THYROIDECTOMY MORBIDITIES:

Preventions & Interventions

ORLINO C. BISQUERA, JR., MD, FPCS
Division of Surgical Oncology, Head & Neck, Breast, Soft
Tissue and Esophago-Gastric Surgery
Department of Surgery, UP-PGH
 Objectives
• Discuss the different thyroidectomy morbidities
with its related anatomy, mechanism of injury,
prevention & intervention.
– Wound complications
• Hemorrhage
• Hematoma
• Seroma
• Infection
– Nerve injury
• Superior layryngeal nerve
• Recurrent Laryngeal nerve
– Metabolic Complication
• Hypocalcemia
– Other neck injuries
• Tracheal injury
• Esophageal injury
Wound Complications: Hemorrhage

• Uncommon
• Life-threatening - < 1%
• Factors for blood loss
– Venous hypertension
– Diffuse goiter with increased vascularity
– Substernal or intrathoracic goiter
– Aberrant blood supply
– Anatomical non-familiarity / poor
surgical technique
 Hemorrhage: Possible Sources
• Anterior jugular
veins
• Thyroid vessels
– Superior & Inferior
– Middle thyroid
– Lobar vessels
• Aberrant blood
supply
• Absent inferior thyroid
artery: 2% - 5%
• Blood supply from
branches of the left
subclavian artery
Hemorrhage: Potential problems

1. Obscures
identification of
RLN and
Parathyroid
glands

2. Hypotension /
Death
 High risk for hemorrhage
• Ectopic Goiters
– Substernal goiter: More common
– Cervical goiter with enlargement towards
mediastinum
– Blood supply from inferior thyroid artery
– Mediastinal goiter: rare
– Intra-thoracic blood supply
Problems:
• Control of the inferior thyroid or intra-thoracic
blood supply
• Venous hypertension from superior vena cava
compression
 Intraoperative Hemorrhage:
Prevention
1. Careful attention to surgical technique
2. Anticipate potential high risk group
Substernal/Mediastinal goiters
Careful planning in surgical approach
Cervical incision alone: Majority
With sternotomy: 2% - 6%
Extensive Mediastinal extension
Mediastinal goiter

Excessive bleeding over avoidance of sternotomy

 Hemorrhage: Intervention
Patient’s status
Identified
source

Stable vital signs Unstable vital signs

Hypotension
Adequate exposure
Proximal / distal
control Excessive
Bleeding vessel bleeding
Identify source Identified
of bleeding precludes
Identifying
*Ligate / repair source of
*Ligate / repair bleeding
bleeding vessel bleeding
vessel
*Resuscitation Effective gauze pack
Resuscitaion
 Wound Complication: Hematoma
• Incidence: 0% -3%
• Factors: Inadequate hemostasis
Increased venous pressure -
coughing / straining on extubation
Bleeding points:
– Temporarily coagulated small vessels
– Residual thyroid gland (subtotal / Ligament of berry)
– Major arteries and
Veins
 Hematoma: Manifestations
• Majority: within 4 hours
post-op
– Neck pain
– Swelling with or without
echymosis
– Continuous soaking of
dressing
– Respiratory distress - “Bull
neck hematoma”
• Laryngeal edema from venous
compression
• Tracheal compression
– Hypotension
 Hematoma: Prevention
• Careful attention to
hemostasis before closure
– Secured suture knots
– Judicious electrocautery use
• Valsalva maneuver
• Cough reflex- airway
suctioning
– Increase venous pressure
– Fills collapsed veins
• Drains / Bulky dressings
– Not prevent hematoma
– Delay recognition
 Hematoma: Intervention
Key: Early intervention

1. No airway compromise
OR exploration & evacuation
Patient not left alone until
hematoma is evacuated

2. Airway compromise (Bull neck)

A. Initial bedside intervention
– Release skin,
subcutaneous & strap
muscle closure
– Endotracheal intubation
B. Operating room exploration &
evacuation
Wound Complication: Seroma
• Incidence: 0% -6%
• Cause: Large dead space
-Graves disease
-Substernal goiter
-MCAG
Prevention: Placement of drain
Intervention: Percutaneous aspiration
 Wound Complication: Infection
• Incidence: <2%
• Clean operation
– Drain / antibiotic: No effect on infection
– Cause: Break in sterile technique
Staph aureus
• Intervention
– Appropriate antibiotics
– Adequate drainage
 Morbidity: Nerve injuries
1. Superior
Laryngeal
nerve
2. Recurrent
Laryngeal
nerve
 Nerve Injury: Superior Laryngeal Nerve

