Clicking Larynx Syndrome after Thyroidectomy: Coincidence or Complication?
- Carlos E Costa Almeida
- 9 de jul.
- 3 min de leitura
Thyroid surgery is one of the most commonly performed procedures in endocrine surgery. Potential complications include recurrent laryngeal nerve (RLN) injury, external branch of the superior laryngeal nerve (EBSLN) injury, vascular injury, hypoparathyroidism, tracheal injury, esophageal injury, and surgical site infection. Although severe complications are uncommon, some may have a significant and lasting impact on patients' quality of life. Recently, while reviewing the literature, I came across a possible new complication that caught my attention. I was genuinely surprised by this case report.
Clicking Larynx Syndrome (CLS) is an extremely rare condition, with only about 20 cases reported in the worldwide literature. It was first described by Dr. R. T. Counter (military surgeon from the UK) in 1978 and is characterized by a clicking sound that occurs during neck movement, swallowing, palpation, or, in rare cases, spontaneously. It can be associated with pain. CLS is a non-malignant condition that is not life-threatening, but can cause anxiety and psychological distress.
CLS is a poorly understood condition. Most reported cases have been associated with previous neck trauma. The proposed underlying mechanisms include a displaced superior cornu of the thyroid cartilage or a reduced distance between the thyroid cartilage and the hyoid bone. Association with thyroidectomy or thyroid cancer is not currently known.
In 2023, Dr. Yumna Njoum and colleagues from Palestine published a case report in the International Journal of Surgery Case Reports describing CLS following thyroidectomy. The patient was a 42-year-old man who had undergone a left hemithyroidectomy three years earlier for papillary thyroid carcinoma (the tumor size was not reported). He complained of a clicking sound, which he stated had first appeared a few days after the thyroidectomy. Neck examination revealed abnormal movement of the thyroid cartilage, producing the clicking sound, with no identifiable provocative factor. Laryngoscopy was unremarkable. Ultrasound and CT with 3D reconstruction demonstrated a normal-sized hyoid bone, a normal distance between the thyroid cartilage and the hyoid bone, a small left thyroid remnant, and a normal right thyroid lobe. Overall, there was no evidence of tumor recurrence or any structural abnormality that could explain the clicking larynx. Additionally, moderate bilateral ossification of the triticeal cartilages was observed. The authors did not consider these ossifications to be the cause of the CLS because, although they have rarely been associated with this syndrome, they are not widely accepted as an isolated etiological factor. Finally, the patient was reassured that his CLS was a benign condition with no evidence of an association with tumor recurrence. This reassurance alleviated his anxiety, and he was discharged home. The authors concluded the case report by stating that the patient continued to experience the clicking symptoms; however, once reassured that they were unrelated to cancer recurrence, he was able to accept them.
CLS has not previously been reported in association with thyroidectomy. Whether this case represents the first reported occurrence remains uncertain. However, as Dr. Yumna Njoum and colleagues suggest, this potential association warrants further investigation through careful observation and follow-up of patients undergoing thyroidectomy. Physical examination, laryngoscopy, and a swallowing laryngeal CT scan are of paramount importance for establishing the diagnosis. When an underlying anatomical or structural abnormality is identified, surgical correction is the treatment of choice.
Therefore, whether Clicking Larynx Syndrome can be associated with thyroidectomy or thyroid cancer remains uncertain. However, this case report raises that possibility, and surgeons should be aware of it. Lack of awareness of this rare condition is one of the main reasons it remains undiagnosed. Ultimately, a condition cannot be diagnosed if it is not recognized, and it cannot be treated if it is not diagnosed. After all, clinicians can only diagnose and treat what they know exists.
Study the textbooks today so that you can recognize tomorrow what you may see only once in a lifetime.
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Dr. Carlos Eduado Costa Almeida
General Surgeon
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