A complete presentation on surgical aspects of goiter.....

1. By
Dr Waseem Ashraf
PG Deptt of General Surgery
Moderator:-
Dr Muneer Ahmad Wani
Associate professor
Deptt of General Surgery
SURGICAL ASPECTS OF
GOITRE

2. THYROID GLAND
The thyroid gland is made of up two lateral lobes
The thyroid extend from the sides of the thyroid
cartilage down to the sixth tracheal ring
These are joined together in the midline by the
isthmus, which overlies the second to fourth
tracheal rings.
In addition, there is often a pyramidal lobe which
projects up from the isthmus, usually on the left-
hand side.

3. RELATIONS OF THE LOBES
 The lobes are conical in shape having:
 An apex
 A base
 Three surfaces:
 Lateral,
 medial,
 posterolateral
 Two borders:
 Anterior
 posterior
 Apex:
 directed upwards and slightly laterally.
 Base:
 th th

4.  Lateral surface: convex and covered by
• Sternohyoid
• Superior belly of omohyoid
• Sternothyroid
• Anterior border of sternocleidomastoid

5.  Medial surface:
• 2 tubes, trachea and oesophagus
• 2 muscles,inferior constrictor and cricothyroid
• 2 nerves,external laryngeal and recurrent laryngeal

6.  Posterolateral surface:
carotid sheath and overlaps
common carotid artery.
 Anterior border: anterior
branch of superior thyroid artery
 Posterior border: separates
medial and posterior surfaces.
• Inferior thyroid artery
• Anastomosis between superior
and inferior thyroid arteries
• Parathyroid glands
• On left side thoracic duct

7. RELATIONS OF ISTHMUS
 Connects lower parts of the 2
lobes.
 Anterior surface: covered by,
• Sternothyroid and sternohyoid
• Anterior jugular vein
• Fascia and skin
 Posterior surface: 2nd
to 4th
tracheal rings.
 Upper border: anastomosis
between right and left superior
thyroid arteries.
 Lower border: Inferior thyroid
veins.

8. 1- arterial :
Blood supply
• superior thyroid
artery
• Branch from E.C.A.
• Related to E.L.N.
– Inferior thyroid artery
– Branch from thyrocervical trunk
– Which is branch of 1st
. Part of
subclavian
– Related to R.L.N.
Others
hyroid ima artery from aorta ( may be abscent )
Accessory tracheal & esophageal braches

9. 2- venous :
Superior thyroid vein
drain to I.J.V.
middle thyroid vein
drain to I.J.V.
inferior thyroid veins
drain to left innominate vein
The middle thyroid vein
Is the shortest so it is the
1st
. To be ligated

10. Superior laryngeal nerve
internal laryngeal nerve
Sensory to m.m of
Larynx above vocal cords
external laryngeal nerve
Motor to cricotyroid
Muscle
It is closely related
To
Superior thyroid artery
Right R.L.N.
Turns around 1st
. Part
Of subclavian artery
Left R.L.N.
Turns around arch of
aorta
Both supply all Intrinsic muscles
Of larynx except (cricothyroid )
& m.m below vocal cords

11. JOLLS TRIANGLE
11

12. Cernea classification
12
17% 56% 27%

13. RLN-Variations
13

14. LYMPHATICS
●
Lymphatic drainage of thyroid gland has been proposed
by Taylor. His studies shows clinically relevant
lymphatic spread in thyroid malignancy
●
Central compartment of neck -
– Tracheal LN
– Chain of LN which lie in tracheo-oesophageal
groove
– One or more LN lying above isthmus – 'delphian
nodes'
●
B/L central LN dissection (level 6 dissection)
– Clears all LN from carotid artery to other and
down into superior mediastinum

15. 15

16. ●
Lateral compartment of neck
●
A constant group of LN lies along IJV on each side
(level 2,3,4). LN in supraclavicular fossa or more
laterally level 5 LN may also be involved in thyroid
malignancy
●
Thoracic duct on left side of neck arches up out of
mediastinum and passes forwards and laterally to
drain into left subclavian vein / IJV
●
Lateral LN dissection –
●
removal of level 2, 3, 4 and 5 LN. Vagus N,
sympathetic ganglia, phrenic N, brachial plexus
and spinal accessory N are preserved

