterized by patients and by instrumental evaluation
during the first postoperative year?
Findings Of 26 patients surveyed, 80% (n = 20) perceived
dysphagia 2 weeks after thyroidectomy; 42% (n = 11) at 6 weeks;
and 17% (n = 4) at 6 months after total thyroidectomy. In contrast,
few patients (8%; n = 2) had any abnormalities found by clinical
assessment or instrumental swallowing evaluation that warranted
further follow-up, and these few abnormalities occurred only at
the 2-week follow-up, not beyond.
Meaning Postthyroidectomy swallowing symptoms are common
and may persist for months postoperatively; the risk of dysphagia
is important to discuss because simple interventions may improve
quality-of-life consequences of patient-perceived
postthyroidectomy dysphagia.
in English. Exclusion criteria were (1) preexisting vocal fold ab-
normalities (eg, polyps, nodules) and/or any neurological con-
dition affecting voice or swallowing ability or (2) new-onset
vocal fold paresis or paralysis lasting longer than 6 months
after the total thyroidectomy procedure.
Semistructured Interviews
All consenting participants participated in semistructured in-
terviews at 2 weeks, 6 weeks, and 6 months after total thy-
roidectomy. Interviews were conducted by trained interviewers
who were not involved in their clinical care. Interviewers un-
derwent a week-long standardized training session in open-
ended interview techniques and in how to use the interview
guide (see interview guide in the Supplement). All interview-
ers also attended monthly data quality meetings led by an ex-
pert in qualitative research design (C.M.) at which selected tran-
scripts were reviewed and consistent approaches to follow-on
probes were established. Interview guides at all time points
combined open-ended questions with standardized prompts.
Each interview took on average 1 hour and covered patient’s
reflections on experiences with cancer from diagnosis through
treatment and recovery, as well as experiences with postsur-
gical complications (see patient handout in the Supplement).
Symptom Identification and Assessment
The interview used 2 different methods to query participant
symptoms. The first approach used open-ended questions to
elicit symptoms that came to mind unprompted, such as “how
have you been feeling since your last interview?” or “what
physical changes have you noticed?” The second method used
prompts in which participants were presented with a stack of
cards listing a range of common postthyroidectomy symp-
toms. These symptoms were chosen after a review of the lit-
erature was performed and commonly reported symptoms ex-
perienced by patients after thyroidectomy were noted. This list
was inductively reviewed with a separate, pilot subset of pa-
tients who had undergone thyroidectomy but who were not
part of the present study: 6 patients with thyroid cancer
(5 women and 1 man; age range, 21-75 years) recruited from
343
 Research Original Investigation
Table 1. Clinical Characteristics of 26 Study Participants
Characteristic
Age, mean (SD) (range), y
Female, No. (%)
White race, No. (%)
Tumor size, mean (SD) (range), cm
Postoperative data
Calcium level, mean (SD) (range), mg/dL
Parathyroid hormone level, mean (SD) (range), pg/mL
Transient hypoparathyroidism,a No. (%)
PAS <1, No. (%)
Temporary vocal fold paresis,b No. (%)
the endocrine surgery clinic for pilot postthyroidectomy in-
terviews designed to test the interview guides. Two were in-
terviewed 2 weeks postoperatively, and 2 were interviewed at
the 6-month follow-up visit. Common postoperative symp-
toms were then collected and used as the prompts in the stack
of prompt cards.
Study participants were asked to identify the cards rep-
resenting symptoms that they currently were experiencing
or had experienced in recent weeks. Multiple cards listed
dysphagia-related symptoms, including “choking,” “cough-
ing,” “hard to chew,” “hard to swallow,” “lump in throat,”
and “trouble swallowing,” and interviewers recorded the
frequency of each complaint in a separate symptom log.
Resultant data were used to measure symptom type and fre-
quency at each time point (2 weeks, 6 weeks, and 6 months
postoperatively). This approach allowed us to compare
unprompted vs interviewer-prompted symptom com-
plaints. Interview data were analyzed inductively using a
grounded theory approach.
Grounded Theory Analysis
Interviews were deidentified and transcribed verbatim. Re-
search team members (C.M., J.O., R.S., and N.P.C.) performed
line-by-line open coding of a subset (n = 15) of transcripts at all
time points to ascertain emergent themes. This process yielded
a set of 225 focused codes, which were then applied to the en-
tire data set using NVivo software (QSR International).16 Cod-
ers underwent a 4-day training session in NVivo 11. To assure
strong inter-coder reliability, every fourth transcript was com-
monly coded by all coding team members, and differences in
coding were adjudicated by consensus at biweekly coding meet-
ings; the team of 6 coders achieved and maintained an excel-
lent inter-coder reliability (κ = 0.79).16 Dysphagia or swallowing-
related codes were analyzed inductively using data from the first
26 participants enrolled.
Instrumental Swallow Evaluation
Potential participants were seen preoperatively for a swallow
evaluation before total thyroidectomy when thyroid cancer was
suspected. If swallowing-related counseling or interventions
were deemed appropriate, these were discussed with partici-
pants at this time. Patients also provided their written in-
formed consent prior to this evaluation and were given an iden-
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Patient-Reported Dysphagia After Thyroidectomy
Value
46.4 (14.1) (21-73)
18 (69)
25 (96) Abbreviations: IQR, interquartile
2.2 (1.4) (0.4-5.5) range; PAS, Penetration Aspiration
Score.
a
Transient hypoparathyroidism was
9.3 (0.7) (7.5-11.2)
defined in this study as calcium
36.2 (40.2) (2-192) levels below 8.0 mg/dL and
4 (15) parathyroid hormone levels below
15 pg/mL.
4 (15)
b
Vocal fold paresis resolving within
3 (12)
6 months of total thyroidectomy.
tification number. After thyroid cancer was confirmed via
biopsy, only those participants with confirmed papillary thy-
roid cancer were included in this study. Patients with all other
cancers were excluded from any follow-up interviews.
At the 2-week postoperative interview, all participants un-
derwent a complete swallowing evaluation, including a modi-
fied barium swallow study to acquire objective data about swal-
lowing function. Repeat testing was performed at subsequent
time points if the modified barium swallow study indicated a
Penetration Aspiration Score (PAS) greater than 2 or if reas-
sessment was indicated based on clinical impression.17
Results
Participants
Of the 26 participants who met inclusion criteria, 18 were
women (69%); the mean (SD) age was 46.4 (14.1) years; and
mean (SD) tumor diameter was 2.2 (1.4) cm (Table 1). Each par-
ticipant was interviewed for a mean of 60 minutes per ses-
sion (range, 45-120 minutes; total combined interview time,
73 hours 36 minutes; Table 1). At the 2-week postoperative visit,
the majority of participants (22 of 26; 85%) had a PAS of 1, in-
dicating no swallowing impairment. Only 2 participants (8%)
(participants 39 and 44) qualified for a follow-up swallowing
evaluation. Loss to follow-up was low. Only 2 participants de-
clined further participation, one citing burdensome length of
time for study procedures as reason for discontinuing, and the
other citing a change in insurance that affected eligibility for
treatment.
Dominant Themes
Inductive analysis of participant interviews yielded 2 emer-
gent themes: (1) dysphagia symptoms were a cause of con-
cern, and (2) participants self-discovered compensatory and
coping strategies to reduce their dysphagia symptoms (Table 2).
Complaints of dysphagia postoperatively were reported by 80%
of participants (n = 20); however, only 4 participants had a PAS
greater than 1, with only 2 of these 4 qualifying for a repeat
evaluation of swallowing. In other words, 80% had subjec-
tive dysphagia symptoms affecting their quality of life (n = 20),
and many participants self-initiated compensatory strategies
to reduce symptoms.
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 Patient-Reported Dysphagia After Thyroidectomy Original Investigation Research

