The surgical approach used in thyroidectomy can significantly impact skin-related quality of life, specifically scarring on the neck.

Patients who underwent transoral endoscopic thyroidectomy had similar long-term health-related QOL as those who had thyroidectomies with a transcervical approach but reported experiencing significantly less skin-related self-consciousness, according to survey findings recently published in Otolaryngology–Head and Neck Surgery.

“Even if patients say they don’t care, a scar on the neck is something that, almost 3 years after the procedure, still bothers some patients,” says Jonathon O. Russell, MD, FACS. “But it can be avoided if patients are interested in avoiding it.”

Russell and colleagues sent web-based surveys to 1,713 patients who underwent either transoral or transcervical resection between August 2017 and October 2021. The researchers used the Short Form Health Survey, the Eating Assessment Tool, Voice Handicap Index, and Dermatology Life Quality Index. All patients underwent surgery a minimum of 6 months before being surveyed.

QOL Between Groups

The response rate was 22% among patients who had transoral surgery (n=108) and 19% among patients who had transcervical surgery (n=129). Respondents had a median age of 44, were primarily women (84%), and were mostly White (76%). The median time between thyroidectomy and the survey was 35 months.

The transoral group had a greater incidence of Graves’ disease (19.4% vs 6.2%; P<0.01) and a lesser incidence of cancer (7.4% versus 18.6%; P<0.01). These differences in groups were consistent with characteristics of patients most likely to choose transoral thyroidectomy, Russell and colleagues note.

Overall, the two groups had similar quality of life scores, the researchers wrote. The transoral group had a Dermatology Life Quality Index mean score of 0.63, compared with 0.99 in the transcervical group. The transoral group had a Voice Handicap Index score of 1.94, whereas the transcervical group’s mean score was 1.67. The mean Eating Assessment Tool score was 2.14 for the transoral group, compared with 2.32 in the transcervical group.

In the Short Form Health Survey’s physical component, the transoral group had a mean score of 52.25, while the transcervical group’s mean score was 51.00. In the mental component, the transoral group had a mean score of 47.74, compared with 47.29 in the transcervical group.

The researchers report that patients in the transcervical group were three times more likely to be self-conscious about their skin than the transoral group as measured by the Dermatology Life Quality Index score (0.26 vs 0.08; P=0.03).

“That’s especially noteworthy because this was a group of patients who self-selected, meaning that patients who had open surgery told us that they didn’t care about their scar,” Dr. Russell explains.

Choosing a Surgical Approach

“Our question when we see patients is, ‘Do you think you will be bothered by having a scar on your neck?’” Dr. Russell continues. “And if they say no, we’re not even going to talk to them about transoral surgery because they don’t care about it. And so even though patients had already told us that they didn’t care about their scar, they were still three times more likely to be self-conscious about their scar after they had one. And that was true almost three years after surgery.”

Dr. Russell added that there were other, more nuanced considerations to take into account.

“Every day when we see patients postoperatively, our patients who are having transoral surgery seem to recover a little bit better,” he says. “Looking at the data, you can see trends in that direction.”

Differences in QOL domains were not statistically significant, Dr. Russell adds, but in the Short Form Health Survey, “in every single domain, the patients who had scarless surgery did better than the patients who had open surgery.”

Both surgeries come with a learning curve for clinicians, Dr. Russell says.

“The difference is that most surgeons learn open thyroid surgery during their training, and most surgeons do not learn transoral thyroid surgery,” he continues. “It just requires an investment of time to learn the technique. Once you have mastered the technique, the difference in operating times and complications, et cetera, is fairly similar [between the two].”