17. PARATHYROID GLANDS
●
They are small semilunar shaped, ochra coloured
glands,situated in a pad of fat generally outside surgical
capsule secreting PTH, which controls serum Ca
metabolism
●
Gland are usually 4 in numbers, two on each side,
occasionally 3-6.
●
Superior parathyroid glands -
●
Develops from 4th pharyngeal pouch and descend
only slightly during devvelopment and their position
remains constant in adult life

18. ●
Generally found at level of pharyngo-oesophageal
junction behind and seperate from posterior border
of thyroid gland
●
Supplied by branch from upper division of inferior
thyroid artery
●
Inferior parathyroid glands
●
Arise from 3rd pharyngeal pouch along with thymus
●
Descend along with thymus and have a wide range
of distribution in adults
●
Usually located short distance from lower pole of
thyroid
●
Supplied by inferior terminal branch of inferior thyroid
artery

20. 20

21. 21

22. Definition
A goitre is an enlarged thyroid gland

23. Epidemiology
International
Worldwide, the most common cause of goiter is iodine deficiency.
It is estimated that goiters affect as many as 200 million of the 800
million people who have a diet deficient in iodine.
Mortality/Morbidity
Most goiters are benign, causing only cosmetic disfigurement.
Morbidity or mortality may result from compression of surrounding
structures, thyroid cancer, hyperthyroidism, or hypothyroidism.
Sex
The female-to-male ratio is 4:1.

24. Classification of goitre
Epidemology
Endemic
 secondary to iodine deficiency
 >10% population
Sporadic
 in iodine sufficient areas
Familial
24

25. Morphology
Diffuse Multinodular
25
Classification of goitre

26. Function
Non-toxic Toxic
26
Classification of goitre

27. WHO classification
Grade 0:- no palpable, no visible
Grade 1:- palpable, no visible in neutral
position
Grade 2:- visible, palpable in neutral
position
27
Classification of goitre

28. Simple nontoxic
 Diffuse hyperplastic
 Colloid goitre
 Nodular goitre
 Solitary nontoxic nodule
 Recurrent nontoxic nodule
Toxic
 Diffuse(primary)-graves disease
 Multinodular(secondry)-plummers disease
 Toxic nodule(solitary)-teritiary
Thyroiditis
 Hashimoto’s autoimmune thyroiditis
 De-Quervains autoimmume thyroiditis
 Riedels thyroiditis 28
Classification of goitre

29. Pathophysiology

30. Diffuse Non-Toxic Goitre
Compensatory Hypertrophy & Hyperplasia due to
Decrease in T3 & T4.
Diffusely Involves Whole Gland.
Not Associated With
Hypo OR Hyperthyroidism.

31. Causes
Physiological Goitre:
 Puberty OR Pregnancy.
Dietary Iodine Deficiency(primary iodine
deficiency):
 In Areas Far From Sea.
Dietary Goitrous Agents(secondary iodine
deficiency):
 Cabbage & Turnips.
 Calcium or Flouride in water.
 PAS, Lithium, Phenylbutazone, Thiouracil,
Carbimazol.

32. Treatment
Small:
No Treatment.
Reassurance.
Iodine Support.
Large/Pressure Symptoms OR
Cosmesis:
Near-Total Thyroidectomy.

33. Fate (of Diffuse Non-Toxic Goitre)
Revert to Normal.
Stays the Same.
Progress to Multi-Nodular Goitre.

34. Multi-Nodular Goitre
 Progression from Diffuse Simple Goitre.
 Discordant growth with functionally and
structurally altered thyroid follicles
 Multinodular Focal Hyperplasia.
 Mostly Euthyroid.

35. 35
Pathogenesis

36. Clinical features
Common in middle aged females(10:1)
Cosmetic
Discomfort
Irritating Cough
Dysphagia
Hyperthyroidism
Hoarseness
Positive Kocher test

37. Complications
Secondary thyrotoxicosis(30%)
Local Symptoms:
Stridor / Dysphagia / Retrosternal
Enlargement / Cosmesis.
Malignant Change (5%).
Haemorrhage into Cyst.