Table 2. Subjective Dysphagia Symptoms and Coping Strategies Reported by Study Participants

Postoperative Follow-up Self-described Dysphagia Symptoms Coping Strategies

2 Weeks “I had a sore throat, so eating was difficult… and it did get better…
but it did interfere… not really wanting to eat, and not getting the
nutrition I should have been getting” (participant 37).
“It’s like there’s something stuck there. And that’s what it feels like
if I eat and go too fast, and it just piles up there” (participant 32).
“I used to be able to take a handful of pills… [now] I can’t take
more than two at a time” (participant 11).
6 Weeks “Sometimes when I am drinking I’ll feel, it’s not even much of a
problem, with actually being able to drink, but I just feel a little pull
in my neck” (participant 8).
6 Months It does at times feel like swallowing is not as easy as it maybe once
was” (participant 28).
“Yeah, it interfered with eating… I couldn’t really eat solid
foods for a while until it got better” (participant 21)
“I just have to be more conscious and take smaller bites… and
chew them for thoroughly” (participant 11)
“It feels like it just isn’t going down, so I just start taking a lot
more fluids, then I feel like I have to kind of push it down…”
(participant 28)
“I don’t like fried or crunchy things because it scratches”
(participant 3)
“I have to chew it up smaller… the piece I used to take and
chew down, you know I can’t do that anymore… I cut the
regular piece in two… and I chew like crazy” (participant 4)
“Even on a little bit… I have to swallow two or three times to
get it down” (participant 4)