Incidence: 0% - 20%
Risk: Proximity to
superior thyroid
vessels
Related anatomy:
Vagus nerve - SLN
Branches: Internal
branch
External branch
Not visualized: 25%
 Superior laryngeal nerve: anatomy

Internal branch: pierces the

thyrohyoid membrane
Sensory innervation-
laryngeal mucous
membrane

External Branch: close

association with superior
thyroid artery lateral to
inferior pharyngeal
constrictor
Diverge from the artery
at the upper border of the
thyroid lobe to innervate
the cricothyroid muscle
 Superior laryngeal nerve injury:
manifestation
• Paralysis of cricothyroid
muscle
– Lengthen and tenses the
vocal cords
• Subtle voice changes
• No airway compromise
• No hoarseness but
restricted vocal range
– Inability for high pitch
• Easy vocal fatiguability
– Vocal cord tension
depends only from
internal laryngeal
musculature
• Tolerated by most CRICOTHYROID MUSCLE
patients Intrinsic laryngeal muscle
Origin: side of cricoid cartilage
• Career-threatening Insertion: Thyroid cartilage lamina &
inferior cornu
Action: Vocal cord tension
 Superior laryngeal nerve injury: Prevention

• Ligate superior
thyroid vessel
close to the
thyroid lobe
– Individual branch
ligation
– Dissection from
medial to lateral
direction while
the superior pole
is retracted
inferiorly
 Superior laryngeal nerve injury:
Intervention
• Delicate terminal fibers
of external laryngeal
nerve
– Cannot be repaired
• Speech therapy
– Value is limited but may
help in laryngeal
compensation
Recurrent laryngeal nerve injury
• Incidence:
– Unilateral nerve injury
• Permanent: 1% - 1.5%
• Temporary: 2.5% - 5%
– Bilateral nerve injury
• Rare
• High Risk: Advanced disease
 Recurrent laryngeal nerve:
Anatomy
Origin: Vagus Nerve
Right: recurs behind the
subclavian artery
Left: recurs behind the aortic
arch
Nerve courses upward via the
tracheoesophageal groove
Enters the larynx at the
cricothyroid joint area
Function:
Innervation of internal laryngeal
musculature

Non-recurrent: 1%
 Recurrent laryngeal nerve:
Landmarks for identification
Relationship to inferior
thyroid artery
Posterior: 50%
Between branches: 25%
Anterior: 25%

Relationship with inferior

thyroid cornu
RLN laryngeal entry: 1 cm
below the inferior thyroid
cornu (palpable)
: constant landmark for
RLN identification
Recurrent laryngeal nerve:
Mechanisms of injury