38. Investigations
TSH, T3, T4
USG Neck
USG guided FNAC
X-ray Neck
Indirect laryngoscopy
CT scan
38

39. MANAGEMENT
Observation
Levothyroxine(LT4) suppression
therapy
I131131 therapy
Surgical resection
39

40. Observation
Asymptomatic euthyroid patients
Small to moderate sized goitre
No risk for malignancy
Should be
Periodically examined with USG
Progressive growth
Concern of malignancy-FNAC
40

41. Levothyroxine(LT4)
suppression therapy
Goitre with subclinical/overt
hypothyroidism
Concerns
tendency for the goitre to return to its
previous size when therapy is
discontinued
elderly and in those with cardiac
disease
41

42. I131131 therapy
131I therapy may be considered for
large goiters in older patients,
Especially those considered at high
operative risk and for those who refuse
surgery
Studies have shown a reduction of
approximately 40% in goiter size after
treatment with 131
Therapeutic 131I doses ranged
from 12 to 90 mCi.
42

43. Post I131 complications
Respiratory compromise
Hypothyroidism
43

44. Surgery for MNG
Indications
Mechanical obstruction
Suspicion of malignancy
Cosmetic issues
 hyperthyroidism
Retrosternal extension
Prevention of future complications
Uncertain diagnosis
44

45. Surgery for MNG
Subtotal thyroidectomy-historical
Total thyroidectomy
Lobectomy-unilateral goitre
45

46. 46

47. Toxic goitre
47

48. Diffuse toxic goitre (graves)
Most common cause of hyperthyroidism
Irish physician-Dr Robert Graves in 1835
Common-young females(20 to 40)
Whole gland involved
50% family h/o autoimmune endocrine disease
Hypertrophy and hyperplasia-abnormal TSH –R
Ab bind to TSH receptor disproportionate and
prolonged effect
Genetic susceptibility

49. Toxic nodular goitre
Middle aged/elderly
Eye signs –rare
Secondary TT
Nodules-inactive
Internodular tissue - overactive
Toxic adenoma-autonomous

50. Toxic nodule
Solitary overactive nodule
Part of generalised nodularity or two
toxic adenoma
Autonomous
TSH- suppressed by high T3 and T4
Normal surrounding thyroid tissue –
suppressed and inactive

51. Clinical Features
Symptoms
 Tiredness
 Emotional liability
 Heat intolerance
 Weight loss
 Excessive appetite
 Palpitation
 Diarrhoea
 Amenorrhoea
 Blurring of vision or double vision

52. Signs
Tachycardia
Hot moist palms
Exophthalmos
Lid lag retraction
Agitation
Thyroid swelling
bruit
Clinical Features

53. Cardiac rhythm
- Increased sleeping heart rate( sinus
tachycardia)
- Arryhthmias, multiple extra systoles,
paroxysmal atrial tachycardia
- Paroxysmal atrial fibrillation
- Persistent atrial fibrillation, no response to
digoxin
Myopathy
 Proximal limb muscle weakness ( thyrotoxic
myopathy)
Clinical Features

54. Eye Signs
Exophthalmos
 Unilateral or bilateral
 Infiltration of retrobulbar tissue with fluid and
round cells
Retraction/spasm of upper eyelid
Levator palpabre superiaris supplied partly
by sympathetic fibers
Graves ophthalmopathy is autoimmune
disease

55. Diplopia –weakness of elevator (inferior
oblique
Papilloedema and corneal ulcer
Malignant exophthalmos
Graves ophthalmopathy-autoimmune
disease-Ab mediated effects on the
ocular muscles
Eye Signs

56.  Von Graefe's sign (lid lag sign)
Eye Signs

57. Eye Signs
Dalrymple's sign
57

58. Eye Signs
Joffroy sign (absent creases in the
forehead on superior gaze)
58

59. Eye Signs
Stellwag sign (incomplete and
infrequent blinking
59

60. Eye Signs
Möbius sign (poor convergence)
60

61. Pretibial myxoedema
thickening of skin –mucin like
deposit

62. Thyroid acropathy

63. Treatment
1. Rest , Sedation
2. Antithyroid drugs
3. Surgery
4. Radioiodine

64. Drugs
1. Antithyriod drugs- <45yr small goitre
- carbimazole
- propylthiouracil
- oxidation and binding of Iodine to
tyrosine
2. B Adrenergic blockers
-propranolol,nadolol
3. Iodides

