ENDOCRINOLOGY
Thyroid disease and
thyroid surgery
Mohammed Baillal Shahid
Bartosz Cetera
Abstract
Disorders of the thyroid gland are common within the global adult pop-
ulation. In the UK thyrotoxicosis has a prevalence of 2% in women and
0.2% in men. The prevalence increases to greater than 5% in those
aged over 60. Similarly, hypothyroidism is found in 2% of the UK pop-
ulation and in a higher propotion of those over 60 at 5% (National Insti-
tute for Health and Care Excellence [NICE], 2019). Thyroid disease
affects the normal structure and function of the thyroid gland with multi-
systemic effects and a range of disease severity. Certain thyroid disor-
ders are amenable to surgical correction and are encountered with
increasing frequency by the anaesthetist. A sound understanding of
the pathophysiology of thyroid disease including associated systemic
effects is essential in providing safe perioperative care to these patients.
In this educational article we will consider thyroid anatomy, pathophys-
iology and perioperative anaesthetic management for patients present-
ing for thyroid surgery in the context of hyperthyroidism, hypothyroidism
and thyroid malignany.
Keywords Difficult airway; hyperthyroidism; hypothyroidism; thyroid;
thyroid cancer; thyroid function tests; thyroid surgery; thyroidectomy
Royal College of Anaesthetists CPD Skills Framework: General, urological
and gynaecological surgery
Anatomy
The thyroid gland originates embryologically from the floor of the
pharynx. It is located in the anterior neck, at the level of the second
and third tracheal rings and consists of two lobes on either side of
the trachea, joined by the thyroid isthmus. Each lobe has an upper
and lower pole, and occasionally a third lobe, the pyramidal lobe,
which arises anteriorly from the thyroid isthmus. The normal
thyroid gland weighs between 10 g and 20 g in the average adult.
The thyroid gland is a highly vascular structure. The arterial
supply is derived from the superior and inferior thyroid arteries, and
venous drainage is via the superior, middle and inferior thyroid
veins. The thyroid ima artery, which arises from the aortic arch or
innominate artery, is found in approximately 3% of patients and
may be enlarged in those with goitre. It requires meticulous control
during thyroidectomy to prevent serious haemorrhage.
Figure 1 highlights important structures passing near the
thyroid gland. Note the close relationship between the recurrent
laryngeal and superior laryngeal nerves to the thyroid gland.
They are at risk of damage during surgery.
Mohammed Baillal Shahid FRCA is an Anaesthesia Registrar in the
North West of England, UK. Conflicts of interest: none declared.
Bartosz Cetera (EDIC EDAIC) is Locum Consultant Anaesthetist at
Manchester Royal Infirmary, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10
Learning objectives
After reading this article, you should be able to:
C understand basic anatomy and physiology of the thyroid gland
C describe the classical features of hyperthyroidism,
hypothyroidism and their management
C list main indications for thyroid surgery
C discuss different anaesthetic techniques to manage a patient for
thyroid surgery
C discuss postoperative complications of thyroid surgery and their
management
The lobes of the thyroid gland and the isthmus contain small
globular sacs, follicles. The follicles are lined with follicular cells
which secrete fluid, called colloid (Figure 2). Colloid contains the
prohormone thyroglobulin. The follicular cells also contain the
enzymes needed to synthesize thyroglobulin, as well as the
enzyme thyroperoxidase needed to produce thyroid and release
them hormones from thyroglobulin.
The hormones secreted by the thyroid gland are tri-iodothyr-
onine (T3), tetra-iodothyronine (T4-thyroxine) and calcitonin
(produced by parafollicular cells). T3 and T4 are produced from
tyrosine, found in thyroglobulin, which combines with iodine in
the colloid. The hormones, T3 and T4, are held bound to thyro-
globulin until they are secreted by the follicular cells into the
bloodstream.
Regulation of thyroid hormone synthesis
Thyroid production is coordinated between the hypothalamus,
anterior pituitary and thyroid gland, via a negative feedback
system: thyrotropin-releasing factor (TRH) is secreted from the
hypothalamus, stimulating the secretion of thyroid-stimulating
hormone (TSH) from the anterior pituitary gland (Figure 3).
TSH stimulates the follicular cells to synthesize and secrete
thyroid hormones. These thyroid hormones, in a euthyroid state
regulate the body’s metabolic rate, cardiac and digestive func-
tion, muscle control, brain development, mood and bone
maintenance.
Thyroid function tests
Dysfunction of the thyroid gland and thyroid hormone pro-
duction can cause underactivity (hypothyroidism) or over-
activity (hyperthyroidism). Diagnosis is made by measuring
thyroid function. Thyroid function tests (TFTs) measure the
serum levels of TSH, total T4 or T3, free T4 or T3, and if
required rT3 (reversed T3 einactive form of T3) concentrations
(increased levels of rT3 have been noticed in severe trauma,
severe infection, starvation, anorexia, and after surgery). The
results of thyroid function tests must always be interpreted in
light of the clinical status of the patient. Awareness of the
clinical problems that can be associated with different patterns
of TFTs helps with further investigation and management. The
guide to interpretation of thyroid function tests is in given in
Table 1.
594 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY

The thyroid gland and its relationship to recurrent laryngeal nerves,

superior laryngeal nerves, larynx and vasculature

Vagus n.
Superior laryngeal n. External carotid a.

Internal branch of Superior thyroid a.

superior laryngeal n.

External branch of Common carotid a.

superior laryngeal n.

Inferior thyroid a.

Thyrocervical trunk

R. recurrent laryngeal n.

L. recurrent laryngeal n.

Note relationship of branching

of arteries to pretracheal fascia

Superior thyroid artery

from external carotid

Upper pole

Behind sympathetic
Lateral lobe chain

Lower pole Inferior thyroid artery

from thyrocervical
trunk (other branches
Isthmus
are ascending cervical,
(on rings 2,3,4)
transverse cervical and
suprascapular)
Thyroidea ima
(3% from aorta)

Note intimate relationship of branches of the inferior thyroid artery to the recurrent laryngeal nerve

Figure 1

Hyperthyroidism Excess levels of circulating thyroid hormone causes a hyper-

metabolic state and is associated with an increased sensitivity to
The prevalence of overt hyperthyroidism is 0.5e0.8% in Europe,
circulating catecholamines. Patients may present with a goitre,
and 0e5% in the USA.1 The incidence of hyperthyroidism in-
eye symptoms, difficulty in breathing, anxiety, irritability, diffi-
creases with age and is more frequent in women. The incidence
culty in sleeping, a rapid or irregular cardiac rhythm, tremor,
of mild hyperthyroidism is higher in iodine-deficient areas than
excessive sweating, heat sensitivity, associated weight loss and
in iodine-sufficient areas.
changes in skin and hair (Table 2). If the aetiology of thyrotox-
Hyperthyroidism is defined as increased thyroid hormone
icosis is not clear after physical examination and biochemical
synthesis and secretion, whereas thyrotoxicosis refers to the
tests then the diagnosis can be confirmed by thyroid scintig-
clinical syndrome of excess circulating thyroid hormones, irre-
raphy. In scintigraphy, the radioactive isotope distributes ho-
spective of the source.
mogeneously throughout both lobes of the thyroid gland. In

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 ENDOCRINOLOGY
Microscopic structure of thyroid gland
Follicular cells Parafollicular
cells
Colloid
Follicle consists of simple epithelium from follicular cells.
Parafollicular cells are adjacent to follicles and reside in the
connective tissue.
Figure 2
patients with hyperthyroidism, the pattern of uptake varies with
the underlying disorder. A struma ovarii is a rare form of tumour
that contains thyroid tissue and may be a cause of hyperthy-
roidism. In this rare case, the radioactive isotope is uptaken by
the tumour outside the normal thyroid gland allowing for its
detection.
The most common forms of hyperthyroidism include diffuse
toxic goitre (Graves’ disease), toxic multinodular goitre (Plum-
mer disease) and toxic adenoma.

