Clinical practice guideline: improving voice outcomes after thyroid surgery.

OBJECTIVE: Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient's voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period. PURPOSE: The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well. RESULTS: The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient's voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient's voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

Anesthesiology-the john adriani story.

Several authors have told the John Adriani story, but his proper recognition in developing the specialty of anesthesiology and his place as a pioneer have never been presented as such. The following article outlines his training and experiences in the early days of anesthesiology. The story of the many problems he encountered and how he developed teaching programs that remain in existence today is one to be admired and appreciated. Much of the information is from personal conversations with Dr Adriani. During his tenure as the Director of Anesthesia at Charity Hospital, I was a surgical house officer in the early 1960s and returned as an anesthesiology trainee in the late 1970s. We became close personal friends. He gave me hundreds of his slides, and we had many discussions about the past and current state of the specialty of anesthesiology.

Pain management - the challenge.

Chronic pain is a significant public health problem in the United States. While the understanding that pain is an important biological signal has always been appreciated by health care professionals, management of pain has now come under significant scrutiny following its recognition as the fifth vital sign. Since the measurement of pain is not objective, the answers to questions regarding how to best manage the problem are not always self-evident. Multiple modalities, including interventional procedures and noninvasive techniques, are available for the treatment of pain. Acute pain is usually self-limiting when a reversible element can be identified. If acute pain is undertreated, it may become chronic in nature with the attendant problems of prolonged pain. Chronic pain creates psychological and social problems that are difficult and frustrating for both patient and physician. A multimodal therapeutic program in which the patient is an active participant can satisfactorily manage most pain problems. The use of opioids is considered legitimate medical therapy for chronic nonmalignant pain. If the need for opioid therapy is felt to be indicated, the physician should adhere to recommended guidelines as published by state licensing boards and professional organizations. Successful pain management is a rewarding experience for health care professionals.