International Journal of Surgery 56 (2018) 73–78

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International Journal of Surgery

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Original Research

The incidence of vocal fold motion impairment after primary thyroid and T
parathyroid surgery for a single high-volume academic surgeon determined
by pre- and immediate post-operative fiberoptic laryngoscopy
Vaninder K. Dhillona, Eleni Rettiga, Salem I. Noureldinea, Dane J. Genthera, Ahmed Hassoonb,
Mai G. Al Khadema, Ozan B. Ozgursoya, Ralph P. Tufanoa,∗
a
Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
b
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Vocal fold motion impairment (VFMI) is a well-recognized complication of thyroid and parathyroid
Recurrent laryngeal nerve surgery. Preoperative counseling requires a thorough understanding of the incidence, risk factors, and value of
Thyroidectomy early diagnosis of postoperative VFMI. Our objective is to describe the incidence of and risk factors for VFMI for
Parathyroidectomy a single high-volume academic surgeon, and to assess the utility of immediate postoperative fiberoptic lar-
Vocal fold paralysis
yngoscopy (FOL) in early diagnosis of VFMI.
Palsy
Paresis
Methods: Retrospective cohort study of patients undergoing primary thyroid and parathyroid procedures by a
Hoarseness single high-volume surgeon at an academic tertiary care center. All patients underwent preoperative and im-
Complications mediate postoperative FOL. The primary outcome was incidence of VFMI, either temporary (< 1 year) or per-
Laryngoscopy manent (1 year or more). The unit of analysis was number of recurrent laryngeal nerves (RLN) at risk. Risk
factors for VFMI were analyzed using logistic regression, reporting unadjusted and adjusted odds ratios (OR and
aOR) and 95% confidence intervals (CI).
Results: The study population comprised 1547 patients undergoing 1580 procedures for a total of 2527 nerves at
risk, excluding the 27 nerves found to have motion impairment on preoperative FOL. Sixty-seven new incidents
of VFMI were identified on postoperative FOL, with an additional six new incidents detected after voice com-
plaints prompted FOL upon follow-up. Thus, the incidence of postoperative VFMI was 2.9% of RLNs at risk (73 of
2527). The sensitivity and negative predictive value of immediate postoperative FOL were 92% and 99.8%
respectively. Permanent VFMI occurred in 9 cases (0.4%), 3 of which were from intentional RLN transection for
malignancy. Odds of VFMI were significantly lower after parathyroidectomy (aOR = 0.1, 95%CI = 0.01–0.8
compared with hemithryoidectomy) and higher with central neck dissection (aOR = 2.4, 95CI = 1.0–5.9).
Among cases of malignancy, odds of VFMI increased significantly with increasing T-stage (adjusted
ptrend < 0.001).
Conclusion: VFMI is rare and usually temporary after primary thyroid and parathyroid procedures, with in-
creased risk associated with larger primary malignancies and the inclusion of central neck dissection. Immediate
postoperative FOL is useful for early detection of VFMI that may allow for clear definition of temporary and
permanent immobility rehabilitation especially if there is evidence to support early intervention.

1. Introduction is reported to occur in 0.3–3.5% of thyroid surgeries [1–3], while

temporary VFMI is seen in 3.0–8.9% [1,4–6]. The rate of permanent
Vocal fold motion impairment (VFMI) is a well-recognized compli- VFMI after parathyroidectomy approaches 0% due to the very limited
cation of thyroid and parathyroid surgery. Permanent VFMI is rare and traction on the recurrent laryngeal nerve (RLN) during dissection [7].

