Comparison Between Patient-Perceived Voice Changes and Quantitative Voice Measures in the First Postoperative Year After Thyroidectomy: A Secondary Analysis of a Randomized Clinical Trial | Endocrine Surgery | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Original Investigation
From the American Head and Neck Society
November 2018

Comparison Between Patient-Perceived Voice Changes and Quantitative Voice Measures in the First Postoperative Year After Thyroidectomy: A Secondary Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Division of Otolaryngology–Head and Neck Cancer, Department of Surgery, School of Medicine and Public Health, University of Wisconsin–Madison, Madison
  • 2Department of Biomedical Engineering, University of Wisconsin–Madison, Madison
  • 3Qualitative Health Research Consultants, Madison, Wisconsin
  • 4Department of Sociology, Drexel University, Philadelphia, Pennsylvania
  • 5Wisconsin Surgical Outcomes Research Program, Department of Surgery, School of Medicine and Public Health, University of Wisconsin–Madison, Madison
  • 6Division of Endocrine Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin–Madison, Madison
  • 7Department of Communication Sciences and Disorders, University of Wisconsin–Madison, Madison
JAMA Otolaryngol Head Neck Surg. 2018;144(11):995-1003. doi:10.1001/jamaoto.2018.0309
Key Points

Question  How do patient-perceived voice changes compare with quantitative vocal measures during the first year after thyroidectomy?

Findings  In this mixed methods study of 42 patients with clinically node-negative papillary thyroid cancer, voice changes were perceived by 57% of participants 2 weeks after surgery. During semistructured interviews, most of those affected by voice symptoms reported continued voice-related quality-of-life consequences out to 1 year after surgery; these deficits were not captured by the Voice Handicap Index or other quantitative assessments.

Meaning  This study highlights the importance of directly querying patients about postoperative voice changes and questions the sensitivity of commonly used, validated patient-reported outcome measures and other quantitative assessments of voice.


Importance  Voice changes after thyroidectomy are typically attributed to recurrent laryngeal nerve injury. However, most postoperative voice changes occur in the absence of clinically evident vocal fold paralysis. To date, no study has compared the prevalence, duration, and consequences of voice-related disability from the patient perspective with use of quantitative vocal measures.

Objectives  To assess the quality-of-life consequences of postthyroidectomy voice change from the perspective of patients with thyroid cancer and to compare patient-perceived voice changes with changes in quantitative vocal variables at 5 time points in the first postoperative year.

Design, Setting, and Participants  This prospective mixed methods observational study within a randomized clinical trial occurred at the University of Wisconsin Hospital and Clinics. Participants were 42 patients with clinically node-negative papillary thyroid cancer without a preexisting vocal cord paralysis who were recruited and enrolled from outpatient clinics between June 6, 2014, and March 6, 2017, as part of the ongoing randomized clinical trial.

Intervention  Total thyroidectomy.

Main Outcomes and Measures  Semistructured interviews, symptom prevalence, and instrumental voice evaluations (laryngoscopy, phonation threshold pressure, Dysphonia Severity Index, and Voice Handicap Index) occurred at baseline (n = 42) and 2-week (n = 42), 6-week (n = 39), 6-month (n = 35), and 1-year (n = 30) postoperative time points.

Results  Participants had a mean age of 48 years (interquartile range, 38-58 years; age range, 22-70 years) and were mostly female (74% [31 of 42]) and of white race/ethnicity (98% [41 of 42]). Impaired communication was the primary theme derived from patient interviews from before thyroidectomy to after thyroidectomy. Voice changes were perceived by 24 participants at 2 weeks after thyroidectomy. After surgery, voice symptoms were prevalent and persisted for 50% (21 of 42) of participants out to at least 1 year of follow-up. Quantitative vocal perturbations were detected in the Dysphonia Severity Index and Voice Handicap Index at the 2-week follow-up but returned to baseline levels by the 6-week follow-up visit.

Conclusions and Relevance  Voice changes are common after surgery for papillary thyroid cancer and affect quality of life for many patients out to 1 year of follow-up. Directly querying patients about postoperative voice changes and questioning whether commonly used aerodynamic and acoustic variables detect meaningful voice changes are important in identifying patients whose quality of life has been affected by postthyroidectomy dysphonia.

Trial Registration Identifier: NCT02138214