Graves’ disease is an autoimmune disorder and the most
common form of hyperthyroidism, accounting for 75% of
all cases in the UK, and approximately 60e80% of cases of
thyrotoxicosis. Women are most commonly affected, with
peak incidence in 20e40 year olds. Pregnant women with
uncontrolled Graves’ disease are at greater risk of
miscarriage, premature birth and having a baby with low
birth weight. Thyroid-stimulating autoantibodies stimulate
thyroid gland growth, hormone synthesis and release,
which may lead to thyroid ophthalmopathy and pretibial
myxoedema.

Plummer disease (toxic multinodular goitre) occurs most
frequently in regions of iodine deficiency and is respon-
sible for 15e20% of cases of thyrotoxicosis in the UK and
Europe, in areas of endemic iodine deficiency, toxic
multinodular goitre accounts for approximately 58% of
cases of hyperthyroidism. Those over 60 years old are
most at risk of developing the disease and it is charac-
terized by a marked enlargement of the thyroid gland
(goitre) with firm thyroid nodules and overproduction of
thyroid hormone.

Toxic adenoma is an autonomously functioning thyroid
nodule that causes hyperthyroidism. It is responsible for
approximately 3e5% of cases of thyrotoxicosis worldwide
and in the UK. These nodules are almost always benign.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10
Thyrotoxicosis crisis (thyroid storm)
A thyrotoxicosis crisis (thyroid storm) is an acute, lifethreatening,
hypermetabolic state caused by an excessive amount of thyroid
hormones. It represents the severe end of the spectrum of thyro-
toxicosis and is characterized by compromised organ function. It
may be the initial presentation of thyrotoxicosis in children,
particularly neonates.2 It is most commonly associated with Graves’
disease, and although is a rare condition the mortality rate is high,
10e30%. A thyrotoxicosis crisis is usually triggered by a precipitant
such as stress, surgery, sepsis, diabetic ketoacidosis (DKA), preg-
nancy or a thromboembolic event. The pathophysiology is poorly
understood, but clinical features represent manifestations of organ
decompensation, with fever seen almost universally:

a hypermetabolic state, fever and increased oxygen
consumption

increase sympathetic activity, from an increased sensitivity
to catecholamines

organ dysfunction: central nervous system (agitation in the
young, lethargy in the elderly), gastrointestinal upset
(diarrhoea, deranged liver function tests) and cardiac
(heart failure, tachy-arrhythmias).
Management includes organ support in the intensive care unit
(ICU): fluids, active cooling, antipyretics (avoid salicylates, as
they displace T4 from thyroxine-binding globulin) and measures
taken to reduce thyroid hormone synthesis, hormone release and
inhibition of the peripheral effects of excessive thyroid hormone.
This involves initiation of thionamides (propylthiouracil) b-
blockade and glucorticoids (to counteract relative adrenal
insufficiency secondary to hypermetabolism). In addition, the
management of thyroid storm should not disregard the search
and appropriate treatment of any precipitating factors.3
Anaesthesia considerations: hyperthyroidism (elective
surgery)
The management of hyperthyroidism aims to prevent the
complication of a ‘thyroid storm’, and patients should be
euthyroid before surgery. Anaesthesia and surgical stress in pa-
tients with untreated/uncontrolled hyperthyroidism can be
complicated by congestive cardiac failure, tachy-arrhythmias,
respiratory muscle weakness and progress to life-threatening
thyrotoxicosis (thyroid storm).
Thyroid control is usually achieved by the use of antithyroid
drugs, such as carbimazole, propylthiouracil and radioactive
iodine. b-blockers, in particular propranolol, are used to
ameliorate the symptoms of hyperthyroidism and may be effec-
tive in the acute preoperative phase.3
Anti-thyroid (thionamides) drugs:
Carbimazole is an oral prodrug that is rapidly metabolized to
methimazole. It inhibits thyroid peroxidase and blocks the
oxidation of iodide to iodine. Carbimazole (methimazole) is
more potent than propylthiouracil and has a longer duration of
action. It is contraindicated for use in the first trimester of
pregnancy due to the risk of teratogenesis.
Propylthiouracil is used as a second-line agent. It inhibits the
conversion of thyroxine (T4) to tri-iodothyronine (T3). Propylth-
iouracil continues to remains the drug of choice for life threatening
severe thyrotoxicosis. It is prescribed to those intolerant to carbi-
mazole or women in the first trimester of pregnancy.
596 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY

A negative feedback loop controls the regulation of thyroid hormones level

1) Metabolic rate and/or T3 and T4

concentration in blood.....

Low? High?
• Hypothalamus releases TRH. • Hypothalamus stops TRH release
This triggers TSH release by • Anterior pituitary stops TSH release
the pituitary.

TRH release
TRH TSH 4) Negative feedback:
• Elevated T3 and T4 levels inhibit
release of TRH and TSH

–
Thyroid follicle cells

TSH release

T3 release

3) Effects of T3 and T4 release:

T4 release • Increased basal metabolic
rate of body cells
TSH • Rise in body temperature
(calorigenic effect)
2) Effects of TSH release:
• Triggers release of T3 and T4
by thyroid follicle cells

T3, tri-iodothyronine; T4, thyroxine; TRH, thyrotropin-releasing factor; TSH, thyroid-stimulating hormnone.

Figure 3

Serious adverse effects of anti-thyroid drugs include agranu-
locytosis, aplastic anaemia, hepatitis, polyarthritis, and vasculitis.
All of these adverse effects, occur more frequently with pro-
pylthiouracil. These drugs take 6e8 weeks to work and should be
administered until thyroid function normalizes.
A euthyoid state is usually achieved within 3e8 weeks of
taking thionamides.
Iodine is required for normal thyroid function, but excessive
iodine inhibits iodine binding (a transient phenomenon, known
as the WolffeChaikoff effect). It blocks the conversion of T4 to
T3, inhibits the release of thyroid hormone from the gland and
reduces the vascularity of the thyroid gland. Where hyperthy-
roidism is severe or surgery is urgent treatment with iodine may
shorten the time to achieving euthyroid state. A 10-day course of
oral iodine prior to surgery for Graves’ disease can reduce blood
flow in the thyroid gland. Today, iodine does not have a major
role in the treatment of hyperthyroidism.
Radioactive iodine (isotope 131) causes a thyroid-specific in-
flammatory response, resulting in fibrosis and destruction of the
thyroid gland over a period of weeks to months. Radioactive
iodine is frequently used for the treatment of Graves’ disease in
adults. Following treatment, patients have to follow radioprotec-
tion measures that include avoiding contact with pregnant woman
and children for 3 weeks as the majority of the radioactive iodine
that has not been absorbed by the thyroid gland is excreted in
urine, tears and saliva in the next few days following treatment.
Drugs for symptom relief
b-blockers: Many of the neurologic and cardiovascular symptoms
(Table 2) associated with thyrotoxicosis can be relieved by
b-blockers such as propranolol. They are often started as soon as
the diagnosis of hyperthyroidism is made. Once the patient is
cardio-stable (with thionamides, surgery, or radioactive iodine),
the b-blocker is stopped. Propranolol is the most widely studied

