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Neural-monitored thyroidectomy preserves professional singers’ voices
LAS VEGAS — Using neural-monitored technology to avoid injury to the vocal cord, a surgeon here showed how he preserved the voices of 27 professional voice users who underwent thyroidectomies.
“There is substantial consequences to nerve injury in these patients. This represents really the only comprehensive vocal outcome analysis in a series of professional singers undergoing thyroid surgery,” Gregory Randolph, MD, FACS, FACE, of Massachusetts Eye and Ear Infirmary, said at the AACE 23rd Annual Scientific & Clinical Congress. “When neurally monitored, thyroid surgery can be tolerated well in professional users.”
Randolph presented a prospective database study consisting of 30 professional voice users such as music teachers, religious cantors and professional singers ranging from Motown to country to opera (mean age 44.81 years; 44% were opera singers; 27 completed follow up) who underwent thyroid surgery between August 2012 and March 2014. In these surgeries, Randolph and colleagues utilized neural monitoring to electrically stimulate the laryngeal nerve intermittently throughout surgery, confirming its connectivity and giving the surgeon a guide to the vocal cord.
“It doesn’t replace good surgical technique. It doesn’t replace need for surgical anatomy knowledge, but it adds information,” Randolph said. “The nerve is not always so evident. ... With neural stimulation, you can determine exactly where that nerve is, so it adds to the visual information.”
The researchers collected voice handicap index, singing voice handicap index and evaluation of the ability to sing easily surveys along with questions formulated by the laryngologist team, including vocal parameters affected during recovery and time to return to performance.
The vocal instrument mean scores did not differ significantly postoperatively from those collected preoperatively and 100% returned to professional performance. Their mean time from surgery to return to performance was 2.26 months. The most common reasons for delay in performance within that recovery period were pitch control and modulation, strength, high range and fatigue, Randolph explained.
“We think that the superior laryngeal nerve-type symptoms that these patients experience during this 2.2 month recovery phase are probably reflecting some transient alteration of function of the cricothyroid muscle. ... It may be this muscle, even if the nerve is preserved, the muscle may not function perfectly normal,” Randolph said. “Other regional muscles such as strap muscle division are also important in limiting this period of time where this recovery phase is over. The more ablative, the more aggressive the strap muscle management, think the more regional scarring and longer this period of recovery may be. So gentle management of all the muscles – cricothyroid as well as straps – we think are important.”
For more information: Randolph G. General Session. Presented at: AACE 23rd Annual Scientific & Clinical Congress; May 13-18, 2014; Las Vegas, Nevada.
Disclosures: Randolph does not have any relevant financial disclosures.
Perspective
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Obviously if you’re a vocalist with a really wide range, you don’t want to lose that. Gregory Randolph, MD, FACS, FACE, has been a pioneer in the recurrent laryngeal nerve monitoring field, placing tiny electrodes into endotracheal tubes that are inserted right next to the vocal cords and connected electrically to the tip of the cutting device that the surgeon uses in the neck. Using this ingenious setup, surgeons can get an electrical warning if they are cutting too close to the nerves that control the vocal cords.
It’s helped a lot because when you're working in the small and sometimes deep surgical space, you must operate near these all-important nerves. Sometimes, even if you think you can see the nerves, you get closer than you realize and damage can occur. While not perfect, recurrent laryngeal nerve monitoring gives the careful surgeon an extra cushion of protection for the vocal apparatus. It’s an alarm device that protects patients and improves outcomes.