∗
Corresponding author. Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins School of Medicine, Johns Hopkins Outpatient
Center, 601 N. Caroline Street, 6th floor, Baltimore, MD, 21287, USA.
E-mail address: rtufano1@jhmi.edu (R.P. Tufano).

https://doi.org/10.1016/j.ijsu.2018.06.014
Received 25 February 2018; Received in revised form 16 April 2018; Accepted 12 June 2018
Available online 14 June 2018
1743-9191/ © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
V.K. Dhillon et al.
The reported incidence of VFMI varies significantly, which may be due
to variation in the methodologies used to diagnose RLN injury (e.g.,
voice alone, indirect laryngoscopy, videostroboscopy, fiberoptic lar-
yngoscopy [FOL], and more recently transcutaneous ultrasound), with
each method having significantly different sensitivities and specificities
[1]. Laryngoscopy for evaluation of vocal fold motion is the gold
standard for assessment of VFMI [13], however few studies have in-
corporated visualization of the vocal folds as part of routine post-
operative assessment [8,10]. Notably, using voice quality alone has
been shown to underestimate the true incidence of VFMI after thyroid
and parathyroid surgery, as unilateral VFMI can occur without voice
changes [11] (see Table 4).
The purposes of this study were to describe the incidence of VFMI
for a high volume surgeon in an academic teaching hospital after pri-
mary thyroidectomy and parathyroidectomy incorporating pre-opera-
tive and immediate postoperative FOL, and to assess patient- and dis-
ease-related risk factors for VFMI.
2. Methods
2.1. Data source and patient population
We collected data from medical records of all consecutive patients
who underwent primary thyroid procedures (with or without central
neck dissection) or primary parathyroid procedures between March
2004 and December 2015. All procedures were performed by a single
surgeon (R.P.T.) who had been performing high volume [16] thyroid
and parathyroid surgery independently, at a university-based tertiary
care center, for more than 3 years prior to the data collection starting
point. We identified all patients who underwent primary para-
thyroidectomy, hemithyroidectomy, total thyroidectomy, completion
thyroidectomy, substernal thyroidectomy with or without sternal split,
and total or completion thyroidectomy with central neck dissection, in
which one or both RLNs were surgery-naïve and at risk of injury.
Completion thyroidectomy was considered a primary procedure and
included in this analysis if no prior dissection had been performed on
the side in question, as the RLN would therefore be anatomically intact
and undisturbed. Patients with confounding laryngotracheal invasion of
thyroid cancer and those undergoing reoperative thyroid surgery with a
previously dissected RLN were excluded from the study. This retro-
spective study was approved by the Institutional Review Board of XXX
Medicine, and informed consent was waived in accordance with the
Health Insurance Portability and Accountability Act.
2.2. Surgical technique
In all thyroidectomy cases, the RLNs at risk were identified using
direct visualization and dissected intraoperatively to the extent the
surgeon felt it was necessary to allow for attempted preservation.
Intraoperative nerve monitoring of the RLNs was performed routinely
using either the NIM 2.0 or the 3.0 intermittent nerve monitoring
system (Medtronic, Minneapolis, MN).
2.3. Assessment of vocal folds
Vocal fold function was assessed by the operating surgeon (R.P.T.)
using FOL at the preoperative visit and immediately following ex-
tubation in the operating room at the conclusion of the surgical pro-
cedure. The primary surgeon used a flexible nasolaryngoscope with an
associated halogen light source over the time period by which this study
was analyzed. The postoperative laryngeal examination included at a
minimum the analysis of the symmetry of arytenoid and true vocal fold
motion during respiration and active abduction and adduction, with
