DYSPHAGIA AND DYSPHONIA IN PATIENTS WITH THYROID
Acta Medica Mediterranea, 2013, 29: 59
DYSPHAGIA AND DYSPHONIA IN PATIENTS WITH THYROID GOITER BEFORE AND AFTER THYROIDECTOMY: POSSIBLY RELATED TO THE PHARYNGO-ESOPHAGEAL REFLUX LARYNGITIS?
SALVATORE LO MONTE, FABRIZIO RABITA, GIUSEPPE LO RE, EUGENIO FIORENTINO, MASSIMO MIDIRI
Department of Radiology, University of Palermo, Italy
[Disfagia e disfonia in pazienti con gozzo tiroideo prima e dopo tireidectomia: possibile correlazione con la faringo-laringite da
reflusso esofageo? Valutazione videofluorografica]
Purpose: The aim of our study was to investigate the presence of pharyngo-oesophageal reflux laryngitis in patients with
nodular goiter and local symptoms, before and after non complicated total thyroidectomy (TT), to assess whether its presence could
have a role in the origin of swallowing problems and voice and throat discomfort.
Materials and methods: During a months period 144 patients with non-toxic nodular goiter, were selected to be subjected to
intervention of total thyroidectomy. Before surgery, these patients underwent a optic-fiber video-laryngoscopy (VLS), and a videofluorographic study of swallowing (VFFS).
Results: Was not found a statistically significant difference between the pre-and post-operative.
Conclusions: Our results suggest that in the presence of local symptoms, initially attributed to thyroid disease, physicians
should investigate further before thyroidectomy, in order to identify the possible association of these symptoms with a pharyngooesophageal reflux laryngitis
Key words: Thyroid goiter, thyroidectomy, pharyngo-laryngitis, videofluorografia.
Received December 19, 2012; Accepted January 03, 2013
Non-toxic nodular goiter is a condition present
in endemic areas, in 25-33% of the population(1) and
local-regional symptoms are included in a range
that goes from 13 to 50% of patients undergoing
surgery for benign nodular disease(2, 3). Swallowing
disorders, voice and throat discomfort are usually
reported by patients with solitary thyroid nodules or
multinodular thyroid disease. Recently a highly significant correlation between symptoms and the
“pharyngolaryngitis reflux” (LPR), a term that
refers to the rise of gastric juice at pharyngolaryngeal, has been proved(4,5,6).
The aim of our study was to investigate the
presence of pharyngo-laryngitis reflux in patients
with nodular goiter and local symptoms, before and
after non complicated total thyroidectomy (TT), to
assess whether its presence could have a role in the
origin of swallowing problems and voice and throat
Materials and methods
During a 6 months period 144 patients with
non-toxic nodular goiter, were selected to be subjected to intervention of total thyroidectomy.
The diagnostic workup included medical history, clinical examination, ultrasound, thyroid scan,
fine needle aspiration biopsy with cytological sampling (FNAB) and the dosage of thyroid hormones.
The main indications for total thyroidectomy,
always provided by an endocrinological-surgical
physicians team, were: an increase in the size of
nodular goiter during treatment with L-thyroxine
with TSH suppression; an increase in the volume of
one or more nodules, even without treatment; a
cytological suspicion of malignancy.
During the interview, 50 patients (34.7%)
complained of swallowing disorders, voice, or sore
throat, but only of them (23.6%) gave their
informed consent to participate in the study.
Before surgery, these 34 patients underwent to
optic-fiber video-laryngoscopy (VLS), and a videofluorographic study of swallowing (VFFS). Followup, within 4 months after surgery, included another
clinical interview -anamnestic, and at least 3 VLS
and VFSS. Only 25 patients (17.3%) completed the
follow-up and were recruited for the study.
In order to carry out a more relevant, to the
purpose of the study, local-regional symptoms
were, classified into three different groups:
• swallowing disorders or dysphagia;
• voice disorders;
• pharyngeal discomfort.
VFSS examinations(7,8) were performed with a
remote-controlled device with digital C-arm
(Remote Controlled Multifunctional Eurocolumbus
TR3D, Milan, Italy) equipped with 16-inch image
intensifier, focal spot of 0.6 to 1.2 mm and a maximum potential difference of 150 in writing and 120
PKV in fluoroscopy. For the study of esophageal
motility digital cineradiographic sequences were
acquired, with 12 images/second frequency and
1024x1024 matrix. Images were captured both with
the patient in the upright position (with dynamic
sequences in LL and AP) and in the prone position
with abdominal compression, and in the supine
position for the evaluation of any signs of gastrooesophageal reflux with Water siphon test
All examinations were performed with at least
two consistencies of barium sulphate (HD
Prontobario 250% weight-volume and Prontobario
60% weight-volume, Bracco, Milan, Italy). The
parameters considered to assess the alterations of
• Elevation of the hyoid bone and epiglottal
tilting (abnormal laryngeal movement);
• Stasis of the bolus in the pharynx, in valleculae and/or pyriform sinuses.
The VFFS was considered positive even if
only one of the two conditions was present.
Cricopharyngeal muscle contraction and the presence of any gastroesophageal reflux until the proximal third of the esophagus, the latter appreciably
with the “water siphon test” (WST), were also
S. Lo Monte, F. Rabita et Al
Before surgery: Each of the 25 patients complained at least one group of local symptoms; 80%
of patients (n 20) at least two; 56% (n 14) three.
The pharyngeal discomfort was the most frequent
symptom (80% of patients), followed by swallowing and voice disorders. Although already altered
the elevation of the hyoid bone, the tilting epiglottal
and stasis of the bolus in the pharynx, which were
present in approximately 50% of patients, the VFFS
has been highly successful in identifying swallowing problems, in patients who complained of a single group of symptoms, two or three, respectively,
in a percentage of 88%, 90% and 86%. The VLS
was positive for signs of pharyngo-laryngitis less
frequently than VFFS, with positive rates of 68% in
patients who complained of a group of symptoms
and of 65% and 57% for those who had complained
two or three groups of symptoms.
After surgery: a statistically significant difference between the pre-and post-operative was
not found, both considering each group of symptoms separately and combining two of the three.
Excluding the symptoms appeared ‘de novo’, VLS
and VFSS persist positive after surgery.
Our results suggest that in the presence of
local symptoms, initially attributed to thyroid disease, physicians should investigate further before
thyroidectomy, in order to identify the possible
association of these symptoms with a pharyngooesophageal reflux laryngitis. When, instead, the
need for surgery can not be delayed, patients should
be informed of the possibility that some symptoms
may persist even after removal of the thyroid and
subsequently require treatment with PPI. This is the
first study that correlates the local symptoms with
the pharyngo-laryngitis reflux in patients with
nodular non-toxic goiter, proposing a new hypothesis for the justification of an unclear correlation
between these symptoms and the total thyroidectomy, nevertheless, further studies involving larger
cohorts of patients and for longer periods of followup are needed in order to confirm these results.
Dysphagia and dysphonia in patients with thyroid...
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