Key Points
Question
What are the risk factors for airway complications after thyroplasty and arytenoid adduction?
Findings
This cohort study using a national inpatient database to evaluate 8626 adults patients (>16 years old) found that advanced age, type of surgery, use of anticoagulant and antiplatelet drugs, chronic pulmonary disease, and metastatic cancer were associated with higher rates of airway complications.
Meaning
These findings suggest that optimized management of anticoagulant and antiplatelet therapy, preoperative risk assessment, and perioperative airway management for chronic pulmonary disease may reduce the risk of airway complications.
Abstract
Importance
Thyroplasty and arytenoid adduction are common phonosurgical procedures that generally have low complication rates. However, although rare, airway complications can be life-threatening, and the risk factors remain unclear.
Objective
To evaluate the short-term risks of airway obstruction and death within 14 days postoperatively associated with thyroplasty and arytenoid adduction, and to identify modifiable risk factors.
Design, Setting, and Participants
This cohort study used data from the Japanese Diagnosis Procedure Combination database to identify eligible participants from among the patients who underwent thyroplasty or arytenoid adduction from July 2010 to December 2021. Multiple regression and time-dependent Cox regression were used to assess risk factors. Data were analyzed from September 2024 to April 2025.
Exposure
Thyroplasty and arytenoid adduction and potential risk factors, including antiplatelet use, gastroesophageal reflux disease, chronic pulmonary disease, and surgical procedures.
Main Outcomes and Measures
Tracheostomy, tracheal intubation, or death within 14 days postoperatively.
Results
The analysis included 8626 patients (mean [SD] age, 60.2 [16.2] years; 3127 female [36.3%] and 5499 male [63.7%]), among whom the overall complication rate was 2.03% and the mortality rate, 0.13%. Multivariable analysis showed a clinically meaningful increase in the risk of airway complications associated with advanced age; complexity of the surgical procedure (arytenoid adduction and type III and IV thyroplasty); continuous use of antiplatelets (adjusted relative risk [aRR], 3.49; 95% CI, 1.28-9.54); resumption of antiplatelets (aRR, 2.86; 95% CI, 0.89-9.19) or anticoagulants on postoperative day 1 (aRR, 3.20; 95% CI, 0.77-13.25); presence of chronic obstructive pulmonary disease; and metastatic cancer.
Conclusions and Relevance
These findings indicate that appropriate management of anticoagulant and antiplatelet therapy, as well as preoperative risk assessment and perioperative airway management for patients with chronic pulmonary disease may help reduce the risk of short-term airway complications after thyroplasty and arytenoid adduction. Individualized risk management in patients undergoing thyroplasty and arytenoid adduction is needed.
This cohort study assesses airway complications after thyroplasty and arytenoid adduction to identify associated risk factors.
Introduction
Thyroplasty and arytenoid adduction are phonosurgical techniques first introduced by Payr in 19151 and refined by Isshiki et al in the 1970s.2,3,4 Thyroplasty and arytenoid adduction are effective in treating vocal cord dysfunction by modifying vocal cord structure. Surgical procedures for thyroplasty are mainly categorized into 4 types: medialization, lateralization, shortening, and lengthening of the vocal folds. Arytenoid adduction can be performed as a standalone procedure or in combination with thyroplasty to optimize vocal fold positioning and closure.5 Although these procedures are generally considered to be safe, they have rare complications such as life-threatening bleeding and laryngeal spasm that can lead to airway obstruction in the short term and implant displacement or extrusion in the long term.6,7,8,9,10
Various risk factors for thyroplasty and arytenoid adduction have been explored. The use of thyroplasty in patients who have undergone irradiation has been extensively examined.10,11,12,13 Although a history of radiation contraindicated thyroplasty in the past,11 in 2014, vocal fold medialization with calcium hydroxylapatite injection was shown to be safe in patients after irradiation therapy.12 In 2016, a small cohort (n = 14) of patients postirradiation also showed no complications.13 The safety of thyroplasty for patients after irradiation was confirmed in a meta-analysis.10 Although other risk factors, such as antiplatelet use or gastroesophageal reflux disease (GERD), were sometimes observed in small cohorts, conclusions could not be made because of the rarity of thyroplasty complications.14,15 In general, thyroplasty and arytenoid adduction are functional surgeries with few complications, but even a few complications of functional surgery are cause for serious concern.
