Classifying pain in transoral endoscopic thyroidectomy

  • D. Zhang
  • E. CarusoEmail author
  • H. Sun
  • A. Anuwong
  • R. Tufano
  • G. Materazzi
  • G. Dionigi
  • H. Y. Kim
Original Article



Knowledge of visual analog scale (VAS) pain assessment for transoral endoscopic thyroidectomy vestibular approach (TOETVA) is limited. The purpose of this analysis was to classify the postoperative discomfort scores in patients undergoing TOETVA compared to open thyroidectomy.


Observational clinical study of patients who underwent thyroidectomy by VAS pain assessment from September 2016 to March 2017. Patients were stratified into two groups: patients eligible for TOETVA (Group TOETVA) and non-candidates for endoscopic intervention (open thyroidectomy approach—OTA). VAS was recorded in the recovery room, at 24 h, + 2, + 5, + 15, + 30, + 90 days, and 6 months after surgery. Pain assessment was stratified in VAS-lower lip, VAS-chin, VAS-jaw, VAS-anterior neck, VAS-cervical/back, VAS-swallowing, VAS-brushing, VAS-speaking, and VAS-shaving. Secondary outcome assessed were analgesic rescue dose, morbidity, operative notes, hospital stay, and histopathology.


41 TOETVA and 45 OTA constituted the analysis. There were differences between the TOETVA and OTA for age, gland volume, mean nodule diameter, coexistence thyroiditis, bilateral procedures, and use of drain. Operative time was longer in TOETVA. Results indicated that TOETVA was associated with reduced neck, cervical back, and swallowing VAS scores in the 24 h after surgery. Conversely, jaw and brushing teeth resulted in higher VAS score in TOETVA group. OTA patients never experienced lower lip or chin pain. The use of rescue analgesics did not differ between the two groups.


VAS was used to measure treatment outcome in TOETVA. VAS scores achieved overall a minimal clinical importance difference from the two procedures. There appears to be both a short- and long-term different range of interpretations of pain between TOETVA and OTA.


Thyroid surgery TOETVA Postoperative pain management VAS Analgesia 


Author contributions

Conception and design: all authors. Administrative support: all authors. Collection and assembly of data: all authors. Data analysis and interpretation: all authors. Manuscript writing: all authors. Final approval of manuscript: all authors.



Compliance with ethical standards

Conflict of interest

No authors of this study have financial relationships with the surgical industry or other personal, professional, or financial conflicts of interest in the publication of this study.

Ethical approval

This study was approved by the Ethics Committee of the Institutional Review Board (Protocol n. 17-oyi211).

Informed consent

Informed consent was obtained from all participants in the study.


