World J Surg (2016) 40:636–643

DOI 10.1007/s00268-015-3323-y

ORIGINAL SCIENTIFIC REPORT

Changes of Laryngeal Mobility and Symptoms Following Thyroid

Surgery: 6-Month Follow-Up
Antje E. Gohrbandt1 • Anna Aschoff1 • Bernhard Gohrbandt2 • Annemarie Keilmann3 •

Hauke Lang1 • Thomas J. Musholt1

Published online: 11 November 2015

Ó Société Internationale de Chirurgie 2015

Abstract
Objective Swallowing disorders are frequent complaints after thyroidectomy even in the absence of recurrent
laryngeal nerve palsy. The aim of this study was to assess different symptoms in relation to laryngeal mobility
following thyroidectomy.
Materials and methods 53 patients (mean age 52.4 ± 12.5 years; 36 female) with initially benign diagnosis and
intact recurrent nerve functioning were prospectively evaluated. Laryngeal movement was analyzed by ultrasound
preoperatively and 1, 3, and 6 months postoperatively. In addition, a dysphagia and voice-specific quality-of-life
questionnaire was used.
Results Mean laryngeal movement differed between genders preoperatively and postoperatively resulting in a
recovery predominantly in women (reduction of mobility at 1, 3, and 6 months postoperatively in females was 6.0,
3.7, and 1.5 mm, and in males 13.8, 11.7, and 10.3 mm, respectively). Mainly, women reported hoarseness (9
females) and cervical discomfort (7 females, 3 males) 1 month postoperatively. After 6 months, these complaints
resolved (cervical discomfort 1 female).
Conclusion Laryngeal mobility was significantly impaired postoperatively and only females revealed a recovery
close to baseline after 6 months. Although showing only a small grade of recovery of laryngeal movement, subjective
clinical symptoms were found to be rare in male patients.

Introduction
& Antje E. Gohrbandt
[email protected] Total thyroidectomy (TT) is a widely established and safe
1
procedure for benign thyroid pathologies. In 2013, 41,011
Section of Endocrine Surgery, Department of General,
total thyroidectomies were performed in Germany consti-
Visceral and Transplantation Surgery, Medical Centre of the
Johannes Gutenberg University Mainz, Langenbeckstrasse 1, tuting a large cohort with potential morbidity [1]. Other
55131 Mainz, Germany groups reported a frequency of voice alterations and dys-
2
Department of Thoracic and Cardiovascular Surgery, phagia in 37–87 % subsequent to total thyroidectomy [2–6].
Medical Centre of the Johannes Gutenberg University Mainz, Major reasons for these complaints are related to injuries of
Langenbeckstrasse 1, 55131 Mainz, Germany the recurrent laryngeal nerve (RLN) or impairments of the
3
Department of Otorhinolaryngology, Medical Centre of the external branch of the superior laryngeal nerve (EBSLN).
Johannes Gutenberg University Mainz, Langenbeckstrasse 1, The reported incidence of persistent unilateral paresis of the
55131 Mainz, Germany