Therefore, we conducted a cohort study using a large national database to determine the short-term safety and risk factors of thyroplasty and arytenoid adduction for airway obstruction and death. Various potential risk factors from previous cohort studies, case reports, and expert opinions were considered.
Methods
This cohort study was approved by the institutional review board of the Institute of Science Tokyo (No. M2000-788). Informed consent was not required because of the study’s secondary use of anonymous administrative data. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
Data Source
We retrospectively collected and analyzed the data of patients who underwent thyroplasty or arytenoid adduction from July 1, 2010, to December 31, 2021, from the Japanese Diagnosis Procedure Combination (DPC) database. The DPC is a national inpatient database with more than 1700 acute care hospitals contributing data during the study period.
Patient Selection
We identified 9754 patients who underwent thyroplasty and arytenoid adduction during hospitalization; outpatient procedures were not included in the DPC database. To clearly define the surgical reason for hospitalization, multiple exclusion criteria were applied (Figure 1). We excluded patients who underwent multiple sequential laryngeal surgical procedures during a single hospitalization, pediatric patients (younger than 16 years), and any patient who experienced airway problems (tracheostomy or tracheal intubation) before thyroplasty or arytenoid adduction. In addition, patients who underwent thyroplasty and arytenoid adduction more than 5 days after the date of admission were excluded to minimize the likelihood of hospitalization for reasons unrelated to the surgical procedure.
Figure 1. Participant Flow Diagram.
Primary Outcome and Baseline Variables
Tracheostomy, tracheal intubation, and death within 14 days postoperatively were defined as short-term airway complications of thyroplasty and arytenoid adduction. The primary outcome was the presence of airway complications.
We collected baseline characteristics from the medical records, including age at admission (categorized as <45, ≥45 to <65, ≥65 to <80, or ≥80 years), sex, body mass index (calculated as weight in kilograms divided by height in meters squared; categorized as <20, ≥20 to <26, or ≥26), smoking status (current/past or never), and Charlson Comorbidity Index (CCI; score 0, 1, or ≥2).16 The CCI is a widely used and validated measure to predict in-hospital mortality for each patient.17 We collected medical history of radiation and chemotherapy against head and neck cancer (yes or no), neck dissection (1 side or both sides), and thyroidectomy (1 side or both sides).6 Data on a history of GERD and preoperative prescription of histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) were collected because GERD was noted as a risk of inspiratory distress after thyroplasty.18
We categorized 3 types of thyroplasty and arytenoid adduction in accordance with Japanese administrative cost classifications (K4001: thyroplasty type I; K4002: arytenoid adduction and thyroplasty types III and IV; and K4003: thyroplasty type II). It should be noted that when thyroplasty type I and arytenoid adduction were performed together, they were recorded under the code K4002. Consequently, we could not distinguish between thyroplasty type III, thyroplasty type IV, arytenoid adduction, and thyroplasty type I combined with arytenoid adduction.
We considered centers of thyroplasty type II certified by the Japan Laryngological Association to be high-volume centers of thyroplasty because the advanced skill of a laryngoplastic surgeon has been shown to be important for preventing surgical complications.14,19 We also collected data on interventions, including anticoagulant and antiplatelet use (no use, continuous use, resumption on the first postoperative day [POD], or resumption on the second POD or more), perioperative antibiotics (yes or no),15,20 and perioperative steroids (yes or no).