65. Advantages : no surgery
rapid control of
thyrotoxicosis
avoids radioiodine
Disadvantages : treatment is prolonged
failure rate-50%
SE : agranulocytosis / aplastic
anemia
Dose :10mg 3-4 times/day
Replacement – thyroxine 0.1 mg – 0.15 mg

66. Surgery
<45 yr large goitre
Toxic nodule
Toxic nodular goitre
Advantage: goitre removed
Cure rapid
Cure rate-high

67. Disadvantage : recurrence - 5%
- risk of surgery
- hypothyroidism-20-45%
- hypoparathyroidism

68. Radio iodine
Indictions : >45 yr
recurrent thyrotoxicosis
after surgery
Advantages : no surgery ,no drug
Disadvantages : isotope facility must be
available

69. Thyroidectomy
69

70. Thyroidectomy
●
INDICATIONS
●
As therapy for patients with thyrotoxicosis
●
To treat benign and malignant thyroid tumours
●
To alleviate pressure symptoms (respiratory
distress, dysphagia) with benign/ malignant
process
●
Cosmetic purpose
●
To establish a definitive diasgnosis of a mass
within thyroid gland, especialy when cytological
analysis is either non diagnostic or
indeterminate

71. TYPES
●
Thyroid lobectomy /
Hemithyroidectomy
●
Subtotal thyroidectomy
●
Near total thyroidectomy
●
Total thyroidectomy
●
Completion thyroidectomy

72. PRE OPERATIVE
EVALUATION
●
Ultrasonography
●
Fine needle aspiration cytology –
FNAC
●
Thyroid function tests – TFT
●
CT scan
●
Thyroid uptake scan
●
Laryngoscopy
●

73. PRE OPERATIVE
PREPARATION
●
Hypothyroidism
●
Hyperthyroidism

74. PRE OPERATIVE
CONSENT
●
Scar
●
Airway obstruction
●
Voice changes
●
Hypoparathyroidism
●
Hypothyroidism

75. 75
THE OPERATING THEATRE

76. 76
 patient should be placed in the supine position on the
operating table with the arms tucked close to the side.
 A folded sheet or a thyroid pillow is placed vertically
under the patient’s shoulders to extend the head and neck.
 This neck extension should be performed with great caution
and with the assistance of the anesthesiologists to ensure that
endotracheal tube is secured and the neck is not overextended.
 It is helpful to have the operating table placed in a reverse
Trendelenburg position to decrease the cervical venous
pressure.
 The patient’s hair may be covered with a mesh cap to
avoid contamination of the field. An adhesive tape may be
applied to cover up both ears.
PATIENT POSITIONING

77. PATIENT POSITIONING

78. 78
SKIN PREPARATION AND
DRAPING
 The operative field is then prepared with a routine surgical
maneuver.
 The anterior cervical region is prepared bilaterally from
the angles of the mandible, posteriorly to the anterior borders
of the trapezius, and inferiorly over the anterior chest wall to
the line between the nipples.
 When the surgical prep solution is completely dry, the
operative field is defined with disposable operative
drapes.
 We cover the patient’s head and face with a transparent
plastic sheet that is made adherent to the skin to see through
the patient’s face and the endotracheal tube.
 And a large sterile drape is covered over the patient’s
shoulder, anterior chest wall, and lower body to complete the

79. 79
SKIN PREPARATION AND
DRAPING

80. 80
SKIN PREPARATION AND
DRAPING

81. 81
SKIN INCISION AND
DISSECTION

82. 82
SKIN INCISION AND
DISSECTION

83. 83
SUPERIOR FLAP
DISSECTION

84. 84
INFERIOR FLAP
DISSECTION

85. 85
 The cervical fascia is opened in the midline from the thyroid cartilage
to the suprasternal notch to expose the full length of the strap muscles.
 The sternohyoid muscle and underlying sternothyroid muscle are
also separated in the midline from the thyroid cartilage to the
suprasternal notch.
The isthmus is then divided in the midline with the
electrocautery or the ultrasonic sheers (the Harmonic).
 The operator should make sure that there is no lesion in the isthmus
before the isthmectomy by preoperative ultrasound or computed
tomography.
Isthmectomy can give more room in the
operative fi eld, and dissection of the posterior surface of the
thyroid off the trachea enables better mobilization of the gland
to the medial part.
MIDLINE INCISION AND
ISTHMUSECTOMY

