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7 38. A) Completion thyroidectomy should be offered to those patients for whom a bilateral thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. Therapeutic central neck lymph node dissection should be included if the lymph nodes are clinically involved. Thyroid lobectomy alone may be sufficient treatment for low risk papillary and follicular carcinomas. (SR-M) B) Radioactive iodine ablation in lieu of completion thyroidectomy is not recommended routinely. However, it may be used to ablate the remnant lobe in selected cases. (WR-L) 39. Prior to surgery, the surgeon should communicate with the patient regarding surgical risks, including nerve and parathyroid injury, through the informed consent process and communicate with associated physicians, including anesthesia personnel, regarding important findings elicited during the preoperative workup. (SR-M) 40. All patients undergoing thyroid surgery should have preoperative voice assessment as part of their pre-operative physical examination. This should include the patient's description of vocal changes, as well as the physician's assessment of voice. (SR-M) 41. Preoperative laryngeal exam should be performed in all patients with: A) Preoperative voice abnormalities (SR-M) B) History of cervical or upper chest surgery, which places the R LN or vagus nerve at risk (SR-M) C) Known thyroid cancer with posterior extrathyroidal extension or extensive central nodal metastases. (SR-L) 42. A) Visual identification of the recurrent laryngeal nerve (RLN) during dissection is required in all cases. Steps should also be taken to preserve the external branch of the superior laryngeal nerve (EBSLN) during dissection of the superior pole of the thyroid gland. (SR-M) B) Intraoperative neural stimulation (with or without monitoring) may be considered to facilitate nerve identification and confirm neural function. (WR-L) Table 3. Pre-operative Factors Which May Be Associated With Laryngeal Nerve Dysfunction History Voice abnormality, dysphagia, airway symptoms, hemoptysis, pain, rapid progression, prior operation in neck or upper chest. Physical Exam Extensive, firm mass fixed to the larynx or trachea. Imaging Mass extending to/beyond periphery of thyroid lobe posteriorly and/or tracheoesophageal infiltration, or bulky cervical adenopathy along the course of the RLN or vagus nerve.

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