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 ENDOCRINOLOGY

Thyroid function tests interpretation table and differential diagnosis

TSH, normal Free T4, normal Free T3, normal range Common diagnoses
range 0.4e4.5 range 9.0e25.0 3.5e7.8
mU/litre pmol/litre pmol/litre

Raised Low Low Primary hypothyroidism:

C Chronic autoimmune (Hashimoto’s) thyroiditis-late phase
C Post-radioiodine
C Post-thyroidectomy
C Iodine deficiency
C Thyroiditis (late hypothyroid phase). Viral, bacterial, tuberculosis (TB),
postpartum, lymphocytic
C Biosynthesis defects
C Radiation injury
C Infiltrative disorders (sarcoidosis, amyloidosis)
C Drugs (lithium, p-aminosalicylic acid, iodides)
Secondary hypothyroidism:
C Pituitary or hypothalamic deficiency, reduced TSH (not enough signal to
stimulate thyroid)
Low/normal Low Low Non-thyroid illness syndrome
C Syndrome seen in critically ill patients
Low Raised Raised Primary hyperthyroidism:
C Graves’ disease
C Toxic multinodular goitre (Plummer disease)
C Toxic adenoma
C Thyroiditis (early hyperthyroid-phase) viral, TB, bacterial, lymphocytic,
post-partum
Raised Raised Raised Secondary causes:
C Pituitary adenomas/dysregulation
Tertiary causes:
C Hypothalamus activation
Raised Normal Normal C Subclinical hypothyroidism
Low Normal Normal C Subclinical hyperthyroidism
C Thyroxine intake, and/or tri-iodothyronine intake (T4 may be reduced)
Raised/normal Raised Raised C Interfering antibodies to thyroid hormones
C Familial dysalbuminaemic hyperthyroxinaemia
C Amiodarone
C Intermittent T4 therapy or T4 overdose
C Resistance to thyroid hormone
C Acute psychiatric illness, iatrogenic, struma ovarii, choriocarcinoma,
hydaditiform mole

T3, tri-iodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone.

Table 1

non-selective b-blocker. It effectively controls an increased heart
rate and tremor as well as inhibiting the monodeiodinase type I
enzyme. The monodeiodinase type I enzyme is responsible for
conversion of T4 to the more biologically potent T3.
Calcium channel blockers such as verapamil and diltiazem can
be used to ameliorate symptoms when b-blockers are contra-
indicated or poorly tolerated (e.g. asthma, peripheral vascular
disease, high-degree heart blocks).
Thyroidectomy
Due to the efficacy of anti-thyroid medications and radioactive
iodine therapy, surgery is usually reserved for certain
circumstances, listed below. Surgery is always in addition to
perioperative management drug therapy; anti-thyroid medica-
tion and/or iodine treatment in addition to symptomatic control
with b-blockade.
Indications for thyroid surgery for hyperthyroidism include:

obstructive/compressive symptoms

severe hyperthyroidism in children

severe ophthalmopathy

severe or persistent hyperthyroidism

refractory amiodarone-induced hyper-thyroidism

patients who require normalization of thyroid function
rapidly, e.g. pregnancyethyrotoxicosis occurring in preg-
nancy is life threatening to both mother and fetus

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 ENDOCRINOLOGY

Signs and symptoms of hypothyroidism and hyperthyroidism

Classical features Hyperthyroidism Hypothyroidism

General Weight loss, heat intolerance, ophthalmopathy (diplopia, or
proptosis, upper lid retraction), sweaty skin, pretibial
myxoedema
Respiratory Increased minute volume, reduced compliance, respiratory
muscle weakness, reduced vital capacity
Cardiovascular Sinus tachycardia, atrial fibrillation, increased systolic blood
pressure but reduced peripheral vascular resistance resulting in
increased cardiac output and risk of ischaemic heart disease and
heart failure
Neuromuscular Irritability, tremor, insomnia, agitation, psychosis, anxiety
Gastrointestinal Vomiting, diarrhoea, abdominal cramps, elevated liver enzymes
Metabolic Hyperthermia, hyperglycaemia, hypercalcaemia
Haematological Thrombo/neutrocytopenia
Pharmacodynamics Minimum alveolar concentration (MAC) increased
Pharmacokinetics Clearance increased
Volume of distribution may be reduced/increased
Neuromuscular-blocking drug (NMBD) e shorter time of onset,
shorter duration, patients require larger doses9
Weight gain, cold intolerance,; dry, thickened skin,
enlarged tongue, puffy face
Decreased minute volume attenuated response to
hypoxia and hypercarbia, reduced diffusing capacity
of the lungs for carbon monoxide (DLCO)
Bradycardia, heart blocks, prolonged QT, pericardial
effusion, reduced contractility diastolic hypertension,
raised vascular resistance, reduced cardiac output,
congestive heart failure
Depression, ataxia, delayed relaxation of reflexes,
sleepiness, psychosis
Constipation, delayed gastric emptying
Hypothermia, hypoglycaemia, hyponatraemia,
increase anti-diuretic hormone (ADH) levels
Anaemia, a decrease in factor VIII activity, prolonged
PT time, and acquired von Willebrand disease.
MAC reduced
Clearance reduced
Volume of distribution Increased
NMBD e increased sensitivity

Table 2

severe cardiovascular dysfunction
Tertiary hypothyroidism: Secondary to TRH deficiency and

patients with a single thyroid nodule, as this may be better
treated by excision
Anaesthesia considerations: hyperthyroidism
Patients with overt hyperthyroidism who require urgent surgery
should be closely monitored perioperatively and admission to the
high-dependency unit before and after surgery may be clinically
justified. Perioperative placement of an arterial line and central
venous catheter may be required if there is evidence of hemo-
dynamic instability.1,4 Intraoperatively, an intravenous b-blocker
can be given and titrated to effect to control tachycardia and
hypertension. A calcium channel blocker may be used as an
alternative if b-blockers are contraindicated. A senior anaesthe-
tist, senior surgeon and the intensive care team should be
involved from the early stages of management.
Hypothyroidism
Hypothyroidism is characterized by a deficiency of thyroid hor-
mone. Hypothyroidism is 10 times more common in women than
men. It results in a hypometabolic state and is characterized by a
relative resistance to catecholamines. Typical symptoms and
signs of hypothyroidism are fatigue, lethargy, weight gain, low
mood, depression, cold intolerance, dry skin, hair loss, con-
stipation, paraesthesias and hoarseness (Table 2).
The causes of hypothyroidism can be broadly subdivided into
three distinct categories:

Primary hypothyroism: Related to intrinsic thyroid gland
disease

Secondary hypothyroidism: Characterized by TSH defi-
ciency and may represent pituatry disease
may represent hypothalamic disease.
Approximately 95% of cases of hypothyroidism are primary
in nature.
Causes of primary hypothyroidism

Iodine deficiency: thyroid hormones are essential for fetal
brain growth and development, and severe maternal
iodine deficiency may lead to mental and growth retarda-
tion or cretinism in children. Even mild maternal iodine
deficiency has been associated with lower IQ3

Hashimoto thyroiditis is an autoimmune disease, which
generally affects women in their 40se60s. It produces
TSH-receptor blocking antibodies as well as antibodies
against thyroglobulin, thyroid peroxidase. It initially
causes hyperthyroidism and then, as tissue is destroyed,
results in hypothyroidism. The destroyed parenchyma
then fibroses.