• Stretch
• Swelling
• Transection
• Ligation
 Recurrent laryngeal nerve injury:
Manifestations
• Unilateral injury
– Voice limitation and hoarseness
– Usually with no airway compromise
– Pre-op laryngeal evaluation to determine
relationship with thyroidectomy
– Rarely with aspiration
• Bilateral injury
– Spastic phase
• Adduction of the vocal cords
• Airway obstruction after extubation (stridor)
– Relaxation phase
• Abducted bilateral vocal cords
– high risk for aspiration
– Weak voice
• Slowly the vocal cords assumes paramedian position
– Improvement of voice but with more airway compromise
 Recurrent laryngeal nerve injury:
Preventions
• Good surgical technique
• Visualization of its entire course
– Anatomical familiarity
• Susceptible areas for injury
1. Ligament of berry
– Attaches part of thyroid tissue
to the trachea
– Closest contact between
the nerve & thyroid tissue
– Usually RLN courses posterior
to it
– 25% courses through it
2. Inferior thyroid artery
Posterior: 50%
Between branches: 25%
Anterior: 25%
ANTERO-MEDIAL RETRACTION OF THYROID
Recurrent laryngeal nerve injury:
Intraoperative Intervention
• Nerve ligation
• Release ligature
• Unilateral nerve transection
• Immediate microsurgical repair
–Prevents vocal cord atrophy
• Bilateral nerve transection
• Immediate microsurgical repair
• Tracheostomy
 Recurrent laryngeal nerve injury:
Postoperative Intervention
• Unilateral vocal cord paralysis
• Nerve visualized & preserved:
– Supportive
– Anticipate return of function in 3 – 6
months
• Nerve transected & not repaired
– Laryngoplasty or vocal cord
injection
» Stiffen and medialize the cord
» Allow contralateral cord to
appose during speech
 Recurrent laryngeal nerve injury:
Postoperative Intervention
• Bilateral vocal cord paralysis
– Provide more airway while maintaining voice
– Options:
• Irreversible procedures
– Arytenoidectomy
– Transverse cordotomy
» Widens airway
» No improvement in voice quality
• Timing: 1 year post-injury
 Metabolic Complication:
Hypocalcemia
• Temporary: 0.3% - 49%
Symptomatic within 2 weeks
Resolves within 6 months
• Permanent: 0% - 13%
Requires calcium / vitamin D
to maintain normal calcium 1 year
after thyroid surgery
 Hypocalcemia after thyroid
surgery: Causes
• Devascularization:
direct injury of
blood supply or
indirectly from
hematoma

• Inadvertent
removal of
parathyroid gland
 Parathyroid glands: Related
anatomy
• Vascular
supply
• 90% inferior
thyroid artery
• 10% superior
thyroid artery
 Parathyroid glands: Related anatomy

Embryology & Locations

Superior
4th Branchial pouch
Descends with the thyroid
Posteromedial surface of
the thyroid between upper &
middle 3rd
Inferior
3rd Branchial pouch
Descends with the thymus
Within a circle ( 3 cm diameter)
center is where RLN intersect
the inferior thyroid artery
 Postoperative Hypocalcemia:
Manifestations
• Normal serum calcium: 8.5 -10.5 mg/dl
• Symptomatic hypocalcemia: <8 mg/dl
• Mild symptoms
– Numbness/ tingling: lips, hands & feet
• Chvosteks’s sign – involuntary contraction of
facial musculature upon tapping of cheek over
facial nerve
• Trousseau’s sign- carpal spasm upon
occlusion of arm blood supply to systolic
pressure for 2 minutes
– Painful procedure, usually not done
 Symptomatic Hypocalcemia:
Late symptoms
• Untreated initial symptoms
• Severe symptoms
– Mental status changes-irritability,
disorientation
– Muscle cramps & spasm
– Hypotention
– ECG-prolongation of Q-T interval
– Laryngospasm
– Seizure
• Medical emergency
 Hypocalcemia: Prevention
– Routine identification
of parathyroid glands
– Preservation of
parathyroid blood
supply
• Ligate branches of
inferior thyroid artery
close to the thyroid
gland (tertiary branches)
• Preserve if there is
blood supply from
posterior branches of
the superior thyroid
artery
– Careful dissection of
parathyroid gland off
the thyroid capsule
Parathyroid injury: Intraoperative
Intervention

