Introduction
Anterior cervical discectomy and fusion (ACDF) is one of the most performed surgical procedures for cervical spine pathology. In the United States, over 132,000 procedures are performed annually, and the number is projected to grow over the next two decades.Reference Saifi, Fein, Cazzulino, Lehman, Phillips and An1, Reference Song and Choi2 This procedure employs an anterior approach through horizontal or longitudinal incisions, providing access to the vertebral bodies and intervertebral discs, enabling discectomy and fusion with minimal disruption to the posterior musculature.Reference Song and Choi2
While ACDF is typically effective and safe, complications such as dysphagia, dysphonia and recurrent laryngeal nerve (RLN) injury can arise.Reference Yee, Swong and Park3 Dysphonia, or voice alteration following ACDF, remains an under-recognised and under-reported complication due to inconsistent screening and diagnostic protocols. Jung et al. recently published a systematic review showing the vast discrepancy in the literature regarding the incidence of post-operative dysphonia following ACDF.Reference Jung, Xavier, Wu, Schwartz, Kominsky and Fourman4 This variability may be the result of the use of different outcome measures to define dysphonia. While many of the included studies used perceived symptoms of hoarseness as their primary outcome, others defined it based on RLN injury and vocal fold paralysis. Across retrospective and prospective studies, the reported incidence rates of RLN injury vary widely, ranging from 0.1 per cent to 60.9 per cent, depending on study design, diagnostic modality and cohort characteristics. The pooled incidence rates are 1.2 per cent for retrospective studies and 2.2 per cent for prospective ones.Reference Yee, Swong and Park3, Reference Chandra, Vaishnav, Urakawa, Mok, Dupont and Colaizzo5, Reference Oh, Dibas, Ghozy, Mobbs, Phan and Faulkner6
The proposed underlying pathophysiology of dysphonia post-ACDF is multifactorial and includes trauma from endotracheal intubation, RLN injury during surgery, pressure on RLN branches from the endotracheal tube and cuff, post-operative oedema or haematoma, fibrous tissue formation and compression from spacers and/or implants.Reference Ghanayem7 Currently, there is no consensus protocol or guidelines for assessing post-ACDF dysphonia. Moreover, a recent systematic review highlighted significant methodological limitations in the existing literature, noting that most studies are retrospective with small sample sizes, and nearly half relied on unvalidated patient-reported outcome measures, with inconsistent use of objective instrumental evaluations.Reference Jung, Xavier, Wu, Schwartz, Kominsky and Fourman4 Ideally, dysphonia symptoms should be identified using a combination of psychometrically validated patient-reported outcome measures, such as the Voice Handicap Index (VHI-10), and instrumental assessments like laryngoscopy, which allows for indirect visualisation of the larynx.Reference Rosen, Lee, Osborne, Zullo and Murry8, Reference Sinclair, Bumpous, Haugen, Chala, Meltzer and Miller9
Dysphonia is a heterogeneous construct encompassing both subjective patient-reported symptoms and objectively measured vocal fold dysfunction. Importantly, diagnosis codes for dysphonia in administrative datasets typically reflect symptoms rather than confirmed physiologic impairments. Prior work has demonstrated that objective acoustic or laryngoscopic findings may correlate poorly with a patient’s self-reported voice-related handicap or functional status. This distinction is essential for interpreting dysphonia-related coding data and accurately assessing prevalence, risk and care delivery patterns in post-operative ACDF populations.Reference Francis, Daniero, Hovis, Sathe, Jacobson and Penson10
Existing studies evaluating risk factors for dysphonia post-ACDF, such as patient sex, surgical level and previous operations, are often limited by small sample sizes and retrospective designs, preventing generalisable conclusions.Reference Jung, Xavier, Wu, Schwartz, Kominsky and Fourman4, Reference Oh, Dibas, Ghozy, Mobbs, Phan and Faulkner6, Reference Gowd, Vahidi, Magdycz, Zollinger and Carmouche11 Given the limitations of the current literature and the increasing volume of ACDF surgeries performed annually, this study aims to investigate post-ACDF dysphonia incidence, identify associated risk factors and evaluate diagnostic and therapeutic intervention patterns using a large national cohort.
