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Assessment of Voice Outcomes Following Surgery for Thyroid Cancer

Educational Objective
To describe the prevalence, severity, and characteristics of voice-related complaints following thyroid surgery for differentiated thyroid cancer.
1 Credit CME
Key Points

Question  What is the association between thyroid cancer surgery and postoperative voice outcomes?

Findings  In this population-based study of 2325 patients aged 17 to 89 years diagnosed as having differentiated thyroid cancer, abnormal voice was noted in 272 patients following surgery for thyroid cancer.

Meaning  These findings suggest a need for heightened awareness of voice abnormalities following surgery and warrant consideration in the preoperative risk-benefit discussion, planned extent of surgery, and postoperative rehabilitation.


Importance  An increasing number of surgeries are being performed for differentiated thyroid cancer (DTC). Long-term voice abnormalities are a known risk of thyroid surgery; however, few studies have used validated scales to quantify voice outcomes after surgery.

Objective  To identify the prevalence, severity, and factors associated with poor voice outcomes following surgery for DTC.

Design, Setting, and Participants  A cross-sectional, population-based survey was distributed via a modified Dillman method to 4185 eligible patients and linked to Surveillance, Epidemiology and End Results (SEER) data from SEER sites in Georgia and Los Angeles, California, from February 1, 2017, to October 31, 2018. Multivariable logistic regression and zero-inflated negative binomial analysis were performed to determine factors associated with abnormal voice. Participants included patients undergoing surgery for DTC between January 1, 2014, and December 31, 2015, excluding those with voice abnormalities before surgery.

Main Outcomes and Measures  Abnormal Voice Handicap Index (VHI-10) score, defined as greater than 11. The VHI-10 is designed to quantify 10 psychosocial consequences of voice disorders on a Likert scale (0, never; to 4, always).

Results  A total of 2632 patients (63%) responded to the survey and 2325 met the inclusion criteria. With data reported as unweighted number and weighted percentage, 1792 were women (77.4%); weighted mean (SD) age was 49.4 (14.4) years. Of these, 599 patients (25.8%) reported voice changes lasting more than 3 months following surgery, 272 patients (12.7%) were identified as having an abnormal VHI-10 score, and 105 patients (4.7%) reported vocal fold motion impairment diagnosed by laryngoscopy. In multivariable analysis, factors associated with an abnormal VHI-10 score included age 45 to 54 years (reference, ≤44 years; odds ratio [OR], 1.49; 95% CI, 1.05-2.11), black race (OR, 1.73; 95% CI, 1.14-2.62), Asian race (OR, 1.66; 95% CI, 1.08-2.54), gastroesophageal reflux disease (OR, 1.67; 95% CI, 1.15-2.43), and lateral neck dissection (OR, 1.99; 95% CI, 1.11-3.56).

Conclusions and Relevance  A high prevalence of abnormal voice per validation with the VHI-10 emphasizes the need for heightened awareness of voice abnormalities following surgery and warrants consideration in the preoperative risk-benefit discussion, planned extent of surgery, and postoperative rehabilitation.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: May 20, 2019.

Corresponding Author: Megan R. Haymart, MD, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd, Bldg 16, Room 408E, Ann Arbor, MI 48109 (

Published Online: July 18, 2019. doi:10.1001/jamaoto.2019.1737

Author Contributions: Dr Haymart had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kovatch, Reyes-Gastelum, Hughes, Haymart.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kovatch, Reyes-Gastelum, Hughes, Haymart.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kovatch, Reyes-Gastelum.

Obtained funding: Haymart.

Administrative, technical, or material support: Hughes, Hamilton, Ward, Haymart.

Supervision: Kovatch, Hughes, Haymart.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by grant R01 CA201198 from the National Cancer Institute (NCI). The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention (CDC) National Program of Cancer Registries, under cooperative agreement 5NU58DP006344, and the NCI SEER Program under contract HHSN261201800015I awarded to the University of Southern California. The collection of cancer incidence data in Georgia was supported by contract HHSN261201800003I, task order HHSN26100001 from the NCI and cooperative agreement 5NU58DP003875-04 from the CDC.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The ideas and opinions expressed herein are those of the authors and endorsement by the State of California and State of Georgia Departments of Public Health, the NCI, and the CDC or their contractors and subcontractors is neither intended nor should be inferred.

Meeting Presentations: This work was presented at the 2018 American Head & Neck Society Meeting; April 18, 2018; National Harbor, Maryland; and the 2018 Michigan Otolaryngologic Society Meeting; July 28, 2018; Thompsonville, Michigan.

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