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RLN is 0.8–3.0 %, while bilateral persistent paresis is in general anesthesia. All procedures were performed by
apparent in 0.02–0.05 % [7]. More frequent are pareses of two specialized endocrine surgeons (T.J.M and A.E.G).
the EBSLN, which are observed in up to 28 % [8, 9]. The skin incision was made one fingerbreadth above the
Yet even in the absence of nerve affections, disorders of sternal notch. Subplatysmal skin flap was dissected, and the
the aerodigestive system occur following thyroidectomy. In strap muscles were separated along the midline and re-
those cases, major complaints are hoarseness, difficulties in approximated at the end of the operation. In every patient,
singing, achieving a high pitch or generating a loud voice routine neuromonitoring of the RLN and the vagal nerve
as well as fatigue of the voice, and, consecutively, a was performed. During surgery, the RLN was routinely
potential loss of quality of life [2]. As underlying mecha- identified and exposed throughout the entire continuity in
nisms, damage to vocal cords or trauma to the arytenoid the tracheoesophageal groove, starting from below the
cartilage during intubation, laryngotracheal fixation of the crossing of the RLN with the inferior thyroid artery up to
strap muscles by postoperative adhesions, reduced eleva- the cricothyroid muscle. Every attempt was made to pre-
tion of the larynx, injuries to the extrinsic perithyroidal serve all of its branches during dissection.
nerve plexus, which innervates the pharynx or swelling and The superior thyroid vessels were carefully dissected and
trauma to the cricothyroid muscle, and edema of the nerval ligated very close to the thyroid capsule, while care was
structures are suggested [9–12]. taken not to damage the EBSLN, whenever identifiable.
Many studies examined postoperative voice changes or
swallowing disorders, e.g., by questionnaires or interviews, Patient assessment
comparing different surgical techniques, changes of eso-
phageal motility, or mobility of vocals cords [10–16]. Voice and swallowing characteristics including potential
To our knowledge, perioperative alterations of the disorders were assessed by standardized questionnaires.
laryngeal movement have not been studied as a contribut- Referring to two studies by Lombardi and colleagues [11,
ing cause of postoperative voice and swallowing disorders 15] and adapted from the Sydney Swallowing Question-
to date. The aim of this study was to assess changes of the naire [16], ten key questions upon quality of voice and
laryngeal movement following TT in relation to voice and swallowing disorders were raised. Consecutively, 2 specific
swallowing disorders, potential gender differences, and, questionnaires as depicted in Fig. 1 were presented to each
finally, consequences for the quality of daily life. patient at every study visit in order to evaluate the indi-
vidual complaints at different timepoints. Each of the 20
questions spanned from a minimum score of 1 (no disor-
Materials and methods ders/difficulties) to a maximum of five (permanent prob-
lems or complaints).
All patients scheduled for TT between March 2011 and May
2013 in the Section of Endocrine Surgery of the Department Measurement of the laryngeal mobility
of General, Visceral and Transplantation Surgery at the
Medical Centre of Johannes Gutenberg University Mainz, For measurement of the laryngeal mobility at each study
Germany, were considered eligible for this prospective visit, an ultrasound of the throat was performed as illus-
study. Exclusion criteria were less than 16 years of age, trated in Fig. 2. For ultrasound examination, an elevated
prior vocal cord palsy, previous neck surgery, or malignant upper body position of the patients (30°–45°) was achieved
thyroid diseases infiltrating the surrounding structures. All to allow unhindered swallowing. The thyroid cartilage was
patients participating in this study signed a written informed identified with a 10 MHZ ultrasound probe, and the com-
consent prior to surgery. Patient data were prospectively plete course of swallowing was recorded. The upper rim of
recorded. All patients were evaluated by neck ultrasound the thyroid cartilage served as the anatomical landmark. In
and a questionnaire assessing voice and swallowing quality a second step, the distance between the lower and upper
as well as quality of life preoperatively and 1, 3, and turning points was measured using image processing soft-
6 months after surgery. Diagnostic work-up comprised a ware and a special scaling software (DatInf Measure
standardized functional examination of the RLN pre- and 2.1.2.22). This measurement was performed three times in
postoperatively and ensured to confirm an intact bilateral every patient at each timepoint. Finally, mean values were
nerve and vocal cord function. calculated of these three single measures.

Surgical technique Statistical analysis

Patients underwent a conventional open thyroidectomy Data were prospectively recorded followed by a retro-
defined as a complete bilateral extracapsular thyroidectomy spective analysis performed with the Predictive Analytics

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Fig. 1 Depiction of both Assessment of voice quality

questionnaires presented to each
patient at each study visit never seldom sometimes frequently permanent
1 2 3 4 5

1 Hoarseness of the voice

2 Weakness and whispering of the voice

3 Problems with singing and shouting

4 Deeper voice than preoperatively

5 Monotonous voice

6 More frequent breathing while speaking

7 Alteration of the voice over day

8 Exhausted speaking voice

9 Clearness of the voice not predictable

10 Drop of the voice when strained

Assessment of swallowing complaints

never seldom sometimes frequently permanent
1 2 3 4 5

1 More power needed for swallowing

2 Problems with swallowing of thin

liquids (e.g. tea, coffee)

3 Problems with swallowing of viscous

liquids (e.g. milkshake, soup)

4 Problems with swallowing of soft food

(e.g. mushed potatoes, scrambled egg)

5 Problems with swallowing of solid food

(e.g. meat, apple, carrot)