phonation or cough when possible. VFMI was defined as a new motion
impairment of a vocal fold or no discernible motion after surgery, as
compared to the preoperative examination. Repeat FOL was also
74
International Journal of Surgery 56 (2018) 73–78
performed at follow-up clinic visits for any patients with new voice
complaints despite normal immediate postoperative FOL. Patients with
VFMI and voice changes were offered functional voice therapy with a
speech pathologist to improve laryngeal function, and referred to a
laryngologist as indicated. Permanent VFMI was defined as absence of
complete recovery of vocal fold mobility at one year after surgery or at
the last follow-up visit for patients with less than one year of follow-up
time. Transient VFMI was defined as postoperative VFMI with recovery
of spontaneous motion before one year or last follow-up visit for pa-
tients with less than one year of follow-up time.
2.4. Statistical analysis
Descriptive statistics were reported as N (%), mean (average) and
standard deviation (SD) and/or range and median. The primary out-
come was VFMI, and the unit of analysis was number of RLNs at risk;
vocal folds that were found to be impaired preoperatively were con-
sidered not at risk and excluded from analysis. The sensitivity and ne-
gative predictive value (NPV) of immediate post-extubation FOL ex-
amination were calculated. Characteristics associated with VFMI were
compared using unadjusted and adjusted logistic regression analysis,
and unadjusted and adjusted odds ratios (OR and aOR) with 95%
confidence intervals (CI) were reported. Adjusted analyses were per-
formed separately for all RLNs at risk, and RLNs at risk in malignancy
cases only. All reported p-values are two sided, and p < 0.05 was
considered statistically significant. Data analysis was performed using
Stata 14 (College Station, TX).
The work has been reported in line with the STROCSS criteria [28].
3. Results
3.1. Patient population
A total of 1547 patients underwent 1580 primary surgical proce-
dures during the eleven-year study period, 308 (19%) of which were
parathyroidectomy procedures and 1272 (81%) of which were thyr-
oidectomy procedures. Table 1 summarizes the characteristics of the
patient population, thyroid diagnoses and procedures performed. The
mean patient age was 51 years (range, 6–90). The majority (81%) of
patients were younger than 65 years of age and predominantly (75%)
female. Most procedures were performed for either benign thyroid
nodular disease (N = 581, 37%) or thyroid malignancy (N = 611,
39%), with relatively fewer cases of parathyroid adenomas (N = 310,
20%) and Graves' disease (N = 78, 5%). The most common procedure
was total thyroidectomy (N = 613, 39%). The overall average follow-
up duration was 7 weeks (range 0–122; median 3). Patients with VFMI
were followed for a longer period of time postoperatively, with an
average of 16 weeks (range 1–208; median 7.5).
3.2. Pre- and immediate post-operative vocal fold motion impairment
Preoperatively, FOL examination was performed on all but two
patients. Twenty-seven (2%) vocal folds were found to be impaired on
preoperative assessment in 27 patients, with 15 involving the left vocal
fold and 12 involving the right. Eleven (41%) of these patients were
preoperatively asymptomatic and noted no problems with their voice.
These 27 nerves were considered not at risk due to pre-existing im-
pairment, and excluded from further analysis. Of the 2527 RLNs at risk
of injury, 2476 (98%) were visualized and dissected during the surgical
procedures. Fifty-six RLNs were not visualized during resection of
parathyroid adenomas via focused surgery, but nonetheless were at risk
for injury.
Overall, at the conclusion of surgery, all but 7 (0.3%) RLNs were
visually intact. Four (0.2%) RLNs were unintentionally transected
(Table 2). Three of these were anterior branches injured during dis-
section at Berry's ligament and noted to be adherent the respective
V.K. Dhillon et al. International Journal of Surgery 56 (2018) 73–78

