Thyroid Surgery and Dysphagia Management Guidelines

Preoperative and Intraoperative Considerations

• The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting voice assessment, examining vocal fold mobility if voice is impaired, identifying the recurrent laryngeal nerve(s) during surgery, and preserving the external branch of the superior laryngeal nerve to prevent voice complications 1

Postoperative Care and Dysphagia Management

• Patients should be provided with contact information for the on-call team should they experience chest pain, breathlessness, or become unwell, as recommended by the Gut guideline society 2
• The Gut guideline society suggests considering PPI therapy after any esophageal dilatation that might be required for persistent dysphagia 2
• Symptoms such as retrosternal chest pain, choking, postprandial cough, food sticking, and regurgitation suggest possible structural abnormalities that require direct visualization, as suggested by the American College of Radiology 3

Diagnostic Evaluation

• Esophagogastroduodenoscopy (OGD) with biopsies is the initial diagnostic step in patients with progressive dysphagia, particularly in elderly patients, due to its high diagnostic yield (54%) and ability to exclude malignancy, as recommended by the American Gastroenterological Association and European Society of Gastrointestinal Endoscopy 4, 5
• Modified Barium Swallow (Videofluoroscopy) is the first-line imaging for oropharyngeal dysphagia, evaluating oral cavity, pharynx, and cervical esophagus, and assessing bolus manipulation, tongue motion, hyoid movement, and laryngeal elevation 3
• Barium esophagram (biphasic or single-contrast) is recommended as a secondary test if OGD shows structural abnormality or is normal/inconclusive, to further evaluate the esophagus, with a sensitivity of 80-89% for diagnosing esophageal motility disorders 3, 6
• Esophageal manometry is indicated if a motility disorder is suspected after initial testing, with a sensitivity of 98% and specificity of 96% for diagnosing achalasia, and can help differentiate functional from mechanical obstruction 4, 6
• CT scan is recommended to evaluate the extent of any malignancy in patients with dysphagia and an ulcerated oropharyngeal lesion, and to assess suspected complications (perforation, leak) with a sensitivity of 90-100% 7, 8, 5

4, 3, 8, 5, 6, 9

Treatment and Management

• All therapeutic decisions should be made by a multidisciplinary team, as recommended by the British Journal of Cancer 7
• Treatment options for dysphagia with an ulcerated oropharyngeal lesion include surgery, radiotherapy, brachytherapy, and combined radiotherapy with chemotherapy, as suggested by the British Journal of Cancer 7
• Direct visualization and tissue diagnosis are recommended before any surgical intervention, to determine the appropriate surgical approach, as suggested by the Society of American Gastrointestinal and Endoscopic Surgeons 9
• Monitoring for post-treatment strictures which may require dilatation, and considering PPI therapy after dilatation to reduce recurrence rate, is recommended by the Gut journal 2
• PPI therapy has been shown to reduce the need for esophageal dilatation in peptic strictures, according to the Gut journal 2
• Repeat dilatation during follow-up may be necessary to maintain symptom response if strictures develop, as recommended by the Gut journal 2
• If perforation is suspected, a water-soluble contrast study should be performed before endoscopy, and CT scan should be considered when complications are suspected, with a sensitivity of 90-100% for fish bone impaction 8, 5