Table 3. Frequency of Swallowing Symptoms Reported by Study Participants

Open/Prompt Version, No. (%)

Symptom 2 Weeks 6 Weeks 6 Months
Painful swallowing 12 (46)/NR 2 (8)/NR NR/NR
Lump in throata 2 (8)/12 (48) NR/7 (27) NR/2 (8)
Coughinga NR/11 (44) NR/3 (12) NR/1 (4)
Trouble swallowinga NR/9 (36) NR/6 (23) NR/1 (4)
Increased effort 7 (27)/7 (28) NR/1 (4) NR/NR
Food getting stuck 4 (15)/NR NR/NR 2 (8)/NR
Choking sensationa 1 (4)/3 (12) 1 (4)/3 (12) 1 (4)/1 (4) Abbreviation: NR, no response (item
Difficulty with pills 3 (12)/NR NR/NR NR/NR was either not discussed in the open
interview or was not prompted).
Hard to chewa NR/2 (8) NR/NR NR/NR
a
Interviewer used issued prompts to
Overall 14 (53)/20 (80) 3 (12)/11 (42) 3 (12)/4 (17)
inquire about symptom.

Table 4. Representative Quotes From Participants Describing Dysphagia Symptoms Postthyroidectomy

Symptom Follow-up Direct Quote

Painful swallowing 2 weeks “I had to take [oxycodone] for longer than I wanted to because of the sore throat just … I couldn’t bear it kind of
thing…it was just very uncomfortable, and I could barely eat anything and you know, I had the sore throat so like you
know, you can have soup, you can have milk, and that’s it, you know.” (participant 21)
2 weeks “ …anytime I’d swallow, or even just, you know, you just kind of move around in bed…like the throat area would
hurt … It’s hard to not think about. Um, when you’re throat’s hurting… Yeah. And you can’t just decide you’re not
going to swallow.” (participant 28)
Lump in throat 2 weeks “Sometimes, like when I swallow, I feel like something is there inside the throat…” (participant 12)
Food stuck 2 weeks “…how do you even describe that? Like it was kind of like closed off, and it was just like I was forcing something to like
go down really slow. It’s like it wouldn’t go, and it just like, oh my God, this feels like it’s stuck. But it wasn’t. It went
down. But it was just like, oh my God, it just really, really hurt.” (participant 20)
6 months “I’ll take a bite of something. I’ll chew it up, and swallow, and it doesn’t go down. It goes halfway down. It sticks, and
it kinda cuts off my breathing.” (participant 4)
Increased effort 2 weeks “The trouble swallowing it just, like I said…all these muscles are just so sore that it just was hard to swallow.”
(participant 5)
6 weeks “But it takes like, takes 2 times, sometimes, to swallow.” (participant 4)

See Table 2 for more representative participant quotes.

Subjective Dysphagia
Participants reported a variety of swallowing symptoms fol-
lowing total thyroidectomy, and the frequency of complaints
varied based on ascertainment method: open-ended query vs
symptom card prompts (Table 3); representative quotes can
be found in Table 4.
Open-ended Questions
In response to open-ended questions, 53% of participants
shared swallowing complaints at the 2-week postoperative visit
(n = 14), with 12% (n = 3) reporting persistent swallowing is-
sues at each of the 6-week and 6-month interviews. The most
common symptom reported in the open interview format
2 weeks postoperatively was painful swallowing (46%; n = 12).
Complaints at the 6-week and 6-month assessment were
highly varied, but the common symptoms reported were dis-
comfort with swallowing (8% at 6 weeks; n = 2) and the sen-
sation of food getting “stuck” (8% at 6 months; n = 2). Some
participants’ symptoms manifested as a sensation of choking
(4% each at 6 weeks and 6 months; n = 1). Exemplifying this
was 1 participant who shared “one time I thought I was actu-
ally gonna choke to death” (participant 4).