Table 1

Vocal fold movement assessed by FOL at last follow-up

Characteristics of the patient population.
Characteristic Total procedures

N (%)

Total 1580
Age, mean (SD) 51.3 (14.5)
Age, categorical (years)
< 35 219 (14)
35-44 283 (18)

Motion impairment

Motion impairment
Motion impairment

Motion impairment
45-54 404 (26)
55-64 379 (24)
65+ 295 (19)
Sex

Immobile

Immobile

Immobile
Immobile

Immobile
Female 1183 (75)
Male 397 (25)
Race
White 1126 (71)

Last follow-up (weeks after surgery)

Black 231 (15)
Asian 47 (3)
Other 176 (11)
Thyroid diagnosisa
Benign other than Graves' 581 (37)
Graves' disease 78 (5)
Malignancy 611 (39)
Primary Hyperparathyroidism 310 (20)
T stage (for cases of malignancy)
1 411 (70)

208
2 91 (15)

36
52
20
48
24

27
15
4
3 77 (13)
4 10 (2)
Intraoperative state of RLN at risk
Procedurea
Hemithyroidectomy 247 (16)
Total thyroidectomy 613 (39)
Intentional transection

Intentional transection
Intentional transection
Completion thyroidectomy 88 (6)
Iatrogenic transection
Iatrogenic transection
Iatrogenic transection

Iatrogenic transection
Substernal thyroidectomy, cervical approach 158 (10)
Substernal thyroidectomy, thoracic approach 8 (0.5)
Total thyroidectomy or completion thyroidectomy with 158 (10)
Intact RLN

Intact RLN
unilateral or bilateral central neck dissection
Parathyroidectomy 308 (19)
Characteristics of the ten patients with pre-op mobile vocal folds but permanent vocal fold immobility.

Year of surgery
2004–2005 40 (3)
2006–2007 97 (6)
Right
Right
Right

Right
Right
Right
Side

Left
Left
Left

2008–2009 247 (16)

2010–2011 349 (22)
Benign thyroid disease

Benign thyroid disease

2012–2013 452 (29)

Thyroid malignancy
Thyroid malignancy

Thyroid malignancy
Thyroid malignancy
Thyroid malignancy
Thyroid malignancy
Thyroid malignancy

2014–2015 395 (25)

Preoperative VFP
None 1551 (98)
Unilateral 27 [2]
Diagnosis

Abbreviations: RLN, recurrent laryngeal nerve; FOL, fiberoptic laryngoscopy.

Not examined 2 (0.1)

New postoperative VFMI among at-risk RLNs
None 1501 (95.5)
One vocal cord 69 (4.4)
Total thyroidectomy with central neck dissection (2011)

Total thyroidectomy with central neck dissection (2013)

Two vocal cords 2 (0.1)

Substernal thyroidectomy, cervical approach (2009)

Substernal thyroidectomy, cervical approach (2012)

Abbreviations: SD, standard deviation; VFP, vocal fold paresis.

a
In cases where both a parathyroid and thyroid procedure were performed
the thyroid diagnosis and procedure are listed.

thyroid pathology, while the fourth was injured during dissection

posterior to a deep Zuckerkandl's tubercle near the inferior thyroid
Total thyroidectomy (2006)

Total thyroidectomy (2011)

Total thyroidectomy (2011)
Hemithyroidectomy (2008)

Hemithyroidectomy (2013)

artery. All transected nerves were identified and repaired in-

traoperatively with primary anastomosis [2], interposition nerve graft
Procedure type (year)

[1] or ansa cervicalis anastomosis [1]. The remaining 3 (0.1%) RLNs

were intentionally transected for en bloc oncologic removal of extensive
malignancy involving the RLN, without re-anastomosis. The remaining
2520 (99.7%) RLNs were visually intact at the conclusion of the pro-
cedure (see Table 3).
After the anesthesia team extubated the patient, the operating sur-
geon immediately performed FOL in all but 36 (2.3%) patients. Sixty-
Age

11
32
64
30
57
62
59
52
43

seven new incidents of VFMI, including the 7 cases with transected

Patient
Table 2

nerves, were identified or confirmed on immediate FOL in 65 patients.

Repeat postoperative FOL performed for patient complaints of weak
1
2
3
4
5
6
7
8
9

75
V.K. Dhillon et al. International Journal of Surgery 56 (2018) 73–78

Table 3 Table 4
Characteristics associated with odds of postoperative VFMI for nerves at risk. Adjusted analysis of characteristics associated with odds of postoperative VFMI
for at-risk recurrent laryngeal nerves.
Characteristic Total Number of Odds of VFP p-value
nerves vocal folds Characteristic Adjusted odds of p-value
at riska with postoperative vocal cord
paresis immobility

N (%) N (%) OR (95%CI) aOR (95%CI)