86. 86
MIDLINE INCISION AND
ISTHMUSECTOMY

87. 87
DISSECTION OF
PYRAMIDAL LOBE

88. 88
DISSECTION OF LATERAL
ASPECT OF THYROID
 The sternothyroid muscle is separated more laterally to
the underlying thyroid lobe with blunt dissection unless the
muscle is directly invaded by the thyroid tumor.
 If the thyroid tumor is invading a strap muscle or is adherent
to the muscle, a portion of the muscle should be excised to
ensure that an adequate margin of tissue is obtained as the
tumor is resected.
 The thyroid lobe is then further moved medially with a
blunt “peanut” dissection. .
 These middle thyroid veins are divided between clamps
or with the ultrasonic sheers. Now the thyroid lobe can be
full rotated medially.

89. 89
DISSECTION OF LATERAL
ASPECT OF THYROID

90. 90
DISSECTION OF LATERAL
ASPECT OF THYROID

91. 91
DISSECTION OF THE
SUPERIOR POLE

92. 92
 With the superior thyroid vessels ligated and divided, the
upper pole of the thyroid is completely liberated and can be
lifted anteromedially out of the operative wound.
 This anteromedial retraction is best achieved when two or
three Allis clamps held in the first assistant’s hand apply a
small pressure to create slight tension.
 The location of the superior parathyroid gland is very
much consistent and is in the place of upper third of the thyroid
gland (near the tubercle of Zuckerkandl at the level of
the cricoid cartilage) and has direct contact with the thyroid
capsule posteriorly.
 After a careful dissection is made to create a plane
between the thyroid capsule and superior parathyroid gland,
blunt peanut dissection can push the parathyroid back on a
broad pedicle, safely away from the thyroid gland.
SAVING THE SUPERIOR
PARATHYROID

93. 93
SAVING THE SUPERIOR
PARATHYROID

94. 94
SAVING THE SUPERIOR
PARATHYROID

95. 95
SAVING THE INFERIOR
PARATHYROID
 Approximately 85 % of the inferior parathyroid glands are
found within 1 cm of where the recurrent laryngeal nerve
crosses the inferior thyroid artery, so one can use any of them
as a guide to others.
 Note that the inferior pole vessels are the blood supply to
the inferior parathyroid gland and some to the superior parathyroid
gland, so only the terminal branches that are directly
entering the thyroid gland should be divided.
 If preservation of the parathyroid is not feasible, reimplantation
should be considered. The contralateral sternocleidomastoid
(SCM) muscle is suggested for reimplanting
parathyroid gland in an open thyroidectomy.

96. 96
SAVING THE INFERIOR
PARATHYROID

97. 97
SAVING THE INFERIOR
PARATHYROID

98. 98
THE RECURRENT
LARYNGEAL NERVE

99. 99
THE RECURRENT
LARYNGEAL NERVE

100. 100
THE RECURRENT
LARYNGEAL NERVE

101. 101
RESECTION OF LIGAMENT
OF BERRY

102. 102
 Once the specimen is excised, it is reexamined in order to ensure
that no parathyroid tissue has been inadvertently removed.
 If a normal parathyroid gland is identified on the excised
thyroid specimen, it should be auto transplanted at the end of
the operation.
 At this point, the surgeon must decide whether to perform
a subtotal or total thyroidectomy.
 If the frozen section is proved to be malignant, total thyroid
lobectomy is strongly indicated.
 If the frozen section shows a benign tumor, contralateral
lobectomy is not needed.
 However, cancer can be found in the final (permanent)
diagnosis; therefore, possibility of a delayed completion
thyroidectomy should be informed to the patient.
HISTOLOGICAL
CONFIMATION

103. 103
AUTOTRANSPLANTATION
OF PARATHYROIDS

104. 104
HISTOLOGICAL
CONFIMATION

105. 105
CENTRAL NODE
DISSECTION

106. RECENT ADVANCES
●
Minimally invasive thyroidectomy
●
Closed videoscopic thyroidectomy
●
Minimally invasive video-assisted
thyroidectomy(MIVAT)
●
Robotic transaxillary thyroid surgery