Materials and methods
Database and data collection
This retrospective cohort study was conducted using data from the Mariners dataset from the PearlDiver Patient Records Database (Colorado Springs, CO; www.pearldiverinc.com). The dataset contains information on de-identified insurance claims from over 151 million patients in the United States, spanning from 2010 to 2022. Institutional review board approval was not necessary as the data were de-identified. This information was sourced from all payer types, including commercial insurance, Medicare, Medicaid and self-pay. International Classification of Diseases versions 9 and 10 (ICD-9 and ICD-10) and Current Procedural Terminology (CPT) codes were used to retrieve patient records.
Inclusion criteria were adult patients (≥18 years old) undergoing primary ACDF between the years 2010 and 2022 without a preexisting diagnosis of dysphonia by ICD-9 and ICD-10 coding. Patients undergoing revision ACDF surgery or with a pre-existing dysphonia diagnosis code were excluded. Patients meeting the inclusion criteria were divided into two cohorts, consisting of those with a new post-operative ACDF surgery code for dysphonia and those without ICD-9 or ICD-10 codes for dysphonia following primary ACDF. The timing of new coding for dysphonia was assessed and categorised into three groups: 0–6 months, 6–12 months and more than 12 months following the date of primary ACDF surgery. Demographic data of interest, including age, sex, comorbidities (smoking, diabetes mellitus, obesity) and prior neck surgery (thyroid surgery, carotid endarterectomy), were collected for every patient meeting the inclusion criteria. Intra-operative and post-operative outcomes tested included multi-level ACDF, adjacent segment disease, pseudoarthrodesis and vocal fold paralysis. Dysphonia-related interventions were also compared between post-ACDF dysphonia and non-dysphonia groups and included pre- and post-laryngoscopy and voice therapy.
Statistical analysis
Odds ratios (ORs) with 95 per cent confidence intervals were calculated, stratifying the cohorts by various patient-specific and procedure-specific risk factors. Incidence was defined as the first occurrence of a dysphonia diagnosis ICD code post-operatively, while the prevalence was calculated for procedures and services using CPT and ICD-9 and ICD-10 codes. Incidence rates by post-operative time interval were calculated by dividing the number of patients with a new, first-time code for dysphonia during each defined window (0–6 months, 6–12 months and >12 months from date of surgery) by the total study population of patients undergoing primary ACDF (n = 618,170). Univariate analyses were conducted to identify associations between patient- and surgery-level characteristics and the development of post-operative dysphonia. A conservative p-value threshold of less than 0.01 was used to minimise risk of Type I error given large sample size. Multivariate modelling was not performed due to the limitations of coding-based administrative data and the primary aim of generating unadjusted, hypothesis-generating associations rather than establishing independent predictors. All statistical analyses were conducted using the R version 4.2.1 statistical software integrated within PearlDiver with the following packages: dplyr, stats, ggplot2 as well as with Microsoft™ Excel version 16.94.
Results
Between 2010 and 2022, a total of 618,170 patients who underwent primary ACDF were identified. Of these, complete data were not available for 4,192 patients; thus, 613,978 were included for final analysis (Table 1). Overall, 16,063 (2.6%) patients were found with a new post-ACDF ICD code for dysphonia. Within this group of patients with a new dysphonia code post-operatively, 15,666 had data regarding the timing of diagnosis available, of which 2,928 (18.7%) patients were diagnosed with dysphonia in the first 6 months following ACDF surgery, 1,271 (8.1%) between 6 and 12 months and 11,467 (73.2%) more than 12 months post-operatively (Figure 1).
Within the group of patients with a new dysphonia code post-operatively, 15,666 had data available regarding the timing of diagnosis.
Figure 1 Long description
The bar graph has the x axis label is Postoperative time interval left parenthesis months right parenthesis. The x axis categories are 0 dash 6, 6 dash 12 and greater than 12. The y axis label is Number of patients. The y axis ranges from 0 to 14,000 with tick marks at 0, 2,000, 4,000, 6,000, 8,000, 10,000, 12,000 and 14,000. Three vertical bars are shown. The bar for 0 dash 6 is labeled 2,928. The bar for 6 dash 12 is labeled 1271. The bar for greater than 12 is labeled 11,467.
