Laryngeal exam indications and techniques

Postoperative voice changes are one of the most common and feared complications of thyroid surgery. In most cases, postoperative hoarseness is due to recurrent laryngeal nerve (RLN) injury, although injury to the external branch of the superior laryngeal nerve (EBSLN) can also result in significant vocal issues, including diminished vocal projection and inability to attain higher vocal registers. Voice complaints can also occur in the absence of neural dysfunction and may be present prior to any surgery being performed. Thus, timely and accurate evaluation of laryngeal function optimizes ongoing management efforts and provides important prognostic and outcome information. Only recently has increased awareness of the importance of voice outcomes in thyroid surgery led to the publication of a number of important papers on this topic, with several professional organizations starting to make reference to voice and laryngeal function in their guidelines for best practice. However, recommendations in these guidelines vary, especially with regard to laryngeal examination for patients without voice impairments, with many surgeons using voice symptoms alone to guide the need for laryngeal examination. True laryngeal function may be inaccurately predicted by voice symptoms, and thus controversy remains regarding need for routine laryngeal examination, timing of any such examination, and optimal examination technique(s). This chapter will discuss indications for laryngeal examination in thyroid surgery and current techniques available for voice and laryngeal examination.