Iatrogenic causes: surgery, radiotherapy, iodine, amiodar-
one, lithium and rifampicin

Congenital hypothyroidism (CH) is caused by inadequate
thyroid hormone production in newborns. It can occur
because of an anatomic defect in the gland, an inborn error
of thyroid metabolism or iodine deficiency. CH is the most
common neonatal endocrine disorder, and historically,
thyroid dysgenesis was thought to account for approxi-
mately 80% of cases5

Rare causes: thyroiditis in hypothyroid phase and infiltra-
tive diseases (sarcoidosis, amyloidosis).
Worldwide, iodine deficiency remains the most common cause of
primary hypothyroidism, followed by Hashimoto disease.

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 ENDOCRINOLOGY
Management
The treatment goals for hypothyroidism are to reverse clinical
progression and to correct metabolic derangements and thyroid
hormone levels. This is achieved with supplementation/
replacement, with levothyroxine. Surgery is rarely required, but
may be indicated for large goitres that compromise the patient’s
respiratory and/or oesophageal function typically when hypo-
thyroid iodine deficient patients develop goitre. A goitre develops
as a result of the normal functioning pituitary gland detecting low
levels of thyroid hormine and secreting TSH. This then stimulates
the thyroid gland to grow in size.
Myxoedema coma/crisis
Myxoedema crisis is a rare life-threatening condition of severe
hypothyroidism with physiological decompensation. The condi-
tion tends to occur in patients with longstanding, undiagnosed
hypothyroidism and is usually triggered infection, thromboem-
bolic event, heart failure, trauma, or drugs. It is a medical
emergency and mortality rates are as high as 20e65%.6 Myx-
oedema is more common in older female patients. Of note is that
serum levels of thyroid hormones may be not different to those
found in clinically stable hypothyroid patients. Typical clinical
features include: cardiovascular instability, hypothermia, confu-
sion, reduced consciousness (progressing to coma), hypercapnia
and signs of chronic hypothyroidism (Table 2).
Emergency management is with intravenous T4 and T3
replacement in addition to glucocorticoids, as adrenal insuffi-
ciency may either mimic myxoedema or coexist.
Anaesthesia considerations: hypothyroidism
It is preferable to postpone elective surgery until treatment with
thyroid hormone has achieved euthyroidism. In cases of urgent
or emergency surgery, caution should be taken as anaesthesia/
surgery may trigger a myxoedema crisis.

If major emergency surgery is required, thyroid hormone
levels should be normalized as rapidly as possible, using
IV levothyroxine (T4) in a loading dose of 200e500 mi-
crograms followed by 50e100 micrograms intravenously
daily.7

Simultaneous administration of intravenous liothyronine
(T3) should be considered if there is suspicion for myx-
oedema coma.

If there is any suspicion for concurrent adrenal insuffi-
ciency, glucocorticoids should be administered prior to or
together with thyroid hormone.

Cardiovascular instability can be profound. Cardiac output
can be reduced by up to 50%. There is also down-regula-
tion of b-adrenergic receptors which can make hypoten-
sion and bradycardia difficult to treat.7

Lower doses of anaesthetic agents should be considered,
due to the decreased metabolism of drugs in patients with
hypothyroidism.7

Close monitoring during surgery and in the postoperative
period in a critical care unit is imperative in hypothyroid
patients to reduce the risk of a missed diagnosis and the
correct management of a myxoedema crisis.

Levothyroxine has a long half-life of 5 days. If the enteral
route is unreliable postoperatively the dose may be missed
for up to 5 days, but after this intravenous levothyroxine
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10
should be administered at a dose between 60% and 80% of
the oral dose.7
Non-thyroid illness syndrome
Acute illness and prolonged critical illness can cause changes in
the hypothalamic-pituitary-thyroid (HPT) axis. Changes in thy-
roid function that take place during prolonged critical illness are
also known as low T3 syndrome, or sick euthyroid state. Thyroid
function tests show low levels of T3 and T4, and inappropriately
low TSH. The prognostic significance of these changes is unclear
and there is no evidence to support the use of supplementary
thyroid hormones.
Drugs causing/inducing hypothyroidism
Many drugs we use in our practice can induce hypothyroidism.
Some of them can cause suppression of TSH release (e.g. glu-
corticoids, dopamine, opioids), the others can cause inhibition to
peripheral conversion T4 to T3 (e.g. glucorticoids, propranolol,
amiodarone, benzodiazepines). Barbiturates increase T4 clear-
ance and iodinated contrast agents are well known for inhibition
of thyroid hormones synthesis.
Conditions associated with both hyperthyroidism and
hypothyroidism
Thyroiditis
This condition may present as hyperthyroidism, especially in
early phase, later progressing to hypothyroidism. Thyroiditis
refers to any inflammatory diseases of the thyroid gland, and
may be caused by:

Suppurative thyroiditis, caused by infection, usually
bacterial.

Subacute thyroiditis (subacute granulomatous thyroiditis),
other names: painful thyroiditis or de Quervain’s thyroid-
itis. It is probably caused by a viral infection or a post viral
inflammatory process. The typical phases are: hyperthy-
roidism, euthyroidism, hypothyroidism and restoration of
normal thyroid function.

Postpartum thyroiditis is a destructive thyroiditis induced
by an autoimmune mechanism.

Drug induced (e.g. amiodarone, lithium, interferon).

Radiation thyroiditis.

Fibrous thyroiditis (Reidel’s thyroiditis), a rare disorder of
unknown origin causing a replacement of thyroid tissue by
fibrosis.
Thyroiditis is treated by managing the underlying condition,
for example source control of infection, stopping medicines or
correcting the underlying autoimmune process.8
Thyroid malignancies (Table 3)
Thyroid cancers represent approximately 1% of all new cancer
diagnoses each year. The incidence of thyroid cancer peaks in the
third and fourth decades of life. These cancers are divided into:

papillary carcinomas (80%)

follicular carcinomas (10%)

medullary thyroid carcinomas (MTCs) (5e<10%)

anaplastic carcinomas (1e2%)

rare malignancies include primary thyroid lymphomas and
primary thyroid sarcomas.
600 Ó 2023 Published by Elsevier Ltd.

The majority of thyroid carcinomas arise from the two cell
types present in the thyroid gland: the follicular cells, which give
rise to papillary, follicular and anaplastic carcinomas, and the
neuroendocrine calcitonin-producing C cells, which give rise to
MTCs. Thyroid lymphomas arise from intra-thyroid lymphoid
tissue, and sarcomas from connective tissue in the thyroid gland.
Risk factors associated with thyroid cancer include:9

radiation exposure (papillary thyroid cancer)

obesity (papillary thyroid cancer)

genetics (abnormal RET oncogeneeMTC)

familial adenomatous polyposis (FAP) (papillary thyroid
cancer)

gender: women are diagnosed with three of every four
thyroid cancers

history of breast cancer

low-iodine diet (follicular thyroid cancer)