Statistical Analysis
Baseline characteristics of patients with and without airway complications were summarized using descriptive statistics, prognostic gradient, and unadjusted relative risk. We performed a multivariable Poisson regression analysis to investigate short-term risk factors of thyroplasty and arytenoid adduction for airway obstruction and death. To account for time-dependent covariates, such as antiplatelet and anticoagulant use, we conducted additional analyses using a time-dependent Cox regression model that validated the consistency of our findings from the multivariable regression analysis.21 As part of our sensitivity analyses, we performed multivariable regression models, including either detailed CCI scores or GERD treatment agents. Smoking status had the maximum percentage of missing values (13.17%); κ-nearest neighbor imputation was performed for missing value completion.22
We considered a significance level of .05 (2-sided) for all statistical analyses. Effect sizes are presented as relative risk with 95% CIs. All statistical analyses were performed using R, version 4.2.2 (R Foundation for Statistical Computing) from September 2024 to April 2025.
Results
The study analysis included 8626 patients (mean [SD] age, 60.2 [16.2] years; 3127 female [36.3%] and 5499 male [63.7%]) who met the inclusion criteria. Participant characteristics, treatment information, and airway complications are presented in Table 1. The overall risk of airway complications was 2.03% (175 patients) and the risk of death was 0.13% (11 patients).
Table 1. Patient and Treatment Characteristics Associated With Airway Complications.
| Characteristic | Patients, No. (%) | Percentage of total | Prognostic gradienta | RR (95% CI) | |
|---|---|---|---|---|---|
| Total (N = 8626) | Airway complication (n = 175) | ||||
| Age group, y | |||||
| <45 | 1539 (17.8) | 17 (9.7) | 1.10 | 1.40 | 1 [Reference] |
| ≥45 to <65 | 2870 (33.3) | 56 (32.0) | 1.95 | 1.77 (1.03-3.03) | |
| ≥65 to <80 | 3619 (42.0) | 87 (49.7) | 2.40 | 2.18 (1.30-3.65) | |
| ≥80 | 598 (6.9) | 15 (8.6) | 2.51 | 2.27 (1.14-4.52) | |
| Sex | |||||
| Female | 3127 (36.3) | 60 (34.3) | 1.92 | 0.17 | 0.92 (0.67-1.25) |
| Male | 5499 (63.7) | 115 (65.7) | 2.09 | 1 [Reference] | |
| BMI | |||||
| <20 | 2577 (29.9) | 47 (26.9) | 1.82 | 0.30 | 1 [Reference] |
| ≥20 to <26 | 4840 (56.1) | 103 (58.9) | 2.13 | 1.17 (0.83-1.64) | |
| ≥26 | 1209 (14.0) | 25 (14.3) | 2.07 | 1.13 (0.70-1.83) | |
| Current/past smoker | |||||
| No | 4608 (53.4) | 91 (52.0) | 1.97 | 0.12 | 1 [Reference] |
| Yes | 4018 (46.6) | 84 (48.0) | 2.09 | 1.06 (0.79-1.42) | |
| Certified facility | |||||
| No | 5574 (64.6) | 110 (62.9) | 1.97 | 0.16 | 1 [Reference] |
