We read with interest the article regarding 97 patients who underwent thyroidectomy for Graves’ disease (1). In the retrospective study, 49 patients received open thyroidectomy (OT) and 46 patients received transoral endoscopic thyroidectomy vestibular approach (TOETVA). The outcomes of patients with TOETVA were compared to those of patients with OT. The authors discovered and concluded that patients receiving TOETVA had better cosmetic results (scare-free) than patients with OT. Also, they reported that patients receiving TOETVA experienced significantly less pain than that in patients with OT. The finding has drawn the attention of anesthesiologists who are involved in the pain management perioperatively.
Postoperative acute pain control is essential for the care of the surgical patients (2), particularly in head and neck surgery (3). The prevalence of pain in head and neck surgery has been shown to be higher than in other anatomical sites (3). Postoperative acute pain can be reliably measured with one-dimensional tools such as visual analogue scales (VAS) (2). In the study by Jitpratoom et al. (1), the pain scores measured by VAS were significantly lower in TOETVA patients than in OT patients from the first to third days postoperatively. However, the pain scores in the postoperative care unit and on the day of surgery (day 0) were not reported. More importantly, no perioperative analgesic use of patients was included in the article. A plausible explanation from the incomplete data was made—“TOETVA was the truly minimally-invasive thyroidectomy for patients”. Interestingly, we had different pain control experiences regarding TOETVA which have been performed more than 100 cases in our hospital (a 1,200-bed Medical Center) (4). The results of our audit revealed that similar or more analgesics were needed to achieve adequate pain control for patients with TOETVA perioperatively. Measures of acute pain require careful assessment of a patient's pain score and review of a patient’s analgesic use. Previous research has described there is a trend of a gradual pain decrease during hospital stay, with a peak on the day of surgery (day 0) (3). Accordingly, the pain scores immediately post-surgery as well as analgesic therapy in anesthesia, in the postoperative care unit and in the surgical wards from day 0 to 3 should be described to give the readers complete information regarding acute pain and analgesic therapy in patients receiving TOETVA.
All aspects of pain for patients undergoing head and neck surgery have gained an increasing interest. In particular, pain intensity in the neck can be exacerbated by actions such as speech, chewing and/or swallowing (5). Although TOETVA is a promising new technique, it is not completely studied. More studies regarding postoperative pain assessment and management are needed for patients receiving TOETVA in order to provide a better postoperative care other than a better cosmetic outcome.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Jitpratoom P, Ketwong K, Sasanakietkul T, et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease: a comparison of surgical results with open thyroidectomy. Gland Surg 2016;5:546-52. [Crossref] [PubMed]
- Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. Br J Anaesth 2008;101:17-24. [Crossref] [PubMed]
- Bianchini C, Malago M, Crema L, et al. Post-operative pain management in head and neck cancer patients: predictive factors and efficacy of therapy. Acta Otorhinolaryngol Ital 2016;36:91-6. [PubMed]
- Chen CM, Hung IY, Liu WC, et al. A Great Variation in the Reported Incidence of Postoperative Subcutaneous Emphysema in Trans-oral Vestibular Endoscopic Thyroidectomy. World J Surg 2017. [Epub ahead of print]. [Crossref] [PubMed]
- Terrell JE, Welsh DE, Bradford CR, et al. Pain, quality of life, and spinal accessory nerve status after neck dissection. Laryngoscope 2000;110:620-6. [Crossref] [PubMed]