Cowden disease, (or Cowden syndrome is an autosomal
dominant disease characterized by multiple hamartomas
and an increased lifetime risk of breast, thyroid, uterine,
and other cancers).
A summary of the thyroid malignancies is shown in Table 3.
Papillary thyroid carcinoma
This is the most common primary thyroid tumour. It occurs most
commonly in women, aged 20 to 50, who have been exposed to
excessive radiation. These lesions are often felt as a singular mass
that moves freely and is indistinguishable from a benign lesion;
50% of cases are associated with regional metastasis, but distant
metastasis is rare. Prognosis is very good (95% 10-year survival).
Follicular thyroid carcinoma
FTC is the second most common histological type, accounting for
10% of thyroid tumours. Follicular carcinoma is prevalent in
regions where dietary intake of iodine is low. Both local invasion
Thyroid cancer overview
Cancer Associations
Papillary thyroid Most common
Females 20e50 years
Exposure to radiation, FAP, obesity,
Cowden disease
Follicular Second most frequent
Low dietary iodine
Cowden disease
3x more frequent in females
Preponderance 30e60 years old
Medullary thyroid Slightly more affects female patients
cancer MEN2A, MEN2B or FMTC
Anaplastic Least common, the most aggressive
FAP, familial adenomatous polyposis; FMTC, familial medullary thyroid cancer (an inherited condition and a subtype of MEN2); MEN2A, multiple endocrine neoplasia type
2A; MEN2B, multiple endocrine neoplasia type; MTC, medullary thyroid cancer.
Table 3
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10
ENDOCRINOLOGY
and distant metastases, usually to lung or bone, are common.
The 10-year survival rate is 85%.
Thyroidectomy with dissection of involved lymph nodes is the
primary mode of therapy for the well-differentiated carcinomas
outlined above. If any normal thyroid remnant or metastatic dis-
ease is detected, a therapeutic dose of 131-Iodine is administered
to ablate the tissue to reduce the incidence of disease recurrence.
Multikinase inhibitors (kinases are enzymes that control cell
growth and angiogenesis) are able to block pathways involved in
the proliferation, invasion, and neoangiogenesis of thyroid can-
cer and are approved in some countries for differentiated thyroid
cancers (e.g. sorafenib or lenvatinib).9
Medullary carcinoma (MTC)
MTCs represent approximately 5% of all thyroid malignancies.
De novo cases account for 80% of medullary carcinomas. Fa-
milial cases account for 20% and are associated with MEN2A,
MEN2B or FMTC (familial MTC) syndrome. Children inheriting
an FMTC syndrome have almost 100% risk of developing MTC
and are offered prophylactic thyroidectomy in many centres.9
Both sporadic MTCs and FMTCs are treated with total thy-
roidectomy and lymphatic dissection of the anterior compart-
ment of the neck (level VI). The 10-year survival rate is 65%. In
the presence of local invasion adjuvant radiotherapy may be
used.
Anaplastic carcinoma
Anaplastic thyroid carcinoma is one of the least common thyroid
carcinomas, accounting for 1.6% of all thyroid cancers. It does
have the most aggressive biologic behaviour of all thyroid ma-
lignancies and is associated with one of the worst survival rates
of all malignancies. At least one-half of patients already have
distant metastases at the time of presentation. The most common
metastatic sites are the lungs, bones and brain. The progression
Presentation Progression
Single mass, moves freely 50% association with regional
Indistinguishable from benign lesion metastasis
Distant metastasis rare
95% 10-year survival
Single nodule, minimally invasive or Both local invasion anddistant
widely invasive metastases
10-year survival rate is 85%
MTCs secrete peptides such as The 10-year survival rateis 65%.
carcinoembryonic antigen (CEA) and
calcitonin.
30 % of patients have vocal cord Most patients die within1 year
paralysis, palpable cervical metastases in
40% of patients on initial examination
601 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY
of disease is rapid, and most patients die from local airway
obstruction or complications of pulmonary metastases within 1
year of diagnosis despite all treatment efforts. Surgery is mainly
for palliation of obstructive symptoms.
Primary thyroid lymphoma
Primary lymphomas of the thyroid gland represent approxi-
mately 2e5% of all thyroid malignancies. Most thyroid lym-
phomas are non-Hodgkin B-cell tumours. Radiotherapy and
chemotherapy are the mainstay of treatment options.
Sarcoma of the thyroid gland
Sarcomas that arise in the thyroid gland from connective or
vascular tissue are uncommon. Total thyroidectomy is the main
treatment for thyroid sarcomas. Radiation therapy may be used
as an adjunct.
Thyroid surgery (Box 1)
The main indications for thyroid surgery are:

cancer (or suspected cancer)

hyperthyroidism not controlled with medication and
goitres.
Depending on the indication patients will undergo the
following surgeries, listed from the most radical to more
conservative:

Total thyroidectomy: indicated for thyroid cancer and the
most common operation for toxic multinodular goitre. All
thyroid tissue is removed while attempting to preserve the
laryngeal nerves and the vascular supply to the para-
thyroid glands.

Near total thyroidectomy: can be performed for non-toxic
goitre and for toxic multinodular goitre. Both lobes are
removed except for a small amount of thyroid tissue (on
one or both sides). It is important to note that excision is in
the vicinity of the recurrent laryngeal nerve entry point
and the superior parathyroid gland.

Subtotal thyroidectomy: used to be the most common
operation for non-toxic multinodular goitre (the recurrence
of goitre is higher comparing total/near-total thyroidec-
tomy) and involves the removal of majority of both lobes
leaving behind 3e4 g of thyroid tissue on one or both sides.
Indications for thyroidectomy
C Thyroid cancer
C Obstructive/compressive symptoms
e dysphagia
e stridor, positional dyspnoea, hoarseness
e superior vena cava obstruction
C Hyperthyroidism
e recurrent
e non-responsive to treatment
e treatment contraindicated or not tolerated
C Hashimoto thyroiditis with superimposed lymphoma
C Toxic/non-toxic thyroidal nodule
C Multinodular goitre (toxic or non-toxic)
Box 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10

Hartley Dunhill operation: performed for non-toxic multi-
nodular goitres. It involves the removal of one entire
lateral lobe with isthmus and partial/subtotal removal of
opposite lateral lobe.

Hemithyroidectomy: performed for diseases of only one
lobe. The isthmus is also removed.

Near total lobectomy: removal of one thyroid lobe leaving
behind a small amount of thyroid tissue in one of the lobes
less than 1 cm.