| Yes | 3052 (35.4) | 65 (37.1) | 2.13 | 1.08 (0.80-1.46) | |
| Charlson Comorbidity Index score | |||||
| 0 | 6461 (74.9) | 118 (67.4) | 1.83 | 1.14 | 1 [Reference] |
| 1 | 472 (5.5) | 14 (8.0) | 2.97 | 1.62 (0.94-2.80) | |
| ≥2 | 1693 (19.6) | 43 (24.6) | 2.54 | 1.39 (0.98-1.96) | |
| Surgery type | |||||
| Type I | 4643 (53.8) | 40 (22.9) | 0.86 | 2.98 | 1 [Reference] |
| Arytenoid adduction, type III, and type IV | 3799 (44.0) | 134 (76.6) | 3.53 | 4.09 (2.88-5.81) | |
| Type II | 184 (2.1) | 1 (0.6) | 0.54 | 0.63 (0.09-4.56) | |
| Anticoagulants | |||||
| No use | 8491 (98.4) | 169 (96.6) | 1.99 | 100.00 | 1 [Reference] |
| Continuous use | 29 (0.3) | 0 | 0 | NA | |
| Resumption on POD 1 | 34 (0.4) | 2 (1.1) | 5.88 | 2.96 (0.76-11.43) | |
| Resumption on POD ≥2 | 68 (0.8) | 0 | 0 | NA | |
| Resumption after complications | 4 (0) | 4 (2.3) | 100.00 | 50.24 (43.28-58.33) | |
| Antiplatelets | |||||
| No use | 8196 (95.0) | 152 (86.9) | 1.85 | 99.66 | 1 [Reference] |
| Continuous use | 63 (0.7) | 4 (2.3) | 6.35 | 3.42 (1.31-8.95) | |
| Resumption on POD 1 | 57 (0.7) | 3 (1.7) | 5.26 | 2.84 (0.93-8.63) | |
| Resumption on POD ≥2 | 295 (3.4) | 1 (0.6) | 0.34 | 0.18 (0.03-1.30) | |
| Resumption after complications | 15 (0.2) | 15 (8.6) | 100.00 | 53.92 (46.06-63.12) | |
| Antibiotics | |||||
| No | 1037 (12.0) | 17 (9.7) | 1.64 | 0.44 | 1 [Reference] |
| Yes | 7589 (88.0) | 158 (90.3) | 2.08 | 1.27 (0.77-2.09) | |
| Steroids | |||||
| No | 4988 (57.8) | 80 (45.7) | 1.60 | 1.01 | 1 [Reference] |
| Yes | 3638 (42.2) | 95 (54.3) | 2.61 | 1.63 (1.21-2.19) | |
| Gastroesophageal reflux | |||||
| No | 8051 (93.3) | 160 (91.4) | 1.99 | 0.62 | 1 [Reference] |
| Yes | 575 (6.7) | 15 (8.6) | 2.61 | 1.31 (0.78-2.21) | |
| Head and neck radiation therapy | |||||
| No | 8390 (97.3) | 174 (99.4) | 2.07 | 1.65 | 1 [Reference] |
| Yes | 236 (2.7) | 1 (0.6) | 0.42 | 0.20 (0.03-1.45) | |
| Head and neck chemotherapy | |||||
| No | 8276 (95.9) | 172 (98.3) | 2.08 | 1.22 | 1 [Reference] |
| Yes | 350 (4.1) | 3 (1.7) | 0.86 | 0.41 (0.13-1.28) | |
| Neck dissection | |||||
| None | 8104 (93.9) | 170 (97.1) | 2.10 | 1.37 | 1 [Reference] |
| 1 Side | 274 (3.2) | 2 (1.1) | 0.73 | 0.35 (0.09-1.40) | |
| Both sides | 248 (2.9) | 3 (1.7) | 1.21 | 0.58 (0.19-1.79) | |
| Thyroidectomy | |||||
| None | 8531 (98.9) | 174 (99.4) | 2.04 | 2.04 | 1 [Reference] |
| 1 Side | 75 (0.9) | 1 (0.6) | 1.33 | 0.65 (0.09-4.61) | |
| Both sides | 20 (0.2) | 0 | 0 | NA | |
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); NA, not applicable; POD, postoperative day; RR, relative risk.
Prognostic gradient is the absolute difference in complication rates between the highest- and lowest-risk groups.