Demographics of patients undergoing primary anterior cervical discectomy and fusion (ACDF) surgery
Table 1 Long description
The table summarizes patient demographics and selected health factors for people undergoing primary ACDF surgery, reported as counts and percentages. Age was concentrated in middle and older adulthood: 50 to 64 years was the largest group at 279,133 (45.5 percent), followed by 20 to 49 years at 186,183 (30.3 percent) and 65 to 79 years at 143,135 (23.3 percent). Very few patients were 19 years or younger at 968 (0.2 percent) or 80 years or older at 4,372 (0.7 percent). Sex distribution showed more females than males, with 328,759 females (53.5 percent) and 285,219 males (46.5 percent). Common comorbidities included smoking at 182,270 (29.7 percent), diabetes at 173,373 (28.2 percent), and obesity at 129,548 (21.1 percent). Prior related surgical history was uncommon, including thyroid surgery at 2,421 (0.4 percent) and carotid endarterectomy at 834 (0.1 percent). Percentages may not sum to 100 across sections because categories represent different characteristics rather than a single breakdown.
Demographic data is detailed in Table 1. Patients aged 50–64 years represented the largest age group, comprising 45.5 per cent of the overall cohort, followed by those aged 20–49 years (30.3%) and 65–79 years (23.3%). Most patients were female (53.5%). Among comorbidities, smoking was the most frequently reported (29.7%), followed by diabetes mellitus (28.2%) and obesity (21.1%).
Patients aged 50–64 and 65–79 years had higher odds of developing post-ACDF dysphonia compared to other age groups (p < 0.0001) (Table 2). In contrast, patients under age 50 had significantly lower odds, with the lowest odds observed in those aged less than or equal to 19 years (OR 0.39; 95 per cent CI 0.21–0.72). Female sex (OR 1.43; 95 per cent CI 2.96-3.16; p < 0.0001), smoking (OR 2.41; 95 per cent CI 2.33–2.49), obesity (OR 2.80; 95 per cent CI 2.71–2.89) and diabetes mellitus (OR 1.89, 95 per cent CI 1.83–1.95) were all associated with significantly increased odds of having a new dysphonia code post-ACDF (p < 0.0001). Additionally, a history of thyroid surgery (OR 4.48; 95 per cent CI 3.93–5.10) and carotid endarterectomy (OR 1.61; 95 per cent CI 1.48–1.75) were also associated with higher odds of dysphonia following ACDF.
Demographic data stratified by cohort with associated odds ratio for dysphonia diagnosis
Table 2 Long description
The table compares people who developed dysphonia after ACDF with those who did not, reporting counts, percentages, and odds ratios with confidence intervals for age, sex, and selected comorbidities and surgical history. The strongest association is a history of thyroid surgery, which is much more common in the dysphonia group and corresponds to markedly higher odds. Obesity, smoking, and diabetes are also substantially more frequent among those with dysphonia and each is associated with higher odds. By age, dysphonia is less likely in children and in adults ages 20 to 49, but more likely in adults ages 50 to 64 and 65 to 79; the oldest group shows little difference. Females make up a larger share of the dysphonia group than the no dysphonia group, while males make up a smaller share. A history of carotid endarterectomy is uncommon but is associated with higher odds of dysphonia. Most reported associations are statistically significant, but odds ratios describe association rather than causation and may be influenced by confounding factors.
ACDF = anterior cervical discectomy and fusion; CI, confidence interval.
* p < 0.0001.
Table 3 presents procedure related CPT and ICD-9/ICD-10 codes of interest, along with associated odds ratios for new dysphonia codes following ACDF. Approximately one-third of the total cohort (36.7 per cent) underwent multiple-level ACDF, defined as a fusion involving two or more spinal levels. Multiple-level ACDF was associated with an increased odds of receiving a dysphonia diagnosis code after ACDF (OR 1.20; 95 per cent CI 1.17–1.24; p < 0.0001). Diagnosis of post-ACDF pseudoarthrodesis or adjacent segment disease was also associated with an increased odds of receiving a dysphonia diagnosis code (OR 2.00; 95 per cent CI 1.86–2.15; and OR 1.61; 95 per cent CI 1.48–1.75, respectively). The rate of post-operative vocal fold paralysis in patients assigned a new ICD code for dysphonia after ACDF was 1.9 per cent, compared to 0.4 per cent of patients without a new dysphonia diagnosis code (OR 5.42, 95 per cent CI 4.80–6.12; p < 0.0001).