107. 107
BILATERAL AXILLO-BREAST
APPROACH(BABA)
INDICATIONS:-
Indications for endoscopic thyroidectomy :
(1)benign thyroid nodules (the size of nodule is not
considered to be important, but for beginners, the nodule
less than 3–4 cm in diameter is preferable),
(2) for diagnosis for the nodules of suspicious for
follicular neoplasms or Hurthle cell neoplasm, and
(3) completion thyroidectomy of the patient diagnosed
with follicular carcinoma or Hurthle cell carcinoma of
previous diagnostic lobectomy.

108. 108
Absolute
 the patient with previous open neck surgery,
 Thyroid malignancy which expected to recur easily (i.e.,
medullary thyroid cancer, advanced papillary thyroid cancer,
and poorly differentiated thyroid cancer), and
 overt breast malignancy
Relative
 large size thyroid nodules over 5 cm in
diameter,
 male patient (due to the prominent clavicle and no breast
mound which allows movability of the instruments),
 well-differentiated thyroid
carcinoma over 1 cm in diameter.
CONTRAINDICATIONS

109. 109
BILATERAL AXILLO-BREAST
APPROACH(BABA)
Patient positioning

110. 110

111. 111

112. 112

113. 113

114. 114

115. 115

116. 116

117. 117

118. 118

119. 119

120. 120

121. 121

122. Advantages
Precise anatomical detail due to the
greatly magnified view
Decreased pain ?
Smaller scar ?

123. Limitation
Limited to a small (<3cm) nodule
Contraindicated in :
Suspicion of malignancy
Multinodular goiter
Grave’s disease
Prior surgery
Obese patient

124. Disadvantages
Lack of direct palpation and manipulation
Small working space
Respiratory acidosis and diffuse
subcutaneous emphysema from CO2
insufflation
Minimal bleeding can obscure operative field
Long operative time
Multiple scars in case of conversion or
reoperation for completion thyroidectomy

125. III-Mini-thyroidectomy
A 2.5 to 3cm
incision is
performed
approximately 3 to
4 cm above the
sternal notch
Superior and
inferior
subplatysmal flaps
are created

128. Mini-thyroidectomy
The superior pole
vessels are
approached first

130. Mini-thyroidectomy
The thyroid gland is
delivered through the
incision
The recurrent
laryngeal nerve is
identified
The inferior pole
vessels are divided

134. Advantages
Short operative time
It can be done on an out patient basis
Excellent postoperative pain control
It can be attempted on any thyroid
pathology
In the case of “conversion” the incision
can be extended as needed

135. Advantages
Completion thyroidectomy, when
required, can be performed through the
same incision
The procedure can be performed under
local anesthesia
It has no complications related to neck
insufflation
It has an excellent cosmetic result

136. 45 year old patient after right thyroid lobectomy45 year old patient after right thyroid lobectomy

138. POST OPERATIVE CARE
●
Look for signs of bleeding, respiratory
distress
●
Serum Calcium
●
Removal of drain
●
Reassessment of vocal cord mobility
and thyroid function tests

139. COMPLICATIONS
●
Wound hemmorhage
●
Wound infection
●
Superior laryngeal N injury
●
Recurrent laryngeal N injury
●
Unilateral RLN injury
●
Bilateral RLN injury
●
Hypocalcemia
●
Thyroid storm

140. MANAGEMENT OFMANAGEMENT OF
THETHE
COMPLICATIONSCOMPLICATIONS
OFOF
THYROIDTHYROID
SURGERYSURGERY

141. IMMEDIATEIMMEDIATE
COMPLICATIONSCOMPLICATIONS
HEMORRHAGE
INFECTION
RECURRENT LARYNGEAL NERVE
PALSY
THYROID CRISES OR STORM
RESPIRATORY OBSTRUCTION
PARATHYROID INSUFFICIENCY OR
TETANY

142. LATE COMPLICATIONSLATE COMPLICATIONS
THYROID INSUFFIENCY
RECURRENT THROTOXICOSIS
PROGRESSIVE EXOPHTHALMOS
HYPERTROPHIC SCAR OR KELOID.