6 Repeatedly swallowing necessary to

swallow the meal

7 Sense of obstacle while swallowing

8 Coughing while swallowing solid meal

or viscous liquids

9 Foreign body sensation in the throat

10 Disorders of swallowing decreases

quality of life

Software (PASW for Windows, version 19; SPSS, Chicago, was performed using the Wilcoxon test for paired samples.
IL, USA). All data are expressed as mean ± standard For correlation of the results of the questionnaires and
deviation. To determine significance of mean values of laryngeal mobility, the Spearman test was used. To cal-
laryngeal mobility, the t test was applied. The Pearson’s culate the correlation of non-parametric characteristics
Chi-square test was used for comparison of categorical with each other, the Mann–Whitney U test was applied.
values between genders. The analysis of the questionnaires P values \0.05 were considered significant.

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Fig. 2 Illustration of the

measurement of the laryngeal
mobility by ultrasound ensuring
an identical image section. Left
scene lower turning point of the
laryngeal elevation. Right scene
upper turning point of the
laryngeal elevation. A patient’s
head, B ultrasound probe,
C larynx, D image section

Results Fig. 3, this significant reduction in mean laryngeal mobility

compared to baseline could be assessed in male subjects
During the inclusion period, 101 potential subjects gave (27.8 ± 4.8 mm preoperatively vs. 13.7 ± 2.4 mm at 1 month,
their written informed consent. Of these, 35 subsequently P = \0.001; 16.1 ± 4.1 mm at 3 months, P \ 0.001; and
failed to fulfill the inclusion criteria due to the following 17.5 ± 4.2 mm at 6 months, P \ 0.001, respectively). In
reasons: in 19 patients, more extended surgical procedures women, a significantly reduced mean laryngeal mobility was
were necessary, 15 did not undergo TT, and 1 patient only observed at 1 and 3 months postoperatively, whereas the
showed a palsy of the RLN preoperatively. mobility had almost recovered 6 months after surgery compared
Of the remaining 66 patients, 1 patient showed a post- to preoperative measurements (17.9 ± 4.5 mm preoperatively
operative RLN paresis and 12 patients did not complete the vs. 11.9 ± 3.6 mm at 1 month, P \ 0.001; 14.2 ± 3.7 mm at
6-month follow-up. Finally, 53 patients (52.5 %) were 3 months, P \ 0.001; and 16.5 ± 4.1 mm at 6 months, n.s.,
included in the analysis with a higher proportion of females respectively). These results indicate that the recovery of laryn-
(n = 36, 67.9 %). The subject’s mean age was geal mobility was not complete and remained impaired in rela-
52.4 ± 12.5 years (median 53.9 years). The majority of tion to preoperative values in male patients but not in female
patients suffered from multinodular goiter. In six patients, patients.
an incidental papillary strictly intra-thyroid carcinoma was As expected, gender comparison revealed a significantly
diagnosed. Further patients and perioperative data are larger preoperative mean laryngeal mobility in male sub-
shown in Table 1. jects (27.8 ± 4.8 mm in males vs. 17.9 ± 4.5 mm in
females; P = \0.001). However, this difference was not
Laryngeal mobility significant between the two groups at all postoperative
timepoints due to a greater loss of mobility in men.
Across the whole group, mean laryngeal mobility decreased
significantly postoperatively at 1, 3, and 6 months, respectively, Assessment of voice quality by questionnaire
compared to the preoperative measurement (21.1 ± 6.5 mm
preoperatively vs. 12.5 ± 3.3 mm at 1-month, P \ 0.001; The quality of voice questionnaire included ten aspects.
14.8 ± 3.9 mm at 3-month, P \ 0.001; and 16.8 ± 4.1 mm at Among those, the subjective impression of hoarseness was
6-month follow-up, P \ 0.001, respectively). As depicted in most frequently reported. Patients experiencing frequent or

Table 1 Patient characteristics

Female Male P value

Mean age ± SD (median) (years) 51.1 ± 12.8 (52.5) 55.0 ± 11.7 (53.9) 0.289 (mean age)
Underlying disease (n) 0.528
Multi-nodulous goiter 25 14
Papillary thyroid carcinoma 5 1
Hashimoto thyroiditis 3 0
M. Basedow 3 2
Mean volume of thyroid gland ± SD (median) (ml) 50.6 ± 42.4 (33.0) 62.1 ± 40.6 (49.5) 0.363 (mean volume)
SD standard deviation

