Long-Term Post-Thyroidectomy Dysphagia: Incidence and Risk Factors Hua G, Alkhateeb A, Huang YQ, Blackburn A, Mlynarek A, Payne R, Hier M. Otolaryngology – Head & Neck Surgery Faculty of Medicine, McGill University, Montreal, QC, Canada Introduction Results Conclusions Symptoms of dysphagia are frequently reported after thyroidectomies, even in uncomplicated operations, and can have long-lasting effects on patients’ health and quality on life. The exact reason for these symptoms is not yet well understood. Our results shows that the incidence of moderate to severe long-term post-thyroidectomy dysphagia is around 2.9-9.4%. While there was no statistically significant correlation between long-term dysphagia and the parameters studied, this study suggests a trend towards a modest association between the transection of the sternothyroid muscle and long-term post-thyroidectomy dysphagia. Further studies with objective assessments of dysphagia are warranted to rule out any anatomical impairment. Contact: Michael P. Hier, MD, FRCSC Department of Otolaryngology-Head and Neck Surgery Sir Mortimer B. Davis-Jewish General Hospital Montreal, QC, Canada. mhier@jgh.mcgill.ca Table 1. Patient Characteristics classified by Severity of Long-Term Dysphagia Variable All Dysphagia Control (None) p-value Moderate to Severe (Mild to None) Total (%) 206 35 (17.0) 171 (83.0) - 11 (5.34) 195 (94.7) Mean SIS (range) 1.01 (0-17) 5.91 (1-17) 0 (0-0) <0.001 10.73 (7-17) 0.46 (0-6) Sex (%) Male 38 (18.5) 3 (8.57) 35 (20.5) 0 (0) 38 (19.5) Female 168 (81.6) 32 (91.4) 136 (79.5) 0.149 11 (100) 157 (80.5) 0.222 Mean age (range), years 51.9 (20-90) 51.3 (23-90) 52.0 (20-87) 0.773 55.7 (27-90) 51.7 (20-87) 0.348 Surgical Technique (%) Total Thyroidectomy 140 (68.0) 23 (65.7) 117 (68.4) 1.000 6 (54.5) 134 (68.7) 0.161 Completion Thyroidectomy 16 (7.77) 4 (11.4) 12 (7.02) 0.465 16 (08.21) 0.325 Subtotal Thyroidectomy 50 (24.3) 8 (22.9) 42 (24.6) 5 (45.5) 45 (23.1) 0.140 Left-side 24 (11.7) 20 (11.7) 2 (18.2) 22 (11.3) Right-side 26 (12.6) 22 (12.9) 3 (27.3) 23 (11.8) 0.539 Sternothyroid Preserved 64 (31.1) 7 (20.0) 57 (33.3) 62 (31.8) Sternothyroid Transected 142 (68.9) 28 (80.0) 114 (66.7) 0.085 9 (81.8) 133 (68.2) 0.279 Final Pathology (%) Benign 78 (37.9) 12 (34.3) 66 (38.6) 75 (38.5) Malignant 128 (62.1) 105 (61.4) 0.705 8 (72.7) 120 (61.5) Nodule/Tumor size (range), cm 2.44 (0.1-9.2) 2.34 (0.3-6.0) 2.46 (0.1-9.2) 0.683 2.14 (1.0-6.0) 2.45 (0.1-9.2) 0.493 Radioactive Iodine Treatment (%) 49 (23.8) 41 (24.0) 0.540 47 (24.1) 0.490 SIS: Swallowing Impairment Score (range 0-24; mild 1-6, moderate 7-9, severe 10-24). Long-term dysphagia: symptoms lingering beyond 6 months post-thyroidectomy. Aim The aim of this study is to discover the prevalence of long-term dysphagia (≥6 months) and identify possible risk factors. Methods A retrospective study of 450 consecutive patients undergoing thyroidectomy at a tertiary care academic center from September 2013 to March 2015 was performed. 234 patients were successfully contacted by phone and assessed with the Swallowing Impairment Score (SIS) questionnaire. SIS was used to classify dysphagia as mild if 1-6, moderate if 7-9, and severe if 10-24. Dysphagia was compared to patients’ age, sex, nodule size, final pathology, extent & side of surgery, surgical technique, and radioactive iodine (RAI) treatment. Patients were excluded if they had recurrent laryngeal nerve injury, lateral neck dissection, postoperative hematoma, surgical site infection, radiation/radioactive iodine therapy, or pre-operative dysphagia. Fig. 1 Swallowing Impairment Score questionnaire; Lombardi et al. World J Surg. 2008. References Pereira JA, Girvent M, Sancho JJ, Parada C, Sitges-Serra A. Prevalence of long-term upper aerodigestive symptoms after uncomplicated bilateral thyroidectomy. Surgery. 2003;133(3):318-22. Lombardi CP, Raffaelli M, D'Alatri L, Marchese MR, Rigante M, Paludetti G, et al. Voice and swallowing changes after thyroidectomy in patients without inferior laryngeal nerve injuries. Surgery. 2006;140(6):1026-32; discussion 32-4. Lombardi CP, Raffaelli M, D'Alatri L, De Crea C, Marchese MR, Maccora D, et al. Video-assisted thyroidectomy significantly reduces the risk of early postthyroidectomy voice and swallowing symptoms. World journal of surgery. 2008;32(5):693-700. Lombardi CP, Raffaelli M, De Crea C, D'Alatri L, Maccora D, Marchese MR, et al. Long-term outcome of functional post-thyroidectomy voice and swallowing symptoms. Surgery. 2009;146(6):1174-81. Grover G, Sadler GP, Mihai R. Morbidity after thyroid surgery: patient perspective. The Laryngoscope. 2013;123(9):2319-23. Hyun K, Byon W, Park HJ, Park Y, Park C, Yun JS. Comparison of swallowing disorder following gasless transaxillary endoscopic thyroidectomy versus conventional open thyroidectomy. Surgical endoscopy. 2014;28(6):1914-20. Of 234 patients, 206 met inclusion criteria. 35 of 206 (17%; 95% CI [0.124, 0.228]) had some long-term dysphagia, with a mean SIS of 5.91 (95% CI [4.6, 7.3]). 11 of 206 (5.34%; 95% CI [0.029, 0.094]) patients had moderate to severe long-term post-thyroidectomy dysphagia, with a mean SIS of 10.73 (95% CI [8.6, 12.8]). 28 of 35 (80%) patients with dysphagia had their sternothyroid muscle transected during surgery, compared to 114 of 171 (66.7%) patients without dysphagia (p=0.085). However, this finding failed to reach statistical significance. 9 of 11 (81.8%) patients with moderate to severe dysphagia had their sternothyroid muscle transected during surgery, compared to 133 of 195 (68.2%) patients with mild to no dysphagia (p=0.279). Age, sex, surgical technique, final pathology, nodule/tumor size, and RAI also showed no significant association with long-term post-thyroidectomy dysphagia. Fig. 2 Artist’s Rendition of a Thyroid Gland; verymom.com.