Procedure-related variables of interest with associated odds ratio for dysphonia
Table 3 Long description
The table compares procedure-related factors between ACDF patients who developed postoperative dysphonia and those who did not, and reports odds ratios with confidence intervals. Postoperative vocal fold paralysis occurs in 1.9 percent of patients with dysphonia versus 0.4 percent without, and shows the strongest association with dysphonia, with an odds ratio about 5.4. Pseudoarthrodesis is 5.0 percent with dysphonia versus 2.6 percent without, with an odds ratio about 2.0. Adjacent segment disease is 3.5 percent with dysphonia versus 2.2 percent without, with an odds ratio about 1.6. Multi-level ACDF is 41.0 percent with dysphonia versus 36.6 percent without, with an odds ratio about 1.2. All listed factors are more frequent in the dysphonia group, and the odds ratios indicate association rather than proof of causation.
ACDF = anterior cervical discectomy and fusion; CI, confidence interval.
* p < 0.0001.
Table 4 presents post-operative dysphonia-related diagnostic and therapeutic interventions. Among patients with a new dysphonia code post-ACDF, only 52.7 per cent underwent post-operative laryngoscopy or stroboscopy, 15.0 per cent received voice therapy and 0.7 per cent underwent injection laryngoplasty.
Pre- and post-operative interventions of interest and odds ratios
Table 4 Long description
The table compares how often three post-operative interventions occurred in people with and without dysphonia after ACDF, and reports odds ratios with confidence intervals. Laryngoscopy or stroboscopy was used in 8,466 of 16,063 dysphonia cases (52.7%) versus 21,724 of 597,915 without dysphonia (3.6%), corresponding to about 29.6 times higher odds. Laryngoplasty was rare overall but much more concentrated in the dysphonia group: 113 cases (0.7%) versus 10 cases (less than 0.01%), with an odds ratio about 423.6. Voice therapy occurred in 2,414 dysphonia cases (15.0%) versus 4,714 without dysphonia (0.8%), about 22.3 times higher odds. Across all three interventions, the dysphonia group consistently shows substantially higher utilization than the no-dysphonia group. Odds ratios describe association rather than causation, and the laryngoplasty estimate is based on very small counts in the no-dysphonia group, which can make it less stable.
ACDF = anterior cervical discectomy and fusion; CI, confidence interval.
* p < 0.0001.
Discussion
Voice problems affect one in 13 adults annually, yet a relatively small minority seek healthcare for their voice issues, despite the significant subjective impact these problems have on individuals.Reference Bhattacharyya12 Patient’s report of dysphonia is generally assessed by history and physical examination, including diagnostic laryngoscopy.Reference Stachler, Francis, Schwartz, Damask, Digoy and Krouse13
Dysphonia following ACDF is an under-recognised yet clinically significant complication. The risk factors for post-ACDF dysphonia have been investigated across numerous studies and systematic reviews.Reference Jung, Xavier, Wu, Schwartz, Kominsky and Fourman4, Reference Oh, Dibas, Ghozy, Mobbs, Phan and Faulkner6 A recent meta-analysis of 222 studies reported a pooled hoarseness rate of 2.3 per cent, consistent with the 2.6 per cent incidence observed in our cohort, supporting the validity of large-scale administrative data for studying this complication.Reference Tavanaei, Ansari, Hatami, Heidari, Dehghani and Hajiloo14 Beyond corroborating established risk factors, the present study uniquely examines delayed dysphonia diagnosis coding patterns and documents the low rates of laryngoscopic evaluation and therapeutic intervention in this population. Alsoof et al. performed a similar analysis utilising the same PearlDiver database; however, their study was focused on comparing post-ACDF dysphonia of patients with and without a history of thyroidectomy.Reference Alsoof, Perry, Yang, Zhang, McDonald and Kuris15
To our knowledge, this is the first study to systematically document the timing of dysphonia diagnosis after ACDF, revealing that 73.2 per cent of diagnoses occur more than 12 months post-operatively, a finding not previously reported in the literature. This observation stands in stark contrast to the existing body of research, which focuses almost exclusively on early post-operative dysphonia, typically assessed within days to 6 months following surgery.Reference Jung, Xavier, Wu, Schwartz, Kominsky and Fourman4, Reference Razfar, Sadr-Hosseini, Rosen, Snyderman, Gooding and Abla16, Reference Okano, Salzmann, Ortiz Miller, Hoshino, Oezel and Shue17 Many prior studies are limited by short-term follow-up intervals of less than one year or lack of any specified