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permanent hoarseness according to the assessment of voice

a
quality were categorized into one group and compared to
all other patients. Preoperatively, only four patients (3
females) reported about hoarseness. One month after sur-
gery, nine patients (all females) and, after 6 months, three
patients (2 females) complained about hoarseness. Due to
the overall low frequency of reported hoarseness as a
leading symptom, the aspect was not significantly different
between timepoints and gender. Similarly, there was no
significant association between the laryngeal mobility and
hoarseness at any timepoint (Table 2). The less frequently
reported other aspects were also not significant.

Assessment of swallowing disorders and quality

of life by questionnaire

Foreign body sensation was the most frequent statement in

b
the questionnaire evaluating swallowing disorders and
quality of life. Analogous to the assessment of hoarseness,
patients who frequently or permanently reported a foreign
body sensation in the questionnaire were grouped together.
The symptom was evident predominantly preoperatively
and early postoperatively in females. At 6 months, three
males and one female answered with existing disorders
(Table 3). In general, 56.6 % of our study individuals
reported swallowing disorders. One month after surgery,
the incidence was 47.2 % decreasing to 22.6 and 7.6 % at 3
and 6 months following TT resulting in nearly 85 %
decrease of this symptom 6 months after surgery.
In order to evaluate the potential impact of swallowing
symptoms on daily life question, 10 referred to the quality
of life (QoL). Within our study group, a pre- or postoper-
Fig. 3 Boxplots of the development of laryngeal mobility. a Fe- ative reduction of QoL caused by swallowing problems
males reveal a postoperative recovery almost up to basic laryngeal was rarely stated. Two patients (1 female, 1 male; 3.8 %)
mobility. b Males depicting a substantial decrease and failure
recovery resulting in the remaining near to 50 % mobility deficit indicated a substantial reduction (frequently or permanent)
after 6 months preoperatively. Only 1 female (1.9 %) complained about a
decreased QoL due to a frequent feeling of dysphagia

Table 2 Detailed listing of laryngeal mobility and incidence of hoarseness by timepoint and gender revealing no significant differences
Preoperatively 1 Month 3 Months 6 Months

Females
Hoarse (mm) 20.6 ± 4.2 (n = 3) 11.3 ± 4.3 (n = 9) (n = 0) 13.1 ± 0.6 (n = 2)
Non-hoarse (mm) 17.7 ± 4.5 (n = 33) 12.1 ± 3.3 (n = 27) 14.2 ± 3.7 (n = 36) 16.7 ± 4.1 (n = 34)
P value 0.282 0.572 ./. 0.229
Males
Hoarse (mm) 26.5 (n = 1) (n = 0) 21.6 (n = 1) 20.0 (n = 1)
Non-hoarse (mm) 27.9 ± 5.0 (n = 16) 13.7 ± 2.4 (n = 17) 15.8 ± 4.0 (n = 16) 17.4 ± 4.3 (n = 16)
P value 0.789 ./. 0.177 0.560

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Except significantly higher incidences of foreign body sensations in females preoperatively (* P \ 0.001) and 3 months after surgery (# P = 0.017), no significant differences between genders
1 month subsequent to surgery. No patient reported on a

1 (5.9 %)
1 (5.9 %)
1 (5.9 %)
(n = 17)
drop of QoL at any later timepoint.

Male

0
0
0
0
0
0
1 (2.8 %)
6 months
Discussion

(n = 36)
Female

7.6 %
Swallowing disorders are frequently reported after thyroid

0
0
0
0
0
0
0
0

0
4
surgery. Complaints by patients about difficulties of

1 (5.9 %)
1 (5.9 %)
(n = 17)
swallowing and experience from goiter redo surgery sug-

Male
gest a reduced thyroid mobility postoperatively as a major

0
0
0
0
0
0
0
0
reason of reported swallowing difficulties.
The aim of this clinical study was to evaluate if dif-

3# (8.4 %)
1 (2.8 %)
2 (5.6 %)
1 (2.8 %)
1 (2.8 %)
1 (2.8 %)