• Questionable viability: dusky

parathyroid gland
– SCM autotransplantation
• More predictable function than non-
viable gland left in situ
• Lowers incidence of permanent
hypoparathyroidism
 Parathyroid autotransplantation:
The technique
• Fragment of non-viable
tissue is sent for frozen
section confirmation
– Mince the other fragments
to 1 mm pieces and place in
SCM pocket. Close the
overlying SCM fascia with
suture
• Graft success rate: 50% -
100%
• Autotransplanted gland
revascularization: 3 – 6
weeks
 Postoperative Hypocalcemia:
Intervention
• Mild symptoms: requires prompt calcium
replacement
– Prevents progression to severe tetany
– 15 mg elemental calcium/ kg/day
Oral calcium supplementation 2 – 10 gms / day
in divided dose (b.i.d – q.i.d )
• Calcium carbonate 650 mg tab = 250 mg elemental calcium
• 70kg X 15 =1050 mg elemental calcium/ day = 4 tablets
• 2 tabs b.i.d
Oral Calcium Supplement: Need
for Vitamin D
• Inability to maintain Serum calcium
above 8 mg/dl with oral calcium alone
• Oral calcium supplement is required
beyond 4th post-op day
– Oral calcium dose > 3gms / day
– Calcitriol (1,25 dihydroxy vitamin D) p.o.
• BID with 0.5 – 1.0 ug total daily dose
– Increase GIT Ca absorption
 Postoperative Hypocalcemia:
Intervention
• Severe symptoms
• 10%Calcium gluconate 10 – 30 ml slow IV over 10
minutes
– Repeat dose if necessary to reverse symptoms (maintain serum
calcium above 8 mg /dl)
– Effect diminishes after 2 hours
• 10% Ca gluconate drip (0.5 – 1.5 mg elemental
calcium/Kg/hr)
• 6 ampules = 6 gms calcium = 558 mg elemental Calcium in
in 500 ml D5W
• Infusion at 1 ml / Kg / hour over 8 -24 hours
• Provides steady calcium supplement while oral calcium is being
absorbed
• Monitor calcium q 4 hours
• Discontinue drip: Ionized calcium > 1.12 mmol/L
Start oral calcium at once
 Other neck injury: Trachea
• Large invasive tumors
• Careless dissection of thyroid
from trachea
• High risk area: Ligament of berry
Prevention: Anterior retraction of
thyroid lobe & isthmus while
pressing trachea downward
Avascular pretracheal plane
Intervention:
1. Primary repair
2. SCM patch = >1cm defect
3. Resection & primary Resection
&
anastomosis anastomosis
SCM
4. Tracheostomy through defect flap
 Other neck injury: Pharynx /
Esophagus
• Rare
• Invasive carcinoma
Prevention:
Gentle dissection
Correct dissection plane
Anatomical anticipation
NGT as esophageal guide
Intervention:
Primary repair
Extensive esophageal loss
Flap: SCM / pect major
Jejunal interposition
 SUMMARY
• Thyroidectomy morbidities
– Wound complications
• Hemorrhage Anatomy,
• Hematoma mechanism of
• Seroma injury,prevention
• Infection & intervention
– Nerve injury
• Superior layryngeal nerve
• Recurrent Laryngeal nerve
– Metabolic Complication
• Hypocalcemia
– Other neck injuries
• Tracheal injury
• Esophageal injury
 Morbidity in thyroidectomy

The best intervention is still PREVENTION!

Division of Surgical Oncology, Head & Neck, Breast,
Soft Tissue and Esophago-Gastric Surgery
Department of Surgery, UP-PGH
 Serum Calcium
• Total serum calcium
– Dependent on serum protein for binding
– Low protein Low total serum calcium
– Not reflective of active IONIZED calcium
– Correction: Decrease of 1 gm/dl serum protein

Corresponding Decrease of Total

serum calcium of 0.8 mg/dl
• Ionized Calcium: Free
– Hypocalcemia: severe - < 1.0 mmol / L
mild – 1.0 - 1.12 mmol / L (4.0 mg / dl)
 IV Calcium administration
• 10% Calcium gluconate slow IV 5 minutes
• 10% Ca gluconate drip
• 6 ampules = 6 gms calcium = 540meqs Calcium in
in 500 ml D5W
• Infusion at 1 ml / Kg / hour
• Provides steady calcium supplement while oral
calcium is being absorbed
• Check Magnesium level
– Hypo: Impairs PTH secretion
Increases PTH resistance
 Calcium carbonate tablet: Mild
Hypocalcemia
• 650 mg tab = 250 mg elemental calcium
• Treatment: 15 mg / kg / day
• 70kg X 15 =1050 mg / day = 4 tablets
• 1 tab q.i.d
 Calcium gluconate drip: Severe
Hypocalcemia
• 100mg / ml X 10 ml ampule = 1 gm Ca = 93 mg of
elemental calcium
• 93 X 6 ampules = 558 mg elemental calcium
• Mix in 500 cc D5W = 1mg /ml
• 70 kg x 0.5 mg elemental calcium/kg/hr = 35mg
• 35 ugtt /min = 35 cc / hr = 35 mg /hr
• Objective: 0.5 -1.5 mg elemental calcium
/kg/hr infusion over 8 -24 hours
: Discontinue infusion – Cai >1.12 mmol/L
• Measure ionized calcium q 4 hours