Outcomes and Decision-Making in Older Adults Needing Thyroidectomy

Over 150,000 thyroidectomies are performed annually in the US, of which 25% are performed in older adults (over 65) (1). Older adults pose unique challenges to surgical decision-making as the benefits of surgery must be weighed against surgical risks, co-existing comorbidities, and postoperative quality of life. While single institution studies demonstrate the safety of thyroidectomy in older adults, population based studies cite increased length of stay and complication rates (2-5). Additionally, prior studies demonstrate that older adults tend to undergo less surgery for thyroid cancer and have worse disease-specific survival (6, 7). While the dreaded, classic complication of recurrent or superior laryngeal nerve injury is rare, 30-40% of younger adults with intact nerve function still report clinical sequelae of laryngeal dysfunction such as a change in their voice or dysphagia (8-13). It is not well understood why this occurs or who is at risk for developing these changes. Even less is understood about the impact of thyroidectomy on voice, swallowing, and quality of life (QOL) in older adults, despite the likelihood that older adults are at even greater risk than the younger adults who suffer these sequelae. While, there are no tools to objectively measure laryngeal muscle mass and strength, frailty, in part a sarcopenia phenotype validated in older adults, might serve as a surrogate marker to predict voice and swallowing impairments following thyroidectomy. This thesis attempts to advance our understanding of the outcomes and surgical decision-making in older patients undergoing thyroidectomy. The first contribution of this thesis is to evaluate the impact of thyroidectomy on voice and swallowing in older adults using a prospective longitudinal cohort study. The second contribution is to assess the association between frailty and adverse voice and swallowing outcomes post-thyroidectomy. Identifying at-risk older adults for these sequelae is critical for the development of prophylactic and therapeutic interventions to reduce surgical disability in the many older adults who undergo thyroidectomy. The final contribution of this thesis is to understand surgical decision-making regarding thyroidectomy in older adults utilizing a discrete-choice experiment administered to high-volume endocrine surgeons