1 (2.8 %)
3 months

(n = 36)
ferences in laryngeal mobility correlate with functional

Female

22.6 %
voice and swallowing disorders at various timepoints pre-

12
0

0
and postoperatively. A substantial result represents the fact
that preoperative laryngeal mobility is significantly dif-

2 (11.8 %)

3 (17.7 %)
1 (5.9 %)
1 (5.9 %)
1 (5.9 %)

1 (5.9 %)

1 (5.9 %)
(n = 17)
ferent between genders revealing a nearly 50 % greater

Male
mobility in males. The correlation between gender and

0
0

0
preoperative laryngeal mobility was highly significant
(P \ 0.001). A significant drop of laryngeal mobility

7 (19.6 %)
2 (5.6 %)
1 (2.8 %)
1 (2.8 %)
1 (2.8 %)
1 (2.8 %)

1 (2.8 %)
(n = 36)

1(2.8 %)
1 month
(43 %) was observed postoperatively in the whole cohort.

Female

47.2 %
Additionally, the postoperative drop of laryngeal mobility
Table 3 Detailed information on the different swallowing symptoms and the incidence by timepoint and gender

25
0

0
in males equals the mobility span to females 1 month after
surgery. In contrast, Sundgren et al. reported a non-sig-

1 (5.9 %)
1 (5.9 %)
1 (5.9 %)
1 (5.9 %)
1 (5.9 %)
1 (5.9 %)

1 (5.9 %)
(n = 17)
nificant laryngeal mobility between genders in a cohort of
Male

135 patients [17].

0
0
0
Potentially, the different laryngeal movement between
Preoperatively

7* (19.6 %)
genders could be explained by the diverse anatomic
1 (2.8 %)
2 (5.6 %)
3 (8.4 %)
1 (2.8 %)
2 (5.6 %)
1 (2.8 %)

1 (2.8 %)
5 (14 %)
(n = 36)

structure of the larynx. The angle of the thyroid cartilage is

Female

56.6 %
about 90° in males versus 120° in females and, therefore,

30
0
results in a more prominent larynx in men. Additionally,
Problems with swallowing of soft food (e.g., mushed potatoes, scrambled egg)

the thyroid cartilage is larger and, hypothetically, the

laryngeal musculature is more muscular in males [18]. This
fact may explain the greater extent of the observed pre-
Problems with swallowing of viscous liquids (e.g., milkshake, soup)

operative laryngeal mobility in males in our cohort. By the

Problems with swallowing of solid food (e.g., meat, apple, carrot)

more prominent and larger larynx in males, the potential

area of postoperative adhesions of the sternohyoid and
Problems with swallowing of thin liquids (e.g., tea, coffee)

Coughing while swallowing solid meal or viscous liquids

sternothyroid muscles to the cartilage may result in

Repeatedly swallowing necessary to swallow the meal

stronger scarred adherence to the cartilage. This would

Disorders of swallowing decreases quality of life

imply that the mobility of the larynx may be reduced

significantly more in men than in women and that its
reconvalescence may take longer.
Various evidences exist that the scarred laryngotracheal
Sense of obstacle while swallowing.

Foreign body sensation in the throat

More power needed for swallowing

fixation results in a decreased laryngeal elevation [11, 19–

at any timepoint were observed

21]. Park and colleagues reported on an anti-adhesive

dressing (Interceed) positioned between the laryngotra-
cheal unit and the strap muscles and the strap muscles and
the overlying fat following thyroidectomy. As a result,
study subjects reported about reduced swallowing disor-
ders in comparison to controls 2 weeks after surgery. The
double positioning may also decrease adhesions between
Total (n)

the strap muscles and the overlying fat and, finally, the
platysma and cutaneous layers. Consecutively, potential