Multivariable analysis was used to identify risk factors for airway complications (Table 2). The continuous use of antiplatelets (adjusted relative risk [aRR], 3.49; 95% CI, 1.28-9.54) and resumption of antiplatelets (aRR, 2.86; 95% CI, 0.89-9.19) and anticoagulants on POD 1 (aRR, 3.20; 95% CI, 0.77-13.25) were associated with a clinically meaningful increase in the risk of airway complications. However, the wide confidence intervals and lack of precision in the estimates given the small number of events precluded definitive conclusions about the true magnitude of the effect. Compared with those who underwent thyroplasty type I, patients who underwent arytenoid adduction, thyroplasty type III, and thyroplasty type IV had a very large increase in the risk of airway complications (aRR, 4.28; 95% CI, 2.92-6.29). Although complication rates were higher for arytenoid adduction, thyroplasty type III, and type IV than for type I, the mortality rate was paradoxically higher for type I (complication: 3.53% vs 0.86%; mortality: 0.05% vs 0.19%). Airway complications also increased among patients with comorbidities, although the relationship between the increasing severity of a comorbidity and increasing risk of complications was not observed, and the imprecision in the estimate precluded definitive conclusions. Compared with patients younger than 45 years, those aged 45 to less than 65, 65 to less than 80, and 80 years or older had an increased risk of airway complications (aRR, 1.62; 95% CI, 0.92-2.85; aRR, 2.12; 95% CI, 1.23-3.67; and aRR, 2.30; 95% CI, 1.11-4.75, respectively). No definitive associations were observed for GERD (aRR, 0.82; 95% CI, 0.47-1.42) or history of head and neck radiation (aRR, 0.40; 95% CI, 0.04-3.64).
Table 2. Multivariate Poisson Regression Models for Prognostic Variables Associated With Airway Complications Within 14 Days Postoperatively.
| Characteristic | Multivariable, RR (95% CI) |
|---|---|
| Age group, y | |
| <45 | 1 [Reference] |
| ≥45 to <65 | 1.62 (0.92-2.85) |
| ≥65 to <80 | 2.12 (1.23-3.67) |
| ≥80 | 2.30 (1.11-4.75) |
| Sex (female/male) | 1.05 (0.73-1.52) |
| BMI | |
| <20 | 1 [Reference] |
| ≥ 20 to <26 | 1.06 (0.75-1.50) |
| ≥ 26 | 1.08 (0.66-1.77) |
| Current/past smoker | 1.06 (0.75-1.50) |
| Certified facility | 0.82 (0.59-1.14) |
| Charlson Comorbidity Index score | |
| 0 | 1 [Reference] |
| 1 | 1.61 (0.92-2.83) |
| ≥2 | 1.14 (0.79-1.66) |
| Surgery type | |
| Type I | 1 [Reference] |
| Arytenoid adduction, type III, and type IV | 4.28 (2.92-6.29) |
| Type II | 1.05 (0.14-7.92) |
| Anticoagulants | |
| No use | 1 [Reference] |
| Continuous use | 0 (0-Inf)a |
| Resumption on POD 1 | 3.20 (0.77-13.25) |
| Resumption on POD ≥2 | 0 (0-Inf)a |
| Resumption after complications | 36.23 (12.83-102.32) |
| Antiplatelets | |
| No use | 1 [Reference] |
| Continuous use | 3.49 (1.28-9.54) |
| Resumption on POD 1 | 2.86 (0.89-9.19) |
| Resumption on POD ≥2 | 0.16 (0.02-1.12) |
| Resumption after complications | 45.12 (25.32-80.40) |
| Antibiotics | 1.18 (0.71-1.98) |
| Steroids | 1.02 (0.75-1.40) |
| Gastroesophageal reflux | 0.82 (0.47-1.42) |
| Head and neck radiation therapy | 0.40 (0.04-3.64) |
| Head and neck chemotherapy | 1.47 (0.39-5.52) |
| Neck dissection | |
| None | 1 [Reference] |
| 1 Side | 0.48 (0.12-1.96) |
| Both sides | 1.07 (0.33-3.46) |
| Thyroidectomy | |
| None | 1 [Reference] |
| 1 Side | 0.98 (0.14-7.04) |
| Both sides | 0 (0-Inf)a |
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); POD, postoperative day; RR, relative risk.