Isthmusectomy: involves the removal of the band of
isthmus performed for a single lesion located in the region
of the thyroid isthmus or the pyramidal lobe.
General anaesthetic considerations for thyroid surgery
The preoperative assessment for these patients should include a
general anaesthetic history and examination, as well as specif-
ically exploring signs of systemic involvement. Physiological
signs that can be elicited will involve cardiorespiratory (such as
bradycardia/tachycardia, prolonged QT, pericardial effusion,
heart failure) and neurological systems (irritability, tremor,
insomnia, depression, anxiety) (see Table 2).
The type of thyroid lesion should be identified from the notes,
letters or scans, whether it is malignant or benign, a goitre or solitary
nodule, and the size and extension of the gland, as this will may
affect intubation, positive pressure ventilation and extubation.
The reported incidence of difficult intubation in thyroid sur-
gery ranged from 5.3% to 24.6%,10 which is higher than the
general population (e.g. limited mouth opening, restricted neck
extension, immobile pharynx due to thyroidal mass). Problems
associated with extubation include loss of airway due to tracheal
collapse caused by tracheomalacia from large goitre casuing
prolonged compression and recurrent laryngeal nerve (RLN)
injury associated with vocal cord paralysis (causing stridor and
increasing risk of aspiration). Cancers may also invade and fix
surrounding tissues, reducing the mobility of laryngeal and
pharyngeal structures. Distension of neck veins that do not alter
with respiration may indicate superior vena cava obstruction
with or without thrombosis. It can be diagnosed by eliciting by
Pemberton’s sign (the patient’s face becomes blue and engorged
when both arms are raised straight up. It has been attributed to a
‘cork effect’ resulting from the thyroid obstructing the thoracic
inlet, thereby increasing pressure on the venous system).
Preoperative investigations
The degree of thyroid and concomitant body system dysfunction
should be thoroughly investigated and perioperatively managed.
Routine biochemical tests include thyroid function tests, full
blood count, urea and electrolytes and any specific tests to
identify any associated endocrine disorders such as phaeochro-
mocytoma or hyperparathyroidism. Preoperative investigations
are summarized in Table 4.
Cardiorespiratory/functional assessment: Cardiovascular in-
vestigations should include a preoperative resting ECG. An
echocardiogram is usually not required but can be considered in
those with significant thyroid diease or pre-existing cardiovas-
cular disease. Exercise tolerance and functional assessment is
essential as this can give important clues to how the
602 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY
Preoperative investigations
Investigations
Bloods Full blood count,
Urea, creatinine, sodium, potassium, glucose
Thyroid function tests,
Calcium, magnesium, phosphate, alkaline
phosphatase
Calcitonin, phosphate, alkaline phosphatase
(ALP), metanephrines
Radiographic imaging Chest X-ray
Thoracic inlet views
CT thorax e may allow estimation of
endotracheal tube size
MRI thorax
Cardiorespiratory Electrocardiography
Echocardiography
Pulmonary function test e debatable
usefulness, may assess degree of fixed
obstruction
Other Nasendoscopy/indirect laryngoscopy
C Further assessment of airway and vocal
cords function
ALP, alkaline phosphatase; MEN2A, multiple endocrine neoplasia type 2A; MEN2B, multiple endocrine neoplasia type 2B; MTC, medullary thyroid cancer.
Table 4
cardiorespiratory systems are behaving under stress in conjunc-
tion with thyroid disease. It is important to note that respiratory
symptoms may be caused by compression or obstruction of the
airway, and these should be identified preoperatively. Pulmonary
function tests may be a useful in identifying the presence of fixed
obstruction to air flow in the upper respiratory tract in cases of a
large thyroid gland or retrosternal goitre.
Imaging: Traditionally, chest X-rays and lateral thoracic inlet
views were taken to show evidence of tracheal compression and
deviation. Nowadays, computed tomography (CT) and magnetic
resonance imaging (MRI) provide excellent and detailed images
of the distorted airway anatomy. These can even be reconfigured
to create a three-dimensional reconstruction and virtual fly
through bronchoscopy.
Other investigations: Patients may develop and/or present with a
change in voice, stridor and/or difficulty swallowing. An exami-
nation of the vocal cords and laryngeal anatomy can be carried out
via indirect laryngoscopy (with a laryngeal mirror or optic stylet)
or more commonly fibreoptic nasal endoscopy (FNE). It is
important to be aware that a small percentage of thyroid surgery
patients may have unilateral paralysis of vocal cords before sur-
gery and this should be recorded in the notes preoperatively.
Perioperative management
The perioperative management of these patients can potentially
be very complicated and requires the involvement of expert cli-
nicians. The perioperative period includes induction of
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10
Associated signs and symptoms
Anaemiaehypothyroidism, thrombo/neutrocytopenia-
hyperthyroidism
Hypoglycaemia, hyponatraemia e hypothyroidism
Hyperglycaemia e hyperthyroidism
Hyperthyroidism or hypothyroidism
Hypercalcaemia e hyperthyroidism, MEN2A, MTC
Hypermagnesaemia e hyperparathyroidism, MEN2A
High calcitonin, low phosphate, low ALP e MTC
High metanephrines (phaeochromycytoma) e MTC in MEN2A/B
Tracheal compression and deviation
Tracheal compression in the anteroposterior plane
To evaluate the stenotic region and extension of the retrosternal
goitre
Sinus tachycardia, atrial fibrillation e hyperthyroidism.
Bradycardia, heart blocks, prolonged QT e hypothyroidism
Reduced contractility, pericardial effusion, heart failure e
hypothyroidism
Heart failure, ischaemia e hyperthyroidism
Vocal cord paralysis e thyroid cancers, massive goitre
anaesthesia, intraoperative management, extubation and imme-
diate postoperative care.
Premedication with sedating agents should be avoided for hy-
pothyroid patients as they are more sensitive to sedatives, addi-
tionally benzodiazepines inhibit peripheral conversion of T4 to T3.
Thyroidectomy is routinely performed under general anaes-
thesia with endotracheal intubation. Intraoperative analgesia is
supplemented by either or incisional local anaesthesia or bilat-
eral superficial cervical plexus block which can be performed
after induction. It is also possible to perform thyroidectomy
under regional anaesthesia with a cervical epidural block or
bilateral deep cervical plexus block or bilateral superficial cer-
vical plexus block. It is not routinely practised but has been
described in some specific clinical scenarios (e.g. video-assisted
thyroidectomy). There are complications associated with these
techniques, including vertebral artery puncture, subarachnoid
spread and bilateral phrenic nerve palsy.
The use of a laryngeal mask airway (LMA) has also been
described, but is not recommended and requires close coopera-
tion and communication between the surgeon and anaesthetist.
The use of LMAs is questionable, and especially in cases of
tracheal narrowing and/or deviation.
In the case of a predicted difficult airway the following tech-
niques and steps should be considered:
Pre-induction checks:

All equipment must be checked and oro/nasopharyngeal
airway adjuncts and small-diameter endotracheal tubes
must be available.
603 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY

The anaesthetist should review the most up-to-date CT/
MRI imaging of the neck and airway

The airway plan including plans for failed intubation and
airway loss should be discussed with the entire surgical
team to ensure team preparedness and readiness

The use of difficult airway algorithms/guidelines is
strongly suggested, i.e. Difficult Airway Society guidelines

The location of the cricothyroid membrane either by
palpation or ultrasound scanning should be confirmed.

The surgeons should be readily available in theatre.

Routine monitoring should be applied, i.e. continuous
pulse oximetry, three-lead ECG, non-invasive blood
pressure.

Reliable and suitably large intravenous access must be
secured.

In cases of significant cardiorespiratory disease, an awake
arterial line is strongly recommended.
Large goitres, particularly those requiring sternotomy have
the potential for massive haemorrhage. Large intravenous access
is mandatory and a low threshold should be set for the insertion
of invasive lines (arterial and central venous). Cross-matched
blood should be readily available as well as strategies to mini-
mize overall blood loss and transfusion requirement, i.e. cell
salvage, and prophylactic antifibrinolytics.
In the case of associated severe superior vena obstruction,
intravenous access in the lower limb should be secured and/or
central venous access via a femoral vein (for fluid resuscitation,
infusion of inotropes/vasopressors and haemodynamic moni-
toring in cardiovascularly unstable hypo/hyperthyroid patients).
Pre-oxygenation:

Patients should be adequately preoxygenated and use of
high-flow nasal oxygen is recommended, i.e. trans-nasal
humidified rapid-insufflation ventilatory exchange
(THRIVE) to provide apnoeic oxygenation.

Obese patients may benefit from optimized positioning
facilitated via adjuncts, i.e. Oxford HELP pillow.
Induction:

Inducing in the semi-recumbent or sitting position in
theatre, to reduce risk of aspiration and maximize func-
tional residual capacity to help respiratory mechanics.

An intravenous induction is suggested.
Intubation:

Use of a reinforced or north-facing Ring, Adair and Elwyn
(RAE) tube. A standard endotracheal tube can become
kinked during positioning for surgical access.

Securely tape tube in place once the airway is secured. The
use of an endotracheal tube tie is not recommended as this
can cause venous engorgement of the neck vessels making
surgery more hazardous.