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adhesions of these structures and their influence on adhe- voice disorders following thyroidectomy. Scerrino and co-
sion-related drop of laryngeal mobility were hypothesized workers [12] described a significant association between
[22]. In contrast, Alkan and co-workers could not detect voice disorders and an increased reflux by a loss of eso-
any differences of laryngeal mobility between study phageal muscle tonus.
patients and controls in their study using an anti-adhesive According to various other studies [4, 26, 27], our
barrier between the larynx and the strap muscles in a analysis and assessment of swallowing disorders indicated
smaller cohort [23]. Taking both studies into account, the foreign body sensation as a leading complaint. 56.6 %
adhesions between the strap muscles and the overlying of the patients reported on any swallowing disorders pre-
structures may hypothetically reflect the major cause for operatively and 47.2 % 1 month after surgery. In 22.6 % of
postoperative changes in laryngeal mobility. the study subjects, disorders were indicated at 3 months
Moreover, the sternohyoid and sternothyroid muscles and only 7.6 % of the individuals reported existing com-
are partially tensioning the vocal cords and, thus, exerting a plaints 6 month postoperatively. Comparable results were
fractional effect on the phonation. Therefore, additional observed by Burns and colleagues, but their study group
impairments of the quality of voice could be the result of included a greater proportion of partial thyroid resections
postoperative adhesions. [27]. The symptom of foreign body sensation may be
In the presented cohort, preoperatively 49 % of the caused by thyroid pathologies pre- or postoperatively, but
subjects positively answered at least 1 aspect of the may probably also be related to other reasons, e.g., psy-
assessment of voice disorders, predominantly hoarseness, chogenic reasons or chronic reflux esophagitis. A multi-
regarding the frequency indication by sometimes, fre- factorial cause appears most likely [27–29].
quently, or permanent. The rate of hoarseness was 23 % In our study, swallowing disorders were observed pre-
preoperatively in our study, while Lombardi et al. [4] and postoperatively but did not result in a significant loss of
reported an incidence of 36 %. One month postoperatively, QoL. In contrast, Lombardi et al. [4] described swallowing
72 % of the study individuals complained about voice disorders as a contributor for a substantial loss of QoL.
disorders, mainly hoarseness (49 %) in our study. This Furthermore, we were not able to show a positive cor-
incidence fairly matches the result reported by Lombardi relation between the results of the swallowing assessment
et al. (54 %). However, 3 months after surgery, the fraction and laryngeal mobility. Individuals presenting the greatest
of hoarse patients was greater in the Lombardi’s study than loss of laryngeal mobility did not necessarily report severe
in our cohort (41 vs. 21 %). symptoms.
Hoarseness and exhausted voice are frequent symptoms Besides a relatively small initial sample size that was
following thyroid surgery that are potentially affecting the additionally decreased due to perioperative factors and loss
patient’s daily life and may result in consequences for to follow up, this study has certain further limitations. This
private and professional routine. Potential reasons are small sample size may overestimate or underestimate the
disturbances or damages to the RLN or EBSLN [2, 4, 5, 10, results of the different assessed aspects of both question-
24]. Although the RLN was proven intact prior to and after naires. A major issue concerning the validity of reported
surgery by video laryngoscopy in every patient in our subjective perioperative symptoms is the fact that possible
study, changes of the voice and hoarseness were often vocal or swallowing symptoms prior to surgery or as a
complained. This could potentially be caused by affections potential cause for the detection of thyroid disease were not
to the EBSLN. Although the gold standard to diagnose systematically evaluated within this study, e.g., by testing for
EBSLN paresis would be an EMG, the examination with gastroesophageal reflux or logopedic assessment. Moreover,
video laryngoscopy can also result in the detection of the postoperative assessment of the EBSLN function was not
functional lesions to the EBSLN. However, we have not carried out by EMG, although affections of this branch are
noticed any substantial affections of the EBSLN as a rea- known to be associated with vocal impairment that are
son for hoarseness in these patients. usually discovered by video laryngoscopy.
Additionally, damages following endotracheal intubation Our hypothesis that impairments of the laryngeal
or a probable luxation of the arytenoid cartilage may result in mobility correlates with voice and swallowing disorders
postoperative voice disorders. [2, 11] Moreover, hematoma could not be demonstrated. However, we think that more
or edema formation in the anatomic neighborhood or adhe- future investigations are warranted in order to further
sions to the strap muscles is probable reasons [25]. evaluate the presented results. Additionally, a comparison
Lombardi et al. [11] and Debruyne and colleagues [19] of healthy individuals and patients scheduled for TT may
hypothesized a deranged vascularization and reduction of be useful to investigate other causes of voice and swal-
lymphatic drainage of the laryngeal region as potential lowing disorders.

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