  1. 1.
    Russell JO, Anuwong A, Dionigi G, Inabnet WB, Kim HY, Randolph G (2018) Transoral thyroid and parathyroid surgery vestibular approach: a framework for assessment and safe exploration. Thyroid 28(7):825–829CrossRefGoogle Scholar
  2. 2.
    Dionigi G, Tufano RP, Russell J, Kim HY, Piantanida E, Anuwong A (2017) Transoral thyroidectomy: advantages and limitations. J Endocrinol Invest 40(11):1259–1263CrossRefGoogle Scholar
  3. 3.
    Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G (2018) Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc 32(1):456–465CrossRefGoogle Scholar
  4. 4.
    Bakkar S, Al Hyari M, Naghawi M, Corsini C, Miccoli P (2018) Transoral thyroidectomy: a viable surgical option with unprecedented complications-a case series. J Endocrinol Invest 41(7):809–813CrossRefGoogle Scholar
  5. 5.
    Kehlet H, Jensen T, Woolf CJ (2006) Persistent postsurgical pain: risk factors and prevention. Lancet 367:1618–1625CrossRefGoogle Scholar
  6. 6.
    Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE (2016) 2015 American Thyroid Association Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid 26(1):1–133CrossRefGoogle Scholar
  7. 7.
    Dionigi G, Bacuzzi A, Lavazza M, Inversini D, Boni L, Rausei S (2017) Transoral endoscopic thyroidectomy: preliminary experience in Italy. Updates Surg 69(2):225–234CrossRefGoogle Scholar
  8. 8.
    Dionigi G, Lavazza M, Bacuzzi A, Inversini D, Pappalardo V, Tufano RP (2017) Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): from A to Z. Surg Technol Int 7(30):103–112Google Scholar
  9. 9.
    Dionigi G, Bacuzzi A, Lavazza M, Inversini D, Pappalardo V, Boni L (2016) Transoral endoscopic thyroidectomy via vestibular approach: operative steps and video. Gland Surg 5(6):625–627CrossRefGoogle Scholar
  10. 10.
    Dionigi G, Wu CW, Tufano RP, Rizzo AG, Anuwong A, Sun H (2018) Monitored transoral endoscopic thyroidectomy via long monopolar stimulation probe. J Vis Surg 26(4):24CrossRefGoogle Scholar
  11. 11.
    Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY (2018) Safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach. JAMA Surg 153(1):21–27CrossRefGoogle Scholar
  12. 12.
    Liu N, Chen B, Li L, Zeng Q, Lv B (2018) Subplatysmal or subfascial approach in totally endoscopic thyroidectomy has better postoperative efficacy for voice, sensory, swallowing symptoms and cosmetic result. Cohort study. Int J Surg 31(60):22–27CrossRefGoogle Scholar
  13. 13.
    Jung SP, Kim SH, Bae SY, Lee SK, Kim S, Choi MY (2013) A new subfascial approach in open thyroidectomy: efficacy for postoperative voice, sensory, and swallowing symptoms. A randomized controlled study. Ann Surg Oncol 20(12):3869–3876CrossRefGoogle Scholar
  14. 14.
    Colella G, Giudice A, Siniscalchi G, Falcone U, Guastafierro S (2009) Chin numbness: a symptom that should not be underestimated: a review of 12 cases. Am J Med Sci 337(6):407–410CrossRefGoogle Scholar
  15. 15.
    Lee EG, Ryan FS, Shute J, Cunningham SJ (2011) The impact of altered sensation affecting the lower lip after orthognathic treatment. J Oral Maxillofac Surg 69(11):431–445CrossRefGoogle Scholar
  16. 16.
    Ewbank RL (1980) Mental nerve neuropathy. Oral Surg Oral Med Oral Pathol 50(4):325–326Google Scholar
  17. 17.
    Semikov VI, Osmanov EG, Gryaznov SE, Gorbacheva AV, Patalova AR, Mansurova GT, Kazaryan AM (2018) Evaluation criteria and surgical technique for transoral access to the thyroid gland: experimental Study. J Invest Surg 25:1–7Google Scholar

Copyright information

© Italian Society of Endocrinology (SIE) 2019

Authors and Affiliations

  • D. Zhang
    • 1
  • E. Caruso
    • 2
    Email author
  • H. Sun
    • 1
  • A. Anuwong
    • 3
  • R. Tufano
    • 4
  • G. Materazzi
    • 5
  • G. Dionigi
    • 2
  • H. Y. Kim
    • 6
  1. 1.Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational MedicineJilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid CarcinomaChangchunP.R. China
  2. 2.Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood ‘‘G. Barresi’’, University Hospital G. MartinoUniversity of MessinaMessinaItaly
  3. 3.Minimally Invasive and Endocrine Surgery Division, Department of SurgeryPolice General HospitalBangkokThailand
  4. 4.Department of Otolaryngology-Head and Neck SurgeryThe Johns Hopkins University School of MedicineBaltimoreUSA
  5. 5.Department of Surgical, Medical, Molecular Pathology and Critical AreaUniversity of PisaPisaItaly
  6. 6.Department of Surgery, KUMC Thyroid Center, Korea University HospitalKorea University College of MedicineSeoulSouth Korea

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