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Recovering from Thyroid gland surgery

jmiller,

The following will likely be more information than you or your friend want
or need, perhaps, but this email will go out to a good number of choral
conductors, some of whom might like or need to know different parts of the
info. Does that make sense? Kind of?

My creds for answering your question, just so you know: My job title is
Specialist Voice Educator, and I work at Fairview Voice Center, University
of Minnesota Medical Center, Fairview, in Minneapolis, Minnesota. My
Speech Pathologist/Voice Specialist colleague and I work with physicians
in the upper midwest (mostly Minnesota, of course)to provide therapeutic,
recovery, and preventive care for people who use their voices extensively,
vigorously, and/or skillfully in their livlihood careers or in their
avocational pursuits.

Partial or complete thyroidectomy, or ANY surgery in the neck-throat area
for that matter, has the potential for affecting vocal abilities for good
or ill. Therapeutic, recovery, and preventive care following ANY kind of
surgery, therefore, would be included.

An underfunctioning thyroid gland (pre-surgery) can produce an enlargement
of the vocal folds that would lower a singer's pitch range, particularly
the upper pitch range, 'thicken' voice quality, and reduce vocal volume
capability. A less well known effect would be an alteration of the
brain's neural networks that coordinate larynx muscles during singing and
speaking, such that they would 'learn' to produce more laryngeal muscle
effort to overcome the thickening. Having the surgery, followed by rest-
of-life use of synthetic thyroid medication are ways to 'normalize' vocal
fold anatomy over time and also to 'normalize' several vital whole-body
functions.

Events during neck/throat surgery itself, however, can result in other
changes of larynx and vocal fold function, and those changes can diminish
vocal abilities. One possible consequence of any general surgery can
relate to the manner in which the anesthesiologist administers the
anesthesia and a patient's recovery from its effects. A tube is inserted
past the two vocal folds during all general surgery to maintain an open
airway. In rare cases today, the tube's presence can result in excess
swelling of the folds (inflammation) and, in the case of some long
multiple-hour surgeries, instances of vocal fold nodule formation.

Based on your description of your friend's symptoms, however, I doubt that
vocal fold 'intubation trauma' occurred.

My educated GUESS is that your friend is experiencing a normal healing and
recovery process following her surgery.

CONTEXT. When the human body is deeply 'invaded', surgically or
otherwise, the complete healing and recovery of the affected tissues
always takes quite a long time. In our culture, there seems to be a
desire for fast recovery from any unfortunate happenstance. Add to that
the 'panicked urgency' of a singer who depends on a well-functioning voice
for livlihood or self-identity or both (plus the absence of appropriate
pre- and post-surgical information about healing timelines), and a nearly
predictable, high-distress outcome will be likely.

FIRST POINT OF INFORMATION: The innervation of the larynx includes left-
and right-side sensorimotor nerve bundles that are located just above and
to the sides of thyroid gland. During partial or complete thyroidectomy,
those nerves have to be moved 'out of the way' to optimize their remaining
intact, but their retraction does include some degree of 'stretching'.

The good news is that the retraction of the superior (sometimes) and
recurrent (always) laryngeal nerves almost always results in successful
surgery and the tissues then begin a healing/recovery process that may
last at least two months if not longer.

The bad news is that the nerve tissues may be: (a) injured because they
were 'stretched too much', (b) injured because they were 'compressed too
much' during retraction events, or (c) accidentally severed during the
surgical procedure.

In cases (a) and (b), some of the nerve axons MAY lose their ability to
regenerate themselves into normal function. If enough of them have lost
function, there may be less-than-optimum movement in the vocal fold
closing-opening movements and/or their shortening-lengthening movements.
This condition is referred to as vocal fold paresis (partial paralysis).
Sometimes the injured nerves heal eventually, but if they do, their
healing MAY take longer than other tissues.

In case (c) above, function in the entire severed nerve bundle will be
lost permanently and vocal fold paralysis is the result.

Again, based on your description of your friend's symptoms, my firmly held
educated GUESS is that your friend does not have paralysis of either vocal
fold. There could be some degree of paresis, but IF it is currently
present, I SUSPECT it is temporary and will go away with healing.

Again, I suspect that your friend is experiencing a normal healing and
recovery process following her surgery.

SECOND POINT OF INFORMATION: During this entire pre- and post-surgical
experience, your friend's internal larynx muscles, their activating motor
nerves, their muscle connective tissues, and the vocal folds' cover
tissues, underwent considerable deconditioning. As a result of
deconditioning, her larynx muscles reduced in: (1) strength, (2)
endurance, (3) speed, precision, and smoothness of neuromuscular function,
and (4) bulk. Her connective tissues began to 'shrink'(as their primary
function is to 'hold skeletal parts together'), and her vocal fold cover
tissues 'softened' (became less resilient).

