Efforts to Improve Voice Outcomes After Thyroid Surgery

By Gregory W. Randolph, MD, FACS, FACE

Anatomy illustration of the neck.

The story of Tony Harnell is a poignant example of the importance of voice preservation in patients undergoing thyroid cancer treatment. For many years surgeons have been aware of how important their patients’ voices are and the tragedy of losing or altering it when thyroid surgery causes injury to the recurrent laryngeal [la-rin-je-al] nerve (RLN) or superior laryngeal nerve (SLN). The recurrent laryngeal nerve is responsible for supplying sensation to the main area which generates our voice–the larynx (voice box)–―while the superior laryngeal nerve stimulates the cricothyroid [kri-ko-thiroyd] muscle, which is vitally important in stretching the vocal cord folds and maintaining pitch.

This plight has been illustrated historically through the story of legendary 20th century Italian opera singer Amelita Galli Curci. The coloratura soprano’s career was reportedly lost after the injury of the external branch of the superior laryngeal nerve during her surgery under local anesthesia that altered her ability to sing high pitches. It was said of her in the press at the time, “The surprising voice is gone forever; the sad specter of a ghost replaces the velvet softness.”

The recent work of the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) to develop guidelines for the best voice outcomes in adult patients undergoing thyroidectomy [thi-roy-dek-to-me], the surgical removal of all or part of the thyroid gland, indicates that there are numerous nerve and non-nerve factors that can affect the voice. Vocal cord paralysis may occur immediately following thyroid surgery in up to 10 percent of patients and can be sufficient enough to warrant a change in vocation.

There has been increasing recognition of the importance of laryngeal exam at the time of thyroidectomy. The AAO and the American Head and Neck Society recommend doing laryngoscopy [lar-ing-gos-ko-pe], a procedure in which the physician uses a scope to visually examine the back of the throat, the voice box and vocal cords prior to and following thyroid surgery. Highly sensitive nerve monitoring which identifies the recurrent laryngeal nerve and external branch of the superior laryngeal nerve in an effort to preserve the nerves’ functional integrity is increasingly being used by the most experienced thyroid surgeons. All of these recommendations and advancements highlight the increasingly widespread recognition that the larynx and voice are at the center of the thyroid surgical field, epitomized by the story of Tony Harnell.

Gregory W. Randolph is an Associate Professor of Otolaryngology Head and Neck Surgery at Harvard Medical School and Surgeon at Massachusetts Eye and Ear Infirmary. He has served as Director of the General Otolaryngology Division since 1995 and founded and directs the Division of Thyroid and Parathyroid Surgery. Dr. Randolph has a thyroid and parathyroid surgical practice seeing patients and operating at both Mass Eye and Ear Infirmary and Massachusetts General Hospital. His surgical activity focuses exclusively on thyroid and parathyroid and related neck surgery.