follow-up period. While one case report described delayed recurrent laryngeal nerve palsy presenting on post-operative day 3, and one long-term study found persistent dysphonia in 18.9 per cent of patients at 5–11 years, no prior investigation has characterised the temporal distribution of dysphonia diagnoses across the post-operative period.Reference Yerneni, Burke, Nichols and Tan18, Reference Yue, Brodner and Highland19 The observation of the present study that many dysphonia diagnoses are coded after one year from surgery may reflect under-screening in the immediate post-operative period, inconsistent follow-up practices and variability in symptom recognition by treating providers. Prior studies suggest that while many cases of dysphonia resolve within a few months, symptoms can persist or emerge over a more extended period in a subset of patients.Reference Chen, Huang, Lee, Chen, Wu and Tu20–Reference Zeng, Li, Deng and Xiao22 Additional barriers to early detection include a lack of standardised dysphonia screening protocols, limited peri-operative counselling regarding dysphonia and patient reliance on symptom self-reporting before seeking evaluation. Furthermore, otolaryngology referral patterns suggest that fewer than 10 per cent of patients with dysphonia are evaluated by specialists, and disparities in referral based on sex, geography and race/ethnicity have been documented.Reference Feit, Wang, Demetres, Drenis, Andreadis and Rameau23, Reference Cohen, Kim, Roy and Courey24 Moreover, this delay can be secondary to surgical site changes over time, such as fibrosis or graft migration, that can have a downstream impact on voice function. The findings should be interpreted within the context of administrative claims data, where diagnosis codes largely capture symptom-based reporting rather than confirmed physiologic impairment. This distinction is critical, as prior work has shown that objective voice assessment often correlates poorly with patient-reported handicap or functional status,Reference Francis, Daniero, Hovis, Sathe, Jacobson and Penson10 suggesting that the actual prevalence of post-ACDF dysphonia may be either under- or over-estimated.
Establishing risk factors for post-ACDF dysphonia is essential for surgeons when counselling patients. Several predisposing factors for dysphonia and RLN paralysis following ACDF have been well established, including female sex, diabetes and multi-level surgery.Reference Jung, Xavier, Wu, Schwartz, Kominsky and Fourman4, Reference Oh, Dibas, Ghozy, Mobbs, Phan and Faulkner6, Reference Danto, DiCapua, Nardi, Pekmezaris, Moise and Lesser25 Our findings are consistent with the existing literature, confirming that female sex, age over 50 years, smoking, obesity, diabetes, previous neck surgery and multi-level surgery were associated with higher odds of receiving a dysphonia code post-operatively. We hypothesise that prior neck surgery and multi-level approaches carry a higher risk of iatrogenic RLN injury due to operating in a previously dissected field and longer retraction times resulting in increased post-operative oedema.
This cohort is the first study of this scale to specifically evaluate rates of diagnostic and therapeutic voice-related interventions in the population of patients with dysphonia following ACDF surgery. Our results show that 52.7 per cent of patients with post-ACDF dysphonia underwent post-operative laryngoscopy. Only 15.0 per cent of dysphonic patients received post-operative speech language pathology voice therapy, and 0.7 per cent underwent injection laryngoplasty. In the context of limited population-level data on referral and intervention patterns, our findings suggest that patients are not being adequately referred or objectively assessed for their reported symptoms. These findings mirror those of a recent large-scale database study investigating dysphagia following ACDF, which found a similarly low rate of post-operative diagnostic and therapeutic interventions despite a substantial prevalence of symptoms in at-risk populations.Reference Cochran, Deng, Tabbaa, Razi and Abu-Ghanem26 This underscores a broader trend across post-operative ACDF complications where significant symptoms remain under-evaluated and under-treated. While clinical practice guidelines exist for improving voice outcomes after thyroid surgery, there is currently no consensus protocol for the screening, assessment and treatment of post-ACDF dysphonia.Reference Chandrasekhar, Randolph, Seidman, Rosenfeld, Angelos and Barkmeier-Kraemer27 We advocate for future studies exploring implementation of standardised peri-operative screening tools, such as symptom checklists or routine laryngoscopy, to improve timely detection and referral for management.
