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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1.
Siegel  RL, Miller  KD, Jemal  A.  Cancer statistics, 2017.  CA Cancer J Clin. 2017;67(1):7-30.PubMedGoogle ScholarCrossref
2.
Rosenthal  LH, Benninger  MS, Deeb  RH.  Vocal fold immobility: a longitudinal analysis of etiology over 20 years.  Laryngoscope. 2007;117(10):1864-1870.PubMedGoogle ScholarCrossref
3.
Francis  DO, Pearce  EC, Ni  S, Garrett  CG, Penson  DF.  Epidemiology of vocal fold paralyses after total thyroidectomy for well-differentiated thyroid cancer in a Medicare population.  Otolaryngol Head Neck Surg. 2014;150(4):548-557.PubMedGoogle ScholarCrossref
4.
Francis  DO, Williamson  K, Hovis  K,  et al.  Effect of injection augmentation on need for framework surgery in unilateral vocal fold paralysis.  Laryngoscope. 2016;126(1):128-134.PubMedGoogle ScholarCrossref
5.
Paniello  RC, Edgar  JD, Kallogjeri  D, Piccirillo  JF.  Medialization versus reinnervation for unilateral vocal fold paralysis: a multicenter randomized clinical trial.  Laryngoscope. 2011;121(10):2172-2179.PubMedGoogle ScholarCrossref
6.
Francis  DO, McKiever  ME, Garrett  CG, Jacobson  B, Penson  DF.  Assessment of patient experience with unilateral vocal fold immobility: a preliminary study.  J Voice. 2014;28(5):636-643.PubMedGoogle ScholarCrossref
7.
Leder  SB, Suiter  DM, Duffey  D, Judson  BL.  Vocal fold immobility and aspiration status: a direct replication study.  Dysphagia. 2012;27(2):265-270.PubMedGoogle ScholarCrossref
8.
Brunner  E, Friedrich  G, Kiesler  K, Chibidziura-Priesching  J, Gugatschka  M.  Subjective breathing impairment in unilateral vocal fold paralysis.  Folia Phoniatr Logop. 2011;63(3):142-146.PubMedGoogle ScholarCrossref
9.
Stojadinovic  A, Henry  LR, Howard  RS,  et al.  Prospective trial of voice outcomes after thyroidectomy: evaluation of patient-reported and clinician-determined voice assessments in identifying postthyroidectomy dysphonia.  Surgery. 2008;143(6):732-742.PubMedGoogle ScholarCrossref
10.
Akyildiz  S, Ogut  F, Akyildiz  M, Engin  EZ.  A multivariate analysis of objective voice changes after thyroidectomy without laryngeal nerve injury.  Arch Otolaryngol Head Neck Surg. 2008;134(6):596-602.PubMedGoogle ScholarCrossref
11.
Hong  KH, Kim  YK.  Phonatory characteristics of patients undergoing thyroidectomy without laryngeal nerve injury.  Otolaryngol Head Neck Surg. 1997;117(4):399-404.PubMedGoogle ScholarCrossref
12.
Hillel  AD.  Voice changes after thyroidectomy without recurrent laryngeal nerve injury.  J Am Coll Surg. 2005;200(5):813-813.PubMedGoogle ScholarCrossref
13.
Stojadinovic  A, Shaha  AR, Orlikoff  RF,  et al.  Prospective functional voice assessment in patients undergoing thyroid surgery.  Ann Surg. 2002;236(6):823-832.PubMedGoogle ScholarCrossref
14.
de Pedro Netto  I, Fae  A, Vartanian  JG,  et al.  Voice and vocal self-assessment after thyroidectomy.  Head Neck. 2006;28(12):1106-1114.PubMedGoogle ScholarCrossref
15.
Debruyne  F, Ostyn  F, Delaere  P, Wellens  W.  Acoustic analysis of the speaking voice after thyroidectomy.  J Voice. 1997;11(4):479-482.PubMedGoogle ScholarCrossref
16.
Lombardi  CP, Raffaelli  M, D’Alatri  L,  et al.  Voice and swallowing changes after thyroidectomy in patients without inferior laryngeal nerve injuries.  Surgery. 2006;140(6):1026-1032.PubMedGoogle ScholarCrossref
17.
Sinagra  DL, Montesinos  MR, Tacchi  VA,  et al.  Voice changes after thyroidectomy without recurrent laryngeal nerve injury.  J Am Coll Surg. 2004;199(4):556-560.PubMedGoogle ScholarCrossref
18.
Soylu  L, Ozbas  S, Uslu  HY, Kocak  S.  The evaluation of the causes of subjective voice disturbances after thyroid surgery.  Am J Surg. 2007;194(3):317-322.PubMedGoogle ScholarCrossref
19.
Vicente  DA, Solomon  NP, Avital  I,  et al.  Voice outcomes after total thyroidectomy, partial thyroidectomy, or non-neck surgery using a prospective multifactorial assessment.  J Am Coll Surg. 2014;219(1):152-163.PubMedGoogle ScholarCrossref
20.
Maeda  T, Saito  M, Otsuki  N,  et al.  Voice quality after surgical treatment for thyroid cancer.  Thyroid. 2013;23(7):847-853.PubMedGoogle ScholarCrossref
21.
Lee  JC, Breen  D, Scott  A,  et al.  Quantitative study of voice dysfunction after thyroidectomy.  Surgery. 2016;160(6):1576-1581.PubMedGoogle ScholarCrossref
