Complications of Thyroid Surgery




Abstract


Adequate preoperative assessment, recognition of the compromised airway, optimal preparation, achieving euthyroid status, and intraoperative recurrent laryngeal nerve monitoring minimize the complications of thyroidectomy. We present a case of a hyperthyroid patient with possible tracheal compression, then review the assessment, preparation, and management of such patients, including an approach to the patient with hyperthyroid crisis. We also discuss a postoperative scenario of an evolving airway obstruction and discuss the management.




Keywords

airway obstruction, anesthesia, complications, thyroidectomy, thyroid surgery

 




Case Synopsis 1


A 55-year-old woman with a 5-year history of swelling in the front of the neck presented for subtotal thyroidectomy. She has a history of palpitations on minimal exertion. She gives a history of shortness of breath on lying supine and prefers to sleep on her side. She also has an altered voice. A prominent thyroid gland is palpated on physical examination. The chest radiograph demonstrates moderate displacement of the trachea to the right from the midline. Indirect laryngoscopy revealed bilateral normal vocal cord function.


Case Synopsis 2


The same patient underwent uneventful subtotal thyroidectomy for multinodular goiter. The patient complains of difficulty in breathing 3 hours after surgery. On examination the patient is slightly restless, and mild inspiratory stridor is noted. Pulse oximetry reveals an arterial oxygen saturation of 94% on 2 L/min of nasal O 2 and other vital signs are stable.




Acknowledgment


The authors wish to thank Dr. Samuel A. Irefin for his contribution to the previous edition of this chapter.




Problem Analysis: Case Synopsis 1


Thyroid surgery may range from lobectomy to total thyroidectomy ( Table 51.1 ). Solitary thyroid nodule may be removed by lobectomy or hemithyroidectomy. The most common cause of hyperthyroidism is Graves disease. Toxic adenoma and toxic multinodular goiter (MNG) are other causes of hyperthyroidism. Surgical management of Graves disease involves near-total thyroidectomy. However, aggressive thyroid malignancy may require extensive neck dissection in addition to total thyroidectomy.



TABLE 51.1

Types of Thyroid Surgery
































Thyroid Disease Type of Surgery Potential for Complication
Small solitary nodule Hemithyroidectomy Low risk of injury to laryngeal nerves
Solitary toxic adenoma Ipsilateral lobectomy Hyperthyroidism
Retrosternal goiter Subtotal thyroidectomy Risk of severe bleeding, airway obstruction
May require a sternotomy approach
Graves disease Total thyroidectomy Hyperthyroid crisis
Aggressive malignancy Total thyroidectomy with neck dissection Injury to the laryngeal nerves
May require tracheostomy
Thyroglossal duct cyst excision Sistrunk procedure Inadvertent damage to thyroid cartilage causing severe airway obstruction


Preoperative Assessment


Adequate preoperative assessment with optimal preparation of the patient minimizes the postoperative complications of thyroidectomy. Preoperative assessment involves history, examination, thyroid function tests, imaging, and evaluation of vocal cord function ( Table 51.2 ). Preoperatively it is important to ensure euthyroid status. Graves disease is a common cause of hyperthyroidism, followed by MNG and toxic adenomas.



TABLE 51.2

Preoperative Assessment
























History To assess airway compromise (dyspnea on lying supine)
To assess symptoms of hyperthyroidism/hypothyroidism
Medication history including antiplatelet agents/anticoagulants
Remember: association of pheochromocytoma with medullary carcinoma of thyroid
Examination For retrosternal extension of goiter
Look for SVC obstruction—facial plethora—Pemberton sign
Blood tests Full blood count (methimazole may cause agranulocytosis)
Blood grouping and typing
Thyroid function tests
Imaging Chest x-ray—tracheal deviation
CT scan—anatomic level and extent of tracheal narrowing
Nasendoscopy Assessment of vocal cord function
ECG (e.g., in AF) Assess rhythm, presence of LVH, ischemic changes
Lung function tests
Flow-volume loop
In extrathoracic airway obstruction (goiter) the inspiratory airflow is reduced
This distinguishes local pressure effects caused by the goiter from underlying asthma

AF, Atrial fibrillation; CT, computed tomography; ECG, electrocardiogram; LVH, left ventricular hypertrophy; SVC, superior vena cava.

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Feb 18, 2019 | Posted by in ANESTHESIA | Comments Off on Complications of Thyroid Surgery

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