Total 2527 73 (2.9) a

A. Overall (N = 2528 nerves at risk)
Age (years) Procedure
< 35 369 (15) 13 (3.5) REF Hemithyroidectomy REF
35-44 461 (18) 17 (3.7) 1.0 (0.5–2.2) 0.90 Total thyroidectomy 0.9 (0.4–2.2) 0.89
45-54 640 (25) 19 (3.0) 0.8 (0.4–1.7) 0.63 Completion thyroidectomy 1.2 (0.3–4.9) 0.78
55-64 596 (24) 18 (3.0) 0.9 (0.4–1.8) 0.67 (unilateral or bilateral)
65+ 461 (18) 6 (1.3) 0.4 (0.1–1.0) 0.04 Substernal thyroidectomy 1.4 (0.5–3.8) 0.51
Sex Total thyroidectomy or completion 2.4 (1.0–5.9) 0.05
Female 1891 51 (2.7) REF thyroidectomy with central neck
(75) dissection
Male 636 (25) 22 (3.5) 1.3 (0.8–2.1) 0.32 Parathyroidectomy 0.1 (0.01–0.8) 0.04
Race Age (years)
White 1789 50 (2.8) REF < 35 REF
(71) 35-44 1.2 (0.6–2.5) 0.64
Black 372 (15) 11 (3.0) 1.1 (0.5–2.1) 0.86 45-54 1.0 (0.5–2.1) 0.95
Other 366 (14) 12 (3.3) 1.2 (0.6–2.2) 0.61 55-64 1.1 (0.5–2.3) 0.80
Thyroid diagnosisb 65+ 0.5 (0.2–1.3) 0.14
Benign 898 (36) 24 (3) REF
B. Thyroid malignancies only (N = 1065 nerves at risk)
Graves' disease 151 (6) 6 (4) 1.5 (0.6–3.8) 0.38
T-stage
Malignancy 1102 42 (4) 1.4 (0.9–2.4) 0.16
1 REF
(44)
2 1.9 (0.8–4.4) 0.15
Hyper parathyroidism 376 (15) 1 (0.3) 0.1 (0.01–0.7) 0.02
3 4.1 (1.9–8.9) < 0.001
T stage (for cases of malignancy)
4 7.5 (1.2–48.3) 0.04
1 747 (70) 18 (2.4)
p-trend < 0.001
2 165 (15) 8 (4.9) 2.1 (0.9–4.8) 0.10
Central neck dissectionb
3 139 (13) 14 (10.1) 4.5 (2.2–9.4) < 0.001
No REF
4 13 (1) 2 (15.4) 7.4 (1.5–35.7) 0.01
Yes 1.7 (0.8–3.5) 0.13
p-trend < 0.001
Age (years)
Procedureb
< 35 REF
Hemithyroidectomy 244 (10) 7 (2.9) REF
35-44 0.7 (0.3–1.9) 0.49
Total thyroidectomy 1220 32 (2.6) 0.9 (0.4–2.1) 0.83
45-54 0.8 (0.3–1.9) 0.58
(48)
55-64 0.7 (0.3–1.8) 0.52
Completion 90 (4) 3 (3.3) 1.2 (0.3–4.6) 0.83
65+ 0.3 (0.1–1.4) 0.08
thyroidectomy
Substernal 292 (12) 10 (3.4) 1.2 (0.4–3.2) 0.72 a ’
thyroidectomyc T-stage’ excluded from overall analysis as it only applies to malignancies.
b ’
Total thyroidectomy or 307 (12) 20 (6.5) 2.4 (1.0–5.7) 0.06 Central neck dissection’ (yes/no) included in lieu of procedure type be-
completion cause some categories of ‘Procedure’ included very small numbers when limited
thyroidectomy with to malignant disease. Estimates for T-stage categories are similar when
central neck dissection
‘Procedure’ included instead of ‘central neck dissection’ in sensitivity analysis.
Parathyroidectomy 374 (15) 1 (0.3) 0.1 (0.01–0.7) 0.03
Central neck dissection
No 2220 53 (2.4) REF resolution of motion impairment occurring at an average of 60 days
(88) (range 2–300; median 28). The majority of RLNs with transient VFMI
Yes 307 (12) 20 (6.5) 2.8 (1.7–4.8) < 0.001 (75%) recovered within 3 months, while a subset of RLNs normalized
Year of surgery
2004–2007 212 (8) 6 (2.8) REF
within 3–6 months (19%) and several others within one year (5%).
2008–2009 370 (15) 12 (3.2) 1.2 (0.4–3.1) 0.78 Only 2 patients had bilateral VFMI with all nerves anatomically intact;
2010–2011 557 (22) 23 (4.1) 1.5 (0.6–3.7) 0.40 neither patient required tracheostomy nor experienced permanent im-
2012–2013 732 (29) 25 (3.4) 1.2 (0.5–3.0) 0.67 pairment, with recovery of bilateral vocal fold motion observed at 48 h
2014–2015 656 (26) 7 (1.1) 0.4 (0.1–1.1) 0.08
and 21 days respectively. The remaining 9 (0.4%) cases of VFMI were
a
Excludes 8 cases with unilateral preoperative vocal cord immobility un- deemed permanent on an average follow-up of 48 weeks (range, 4–208;
dergoing unilateral procedure, leaving 0 nerves at risk in these patients. median 27), all of which were unilateral and 6 (0.3%) of which were
Patients with unilateral preoperative vocal cord immobility and bilateral pro- unintentional. Of the 9 incidents of permanent VFMI, 4 vocal folds had
cedure were considered as having one nerve at risk. persistent motion impairment on last follow-up, and the remaining 5
b
In cases where both a parathyroid and thyroid procedure were performed vocal folds were completely paralyzed in a paramedian position
the thyroid diagnosis and procedure are listed. (Table 2).
c
’Substernal thyroidectomy’ includes both cervical and thoracic approaches
due to small number of thoracic approaches (N = 8).
3.3. Characteristics associated with VFMI
voice revealed six additional cases of unilateral VFMI, none of which
Demographic, clinical and pathologic characteristics were com-
became permanent. Therefore, there was a total of 73 newly impaired
pared with VFMI outcomes. In unadjusted analysis, the odds of VFMI
RLNs (2.9%) postoperatively in 71 patients. The sensitivity of im-
were significantly lower among patients older than 65 years (OR = 0.4,
mediate postoperative FOL assessment for VFMI was 92% and the NPV
95%CI = 0.1–1.0, p = 0.04 compared with patients < 35 years of age)
was 99.8%.
and patients undergoing parathyroidectomy (OR = 0.1,
Transient VFMI occurred for 64 (2.5%) RLNs at risk, with complete
95%CI = 0.01–0.7, p = 0.03 compared with hemithyroidectomy). In

