Post Thyroidectomy

Question 1

CASE SCENARIO:
A 30 years old male had total thyroidectomy for carcinoma thyroid. The next day there the
patient had shortness of breath and there was neck swelling. Read the scenario carefully and
answer the questions asked by the examiner.
Q1. What are the risk factors for hematoma formation?

Q2. What are intraoperative measures to reduce the formation of post operative hematoma?

Answer 1

A. Individual Factors Age. Males

B. Medical history factors
Graves’ disease
Total thyroidectomy
Prior thyroid surgery
Anticoagulation medication

C. Associated factors
Thyroid surgery in a low volume hospital
Accompanying neck dissection

Intraoperative Measures
Meticulous haemostasis by vessel sealing or by braided absorbable or non-absorbable sutures
Interrupted closure of strap muscles to facilitate drainage
Skin closure: subcuticular sutures / skin clips / tissue glue
Insertion of drain is at the surgeon’s discretion, however drains do not prevent haematoma
formation (Woods et al, 2014), and may increase risk of wound infection and prolong length of hospital stay (Maroun, et al. 2020)
Effective communication with the anaesthesiologist is essential
A Valsalva maneuver should be carried out (40mm Hg) prior to closure, to detect occult venous bleeding
Minimize the intrathoracic pressure. A rise in intrathoracic pressure is known to be an
important contributory risk factor to post- operative bleeding/haematoma, often caused by
coughing or retching on extubation.

Question 2

Q3. How would you take care of the patient in post operative period?

Answer 2

Care of post-thyroidectomy patients
The operating surgeon must assess the wound for swelling before the patient is discharged
from recovery.
The operation note should clearly document the post-operative instructions and describe the
method of wound closure i.e. clips, subcuticular sutures or glue.
Equipment appropriate to the wound opening should be available at the patient’s bedside in
case of emergency, i.e. Suture removal set, clip remover or paraffin jelly for tissue glue.
Bedside emergency oxygen should always be available in case of desaturation.
Clinical handover at all stages of the patient journey (recovery, ward and shift to shift)
must emphasize the importance of observing for neck swelling/breathing difficulty.
The patient’s ‘scoring’ on the National Early Warning System (NEWS) should be
appropriately escalated.
Experienced surgical personnel should be available in the early post- operative period.
Post-operative review should be performed by the registrar on the evening of surgery.
In the event of distress symptoms nursing staff should communicate urgently with the
Surgical Registrar / Consultant.
If the patient develops airway compromise or more substantial swelling, local emergency
protocols should be followed

Question 3

What are the signs and symptoms of distress due to neck hematoma?

Q5. How would you manage this patient?

Q6. What you will do if the patient is stable:

Q7. What will you do if the patient is deteriorating?

Answer 3

1. Red Flag symptoms
   Post-operative neck swelling
   Difficulty breathing
2. Non-specific symptoms
   Change in voice quality,
   Neck tightness, neck pain/pressure,
   Dysphagia,
   Sweating, agitation and anxiety
   Increased restlessness
   Stridor

I will manage this patient according to the CCRISP protocol starting with ABCDE. I will activate
my team to attach High flow (100 percent) O2, Cardiac monitor, pulse oximeter.
Follow local emergency measures- call for help.
Sit patient upright

The surgeon should organize return to theatre as an emergency without opening wound.
The surgeon should accompany the patient during transfer in case deterioration occurs.
In the theatre, if an anesthetist is present, the patient may be intubated and the wound
opened (Harding, Palazzo et al, 2006).

If the patient is decompensating, the neck wound should be opened to the level of the trachea.
This is the safest rapid method to relieve the airway obstructio

Question 4

Q8. Can we perform tracheostomy?

Q9. What you will do if the patient is unstable?

Q10. What are SCOOP guidelines?

Q11. Whom you will contact?

Q12. How will you protect the airway in this patient?

Q13. What are the other complications patient can get?

Answer 4

No, we should not attempt, as tracheal intubation may be unsuccessful due to laryngeal oedema
and may exacerbate the situation.

If the patient is unstable:
I will immediately open the neck wound at bedside and release the pressure. Along with that I
will consult with my senior.

SCOOP guidelines are recommended by British Association of Endocrine and Thyroid Surgeons
(BAETS).
S- Steri-strips removed
C- Cut subcuticular/subcutaneous sutures
O- Open wound with fingers
O- Open by pushing fingers into wound to separate strap muscles. Open until
anterior wall of trachea is visualized
P – Place finger over bleeding point if visualized

My consultant, anaesthesiologist, and OT department.

After look, listen and feel, I will
1. 2. 4. Administer high flow oxygen (12–15 l/min, preferably humidified, via a reservoir bag.
Chin lift or jaw thrust to open the airway
3. Suction to remove secretions
Either the insertion of an oral Guedel airway (if tolerated) or a soft nasopharyngeal
airway (If gag reflex on Oropharyngeal airway)
5. Call to anesthesia to maintain definite airway

1. RLN injury
2. Hypoparathyroidism leading to hypocalcemi
3. Hypothyroidism
4. External Branch of superior laryngeal nerve injury
5. Wound infection

Question 5

Q14. What will you do if RLN INJURY identifies during the surgery?

Q15. How can you manage the RLN injury if identifies post-operatively?

Q16. This patient is a singer/ teacher, how will you counsel him/her?

Q17. What will happen in case of injury to the EXTERNAL LARYNGEAL NERVE?

Q18. What investigations you will do postoperatively?

Answer 5

1. 2. If no nerve tissue loss, end to end anastomosis
      If there is some nerve tissue/length loss, a graft can be taken from Ansa-cervicalis.
2. 2. Conservative management with speech therapy and steroids
      Medialization of the vocal cords

I will counsel him regarding the hoarseness of voice and loss of pitch of the voice even in the
absence of nerve injury due to tissue edema.

The pitch of the voice will be low and the patient cannot speak loudly

1. Laryngoscopy
2. Serum calcium levels
3. TSH, fT3 and fT4 levels
4. Serum thyroglobulin if the patient is of CA thyroid