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 Research Original Investigation Patient-Reported Dysphagia After Thyroidectomy

Table 5. Compensatory Strategies Used to Compensate for Subjective Swallowing Complaints

2 Weeks After Total Thyroidectomy

Strategy Description Sample Quote

Altering diet (n = 9)
Changing chewing pattern
(n = 3)
Water washes (n = 4)
Changing diet choices to select foods that are easier
to swallow or “feel better” on the throat
Using more cycles during chewing, taking smaller
bites, more careful chewing
Using water or another thin liquid to help clear
residue during or after a meal
“Yeah, it interfered with eating, I’d say. Like I couldn’t really eat solid
foods for a while until it got better.” (participant 21)
“I just have to be more conscious and take smaller bites…and chew
them for thoroughly.” (participant 11)
“It feels like it just isn’t going dow, so I just start taking a lot more
fluids, then I feel like I have to kind of push it down…” (participant 28)

Symptom-Card Prompted Questions
When prompted by the symptom cards, more participants
reported swallowing complaints. At the 2-week interview,
80% had 1 or more swallowing complaints (n = 20), while
42% (n = 11) and 17% (n = 4) reported 1 or more persistent
complaints at the 6-week and 6-month interviews, respec-
tively. The most commonly reported individual symptoms
identified 2 weeks postoperatively were “lump in throat”
(48%; n = 12), “coughing” (44%; n = 11), and “trouble swal-
lowing” (36%; n = 9). At both 6 weeks and 6 months, “lump
in throat” was the most commonly identified symptom
from the prompts (27% at 6 weeks [n = 7] and 8% at 6
months [n = 2]).
Compensatory Strategies for Management
of Subjective Dysphagia
A second theme extracted from patient interviews was par-
ticipant-initiated adaptive strategies to minimize their swal-
lowing symptoms (Table 5). These strategies were reported at
each follow-up time during the open-ended interview por-
tion. Strategies were mentioned by 35% of participants 2 weeks
postoperatively (n = 9), which reduced to 8% (n = 2) at 6 weeks
and 4% (n = 1) at 6 months. The most common strategy was
to take smaller bites. As one participant stated at her 6-month
interview, swallowing was not the same as before the proce-
dure: “I have to take smaller bites of things … if I take less
[I don’t] choke that much” (participant 4).
Discussion
To date, postthyroidectomy dysphagia has not been well
characterized. The goal of this study was to better under-
stand the prevalence of postoperative dysphagia symptoms
among patients who have undergone total thyroidectomy
for papillary thyroid cancer, directly from the patient’s per-
spective using rigorous qualitative research methods. We
used multiple approaches to ascertain the patient experi-
ence related to their postoperative swallow function using
both open-ended interviews and interviewer prompts longi-
tudinally over 6 months.
Our findings suggest that dysphagia symptoms are more
common than previously reported5-7 and that they can per-
sist for months following surgery. Specifically, we found that
at least 80% of patients had dysphagia symptoms 2 weeks
postoperatively (n = 20) and, while that percentage reduced
over the 6-month study period, dysphagia symptoms per-
sisted in some cases, suggesting that further surveillance of
these symptoms may be required. Interestingly, these symp-
toms rarely had objective correlates on instrumental swal-
lowing assessment. Thus, the best way to understand these
symptoms is by surveying and listening to patients using
qualitative approaches.
Swallowing symptoms and persistence of complaints re-
ported in our study, including sensation of residue, painful
swallowing, and difficulty swallowing, are consistent with pre-
vious studies of patients following thyroidectomy.5,7,10,11,13
However, in contrast to previous studies, which used cross-
sectional or retrospective methods, ours was designed a priori
to assess the longitudinal nature of dysphagia complaints. This
study also allowed patients to describe what they were expe-
riencing and the affect these symptoms had on quality of life
in their own words.
Our study is the first to chronicle how patients adapt to
and self-manage their dysphagia complaints postthyroidec-
tomy. Participants described adaptive behavioral strategies
to minimize dysphagia at each assessment time. Compensa-
tory strategies used by our participants are consistent with
clinical recommendations for patients who are experiencing
dysphagia or increased residue in the valleculae and
pharynx.18-20 In some cases, these strategies were used in
response to choking incidents, as evidenced by participant
4, who gained increased awareness for the need to take
smaller bites after experiencing sensations of choking. Par-
ticipants reported having concerns about what they were
able to eat, how they would get enough nutrition, the
unpleasantness of painful swallowing, and anxiety about
choking when not implementing strategies. These reports
clearly show that swallowing symptoms can have a signifi-
cant effect on quality of life, which resulted in expressions of
anxiety, frustration, and insecurity.
It is also important to note that the frequency of symp-
toms differed depending on the ascertainment methodol-
ogy. Participants were not always forthcoming about swal-
lowing complaints during the open interview. The frequency
of dysphagia complaints was much higher during the
prompted portion of the 2-week postoperative interview:
80% (n = 20) via prompts vs 53% (n = 14) via open interview.
In fact, this was true across all time points (6 weeks: 42%
[n = 11] via prompts vs 12% [n = 3] via open interview; 6
months, 17% [n = 4] via prompts vs 12% [n = 3] via open
interview). This suggests that patients may not openly share
their subjective dysphagia complaints with clinicians.
Underreporting by patients may explain why clinicians may
not be sufficiently aware of the dysphagia sequelae of thy-
roidectomy. Based on the commonness of these symptoms