The head end of the patient is positioned away from the
anaesthetist during thyroid surgery with direct view of the
patient by the anaesthetist obscured by surgical drapes.
The endotracheal tube must be taped securely as well as all
breathing circuit connections checked and tightly fitted
together to avoid an inadvertent disconnection during
surgery.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10

Intubation can be performed with either:

Direct laryngoscopy

Videolaryngoscopy

Optical intubating stylet (Bonfils intubating stylet)

Awake videolaryngoscopy.

Awake fibreoptic intubation in cases with laryngeal
displacement, but this may not be appropriate for cases
associated with severe airway compression, as the
bronchoscope may completely occlude the remaining
airway. In these cases, an optical stylet or awake vid-
eolaryngoscopy may be the optimal approach

An awake tracheostomy may not be possible in these
patients, especially those with an enlarged goitre.

In severe cases of subglottic obstruction insertion of
ventilating rigid bronchoscope, may be required and
surgeons should always be present during intubation if
there are concerns regarding airway management in
these patients.

Retrosternal goitre may cause tracheal obstruction,
compression, deviation and/or tracheomalacia,
causing problems with both intubation and ventilation.

Patients with massive mediastinal masses can have
complete airway obstruction post-induction of anaes-
thesia due to soft tissue compression of the trachea.
These cases should be considered for cardiopulmonary
bypass and managed in centres with such facilities
readily available.
Intraoperative
The patient is positioned slightly head-up to improve venous
drainage, with the neck extended. The head is stabilized with a head
ring and positioned with a shoulder roll. The arms are extended and
lie alongside the patient’s torso. These manoeuvres maximize
exposure of the thyroid. The eyes should be lubricated, taped and
padded, particularly if there is evidence of thyroid eye disease.

Anaesthesia may be maintained via inhalational or total
intravenous anaesthesia (TIVA).

A urinary catheter is not routinely required but should be
considered in anticipated prolonged surgery lasting over 4
hours.

Intravenous dexamethasone 8 mg can potentially aid in
reducing postoperative laryngeal oedema.

Intraoperative electrophysiological monitoring (IONM) can
be used to identify the target nerves (vagal nerves and the
recurrent laryngeal nerves) to avoid injury and to assess
real-time integrity and function during thyroid surgery. A
reinforced endotracheal tube with integrated electromy-
ography (EMG) electrodes is positioned at the level of the
vocal cords. IONM can also be used to and identify the
nerves if there is anatomical distortion secondary to scar
tissue in patients with a history of previous neck surgery or
radiotherapy. Muscle relaxants should either be avoided
completely, used in a reduced dose, or short-acting agents
such atracurium or mivacurium should be used. An
alternative strategy is the use of rocuronium and reversal
to normal neuromuscular functioning with sugammadex.

A qualitative nerve stimulator should be applied and de-
gree of neuromuscular block monitored regularly such that
it can be communicated to the surgeons.
604 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY
Remifentanil
The use of remifentanil combined with either volatile anaesthesia
or as part of a TIVA technique can be particularly advantageous
in thyroid surgery because:

It obtunds laryngeal reflexes and prevents coughing in the
absence of muscle relaxation and provides optimal surgical
conditions.

It provides a high degree of titrability to surgical stimu-
lation avoiding surges in blood pressure and allowing a
degree of permissive hypotensive anaesthesia. This im-
proves surgical conditions and minimizes surgical blood
loss.
Complications after thyroidectomy
Immediate/acute complications
Laryngeal oedema
C Respiratory obstruction
C Multiple attempts at laryngoscopy, venous obstruction from an
enlarging haematoma
C Management: steroids, humidified oxygen, nebulized adrena-
line, re-intubation may be necessary
Haematoma
C Respiratory compromise
C Postoperative bleeding
C Reduced by checking haemostasis prior to closure with a Val-
salva manoeuvre
C Management: release the collection of blood. Clip removers or
stitch cutters must be with the patient, re-intubation may be
necessary
Tracheomalacia
C Respiratory compromise, stridor
C Caused by long-standing large-sized goitre
C Should be considered before extubation (cuff leak test)
C Management: in case of severe stridor immediate re-intubation,
later: internal stenting, external stenting, or tracheostomy
Injury to recurrent laryngeal nerve
C Severe respiratory distress e bilateral injury
C Postoperative hoarseness and breathlessness e partial injury
C Stretching/traction is the main mechanism of injury, sometimes
complete/partial transection
C Management: in case of respiratory compromise immediate re-
intubation, later tracheostomy.
C The risk of injury is 6.7% postoperatively compared with 0.7% at
12 months after surgery (high recovery rate)
Injury to superior laryngeal nerve
C Usually asymptomatic, mild hoarseness or decreased vocal
endurance, sometimes dysphagia
C Most commonly injured in thyroid surgery, estimated rate 0
e25%
C Management: speech therapy
Pneumo/haemo/chylothorax (may present intraoperatively)
C Consider in the event of intraoperative hypoxemia, difficulty in
ventilation or cardiovascular instability
C Rare
C Postoperative respiratory distress
C Management: chest drain decompression
Table 5
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10
Extubation

Performed in the spontaneously breathing and fully awake
patient. If there is suspicion of recurrent laryngeal nerve
injury this can be visualized prior to extubation using a
fibreoptic endoscope through a laryngeal mask airway.

Avoid coughing or straining on the endotracheal tube as
this may exacerbate a surgical site haematoma.

A remifentanil extubation technique can be advantageous
at achieving a smooth extubation.

It is considered good practice to check for an air leak with
deflation of the endotracheal cuff prior to extubation, to
ensure there is minimal laryngeal oedema.
Intermediate to late complications (hours to days)
Hypocalcaemia
C Caused by direct trauma, damage to supplying arteries or
removal of the parathyroides
C Or transient hypocalcaemia (caused by hypothermia, ischaemia)
C Initially asymptomatic
C Circumoral paraesthesiae, mental status changes, tetany, car-
popedal spasm, laryngospasm, seizures, QT prolongation on
ECG, cardiac arrest. The Chvostek sign or the Trousseau sign.
C Management: in symptomatic patients intravenous calcium
gluconate, otherwise oral replacement is with activated
vitamin D
Thyroid storm
C May result during surgery in patients with hyperthyroidism
C It can develop preoperatively, intraoperatively, or
postoperatively
C Management: organ support in the intensive care unit, fluids,
active cooling, antipyretics, thionamides, b-blockade and
glucorticoids
Postoperative nausea and vomiting (PONV)
C Delayed recovery
C High rates in thyroid surgery (63e84% patients undergoing
thyroid surgery)
C Management: anti-emetics, propofol intravenous anaesthesia
and dexamethasone reduce symptoms
Infection
C Infection occurs in less than 1e2% of all cases
C Management: antibiotics, rarely wound exploration
Neuropraxia of cutaneous nerves
C Paraesthesia of anterior cutaneous nerves of neck
C Direct damage during incision
C Management: conservative
605 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY

Where there is a high risk of postoperative tracheomalacia, Hypocalcaemia

the surgical team may request partial withdrawal of the
endotracheal tube just proximal to the goitre under direct
vision in order to visualize the extent of malacia. In case of
severe tracheomalacia the patient should not be extubated.

Recover sitting upright as much as tolerated in order to aid
venous drainage and prevent facial/neck swelling.