76
V.K. Dhillon et al.
contrast, odds of VFMI were significantly increased by the performance
of central neck dissection (OR = 2.8, 95%CI = 1.7–4.8, p < 0.001
compared with no central neck dissection) and, among patients with
malignancies, higher T-stage (ptrend < 0.001). VFMI was not sig-
nificantly associated with sex, race, thyroid pathology, or calendar
period in which the surgery was performed.
The only factors that remained significantly associated with VFMI
upon adjusted analysis were the type of surgery, with lower risk from
parathyroidectomy (OR = 0.1, 95%CI = 0.01–0.8, p = 0.04) and
higher risk from inclusion of central neck dissection (OR = 2.4,
95%CI = 1.0–5.9, p = 0.05), and among malignancies, tumor stage
(OR 7.5, 95%CI = 1.2–48.3 for T4 versus T1; ptrend < 0.001 for higher
OR with increasing T stage).
4. Discussion
The overall risk of VFMI after thyroid or parathyroid surgery is low,
but is not insignificant even in experienced hands. Our data suggest that
VFMI risk is highest for patients undergoing central neck dissection or
who have large tumors, while it is nearly zero for patients undergoing
parathyroid surgery. These findings should inform patient counseling.
We also report that immediate postoperative FOL may be useful for
early identification of most VFMIs, allowing for improved commu-
nication with patients and early voice and swallow rehabilitation.
In our study, the incidence of postoperative VFMI was 2.9% of
nerves at risk, which is consistent with the low rates reported in com-
parison studies [10,13–15]. Preoperative discussions with patients
should include a discussion of this non-negligible risk and its implica-
tions for speech and swallowing, and the potential need for re-
habilitation. Importantly, there is evidence for an inverse association of
post-thyroidectomy complication rates with surgeon volume [16,17].
We therefore recommend that thyroid and parathyroid surgeons should
endeavor to assess their own true rate of VFMI in order to appropriately
counsel patients. Interestingly, our data did not show a learning curve
as the rate of VFMI did not significantly change over the study period.
This may be attributable to the fact that the senior author (R.P.T) was
performing a relatively high volume of thyroid surgery for several years
prior to the study period, so any learning curve may not have been
captured in these data.
The primary determinants of postoperative VFMI in our study were
type of surgery and, for malignancies, tumor size. The high risk for RLN
injury in thyroidectomy with central neck dissection is related to the
dissection of the lymph node packet along the course of the entire RLN
in the neck. Considerable nerve manipulation may be required in order
to achieve a comprehensive dissection [18]. The increased risk of VFMI
with larger tumor sizes is consistent with other studies, and may also
suggest a higher rate of nerve manipulation [6,19–21]. Furthermore, six
out of nine permanent RLN paralyses were on the right side compared
to left, and while non-significant, can be inferred that there is a higher
likelihood of neurophysiologic injury along a longer coursing right RLN
during dissection. The low risk of VFMI with parathyroidectomy sup-
ports the practice of not always identifying and dissecting out the RLN
during parathyroid surgery [3,7].
While we universally utilize IONM for all thyroid and parathyroid
cases within our group, we acknowledge that four RLNs were unin-
tentionally transected despite the use of nerve monitoring. All of these
dissections were performed by the primary surgeon (R.P.T.) with the
assistance of a fellow or senior resident trainee; it is important to note
that iatrogenic injury in the form of transection with permanent vocal
fold paralysis, though rare, can still occur despite extensive surgical
experience and best efforts to prevent it with standardized operative
technique and IONM. IONM is a universal component to all thyroid and
parathyroid cases that have spanned the lifetime of the primary sur-
geon's (R.P.T.) practice. While we do not establish the details of our set
up and standard protocol for using the IONM, it is important to note
that we had no correlative data between an observed signal loss and
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International Journal of Surgery 56 (2018) 73–78
post-operative VFMI for any of the patients within this study. We
