Comparing trans-oral endoscopic thyroidectomy vestibular approach and trans-areolar approaches regarding postoperative infections and swallowing difficulty

Abstract

BACKGROUND

Due to the increasing rate of thyroid nodules diagnosis, and the desire to avoid the unsightly cervical scar, remote thyroidectomies were invented and are increasingly performed. Transoral endoscopic thyroidectomy vestibular approach and trans-areolar approaches (TAA) are the two most commonly used remote approaches. No previous meta-analysis has compared postoperative infections and swallowing difficulties among the two procedures.

AIM

To compared the same among patients undergoing lobectomy for unilateral thyroid carcinoma/benign thyroid nodule.

METHODS

We searched PubMed MEDLINE, Google Scholar, and Cochrane Library from the date of the first published article up to August 2025. The term used were transoral thyroidectomy vestibular approach, trans areolar thyroidectomy, scarless thyroidectomy, remote thyroidectomy, infections, postoperative, inflammation, dysphagia, and swallowing difficulties. We identified 130 studies, of them, 30 full texts were screened and only six studies were included in the final meta-analysis.

RESULTS

Postoperative infections were not different between the two approaches, odd ratio = 1.33, 95% confidence interval: 0.50-3.53, the χ² was 1.92 and the P-value for overall effect of 0.57. Similarly, transient swallowing difficulty was not different between the two forms of surgery, with odd ratio = 0.91, 95% confidence interval: 0.35-2.40; the χ² was 1.32, and the P-value for overall effect of 0.85.

CONCLUSION

No significant statistical differences were evident between trans-oral endoscopic thyroidectomy vestibular approach and trans-areolar approach regarding postoperative infection and transient swallowing difficulties. Further longer randomized trials are needed.

Key Words: Trans-oral endoscopic thyroidectomy vestibular approach; Trans-areolar approaches; Postoperative; Infections; swallowing difficulty

Core Tip: Due to the increasing rate of thyroid nodules diagnosis, and the desire to avoid the unsightly cervical scar, remote thyroidectomies were invented and are increasingly performed. Transoral endoscopic thyroidectomy vestibular approach and trans-areolar approaches are the two most commonly used remote approaches. No previous meta-analysis has compared postoperative infections and swallowing difficulties among the two procedures. Therefore, we reviewed the literature on this important topic to the better choice of scarless surgery procedure.

INTRODUCTION

Thyroid nodules are common in particular among the old age group (5%-12%), and due to the advanced methods of imaging. The trans-cervical thyroidectomy is the gold standard for low-risk differentiated thyroid carcinoma. However, the unsightly cervical scar challenged the surgeons for the remote scar-less thyroidectomy approaches[1]. The minimally invasive approaches and remote approaches are now increasingly performed in particular among women to avoid the disfiguring unwanted scar in the neck[2].

Huscher invented remote endoscopic thyroidectomy in the year 1997, then many approaches rapidly evolved[3]. The first transoral thyroidectomy - trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) was performed by Thomas Wilhelm in 2008[4]. The TOETVA is the only true scarless thyroidectomy[5]. Other remote thyroidectomies with minimal scars are trans-areolar thyroidectomy, retro auricular approach, bilateral breast axillary, and endoscopic axillary approach[6,7]. The trans-areolar approach approaches incise the breast bilaterally through the areolar to reach the thyroid gland. On the other hand, the transoral thyroidectomy vestibular approach involves three incisions in the oral vestibule: Two lateral incisions for 5 mm trocars and one transverse incision in the midline of the oral vestibule for a 10mm port, and dissect the anterior neck to reach the thyroid gland to avoid the unwanted anterior neck scar and improve the patient’s quality of life[8,9]. The Francophone Association of Endocrine Surgery, and French Society of Endocrinology, and French Society of Nuclear Medicine recommend TOETVA for patient with thyroid nodule < 4 cm, and < 2 cm for Bethesda category II, III or IV lesions, and Bethesda category V or VI lesions respectively. The recommended thyroid volume is < 45 mL, and good oral hygiene is required to avoid infection[10]. Contraindications for transoral thyroidectomy include the presence of metastatic lesions to the cervical lymph nodes. A body mass index greater than 30-35 is a relative contraindication[11].