Inf suggests divergence or an excessively large value, whereas relative risk of 0 indicates a lack of observed events in the relevant category.
Sensitivity Analysis
We conducted 3 sensitivity analyses based on the main results. First, we used person-year and time-dependent Cox regression models to consider time-dependent covariates such as antiplatelet and anticoagulant use (Figure 2). The results of the time-dependent Cox regression model were consistent with the main results (continuous use of antiplatelets: adjusted hazard ratio [aHR], 3.66; 95% CI, 1.30-10.32; resumption of antiplatelet therapy on POD 1: aHR, 7.91; 95% CI, 2.48-25.18). Second, we grouped the data by CCI score and considered the top 10 factors affecting the CCI. Patients with metastatic cancer and chronic pulmonary disease had a much greater risk of airway complications in the analysis based on CCI score (Table 3). We conducted an additional multivariable regression analysis specifically on patients who underwent surgery under local anesthesia (aRR, 2.26; 95% CI, 0.86-5.96). Third, we identified a moderate reduction in complications associated with PPIs (aRR, 0.63; 95% CI, 0.35-1.12) and a slight increase associated with H2RAs (aRR, 1.06; 95% CI, 0.44-2.54); however, in both cases the number of events and imprecision in the effect size estimates precluded definitive conclusions (eTable 2 in Supplement 1).
Figure 2. Cumulative Airway Complication and Antiplatelet Resumption, on Postoperative Day (POD).
Table 3. Multivariate Poisson Regression Models of Top 10 Segmentalized Comorbidities for Prognostic Variables Associated With Airway Complications Within 14 Days Postoperativelya.
| Comorbidity | Multivariable RR (95% CI) |
|---|---|
| Congestive heart failure | 0.78 (0.32-1.93) |
| Peripheral vascular disease | 0.66 (0.30-1.44) |
| Cerebrovascular disease | 1.30 (0.58-2.93) |
| Chronic pulmonary disease | 1.79 (1.05-3.05) |
| Peptic ulcer disease | 1.12 (0.58-2.17) |
| Mild liver disease | 1.64 (0.60-4.45) |
| Diabetes without chronic complication | 1.07 (0.63-1.80) |
| Kidney disease | 1.82 (0.66-4.99) |
| Cancer | 0.63 (0.39-1.01) |
| Metastatic cancer | 3.44 (1.92-6.17) |
Abbreviation: RR, relative risk.
Full results are provided in eTable 1 in Supplement 1. Model adjusted for age, sex, body mass index, current/past smoker, certified facility, type of operation, anticoagulants, antiplatelets, antibiotics, steroids, gastroesophageal reflux, head and neck radiation therapy, head and neck chemotherapy, neck dissection, and thyroidectomy.
Discussion
In this large-scale retrospective cohort study, we examined risk factors for thyroplasty and arytenoid adduction using a national inpatient database in Japan. The mortality and airway complication rates were low, which was consistent with previous reports.23 Our multivariable analysis revealed several factors associated with risk of airway complications. Specifically, advanced age, surgery type, and anticoagulant (resumption after POD 1, resumption after complications) and antiplatelet (continuous, resumption after POD 1, resumption after complications) use were associated with a higher likelihood of airway complications. These results may provide a foundation for developing targeted interventions to mitigate airway complications and enhance the safety of functional surgical procedures.
Antiplatelet use and the resumption of antiplatelet therapy on POD 1 were associated with more airway complications, as mentioned in a previous report.15 The time-dependent Cox regression model demonstrated similar trends. Furthermore, most airway complications occurred by POD 1 (eTable 2 in Supplement 1), and patients who resumed antiplatelet therapy by POD 3 experienced no adverse events associated with antiplatelet withdrawal (eTable 3 in Supplement 1). Hence, if cessation is feasible, patients taking routine antiplatelet medications should discontinue treatment before surgery and resume it on POD 2 or 3. The resumption of anticoagulant on POD 1 was also associated with an increase in airway complications, although this could not be verified because of the low usage rates.
