Is there a case for selective, rather than routine, preoperative laryngoscopy in thyroid surgery?

Guzmán Franch-Arcas, Carmen González-Sánchez, Yari Yuritzi Aguilera-Molina, Orlando Rozo-Coronel, José Santiago Estévez-Alonso, Ángel Muñoz-Herrera


Background: According to some authors, routine preoperative laryngoscopy should be the standard of care in all patients undergoing thyroid surgery. The rationale for this approach is (I) the risk that a patient has a preoperative vocal cord palsy (VCP) without symptoms; (II) the presence of VCP preoperatively is suggestive of invasive malignancy; (III) it is relevant for the use of intraoperative nerve monitoring; and (IV) surgical strategy may be better defined if a paralysed vocal cord is detected preoperatively.
Methods: This is a review of studies of patients who underwent routine preoperative laryngoscopy to anticipate preoperative VCP and that evaluated related risk factors, including previous surgery, voice function complaints, and a diagnosis of malignancy. The estimated risk of sustaining preoperative VCF in the absence of these factors was determined. The relevant current guidelines from different professional bodies are also addressed.
Results: The level of evidence that supports routine preoperative laryngoscopy is weak. The risk of harboring preoperative VCP in the absence of previous neck or other risk-related surgery, advanced malignancy or voice symptoms is very low (0.5% of cases).
Conclusions: Selective rather than routine use of preoperative laryngoscopy may be acceptable provided that the risk of undetected paralysis is as low as can be reasonably ascertained from the available literature.