TOETVA complications are similar to conventional cervical thyroidectomy. However, site infections, thermal injury, and mental nerve injury are reported and should be explained to the patients before surgery[12]. The long operative time is thought of as a predictor of postoperative infections in the most popular scarless thyroidectomy (TOETVA). TOETVA is the only true remote scarless thyroidectomy. Literature comparing TOETVA and trans-areolar thyroidectomy regarding postoperative infections scarce. Our findings are important for preoperative decision regarding these two commonly used remote thyroidectomies. This meta-analysis aimed to compare trans-areolar thyroidectomy and TOETVA regarding postoperative infections and swallowing difficulties.

MATERIALS AND METHODS

This meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to compare infection rate, and swallowing difficulties in patients who underwent TOETVA and trans-areolar approaches.

Eligibility criteria according to PICOS

According to PICOS (Population, Intervention, Comparison, Outcomes and Study), randomized controlled studies, prospective, and retrospective cohorts, and case-control studies were eligible. Case series, case reports, and studies without methodologies (editorials, opinions, and letters to editors) were excluded. The studies must compare trans areolar thyroidectomy, and transoral thyroidectomy vestibular approach regarding infections rate, and swallowing difficulties.

Outcome measures

The outcome measures were postoperative infections, and swallowing difficulties.

Literature search and data extraction

We searched PubMed, MEDLINE, Google Scholar, and Cochrane Library from the date of the first published article up to August 2025. The term used were transoral thyroidectomy vestibular approach, trans-areolar thyroidectomy, scarless thyroidectomy, remote thyroidectomy, infections, postoperative, inflammation, dysphagia, and swallowing difficulties. In addition, we screened the titles, abstracts, and references of the included studies were relevant articles. We identified 130 studies and 30 stands after the removal of duplication; 30 full texts were screened and only six studies were included in the final meta-analysis. A datasheet was used to extract the author’s name year and country of publication, study type, the number of infections in the TOETVA, and trans-areolar thyroidectomies, type of the operation (lobectomy or total thyroidectomy), the reason for surgery, postoperative infections, and swallowing difficulties (Figures 1 and 2; Tables 1, 2, and 3).

Figure 1 A comparison of trans-areolar thyroidectomy and transoral thyroidectomy vestibular approach regarding postoperative infections and swallowing difficulties. The Preferred Reporting Items for Systematic reviews and Meta-Analyses chart.

Figure 2 Comparative postoperative morbidity: Infections and swallowing difficulties after transoral vs areolar thyroidectomy. A: Postoperative infections among patients with transoral approach and areolar thyroidectomy; B: Swallowing difficulties among patients with transoral approach and areolar thyroidectomy. CI: Confidence interval; M-H: Mantel-Haenszel.

Table 1 Basic characteristics of patients with transoral approach and areolar thyroidectomy, mean ± SD.

Ref.	Country	Age/years	Females	Type of operation	Pathology
Guo et al[14]	China	29.8 ± 0.96 vs 33.75 ± 1.19	All women	Lobectomy	Papillary thyroid microcarcinomas
Shen et al[15]	China	37.8 ± 12.4 vs 41.2 ± 11.9	63.2% vs 64.9%	Lobectomy	Benign thyroid nodules
Xu et al[9]	China	30.46 ± 6.93 vs 33.3 ± 6.94	91.7% vs 88.6%	Lobectomy	Papillary thyroid microcarcinomas
Yan et al[8]	China	32.14 ± 6.54 vs 34.56 ± 7.06	73.8% vs 83.3%	Lobectomy	Papillary thyroid microcarcinoma
Zhang et al[17]	China	22.2 ± 3.0 vs 23.7 ± 3.8	91.7% vs 100%	Lobectomy	Unilateral papillary thyroid carcinoma
Zhang et al[16]	China	33.4 ± 6.8 vs 34.4 ± 7.6	70.4% vs 100%	Lobectomy	Unilateral papillary thyroid carcinoma

Table 2 Postoperative infections among patients with transoral approach and areolar thyroidectomy.

Ref.	Country	Study type	TOETVA	Areolar approach	Results
Guo et al[14]	China	Retrospective	1/40	0/40	Not significant
Shen et al[15]	China	Prospective	1/57	3/74	Not significant
Xu et al[9]	China	Retrospective	1/48	1/44	Not significant
Yan et al[8]	China	Retrospective	3/48	2/42	Not significant
Zhang et al[17]	China	Retrospective	1/60	0/65	Not significant
Zhang et al[16]	China	Retrospective	1/45	0/50	Not significant

TOETVA: Trans-oral endoscopic thyroidectomy vestibular approach.

Table 3 Swallowing difficulties among patients with transoral approach and areolar thyroidectomy.

