Vocal palsy increases the risk of lower respiratory tract infection in low-risk low-morbidity patients undergoing thyroidectomy for benign disease: a big data analysis

Abstract

Objectives

Thyroidectomy is the commonest and most rapidly-growing operation which places normally-functioning laryngeal nerves at risk of injury. Laryngeal palsy is a major risk-factor for dysphonia, dysphagia, and less commonly, airway obstruction. We investigated the association between post-thyroidectomy vocal palsy and long-term risks of pneumonia and laryngeal failure.

Design

An N=near-all analysis of the English administrative dataset using a previously-validated informatics algorithm to identify young and otherwise low-risk patients undergoing thyroidectomy for benign disease. Information about age, sex, morbidities, social deprivation, and postoperative and late complications were derived.

Main Outcome Measures

Between 2004 and 2012, 43,515 patients between the ages of 20 and 69 who had no history of cancer, neurological, or respiratory disease underwent first-time elective total or hemithyroidectomy without concomitant or late neck dissection, parathyroidectomy, or laryngotracheal surgery for benign thyroid disease. Information about age, sex, morbidities, and in-hospital and late complications was recorded.

Results

Mean age at surgery was 46±12. There was a strong female preponderance (85%) and most patients (89%) had no recorded Charlson morbidities. Most patients (65%) underwent hemithyroidectomy. Late vocal palsy was recorded in 449 (1.03%) patients and its occurrence was an independent risk factor for emergency hospital readmission (n=7113; Hazard Ratio 1.52; 95% Confidence interval 1.21-1.91), hospitalisation for lower respiratory tract infection (n=944; HR 2.04; 95% CI 1.07-3.75), dysphagia (n=564; HR 3.47; 95% CI 1.57-7.65) and gastrostomy/tracheostomy placement (n=80; HR 20.8; 95% CI 2.5-171.2). Independent risk-factors for late vocal palsy were age, burden of morbidities, total thyroidectomy, and postoperative bleeding. Female sex and annual surgeon volume >30 were independently protective.

Conclusions

There is a significant association between post-thyroidectomy vocal palsy and long-term risks of hospital readmission, dysphagia, pneumonia, and gastrostomy/tracheostomy tube placement. This adds weight to the need, from a thyroid surgical perspective, to undertake universal post-thyroidectomy laryngeal surveillance with a focus on postoperative dysphagia and aspiration, and from a medical/respiratory perspective, to initiate investigations to identify occult vocal palsy in patients who present with pneumonia, who have a history of thyroid surgery.

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