Balancing hemostasis and function: the impact of hemostatic materials on voice and swallowing outcomes in nerve-preserved thyroidectomy.

OBJECTIVE

Post-thyroidectomy dysphonia may occur even when recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) integrity are preserved. Hemostatic materials (HMs) are widely used to enhance intraoperative hemostasis and reduce postoperative drainage; however, their use may introduce a functional trade-off between bleeding control and postoperative voice and swallowing outcomes. This study aimed to evaluate how different HMs balance hemostatic efficacy and functional preservation in nerve-preserved total thyroidectomy.

METHODS

This retrospective study included adult patients who underwent primary nerve-preserved total thyroidectomy with standardized intraoperative neuromonitoring (IONM). Patients were categorized into three groups according to HM use: no hemostatic material (NHM), fibrin sealant (Tisseel, TIS), and polysaccharide-based agent (4DryField PH, 4DF). Objective voice parameters and subjective voice and swallowing assessments were obtained preoperatively and at six weeks postoperatively.

RESULTS

175 patients were analyzed (NHM:74/TIS:30/4DF:71), with comparable demographic, surgical, and pathological characteristics among groups. TIS provided the most robust hemostatic effect, with 0% drain placement, but was associated with significantly greater deterioration in pitch-related voice parameters and patient-reported voice outcomes. In contrast, 4DF showed postoperative voice outcomes comparable to NHM and demonstrated a significantly lower incidence of swallowing impairment (p = 0.007).

CONCLUSION

In nerve-preserved total thyroidectomy, hemostatic efficacy and functional preservation exist along a balance rather than a binary choice. Tisseel provides superior bleeding control through robust tissue sealing, however, their strong mechanical restriction on key extralaryngeal muscles may compromise postoperative voice function. 4DF achieves adequate hemostasis while preserving voice and swallowing function. These findings support a personalized, anatomy-aware selection of hemostatic materials, emphasizing functional priorities and precise avoidance of critical voice-related structures, rather than routine or uniform application.