Ref.	Country	Study type	TOETVA	Areolar approach	Results
Shen et al[15]	China	Prospective	3/57	7/74	Significant
Xu et al[9]	China	Retrospective	3/48	2/44	Significant
Zhang et al[16]	China	Retrospective	2/45	1/50	Not significant

TOETVA: Trans-oral endoscopic thyroidectomy vestibular approach.

Risk of bias assessment

For the risk of bias, we used the Newcastle Ottawa Scale assessed the quality of the included studies (Table 4)[13].

Table 4 The risk of bias of the included studies (Newcastle Ottawa Scale).

Ref.	Selection	Compatibility	Outcome	Score
Guo et al[14]	2	2	3	7
Shen et al[15]	2	2	3	7
Xu et al[9]	2	2	3	7
Yan et al[8]	2	2	3	7
Zhang et al[17]	2	1	3	6
Zhang et al[16]	2	2	3	7

Statistical analysis

The RevMan system, Version 5.4 was used. After enter of the dichotomous data by the author, the fixed effect was used for infections and swallowing difficulties due to the non-significant heterogeneity. Forest plots were generated to estimate the odds ratio (OR) at 95% confidence interval (CI). The χ², and I² were generated for the degree of heterogeneity (heterogeneity of < 25% was considered mild and heterogeneity ≥ 50% was considered significant). A P < 0.05 was considered significant.

RESULTS

Six studies were included this meta-analysis[8,9,14-17]; five studies were retrospective, and one prospective cohort. However, all were conducted in China. Postoperative infections were not different between the two approaches, OR = 1.33, 95%CI: 0.50-3.53, the χ² was 1.92 and the P-value for overall effect of 0.57 (Figure 2A). Transient swallowing difficulty was not different between the two forms of surgery, with odds ratio, 0.91, 95%CI: 0.35-2.40; the χ² was 1.32, and the P-value for overall effect of 0.85 (Figure 2B).

DISCUSSION

To the best of my knowledge, this is the first meta-analysis to compare TOETVA and trans-areolar approach regarding infections and transient swallowing difficulties. Infections were not different between TOETVA and trans-areolar approach, operation through the contaminated oral cavity to the sterile neck might disseminate infections with abscess formation, airway compression, and systemic infection[18,19]. The current meta-analysis suggests no increase in infection in TOETVA compared to areolar approach. Surgical site infections following TOETVA are not common, Tae et al[20] reported a prevalence of 6% (preoperative and postoperative) despite 14 days antibiotics cover, and Fu et al[21] found a 7.4% infections rate. Some studies showed lower rates of surgical wound infections in the rate of 0.1% to 1%[22-24]. The discrepancy in the surgical site infections could be attributed to the inclusion and exclusion criteria as some studies included all, the grades of surgical site infections including minor erythema, while other included only the severe infections. Strict septic measures are necessary to avoid infections, the use of the same suction instruments in the surgical space and the mouth should be avoided[25]. The use of antibiotics in TOETVA is controversial, Yi et al[26] in their randomized controlled trial found no effects of antibiotics, similarly, Cabungcal et al[27] found no benefits of antibiotics use. Sepsis is a rare but serious complication of thyroidectomy leading to serious comorbidities including stroke, cardiac and renal complications, and death, Waqar et al[28] in their recent study found that nearly one third of infections are due to surgical site infections, followed by pneumonia in 18.6%, and urinary tract infections in 16.2%. the risk factors were male gender with low body mass index, pulmonary disease, diabetes, and long operative time > 150 minutes.

Transient swallowing difficulties are commonly encountered after thyroidectomy (conventional and remote), the majority will resolve in 2-3 months following surgery, while a minority of patients reported dysphagia at one year. Importantly, no significant statistical difference was reported regarding swallowing difficulties between conventional and remote approaches at 2-3 months following surgery[29]. Swallowing difficulties after TOETVA might take long time to recover compared to conventional thyroidectomy, a plausible explanation could be neck fixation and adhesion the operation[30]. The study limitations were that we included only six studies all of them were conducted in China.

CONCLUSION

No significant statistical differences were observed between TOETVA and trans-areolar approach thyroidectomy regarding swallowing difficulties, and infections. Further longer randomized trials are needed to inform the scientific community regarding the two most commonly used scarless thyroidectomies.

ACKNOWLEDGEMENTS

We would like Mohanad Osman, medical student, Fahd Bin Sultan University (Tabuk, Saudi Arabia) for formatting the Figures and recording the core tip.