甲状腺切除术后声音恢复模式中患者相关因素与手术因素的交互作用：一项前瞻性队列研究。

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中文摘要

背景： 相当一部分患者在甲状腺切除术后即使没有临床可检测的喉神经损伤，仍会出现持续的声音相关症状。因此，识别与声音恢复延迟相关的因素十分重要，因为术后声音改变可能影响发声表现和职业用声。本研究在六个月的随访期内，考察了患者相关因素（年龄、性别、体重指数[BMI]）和手术变量（甲状腺体积、手术类型和手术持续时间）与术后声音恢复阶段的关联。方法：这项前瞻性队列研究纳入了在三级转诊中心接受甲状腺切除术的292名连续成人患者，其术前声音和喉部检查均正常。既往有颈部手术、既存声音障碍、反流性疾病或术中喉神经损伤的患者被排除。在四个预先设定的术后时间点进行多维客观嗓音评估。恢复阶段按序数定义，依据为首次随访时所有客观嗓音参数均恢复正常。采用多项logistic回归检验BMI与手术变量之间的多变量关联和交互作用。结果：三个回归模型检验了BMI与手术变量之间的交互作用，以恢复阶段4（六个月时仍未恢复正常）为参照类别。所有三个模型均具有统计学意义（χ2(15) ≥ 86.32，p < 0.001）。手术持续时间在各模型中均与恢复阶段独立相关，手术时间越长，相对于阶段4，处于阶段2和阶段3恢复的比值比越低（p ≤ 0.041）。甲状腺体积也与恢复相关，体积越大，相对于阶段4，达到阶段1恢复的比值比越高（p = 0.008）。观察到BMI与手术持续时间之间存在显著交互作用（LR χ2(3) = 12.10，p = 0.007），BMI与手术类型之间也存在显著交互作用（LR χ2(3) = 15.17，p = 0.002），两者均由阶段3与阶段4的比较所驱动。未发现BMI与甲状腺体积之间存在显著交互作用（p = 0.294）。结论：患者相关因素（BMI）和手术因素均与术后声音恢复阶段相关。BMI与恢复之间的关联因手术持续时间和手术类型而异，但不因甲状腺体积而异。这些发现可能支持风险分层和更有针对性的术后客观声音恢复监测。未来需要采用适当序数回归模型和区间删失生存方法的多中心研究，以进一步阐明甲状腺切除术后个体化的恢复模式。

英文摘要

Background: A substantial proportion of patients experience persistent voice-related symptoms after thyroidectomy, even without clinically detectable laryngeal nerve injury. Identifying factors associated with delayed voice recovery is therefore important, as postoperative voice alterations may influence vocal performance and occupational voice use. This study examined the associations of patient-related (age, sex, body mass index [BMI]) and surgical variables (thyroid volume, type, and duration of surgery) with postoperative voice recovery stage within a six-month follow-up period. Methods: This prospective cohort study included 292 consecutive adults undergoing thyroidectomy at a tertiary referral center with normal preoperative voice and laryngeal findings. Patients with prior neck surgery, pre-existing voice disorders, reflux disease, or intraoperative laryngeal nerve injury were excluded. Objective voice assessment was performed multidimensionally at four predefined postoperative time points. The recovery stage was defined ordinally according to the first follow-up demonstrating normalization of all objective voice parameters. Multinomial logistic regression was used to examine multivariable associations and interactions between BMI and surgical variables. Results: Three regression models examined interactions between BMI and surgical variables, with recovery stage 4 (no normalization by six months) as the reference category. All three models were statistically significant (χ2(15) ≥ 86.32, p < 0.001). Duration of surgery was independently associated with recovery stage across models, with longer surgery associated with lower odds of recovery at stages 2 and 3 relative to stage 4 (p ≤ 0.041). Thyroid volume was also associated with recovery, with higher volume associated with greater odds of stage 1 versus stage 4 recovery (p = 0.008). Significant interactions were observed between BMI and duration of surgery (LR χ2(3) = 12.10, p = 0.007) and between BMI and type of surgery (LR χ2(3) = 15.17, p = 0.002), both driven by the comparison of stage 3 with stage 4. No significant interaction was found between BMI and thyroid volume (p = 0.294). Conclusions: Both patient-related (BMI) and surgical factors were associated with postoperative voice recovery stage. The association between BMI and recovery differed according to surgical duration and type, but not thyroid volume. These findings may support risk stratification and more tailored postoperative monitoring of objective postoperative voice recovery. Future multicenter studies using appropriate ordinal regression models and interval-censored survival methods are warranted to further clarify individualized recovery patterns following thyroidectomy.