Hoarseness after thyroidectomy: blame the endocrine surgeon alone?

Hoarseness is a postoperative complication of thyroidectomy, mostly due to damage to the recurrent laryngeal nerve (RLN). Hoarseness may also be brought about via vocal cord dysfunction (VCD) due to injury of the vocal cords from manipulations during anesthesia, as well as from psychogenic disorders and respiratory and upper-GI related infections. We reviewed the literature aiming to explore these potential surgical and non-surgical causes of hoarseness beyond thyroidectomy and the role of the endocrine surgeon. Is he/she alone to blame?

The MEDLINE/PubMed database was searched for publications with the medical subject heading "hoarseness" and keywords "thyroidectomy", "RLN", "VCD" or "intubation". We restricted our search till up to May 2013.

In our final review we included 80 articles and abstracts that were accessible and available in English. We demonstrated the incidence of hoarseness stemming from surgical and non-surgical causes and also highlighted the role of intubation as a potential cause of injury-related VCD.

Hoarseness is a relatively common complication of thyroidectomy, which can be attributed to many factors including surgeon's error or injuries during intubation as well as to other non-surgical causes. However, compared to procedures such as cervical spine surgery, mediastinal surgery, esophagectomy and endarterectomy, thyroidectomy would seem to be a procedure with a relatively low rate of recurrent laryngeal nerve palsies (RLNPs). It is often difficult to determine whether the degree of hoarseness after thyroidectomy should be attributed only the surgical procedure itself or to other causes, for example intubation and extubation maneuvers. The differential diagnosis of postoperative hoarseness requires the use of specific tools, such as stroboscopy and intra- and extralaryngeal electromyography, while methods like acoustic voice analysis, with estimation of maximum phonation time and phonation frequency range, can distinguish between objective and subjective deterioration in the voice. The importance of medical history should be also emphasized.