Introduction: As the incidence of differentiated thyroid cancer (DTC) rises, an increasing number of thyroid surgeries are being performed. One of the more common complaints following thyroid surgery is change in voice, which may be related to cancer extension or more commonly surgical complications including injury of the recurrent or superior laryngeal nerve. The Voice Handicap Index (VHI, Jacobson et al, 1997), and abbreviated Voice Handicap Index-10 (VHI-10, Rosen et al, 2004) are validated tools used to identify voice abnormalities adversely affecting quality of life. VHI-10 identifies an abnormal voice as a score >11 based on normative data. This study aims to describe the prevalence, severity, and characteristics of voice-related complaints following thyroid surgery through use of the VHI-10.
Methods: A cross-sectional, population-based survey of patients diagnosed with DTC in 2014-2015 at SEER sites Georgia and Los Angeles was administered from February 2017 to present. A modified Dillman survey method was used to encourage response. Survey elements included patient reported demographics, post-surgical complications, and outcomes including results from the validated VHI-10 questionnaire.
Results: Of 977 patients completing the survey, 758 (77.6%) were female. Median age was 54.0 years (range 21-82). A total of 269 (27.5%) patients reported voice changes more than three months following surgery, 93 (9.5%) patients reported voice problems prior to surgery, and 55 (5.6%) patients reported being diagnosed with vocal fold paralysis/palsy (VFP) by laryngoscopy. A majority (74.5%) of patients with VFP also had voice complaints persisting ≥3 months following surgery. VHI-10 questionnaire revealed a total of 138 (14.1%) patients scoring in the abnormal range (>11, based on normative data). Patients reporting voice changes ≥3 months following surgery had a median VHI-10 score of 8.0 (range 0-36), with 98 (36.4%) scoring in the abnormal range (Table 1). Patients reporting voice problems prior to surgery had a median VHI-10 score of 7.0, with 30 (32.3%) scoring in the abnormal range. Patients reporting VFP had an elevated median VHI-10 score of 15.0 (range 0-36) compared to those without VFP (median 0, range 0-38). Further, a greater proportion of those with VFP (33, 60.0%) scored in the abnormal range on VHI-10 relative to those without VFP (104, 11.5%) (p<0.001). In the subset of patients scoring in the abnormal range on VHI-10, common complaints included “my voice makes it difficult for people to hear me” and “the clarity of my voice is unpredictable”.
Conclusion: Voice complaints following surgery for thyroid cancer are common. These complaints are frequently underreported in the literature due to limited long-term follow-up, reliance on surgeon report, focus on single institution studies with high volume surgeons, and rare use of validated scales to assess impact on voice. Our findings of a high prevalence of voice complaints post thyroid surgery and a larger than expected number with abnormal VHI-10 score suggest a need for heightened awareness, consideration of referral to high volume centers, de-escalation of surgical treatment when appropriate, and early referral for voice therapy or procedural intervention.