Arytenoid adduction, thyroplasty type III, and thyroplasty type IV were clearly associated with airway complications as mentioned in previous reports.7,24 Importantly, rates of airway intervention observed in our study were generally comparable to those reported in prior literature, and the mortality rate remained low across these procedures. However, patients who underwent thyroplasty type I had a higher mortality rate than those who underwent arytenoid adduction, thyroplasty type III, or thyroplasty type IV, despite a relatively lower frequency of airway interventions than in procedures such as arytenoid adduction. This paradoxical finding suggests an underestimation of potential risk, possibly owing to the widespread perception that type I thyroplasty is a relatively safe procedure.6,7 These results highlight the importance of preoperative evaluation of surgical indications for patients with substantial comorbidities. Patient education on postoperative vocal rest and early recognition of laryngeal symptoms is also crucial.
Metastatic cancer and chronic pulmonary diseases were associated with higher rates of airway complications. We also performed a subgroup analysis focusing on patients who underwent thyroplasty and arytenoid adduction with local anesthesia because chronic pulmonary disease was associated with an increased risk of airway complications following general anesthesia.25,26 Chronic pulmonary disease showed an increase in the risk of airway complications in the subgroup analysis of patients treated with local anesthesia, although the estimate was imprecise and consequently, no definitive conclusions can be made. The observed increase, if true, may reflect underlying airway vulnerability, possibly related to airway hyperresponsiveness in asthma or excessive secretions and impaired clearance in chronic pulmonary disease.26,27 Future studies are warranted to clarify these potential mechanisms.
Our findings that advanced age and metastatic cancer were associated with increased risk of airway complications were consistent with previous reports indicating that a poor systemic condition could increase the likelihood of postoperative complications.28,29 GERD was associated with a slight reduction in airway complication, but the imprecision of the estimate prevents definitive conclusions. These findings are contrary to those of a previous case report, which suggested that GERD was associated with airway complications.18 The use of PPIs was associated with a reduction in airway complications, although no definitive conclusions can be made. It is unlikely that there was a reversal of causality related to medications for preventing gastric ulcers during mechanical ventilation because PPIs and H2RAs were detected as preoperative routine medications. Several studies have reported that GERD may exert harmful effects on the larynx through acid exposure, highlighting the potential benefit of appropriate treatment, such as PPIs.30,31,32,33 A possible explanation for these patterns may lie in clinical practices in Japan. The estimated prevalence of GERD is approximately 15%, and a substantial number of cases are thought to be underdiagnosed.34 It is not uncommon for patients with nonspecific upper gastrointestinal symptoms, such as heartburn or epigastric discomfort, to be treated empirically with H2RAs,35 despite clinical guidelines recommending PPIs as the first-line treatment.36,37 This potential deviation from evidence-based practice could produce suboptimal acid suppression in some cases, possibly contributing to airway vulnerability, particularly during the perioperative period. Although these findings were exploratory and not conclusive, they suggested that the relationship between GERD treatment and airway complications warrants further investigation, particularly with attention to diagnostic accuracy and appropriate therapeutic selection.
A history of irradiation and other treatments for head and neck cancer was not associated with airway complications, consistent with the findings of recent reports.6,10,12,13 Although a history of irradiation was once considered to be a contraindication, our results provided further reassurance regarding the safety of thyroplasty and arytenoid adduction in patients with a history of head and neck cancer.