therefore we do no attribute any change to our results in particular from
changes or abnormalities from the use of IONM. In an analysis of six
studies with more than 100 nerves at risk, Dralle et al. demonstrated
that the rate of permanent recurrent laryngeal nerve palsy varied from
0% to 11% [18]. The study group showed that IONM can lower the rate
of vocal fold paralysis, but it was not statistically significant as com-
pared to RLN visualization alone [18]. IONM cannot substitute for vi-
sual identification and vigilant dissection of the RLN in thyroid surgery.
Our data support the use of preoperative laryngoscopy to assess pre-
existing VFMI in order to allow for accurate identification of iatrogenic
complications, in agreement with previously published studies [12,13].
In this cohort, twenty-seven patients with preoperative VFMI were
identified, some of whom otherwise might have been erroneously
considered iatrogenic VFMI if only detected post-operatively, which
would have skewed our risk estimates considerably. It is important to
note that the primary surgeon performed flexible laryngoscopy without
any significant technical or instrument adjustments over the time
course of the study.
There is no current consensus on the optimal timing of post-
operative FOL to assess iatrogenic VFMI [8]. We have incorporated
immediate postoperative FOL into our practice and believe it is ad-
vantageous for several reasons. Most importantly, early FOL allows for
early patient counseling in order to set expectations and plan for in-
terventions that may improve voice and swallowing outcomes. Early
intervention by a Speech-Language Pathologist has been shown to im-
prove patient satisfaction on subjective outcome measures [22,23], and
it is well established in laryngology literature that intervention in the
form of early vocal fold augmentation is beneficial for select patients
with unilateral VFMI in improving voice related quality of life [24,25].
In addition, thyroid and parathyroid surgeries are becoming same day
surgeries [26,27], with patients being discharged postoperatively and
seen weeks later in follow up. In such cases, VFMI may be missed in the
absence of early FOL and patient concerns not addressed, even if
normal function may be restored by the time of outpatient follow-up
1–2 weeks postoperatively [8]. Immediate postoperative FOL provides
timely feedback regarding surgical technique that is useful for the
surgeon in identifying surgical nuances that affect RLN function. Fi-
nally, despite the challenges of FOL in a patient just awakened from
general anesthesia, including airway secretions, laryngeal edema, and
variability in patient cooperativeness, the sensitivity and negative
predictive value of immediate postoperative FOL were quite high at
92% and 99.8%, respectively, in our hands. This is consistent with other
reports [8,9,20].
Although this study represented a sizable patient cohort, its gen-
eralizability is limited because it is retrospective and describes a single
surgeon's experience. The retrospective nature of this study has its
limitations, including incomplete patient information and loss of follow
up for patients beyond sixteen weeks. Furthermore, only patients with
symptoms had subsequent follow up FOL after the immediate post-
operative FOL on extubation. We recognize that only those with
symptoms had repeated FOL and the incidence of VFMI post-opera-
tively may be under-represented. Clinically, we only perform FOL those
with symptoms, but for a future prospective study FOL should be done
for all patients including those without symptoms. A prospective study
would standardize a pre-operative FOL as well as a post-operative FOL
and serial follow up for all patients regardless of symptomatology, ac-
curately predicting the NPV and PPV of FOL for thyroid surgery. A
prospective study would also eliminate the incidence of patients lost to
follow up. We acknowledge that the assessment of VFMI by the oper-
ating surgeon introduces a possibility of unconscious bias to these re-
sults. The time-period by which the data was reviewed also may accrue
some heterogeneity for the gaps in data. Our study aim is to exemplify
how FOL in a pre-operative and immediate post-operative setting, can
play a critical role in identifying the true incidence of VFMI in patients,
and that incidence may actually be higher than we currently recognize.
V.K. Dhillon et al. International Journal of Surgery 56 (2018) 73–78

