Thyroid Surgery

Useful Risk Reduction and Management Strategies
Acute respiratory distress following thyroidectomy can be of several types:
• Postoperative hemorrhage and hematoma – usually within 24 h, often 6–8 h after
thyroidectomy, causing laryngeal edema, which if uncorrected may prove fatal
• Excessive wound edema – causing pressure on the larynx and surrounding tissues
• Post-traumatic from endotracheal intubation
• Idiopathic – no apparent cause
Management
• Treat major bleeding with urgent surgical drainage.
• Ice packs on the neck after thyroidectomy – routine use may reduce wound
edema.
• Humidifi ed respiratory environment can relieve all local forms of laryngeal
edema.
• Check for inspissated subglottic mucus sputum retention (plug) – endotracheal
suction.
• Tracheostomy is rarely required.

Post-thyroidectomy hemorrhage into a tightly closed neck can lead to severe
respiratory obstruction requiring urgent reoperation but by “noncontinuously”
closing the fascia leaving “weep holes” to relieve pressure can perhaps avoid
reoperation. External pressure on the neck with a handheld sponge pack until
complete extubation can prevent the venous pressure rise if coughing occurs during
extubation. Drains do not cope with sudden severe hemorrhage or clotted
blood, but are useful in very extensive dissection especially in retrosternal goiter
and in neck dissection. If bleeding is substantial, reopening the wound and hemostatic
control are imperative. Delay may result in substantial laryngeal edema
requiring tracheostomy to ensure an adequate airway. Tracheostomy is rarely necessary,
if bleeding is promptly controlled. Thorough and meticulous hemostasis
and Valsalva testing before closure at the completion of surgery are two risk
reduction strategies for avoiding postoperative bleeding that can be used.
Postoperative hemorrhage is a small, but recognized and signifi cant risk, which if
corrected promptly and urgently is reversible, however, if missed or unaddressed
can prove fatal.
Injury to the external laryngeal nerve is essentially avoidable. To avoid it
requires a sound anatomical knowledge of the area, and this needs to be applied
during the mobilization of the upper pole of the thyroid lobe. Mobilization entails
separating the thyroid lobe from overlying muscle and opening cricothyroid
space, which is frequently called the “avascular” space (of Reeve), so allowing
separation of the cricothyroid muscle and the thyroid gland. There may be a
“crossing” branch from the superior thyroid artery across the space. When the
space is fully mobilized, the external branch of the superior laryngeal nerve can
be viewed. Careful retraction of overlying muscles cephalad and the thyroid gland
caudad helps to improve the view. Mobilizing the cricothyroid space as a fi rst step
in thyroidectomy with cephalad mobilization helps to protect the nerve should it
not be seen. The voice damage that ensues if the nerve is injured is subtle and may
not be noticed. However, if a patient has a voice-dependent occupation, resultant
loss of vocal high pitch and projection can be a problem, as can voice fatigue following
extended use of the voice. Bilateral nerve injury tends to magnify the
problem. Many patients, however, do not seem to notice any change, or perhaps
more correctly, rapidly adapt to the change. Vocal cord change can be diffi cult to
demonstrate other than by video- stroboscopic examination. The use of nerve
monitoring devices may improve the localization and detection of nerve branches
to preserve.
Currently, dysphonia is diffi cult to treat; speech therapy and elapse of time are
useful elements of management. The cricothyroid muscle deserves careful attention
during operation, as muscle injury or intramuscular hematoma can lead to some
subtle voice changes observed after injury to the external branch of the superior
laryngeal nerve.
Death is a rare, but important, risk of thyroid surgery, from bleeding or other
complications, especially in elderly patients and/or those with signifi cant comorbidities.
The risk of death from thyroid or parathyroid surgery equates approximately
with that of the risk of general anesthesia.