THIRD POINT OF INFORMATION: Before the surgery, the thickened state of
the folds (depending on length of time) necessitated more internal larynx
muscle work during speaking and singing. That can alter the neural
networks in the brain that coordinate vocalization toward 'working the
larynx muscles harder' to do talking and singing. Over a long enough
period of time, the neural networks that 'habitually' or automatically
operate voice would incorporate those 'more work' patterns into vocal
functioning.

Following your friend's surgery, there was a period of rest days for her
neck-throat area, during which, one hopes, silence was recommended ('up-
and-walking' occurred, of course). Rest for the surgical area, including
the silence, was needed to allow an initial 'knitting' or adherence
of 'invaded' tissues.

After a period of initial healing, several very easy sigh-glides may have
been done, or could have been done safely, to begin assessing neural
function for vocalization and to begin a GRADUAL vocal reconditioning
process.

CRUCIAL INFORMATION: As relatively stronger voicing becomes appropriate,
keep in mind that the vocalization networks in your friend's brain will
most likely activate the more recent, harder-working coordination patterns
to produce vocal sound-making, speaking, and singing. AND, her brain's
auditory expectation networks for what her speaking and singing
is 'supposed to sound like' will most likely add to the mix of 'harder-
working' neuromuscular vocal coordinations, but...with underconditioned
vocal 'equipment'. In addition, the relative 'impatience' of many singers
typically means that they will want to somewhat aggressively 'test' their
voices so as to bring back their full array of vocal abilities as soon as
possible.

Following neck/throat surgery, FULL vocal ability recovery must wait until
the laryngeal nerves have fully healed along with the other tissues. AS
TO PITCH RANGE, typically, the FULL return of this capability commonly
takes quite a while--at least about two months--and must be dealt with
carefully and patiently.

That is a MAJOR reason why trained and experienced voice therapists are
greatly needed by singers so they can learn or relearn physically and
acoustically efficient neuromuscular coordinations for both their speaking
and singing abilities.

When singers' laryngeal tissues have done an appropriate degree of
healing, as in your friend's current circumstances, I usually suggest the
following:

1. sing a 5-4-3-2-1 scale pattern on an /uh/ vowel (the 'neutral' vowel),
beginning on an easy comfortable pitch that is in their light upper
register voice quality (often labeled 'head voice'), with mezzo-piano to
mezzo-forte volume.

2. The pattern would then be lowered by 1/2 steps until they sing their
lowest easy comfortable pitch with a light lower register voice quality.

3. Then, sing the same scale pattern starting with the same pitch that the
very first pattern was starten on, but this time, each new scale would
begin 1/2 step higher than the previous one, until they come to pitches
that are effortful.

4. For a few days or a week or so, then, the scale pattern would be sung
upward to the point that just a bit of effort is noticed--but no higher--
with the goal of singing those patterns with ease in the neck/throat
area.

5. Whenever those pitches begin to feel easy, then take the scale higher
by 1/2 steps until a bit of effort happens again (probably no more than
two half-steps), and then that becomes the new upper pitch range limit for
several days to a week or so, until those pitches become easy, and then
the process continues until former pitch range resumes.

If singers try to 'push' their pitch range higher by trying to 'make'
higher pitches come out, then they are 'teaching' their brains'
vocalization networks to sing those pitches that way in the future.

6. During the vocal reconditioning process, singing moderate tempo songs
within the entire easy-comfortable pitch range and with gradually
increasing volume would be great for advancing the conditioning. Within
the current pitch and volume ranges, then, singing relatively short
melissmatic passages with gradually increasing speed, and pitch patterns
of increasingly wider pitch intervals, also would advance vocal
conditioning.

For your friend, PATIENCE, PERSISTENCE, and PERSPICACITY is where 'it'
is 'at'(in reverse order of that listing).

Hope this helps.

Leon Thurman
lthurma1(a)fairview.org


[If you or your friend would like to obtain a book in which information
like the above exists plus a lot more--and in language that is written
with us ordinary folk in mind--I would suggest the following book.

Thurman, L., & Welch, G. (Eds.) (2000). Bodymind and Voice: Foundations
of Voice Education. Collegeville, MN: The VoiceCare Network, National
Center for Voice and Speech, and Fairview Voice Center.

Yes, I am the principal author and co-editor of the book, but I know of no
other publication that presents such an encyclopedic array of science-
based voice, voice medicine, and voice education knowledge that is
reasonably digestible. Three ENT docs, an allergist-immunologist, an
endocrinologist, a speech pathologist/voice specialist, and an audiologist
participated in writing the 14 chapters of the book's "Health and Voice
Protection" section.

Information about and ordering of the book can only be accomplished at the
following website: www.voicecarenetwork.org ]