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 Patient-Reported Dysphagia After Thyroidectomy Original Investigation Research

of dysphagia, surgeons and other clinicians interacting with
patients preoperatively should discuss the potential risk of
dysphagia and explicitly query for swallowing concerns in
the postoperative period.
Surprisingly few participants had objective swallowing dys-
function on a modified barium swallow study despite the fre-
quency of swallowing complaints. Specifically, only 4 partici-
pants at the 2-week follow-up visit were found to have a PAS
greater than 1. This contrasts with the 80% of participants
(n = 20) who complained of dysphagia at this time point. Sub-
jective dysphagia is often minimized by clinicians because
these patients are considered “safe” and not at risk for aspi-
ration. However, these complaints should not be ignored be-
cause, as our results show, subjective dysphagia can have a ma-
jor impact on a patient’s quality of life. Subjective dysphagia
can be very troubling for patients and may be compounded by
a lack of counseling or suggested strategies to help reduce the
impact of these symptoms on daily life.
From the time of diagnosis, patients with thyroid cancer
a re b o m b a rd e d w it h a n ove r w h e l m i ng a m o u nt o f
information.9,21 More research is needed to determine the best
way to introduce swallowing symptom management, so pa-
tients may process and use the information to their benefit.
One option is to provide an informational handout about po-
tential swallowing symptoms they may experience postop-
eratively along with helpful strategies (based on patient ex-
periences) to combat these symptoms. One example of how
this handout could be structured is shown in the Supple-
ment. It may also be helpful offer contact information for
speech-language pathologists who can further aid in counsel-
ing patients whether preoperatively or postoperatively about
swallowing strategies.
Limitations
While data in this study only report on patient outcomes up
to 6 months postoperatively, it is possible that dysphagia symp-
toms have greater chronicity than our study was designed to
capture. Additionally, our study focuses only on patients who
did not have consequences of permanent nerve injury. Esti-
mates of dysphagia with this type of procedure would un-
doubtedly be higher if patients with vocal fold dysfunction af-
ter total thyroidectomy were included.
Conclusions
Subjective dysphagia complaints after thyroidectomy are more
common than previously reported and can persist for months
following surgery. Currently, patient expectations and educa-
tion in management strategies are insufficient. Increased
awareness of swallowing sequelae and education for patients
who undergo thyroidectomy would help reduce the anxiety,
frustration, and insecurity surrounding postoperative
dysphagia.

ARTICLE INFORMATION
Accepted for Publication: December 22, 2017.
Published Online: March 8, 2018.
doi:10.1001/jamaoto.2017.3378
Author Contributions: Drs Connor and Sippel had
full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Wendt, Macdonald,
Orne, Sippel, Connor.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Krekeler, Francis.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Krekeler, Wendt, Francis.
Obtained funding: Sippel, Connor.
Administrative, technical, or material support:
Wendt, Francis, Sippel, Connor.
Study supervision: Macdonald, Orne, Francis,
Sippel, Connor.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest. No
disclosures were reported.
Funding/Support: During the conduct of this
study, Ms Wendt and Drs Orne, Sippel, and Connor
report receiving grants from the National Institutes
of Health (NIH); Ms Wendt received grant support
from the University of Wisconsin Carbon Cancer
Center (UWCCC); Dr Connor received grant support
from the National Cancer Institute. This study was
funded by the National Institutes of Health
(R01CA176911), UWCCC Support Grant (P30
CA014520), and the Voice Research Training Grant
(T32DC009401). Salary support for Dr Francis was
provided by grant K23DC013559 from the NIH
National Institute on Deafness and Other
Communication Disorders.
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Meeting Presentation: This article was presented
in oral format at the American Speech and Hearing
Association Annual Meeting; November 18, 2016;
Philadelphia, PA.
Additional Contributions: We acknowledge the
valuable contributions of all those involved in the
clinical trial who made this article possible,
specifically Heidi Kletzien, MS, University of
Wisconsin, Madison, and Reese Randle, MD, and
Susan Pitt, MD, University of Wisconsin Hospital
and Clinics, who helped in the general discussion
and interpretation of findings presented in this
article. Special thanks to the clinical staff at the
University of Wisconsin Voice and Swallow Clinics
for their guidance, generous collaboration, and
steadfast commitment to improving care for this
patient population. They received no compensation
for their contributions beyond that received in the
normal course of their employment.
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