22.
Lee  DY, Lee  KJ, Hwang  SM,  et al.  Analysis of temporal change in voice quality after thyroidectomy: single-institution prospective study.  J Voice. 2017;31(2):195-201.PubMedGoogle ScholarCrossref
23.
Solomon  NP, Helou  LB, Henry  LR,  et al.  Utility of the Voice Handicap Index as an indicator of postthyroidectomy voice dysfunction.  J Voice. 2013;27(3):348-354.PubMedGoogle ScholarCrossref
24.
Henry  LR, Helou  LB, Solomon  NP,  et al.  Functional voice outcomes after thyroidectomy: an assessment of the Dsyphonia Severity Index (DSI) after thyroidectomy.  Surgery. 2010;147(6):861-870.PubMedGoogle ScholarCrossref
25.
Solomon  NP, Helou  LB, Makashay  MJ, Stojadinovic  A.  Aerodynamic evaluation of the postthyroidectomy voice.  J Voice. 2012;26(4):454-461.PubMedGoogle ScholarCrossref
26.
Rueger  RG.  Benign disease of the thyroid gland and vocal cord paralysis.  Laryngoscope. 1974;84(6):897-907.PubMedGoogle ScholarCrossref
27.
Neri  G, Castiello  F, Vitullo  F, De Rosa  M, Ciammetti  G, Croce  A.  Post-thyroidectomy dysphonia in patients with bilateral resection of the superior laryngeal nerve: a comparative spectrographic study.  Acta Otorhinolaryngol Ital. 2011;31(4):228-234.PubMedGoogle Scholar
28.
Kuhn  MA, Bloom  G, Myssiorek  D.  Patient perspectives on dysphonia after thyroidectomy for thyroid cancer.  J Voice. 2013;27(1):111-114.PubMedGoogle ScholarCrossref
29.
Creswell  JW.  Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Thousand Oaks, CA: SAGE Publications; 2013.
30.
Charmaz  K.  Constructing Grounded Theory. Thousand Oaks, CA: SAGE Publications; 2014.
31.
Jacobson  BH, Johnson  A, Grywalski  C,  et al.  The Voice Handicap Index (VHI). Development and Validation. 1997;6(3):66-70.  Am J Speech Lang Pathol. 1997;6:66-70. doi:10.1044/1058-0360.0603.66Google ScholarCrossref
32.
Titze  IR.  Phonation threshold pressure: a missing link in glottal aerodynamics.  J Acoust Soc Am. 1992;91(5):2926-2935.PubMedGoogle ScholarCrossref
33.
Wuyts  FL, De Bodt  MS, Molenberghs  G,  et al.  The Dysphonia Severity Index: an objective measure of vocal quality based on a multiparameter approach.  J Speech Lang Hear Res. 2000;43(3):796-809.PubMedGoogle ScholarCrossref
34.
Zhuang  P, Swinarska  JT, Robieux  CF, Hoffman  MR, Lin  S, Jiang  JJ.  Measurement of phonation threshold power in normal and disordered voice production.  Ann Otol Rhinol Laryngol. 2013;122(9):555-560.PubMedGoogle ScholarCrossref
35.
Plexico  LW, Sandage  MJ, Faver  KY.  Assessment of phonation threshold pressure: a critical review and clinical implications.  Am J Speech Lang Pathol. 2011;20(4):348-366.PubMedGoogle ScholarCrossref
36.
Solomon  NP, DiMattia  MS.  Effects of a vocally fatiguing task and systemic hydration on phonation threshold pressure.  J Voice. 2000;14(3):341-362.PubMedGoogle ScholarCrossref
37.
Goy  H, Fernandes  DN, Pichora-Fuller  MK, van Lieshout  P.  Normative voice data for younger and older adults.  J Voice. 2013;27(5):545-555.PubMedGoogle ScholarCrossref
38.
Lee  K, Kletzien  H, Connor  NP, Schultz  E, Chamberlain  CS, Bless  DM.  Effects of aging on thyroarytenoid muscle regeneration.  Laryngoscope. 2012;122(12):2800-2807.PubMedGoogle ScholarCrossref
39.
Van Lierde  K, D’Haeseleer  E, Wuyts  FL, Baudonck  N, Bernaert  L, Vermeersch  H.  Impact of thyroidectomy without laryngeal nerve injury on vocal quality characteristics: an objective multiparameter approach.  Laryngoscope. 2010;120(2):338-345.PubMedGoogle Scholar
40.
Mandrekar  JN.  Measures of interrater agreement.  J Thorac Oncol. 2011;6(1):6-7.PubMedGoogle ScholarCrossref
41.
Cohen  J.  Statistical Power Analysis for the Behavioral Sciences. 2nd ed. London, England: Routledge; 1988.
42.
Chandrasekhar  SS, Randolph  GW, Seidman  MD,  et al; American Academy of Otolaryngology–Head and Neck Surgery.  Clinical practice guideline: improving voice outcomes after thyroid surgery.  Otolaryngol Head Neck Surg. 2013;148(6)(suppl):S1-S37.PubMedGoogle ScholarCrossref
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.

Abstract

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  ClinicalTrials.gov Identifier: NCT02138214

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