143. HEMORRHAGEHEMORRHAGE
Incidence – 0.3-1%
Two types -
 Deep to deep fascia
 Subcutaneous
May be primary or reactionary
A deep bleeding produces tension hematoma.
Usually due to slipping of the ligature of the
superior thyroid artery, though it can also be
from a thyroid remnant or a thyroid vein. This
compresses on the airway & potentially life
threatening unlike the subcutaneous bleeding.

144. HEMORRHAGEHEMORRHAGE
GOOD INTRAOPERATIVE HEMOSTASIS
Don’t traumatize the thyroid
Avoid too much neck dressings
Suction drain ??
Do not waste time on imaging
A tension hematoma requires opening of
the wound, evacuation of hematoma &
ligature of the bleeding vessels
A subcutaneous hematoma can be
aspirated.

145. INFECTIONINFECTION
Cellulitis – erythema, warmth & tenderness
around the wound
Abscess – superficial / deep
Deep abscess associated with fever,
leucocytosis, tachycardia

146. INFECTIONINFECTION
Pus for Gram’s stain & culture
CT for deep neck abscess
Can be prevented by proper hemostasis at the
time of surgery & using suction drain.
Per-operative antibiotics not recommended.
Once established
 Antibiotics
 Drainage of abscess.

147. RECURRENT LARYNGEALRECURRENT LARYNGEAL
NERVE PARALYSISNERVE PARALYSIS
Temporary paralysis is due to pressure of
hematoma on the nerve. Recovers in 3
weeks to 3 month.
Permanent paralysis is rare (<2%) and is
due to undue stretching or its inclusion in
a ligature.
Unilateral –
 1/3 rd are asymptomatic
 Change in voice
 Improves due to compensation by the healthy
cord.
Bilateral- dyspnea & biphasic stridor

148. RECURRENT LARYNGEALRECURRENT LARYNGEAL
NERVE PARALYSISNERVE PARALYSISPrevent injury to the nerve by
 Identify
 ITA ligated far from lobe
 Posterior layer of pretracheal fascia kept intact.
Laryngoscopy, laryngeal EMG
For unilateral paralysis no treatment is required.
For bilateral paralysis
 Tracheostomy (with speaking valve.
 Lateralization of cord
 Arytenoidectomy
 Through endoscope
 Thyroplasty type 2
 Cordectomy
 Nerve muscle implant

150. COMBINED PARALYSISCOMBINED PARALYSIS
Unilateral
 Vocal cord lies in cadaveric position
 Hoarseness of voice & aspiration of liquids.
 Ineffective cough
Bilateral
 Aphonia
 Aspiration
 Ineffective cough
 Bronchopneumonia
ONLY superior laryngeal nerve palsy also occurs rarely &
presents with hoarseness & loss of voice stamina.

151. COMBINED PARALYSISCOMBINED PARALYSIS
Unilateral
 Speech therapy
 Medialise of cord
 Teflon paste injection
 Thyroplasty type 1
 Muscle or cartilage implant
 Arthrodesis of arytenoid joint
Bilateral
 Tracheostomy
 Epiglottopexy
 Vocal cord plication
 Total laryngectomy
SLN: speech therapy

152. THYROID CRISIS /THYROID CRISIS /
STORMSTORM
Acute exacerbation of
hyperthyroidism as the patient has
not been brought to the euthyroid
state before operation.
Tachycardia, fever(>1050
C) ,
restlessness, delirium
Mortality is 10%

153. THYROID CRISIS /THYROID CRISIS /
STORMSTORM
Ensure euthyroid state before operation
Sedation – morphine / pethidine
Hyperpyrexia – ice bags. Tepid sponging, hypothermic
blanket, rectal ice irrigation
Oxygen administration
IV glucose-saline for dehydration
Potassium for tachycardia
Cortisone – 100mg IV
Carbimazole – 10- 20 mg 6th hourly
Lugol’s iodine 10 drops 8th hourly by mouth or potassium
iodide 1g IV
Propranolol – 20-40mg 6th hourly
Digoxin for atrial fibrillation
Diuretics for cardiac failure

154. RESPIRATORYRESPIRATORY
OBSTRUCTIONOBSTRUCTION
Laryngeal edema due to
Tension hematoma
Endotracheal intubation & surgical
handling
More chance in vascular goiters.
Collapse / kinking of the trachea
Bilateral recurrent nerve paralysis
can aggravate obstruction if edema
is present.

