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Use of Prophylactic Steroids to Prevent Hypocalcemia and Voice Dysfunction in Patients Undergoing ThyroidectomyA Randomized Clinical Trial

Educational Objective
To assess the efficacy of preoperative dexamethasone on vocal dysfunction and hypocalcemia after thyroidectomy.
1 Credit CME
Key Points

Question  What is the effect of preoperative dexamethasone on postoperative hypocalcemia and voice dysfunction after thyroidectomy?

Findings  In this randomized clinical trial of 192 patients, those in the dexamethasone group had a lower rate of hypocalcemia, less symptomatic hypocalcemia, and less voice dysfunction in the first 24 hours after thyroidectomy than patients in the placebo group.

Meaning  These findings suggest that single-dose preoperative dexamethasone is safe and effective in reducing postoperative hypocalcemia and voice dysfunction.


Importance  Total thyroidectomy is associated with risks related to temporary hypocalcemia and vocal quality dysfunction. Dexamethasone has been proposed to have a physiological effect on hypocalcemia and voice quality.

Objective  To assess the effect of preoperative dexamethasone used to improve hypocalcemia and postthyroidectomy voice dysfunction.

Design, Setting, and Participants  This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted from January 15, 2014, to December 31, 2019, at the Department of Surgery, Holy Family Hospital in Rawalpindi, Pakistan. All patients with a benign thyroid condition and no preoperative corrected hypocalcemia and voice or vocal quality dysfunction were included. Patients were excluded if they had previous thyroid or neck surgery, known vocal cord dysfunction on laryngoscopy, hearing or voice problems, a history of gastroesophageal reflux, stomach ulcer disease, or contraindications to steroid use.

Interventions  Corrected serum calcium levels and Voice Analog Score defined and measured preoperatively. The dexamethasone group received a 2-mL intravenous dose of 8 mg of dexamethasone 60 minutes before the induction of anesthesia. In contrast, the placebo group received 2 mL of intravenous normal saline (0.9%) 60 minutes before the induction of anesthesia.

Main Outcomes and Measures  Evidence of hypocalcemia and voice dysfunction. Voice dysfunction was defined as a subjective score of less than 50 on a Voice Analog Score scale of 0 to 100 points.

Results  A total of 192 patients (mean [SD] age, 38.9 [12.4] years; 156 women [81.2%]) were included in the study, with 96 patients randomized to each study group (dexamethasone group, mean [SD] age, 39.2 [12.1] years; 75 women [78.1%]; placebo group, mean [SD] age, 38.5 [12.9] years; 81 women [84.5%]). In the first 24 hours after undergoing thyroidectomy, 47 patients (24.4%) developed hypocalcemia and 18 (9.4%) were symptomatic. At 3 days postthyroidectomy, 4 of 96 patients (4.2%) in the placebo group had hypocalcemia compared with no patients in the dexamethasone group. At 24 hours postthyroidectomy, 8 of 96 patients (8.3%) in the dexamethasone group had voice dysfunction compared with 32 of 96 patients (33.3%) in the placebo group. A total of 40 patients (20.8%) reported voice dysfunction. The absolute reduction in the rate of hypocalcemia at 24 hours was 24% (95% CI, 11.9%-35.2%) and at 3 days was 4.2% (–0.44% to 10.0%). The rate of symptomatic hypocalcemia was 19% lower in the dexamethasone group than in the placebo group (95% CI, 11.1%-27.7%). The rate of voice dysfunction was 25% lower in the dexamethasone group than in the placebo group (95% CI, 13.7%-35.7%).

Conclusions and Relevance  In this randomized clinical trial, a single preoperative dose of dexamethasone was safe and effective in reducing postoperative hypocalcemia and voice dysfunction rates in patients undergoing thyroidectomy.

Trial Registration  ClinicalTrials.gov identifier: NCT04752852

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Article Information

Accepted for Publication: July 14, 2021.

Published Online: September 2, 2021. doi:10.1001/jamaoto.2021.2190

Correction: This article was corrected on February 17, 2022, to change 2 incorrect instances of “hypercalcemia” to “hypocalcemia.”

Corresponding Author: Adeel Abbas Dhahri, MS, Royal Infirmary Hospital of Edinburgh, Edinburgh, United Kingdom, EH16 4SA (adeeldhahri@hotmail.com).

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

Concept and design: R. Ahmad, S. H. Ahmad, Kirmani.

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

Drafting of the manuscript: Dhahri, R. Ahmad, Rao, S. H. Ahmad, Ghufran.

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

Statistical analysis: Dhahri, Rao, Bhatti, S. H. Ahmad, Ghufran.

Obtained funding: R. Ahmad.

Administrative, technical, or material support: R. Ahmad, Bhatti, S. H. Ahmad.

Supervision: Dhahri, R. Ahmad, Bhatti, Kirmani.

Conflict of Interest Disclosures: None reported.

Data Sharing Statement: See Supplement 3.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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