5. Conclusion Pract. 63 (4) (2009) 624–629.

Our study demonstrates that amongst one high volume surgeon's
academic tertiary care practice, the rate of VFMI is low but non-negli-
gible. VFMI is highest in patients with larger thyroid cancers and among
those undergoing central neck dissections. Pre- and immediate post-
operative FOL are useful for accurately assessing iatrogenic VFMI, and
are essential for appropriate preoperative counseling as well as early
postoperative intervention in cases of VFMI.
Ethical approval
Ethical approval was given by the Johns Hopkins Institutional
Review Board.
Sources of funding
There are no sources of funding for this research.
Author contribution
• Study conception and design: All authors were involved in the
study conception and design of this study.
• Acquisition of data: Salem I. Noureldine, MD, Dane J. Genther,
MD, Mai G. Al Khadem, MBBCh, Ahmed Hassoon, Ozan B. Ozgursoy
MD, Ralph P. Tufano, MD, MBA.
• Analysis and interpretation of data: Vaninder K. Dhillon, MD,
Eleni Rettig, MD, Salem I. Noureldine, MD, Dane J. Genther, MD,
Mai G. Al Khadem, MBBCh, Ahmed Hassoon, Ozan B. Ozgursoy MD,
Ralph P. Tufano, MD, MBA.
• Drafting of manuscript: Vaninder K. Dhillon, MD, Eleni Rettig,
MD, Salem I. Noureldine, MD, Dane J. Genther, MD, Mai G. Al
Khadem, MBBCh, Ralph P. Tufano, MD, MBA.
• Critical revision of manuscript: Vaninder K. Dhillon, MD, Eleni
Rettig, MD, Ralph P. Tufano, MD, MBA.
Conflicts of interest
Ralph P Tufano has a conflict of interest as he is a consultant for
Medtronic.
Research registration number
Researchregistry3722.
Guarantor
Ralph P. Tufano, MD, MBA.
Acknowledgments
None.
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