155. RESPIRATORYRESPIRATORY
OBSTRUCTIONOBSTRUCTION
Open the wound & release the
tension hematoma
Endotracheal tube if no
improvement. INTUBATION TO BE
DONE BY AN EXPERIENCED
ANESTHETIST as repeated attempts
cause more edema leading to
cerebral anoxia.
The tube is left in place for several
days & steroids given to reduce the

156. PARATHYROIDPARATHYROID
INSUFFICIENCYINSUFFICIENCY
Due to removal of parathyroids or the parathyroid end artery.
Incidence – 1-3%
Occurs 2 – 5% after operation. Can be delayed for 2-3 weeks or
hypocalcemia may be asymptomatic.
Classic triad –
 Carpopedal spasm
 Stridor
 Convulsions
Latent tetany
 Trousseau’s sign
 Chvostek’s sign
Persistant – grand mal epilepsy, cataracts, psychosis, calcification of basal
ganglia, papilledema.

157. PARATHYROIDPARATHYROID
INSUFFICIENCYINSUFFICIENCY
Correct identification of the gland
Ligate vessels distal to the parathyroids.
Recognition of the parathyroid glands, which appear in a variety of shapes
and have a caramel-like color, is critical. When they lose their blood
supply, they turn black. The devascularized gland should be removed, cut
into 1 to 2mm pieces, and reimplanted in the sternomastoid muscle or the
forearm.
Monitor serum Ca for 72 hrs post-operatively.
20 ml 10% solution of calcium gluconate IV
10 ml injected IM
2.5-5 G calcium carbonate / day
PTH is unsatisfactory.
Alfacalcidol

158. THYROIDTHYROID
INSUFFICIENCYINSUFFICIENCY
INCIDENCE :20-25% of patients subjected to
subtotal thyroidectomy for diffuse toxic goiter &
toxic nodular goiters with internodular
hyperplasia
Time: <2 yrs. May be delayed >5yrs.
Transient hypothyroidism may occur within 6
months which is asymptomatic.
Due to change in nature of autoimmune
response.
More chance if less residual thyroid tissue
Cold intolerance, fatigue constipation, weight
gain, myxedema.

159. THYROIDTHYROID
INSUFFICIENCYINSUFFICIENCY
Thyroxine – start with 50 mcg/d, 100mcg/d after 3
weeks, and 150 mcg/d thereafter. Taken as a
single daily dose.
Monitoring –
 TSH in the lower end of reference range (0.15-3.5 mU / l)
 T 4 normal or slightly raised. (10 – 27 pmol / l)
Manage ischemic heart disease with beta
blockers & vasodilators
Increase thyroxine during pregnancy. (50 mcg)
Myxedema coma: IV thyroxine 20mcg 8th hourly
followed by oral.

160. RECURRENTRECURRENT
THYROTOXICOSISTHYROTOXICOSIS
Incidence 5 – 10%
Due to inadequate removal or hyperplasia of remaining
thyroid tissue.

161. RECURRENTRECURRENT
THYROTOXICOSISTHYROTOXICOSIS
Less than 40 yrs – carbimazole
 0-3wks 40-60mg/d
 4-8wks 20-40mg/d
 18-24 months 5-20mg/d
More than 40 yrs – radioiodine
 5-10mCi oral; 75% respond in 4-12 weeks
 Repeated after 12-24 weeks if no improvement.
 Beta blocker / carbimazole cover during lag
period.
 Long term follow-up for hypothyroidism.

162. PROGRESSIVE /PROGRESSIVE /
MALIGNANTMALIGNANT
EXOPHTHALMOSEXOPHTHALMOS
Occurs even when thyrotoxic features
are regressing.
Steroids & radiotherapy.

163. HYPERTROPHIC SCAR /HYPERTROPHIC SCAR /
KELOIDKELOID
Platysma to be divided at a higher level
Occurs if scar overlies the sternum
Some persons are more susceptible.
May follow wound infection.
Intradermal steroids, repeated monthly.