Analgesia: a suggested regime is suggested as follows
e Regular paracetamol
e Regular NSAIDs such as ibuprofen in the absence of
patient contraindications
e A one off dose of a selective cox-2 inhibitor (parecoxib)
is considered safe and has not been shown to increase
bleeding risk11
e Intravenous opiates titrated to effect, i.e. morphine or
oxycodone in the immediate postoperative phase
e Local anaesthetic infiltration of the surgical site
e Bilateral superficial cervical plexus block has been
shown to provide superior analgesia to that of inci-
sional Infiltration and can offer analgesic efficacy in the
early postoperative period for up to 24 hours after
surgery.12
Thyroidectomy complications
Major postoperative complications include wound infection,
bleeding, airway obstruction (compressing haematoma, trache-
omalacia), hypocalcaemia, thyroid storm (usually associated
with Graves’ disease) and recurrent laryngeal nerve injury. The
most common thyroidectomy complications are summarized in
Table 5).
If oral thyroxine cannot be given postoperatively for hypo-
thyroid patients, the dose may be missed for several days.
However, if there is still no ability to administer the drug enter-
ally after 5 days, intravenous levothyroxine should be given at a
dose between 60% and 80% of the oral dose.7
Hypocalcaemia can occur transiently postoperatively in up to
20% of patients5 that have a large goitre excised. The cause is a
secondary hypoparathyroidism secondary to damage to the
parathyroid glands intraoperatively given their close anatomical
relationship to the thyroid gland. Acute hypocalcaemia can cause
paraesthesias, twitching and in extreme cases lead to tetany.
Trosseau’s sign (carpopedal spasm of the digits when a blood
pressure cuff is inflated) or Chvostek’s sign (facial muscle spasm
upon tapping over the parotid gland stimulating the facial nerve)
are also signs that may be elicited. In extreme cases, cardiovas-
cular dysfunction can precipitate into ventricular dysrhythmias.
A low index of suspicion should therefore be held for acute
hypocalcaemia following thyroid surgery and a serum calcium
should be checked shortly post operatively. The treatment for
acute hypocalcaemia involves intravenous calcium administra-
tion (i.e. 10 ml of 10% calcium gluconate) which may need to be
followed up with an intravenous calcium infusion.
Acute neck haematoma following thyroid surgery
Postoperative haemorrhage in the neck requiring re-operation is a
recognized but rare complication of thyroid surgery with an inci-
dence of about 1.6%.13 Hameatoma formation in the neck
following thyroid surgery can be devastating with rapid airway
obstruction, desaturation and ultimately death. This complication
particularly in the patient in extremis requires immediate man-
agement, airway support and urgent haematoma evacuation.
A cornerstone of immediate management remains reopening
of the surgical wound. This is a daunting task for all but the most
experienced operators particularly in a ward setting. The British

Retrosternal goitre (RSG)

Retrosternal goitres are uncommon in the UK and tend to be
managed in tertiary centres. They are most frequently associated
with multi-nodular goitres and symptoms stem from the
compression of surrounding structures. Patients with compres-
sion of the mediastinal structures, trachea and oesopahgus may
present with a range of symptoms from: asymptomatic to dysp-
noea, stridor, hoarseness and dysphagia. The thoracic lymph
duct may also be compressed causing chylothorax and an in-
crease in pressure of the major mediastinal vessels can lead to
pleural effusion. Retrosternal goitres can cause cerebral hypo-
perfusion, as a result of arterial compression (brachiocephalic
artery and left common carotid artery). These goitres may also be
associated with compression of the phrenic nerve and recurrent
laryngeal nerve. The sympathetic chain can also become com-
pressed causing Horner’s syndrome.
These patients may be difficult to bag and mask ventilate,
intubate and positive pressure ventilate and postoperatively
there is a risk of tracheomalacia from prolonged tracheal
compression by the goitre. These are challenging cases to
manage and require high levels of expertise from the anaesthetist moire to facilitate the emergency management of
Figure 4 An aide-me
and surgeon. an acute haematoma following thyroid surgery.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10 606 Ó 2023 Published by Elsevier Ltd.
 ENDOCRINOLOGY
Association of Endocrine and Thyroid Surgeons (BAETs) has
published a quick-reference guideline outlining the step-by-step
approach to rapidly reopening the surgical wound (Figure 4).
Conclusion
Patients requiring thyroid surgery can present in a multitude of
ways. The management of these patients is dependent on the
spectrum of disease severity which can range from simple to
extremely complex. The potential for perioperative complications
can therefore be very high. Safe perioperative care can be pro-
vided to patients with a range of thyroid disease by appropriate
investigation, optimization and perioperative management. A
comprehensive understanding of the different aspects of thyroid
disease and surgery is required. Airway management in such
patients may be challenging and thorough assessment of altered
airway anatomy and function should be undertaken and applied
to induction, intubation and extubation. A https://doi.org/10.1093/bja/aeq096
REFERENCES
1 Langley RW, Burch HB. Perioperative management of the
thyrotoxic patient. Endocrinol Metab Clin N Am 2003; 32:
519e34.
2 Misra M, Singhal A. Thyroid storm. 2022. https://emedicine.
medscape.com/article/925147-overview
3 Lee SL, Ananthakrishnan S, Pearce EN. Iodine deficiency. 2018.
https://emedicine.medscape.com/article/122714-overview#showall
4 De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet 2016;
388: 906e18. https://doi.org/10.1016/S0140-6736(16) 00278-6
Epub 2016 Mar 30. PMID: 27038492; PMCID: PMC5014602.
5 Malhotra S, Sodhi V. Anaesthesia for thyroid and parathyroid
surgery. Continuing Education in Anaesthesia Critical Care & Pain
2007; 7: 55e8. https://doi.org/10.1093/bjaceaccp/mkm006
ANAESTHESIA AND INTENSIVE CARE MEDICINE 24:10
6 Eledrisi MS. Myxedema coma or crisis. 2023. https://emedicine.
medscape.com/article/123577-overview
7 Goldenberg D. Thyroid cancer. 2023. Practice Essentials, Etiol-
ogy, Epidemiology, https://emedicine.medscape.com/article/
851968-overview?form¼fpf (accessed 21 August 2023).
8 Hoffman RP. Thyroiditis. 2022. https://emedicine.medscape.com/
article/925249-overview#showall
9 Palace MR. Perioperative management of thyroid dysfunction.
Health Services Insights 2017; 10: 117863291668967. https://doi.
org/10.1177/1178632916689677
10 Bouaggad A, Nejmi SE, Bouderka MA, et al. Prediction of difficult
tracheal intubation in thyroid surgery. Anesth Analg 2004; 99:
603e6.
11 Gehling M, Arndt C, Eberhart LHJ, et al. Postoperative analgesia
with parecoxib, acetaminophen, and the combination of both: A
randomized, double-blind, placebo-controlled trial in patients
undergoing thyroid surgery. Br J Anaesth 2010; 104: 761e7.
12 Woldegerima YB, Hailekiros AG, Fitiwi GL. The analgesic efficacy of
bilateral superficial cervical plexus block for thyroid surgery under
general anesthesia: A prospective cohort study. BMC Res Notes
2020; 13: 42. https://doi.org/10.1186/s13104-020-4907-7
13 British Association of Endocrine & Thyroid Surgeons. Fifth Na-
tional Audit Report, 2017.
FURTHER READING
Thyroid disease: Assessment and management. NICE Guideline
[NG145]. 2019, https://www.nice.org.uk/guidance/ng145/chapter/
Context#key-facts-and-figures (accessed 21 August 2023).
Teerawattananon C, Tantayakom P, Suwanawiboon B, Katchamart W.
Risk of perioperative bleeding related to highly selective
cyclooxygenase-2 inhibitors: a systematic review and meta-anal-
ysis. Semin Arthritis Rheum 2017; 46: 520e8.
607 Ó 2023 Published by Elsevier Ltd.