These study findings underscore the importance of addressing key risk factors through improved perioperative management protocols (eg, optimization of anticoagulant and antiplatelet resumption timing), implementation of preoperative risk assessment, and careful airway management in patients with chronic pulmonary disease. Further investigations are required to explore strategies for optimizing antiplatelet withdrawal schedules. In addition, for GERD, which has been previously reported as a risk factor,18 its impact should be assessed by considering whether appropriate treatment has been administered. Establishing standardized protocols and increasing evidence on the safety of thyroplasty and arytenoid adduction may contribute to safer implementation and improved perioperative management of these procedures.
Limitations
This study has several limitations. First, the database does not contain hour-level and minute-level time stamps. Consequently, we could not determine whether tracheotomy was performed as a preventive measure when it occurred on the same day as thyroplasty or arytenoid adduction. We confirmed the consistency of the main outcomes in a sensitivity analysis limited to events occurring on POD 1. Second, we defined the use of antibiotics and steroids based on administration on the day of surgery to capture perioperative interventions. However, due to the unavailability of the precise timing of medication administration, some steroids may have been administered postoperatively in response to complications such as laryngeal edema. Third, rehospitalization information for each individual was limited to the same hospital, and our cohort was restricted to inpatient records without corresponding outpatient data because of the nature of the database record. Fourth, our database did not include information on the type of material inserted into the vocal folds, which previous reports have identified as a potential factor for long-term complications.15,38 Fifth, we could not consider the radiation field and cumulative dose because the DPC database included the disease name but not the irradiated field. Sixth, we could not confirm whether appropriate withdrawal periods for antiplatelet and anticoagulant agents were followed. Failure to ensure sufficient withdrawal periods can lead to an overestimation of the relative risk for antiplatelet and anticoagulant use. Seventh, antiplatelet and anticoagulant resumption has a potentially immortal time bias. In the main analysis, we initially used a multivariable regression model to treat patients who used the drug after tracheostomy or tracheal intubation. We performed a time-dependent Cox regression analysis in the sensitivity analysis to address immortal time bias. Finally, the administrative nature of the DPC database prevented us from observing detailed clinical courses individually. Therefore, airway complications or deaths may not necessarily be attributable to surgical manipulation alone. Some cases may have involved airway interventions, such as tracheostomy, due to complications including aspiration rather than bleeding or infection. This means our reported complication rates may overestimate the true incidence of surgery-related airway events. Although the overall complication and mortality rates observed were not substantially different from those reported in the literature, these outcomes do not necessarily reflect airway complications directly caused by surgical procedures. This limitation should be considered when interpreting the associations between surgery and outcomes.
Conclusions
The findings of this cohort study suggest that patients taking routine anticoagulation and antiplatelet medications should withhold these prior to thyroplasty and arytenoid adduction. Anticoagulation and antiplatelet medications can be resumed on POD 2 or 3. Perioperative management of chronic pulmonary disease, including preoperative risk assessment and careful airway monitoring, may help reduce the risk of airway complications. Additional research is warranted to optimize the safety of thyroplasty and arytenoid adduction.
eTable 1. Multivariate regression models including top 10 segmentalized comorbidities for prognostic variables associated with airway complications within 14 days postoperatively
eTable 2. Multivariate regression models including preoperative prescription of histamine-2 receptor antagonists and proton pump inhibitors for prognostic variables associated with airway complications within the 14 days postoperatively
eTable 3. Distribution of airway complications by antiplatelet therapy status and postoperative day
eTable 4. Incidence of adverse events by resumption day of antiplatelet therapy status
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Multivariate regression models including top 10 segmentalized comorbidities for prognostic variables associated with airway complications within 14 days postoperatively
eTable 2. Multivariate regression models including preoperative prescription of histamine-2 receptor antagonists and proton pump inhibitors for prognostic variables associated with airway complications within the 14 days postoperatively
eTable 3. Distribution of airway complications by antiplatelet therapy status and postoperative day
eTable 4. Incidence of adverse events by resumption day of antiplatelet therapy status
Data Sharing Statement