Cohen et al. studied dysphonia referrals using a national administrative U.S. claims database and found that only 10 per cent were referred to Otolaryngology, with older patients and males having greater hazard ratios for otolaryngology referral.Reference Cohen, Kim, Roy and Courey24 This trend was clearly mirrored in our findings, where nearly half of the dysphonic patients did not undergo laryngoscopy, and the majority of dysphonia patients were females. Feit et al. highlighted the existing disparities in laryngology subspecialty in a 2021 scope review.Reference Feit, Wang, Demetres, Drenis, Andreadis and Rameau23 With regards to voice disorders, the disparities most frequently studied were sex/gender, geographic and race/ethnicity. Although our dataset did not evaluate race or socioeconomic status, the observed over-representation of women and older adults among dysphonia cases emphasises the need for equity-focused protocols in post-operative voice care. The creation of standardised screening and referral pathways, similar to the thyroidectomy guidelines, could ensure equitable and effective care.
As with all retrospective database studies, there are inherent limitations that should be considered in the interpretation of these results. Several important limitations stem from the use of administrative claims data. First, the identification of dysphonia was dependent on diagnosis codes, which are subject to variability in coding practices and clinical documentation. Not all symptomatic patients may receive a corresponding diagnosis code, and conversely, some codes may be assigned without confirmatory evaluation. Second, the lack of standardised post-operative screening protocols following ACDF likely contributes to under-reporting. Dysphonia is often recognised only when patients report symptoms, resulting in delays in recognition, documentation and referral. As shown in our findings, a substantial proportion of diagnoses occur more than one-year post-surgery, which may reflect delayed onset, delayed access or delayed documentation of pre-existing symptoms. Third, the availability of specialised care can vary across institutions. Limited awareness among surgical teams and the absence of consistent referral protocols may all reduce rates of appropriate testing or therapy. Lastly, the dataset lacks clinical details necessary to confirm impairment or assess severity. Efforts were made to capture the actual rates of variables of interest in the data set by utilising a broad set of ICD and CPT codes to capture as many true data points as possible. However, the PearlDiver database does not include details related to physical examination, imaging, surgical technique or peri-operative steroid use, which are all factors previously shown to be associated with ACDF outcomes. While univariate analyses in our study identified several important risk factors, we did not perform multivariate modelling. This decision was based on the inherent limitations of claims data, including the inability to control for surgical variables such as approach, hardware, operative time or intra-operative events. Our primary objective was hypothesis generation through unadjusted comparisons, establishing the foundation for future, clinically enriched prospective studies. The primary strengths of this analysis lie in its large cohort size, extended follow-up period allowing for assessment of delayed diagnoses and the novel addition of an assessment of the rate of interventions for dysphonia diagnosis and treatment in this post-ACDF population.
What is already known about this subject:
• Dysphonia is a known complication following anterior cervical discectomy and fusion (ACDF)
• Reported incidence rates vary widely, with inconsistent definitions and diagnostic methods
• There are no standardised guidelines for screening or treating dysphonia after ACDF
What this paper adds to existing knowledge:
• In a national cohort of over 600,000 patients, 2.6 per cent received a post-operative dysphonia diagnosis code after ACDF
• The majority (73.2%) were diagnosed more than 12 months post-surgery
• Risk factors included female sex, age over 50, smoking, obesity, diabetes and multi-level surgery
• Only 52.7 per cent of dysphonic patients underwent laryngoscopy; 15.0 per cent received voice therapy
• These findings highlight gaps in diagnosis and treatment, supporting the need for standardised post-operative voice screening and referral pathways
Conclusions
In this large national cohort study, we found the incidence of receiving an ICD code for dysphonia after primary ACDF surgery is 2.6 per cent, with most diagnoses (73.2 per cent) occurring more than 12 months post-operatively, a finding not previously documented at this scale. Risk factors such as female sex, advanced age, obesity, diabetes and multilevel fusion are associated with increased odds of receiving a new dysphonia code. A small but meaningful number of these patients with post ACDF dysphonia code also receive a coded diagnosis of vocal fold paralysis (1.9 per cent). Despite this, only 52.7 per cent of dysphonia patients underwent laryngoscopy and only 15.0 per cent received voice therapy, highlighting a significant care gap in post-operative voice screening, diagnosis and treatment. This underscores the need for standardised post-operative dysphonia screening and timely referral for evaluation and management. Otolaryngologists are uniquely positioned to lead efforts in establishing standardised post-operative voice screening and referral pathways for this population.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare no competing interests.
