Otolaryngology–Head and Neck Surgery (2008) 138, 98-100
ORIGINAL RESEARCH—HEAD AND NECK CANCER
Hypothyroidism following partial thyroidectomy
Michael Vaiman, MD, PhD, Andrey Nagibin, MD, PhD, Philippe Hagag, MD,
Alex Kessler, MD, and Haim Gavriel, MD, Bat-Yam, Israel; and Ivanovo, Russia
OBJECTIVE: To compare rates of hypothyroidism following
three types of partial thyroidectomy for multinodular goiter.
STUDY DESIGN AND METHODS: All cases of partial thy-
roidectomies (hemi-, near-total, or subtotal) carried out at one
Israeli and one Russian medical center (1990-2006) were retro-
spectively studied to determine the incidence of hypothyroidism
after each procedure.
RESULTS: There were 881 near-total, 1538 subtotal, and 1051
hemithyroidectomies (total 3470). Postoperative follow-up was 2
to 15 years. Twenty-eight percent of the hemithyroidectomy pa-
tients suffered permanent hypothyroidism compared to 100% of
the near-total and 87% of the subtotal patients. Forty-six percent of
the hemithyroidectomy patients suffered temporary hypothyroid-
ism compared to 100% of the near-total and 93% of the subtotal
patients.
CONCLUSION: Subtotal and near-total thyroidectomies pro-
duced a rate of hypothyroidism close to that of total thyroidectomy
compared to 28% after hemithyroidectomy.
SIGNIFICANCE: Partial thyroidectomies provide no decisive
advantage over total thyroidectomies in terms of subsequent re-
quirements of supplemental hormone therapy.
© 2008 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
W hile there is general consensus that the surgical treat-
ment of thyroid cancers is total thyroidectomy (TT),
the optimal operative strategies for treating benign thyroid
diseases remain controversial. The parameters that are usu-
ally considered in this ongoing debate are postoperative
hypothyroidism and the rates of surgical complications. The
various types of thyroidectomies for treating both benign
and malignant thyroid pathology include TT, near-total thy-
roidectomy (NT), subtotal thyroidectomy (ST), and hemi-
thyroidectomy (HT). In the TT technique, the entire gland is
removed from the tracheoesophageal groove, while fewer
than 3 g of thyroid tissue are left along the posterior aspect
of the contralateral lobe in the NTs. The ST approach leaves
no more than 25% of one lobe and it can also be a bilateral
procedure. HT is a lobectomy and is used in cases of
unilateral pathology.
We chose to study multinodular goiter (MNG) from
among the various thyroid pathologies because of its ubiq-
uitousness in the general population (an incidence of MNG
Received June 27, 2007; revised August 22, 2007; accepted September
12, 2007.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2007.09.015
varies between 4% in iodine-sufficient countries1 and 33%
in iodine-deficient areas1,2) and the fact that it is considered
a diffuse disease. Although MNGs are rarely unilateral, they
pose a dilemma in terms of the extent of the thyroidectomy.
STs, NTs, HTs, and TTs are currently used to treat them,
depending on the surgeon’s preference.
Most earlier studies on operative strategies for thyroid-
ectomy concentrated on the rates of well-recognized possi-
ble complications, such as permanent recurrent laryngeal
nerve paralysis and hypoparathyroidism. We designed this
multicenter study to document the incidence of postopera-
tive hypothyroidism associated with three conventional par-
tial thyroidectomies for treating MNG.
MATERIALS AND METHODS
Of the total of 7329 patients who were candidates for this
study, 3859 were excluded for having undergone operations
other than an HT, ST, or NT (n ⫽ 3573) or were lost to
follow-up (n ⫽ 286), leaving a final study cohort of 3470
patients. There were 1452 males and 2018 females whose
mean age was 46.8 years. They had undergone an HT (n ⫽
1051), ST (n ⫽ 1538), or NT (n ⫽ 881) for MNG over a
period of 2 to 15 years earlier and were being followed up
as outpatients in the two participating medical centers. Ex-
clusion criteria were previously known malignancy and/or
final pathologic results containing thyroid neoplasm requir-
ing completion thyroidectomy. Table 1 lists the distribution
and demographic data of the study cohort and Table 2
depicts the distribution of the three investigated procedures
in the two medical centers.
Standard HT, NT, and ST procedures were performed in
which the recurrent laryngeal nerves and parathyroid glands
were identified. The approach used for an individual patient
was chosen according to the surgeon’s judgment. All spec-
imens were routinely examined histologically to confirm
benignity of the pathology. All patients were hospitalized
and routine calcium measurements and indirect laryngosco-
pies were performed. Preoperative hypothyroidism was de-
fined as a baseline TSH level of greater than 5.5 U/mL, and
Vaiman et al Hypothyroidism following partial thyroidectomy 99

Table 1
Distribution and demographic data of the study cohort

Hospital center No. patients M (%) F (%) Mean age, y

Assaf Harofeh (Israel) 1337 472 (35.3%) 865 (64.7%) 49.3

Ivanovo Academy (Russia) 2133 980 (46%) 1153 (54%) 44.5
Total 3470 1452 (41.8%) 2018 (58.2%) 46.8

208 patients (6%) were determined as being in a hypothy- (194 after HT, 231 after ST, and 61 after NT). A completion
roid state before the operation. Temporary postoperative thyroidectomy was performed on 285 patients and the oth-
hypothyroidism was defined as a serum thyrotropin level ers were prescribed an elevated L-thyroxin dose.
greater than 6.0 mIU/L that persisted for at least 8 weeks Thyroid hormone supplement due to hypothyroidism
after surgery. Hypothyroidism was considered as being per- was required in 28% post-HT cases, in 87% post-ST cases,
manent when it persisted at 6 months and more after sur- and in 100% post-NT cases (P ⬍ 0.05 for NT vs HT, and P
gery. Endocrinologists assessed thyroid and parathyroid ⫽ 0.12 for NT vs ST). The usual treatment protocol was
functions using conventional measurements. followed. There was no significant difference between the
Approval for this study was obtained from the Institu- two hospitals in terms of postoperative supplement require-
tional Review Boards and Medical Ethics Committees of ments.
both institutions. There were no untoward surgical complications in any of
the reported cases that might influence the results of this
Statistical analysis study. Recovery was uneventful for all three procedures.
Differences between the groups were analyzed with the
Fisher exact test. P values less than 0.05 were considered
significant.
DISCUSSION
Although the technique of performing a TT had signifi-
RESULTS cantly improved in the 1970s,3 surgeons still preferred per-
forming STs even though the reported incidence of hypo-
The rates of hypothyroidism for each of the three types of
thyroidism after ST ranged from 25%4 to as high as 87.5%.5
surgery in both hospitals are presented in Table 3. The
During the 1980s through 1990s, some surgeons favored ST
inter-hospital difference for postoperative hypothyroidism
for treating benign diseases due to its proposed lower inci-
was insignificant (P ⬎ 0.01). The median durations of
dence of surgical complications and postoperative euthyroid
hospitalizations were 2.9 days for HT, 3.3 days for NT, and
state,6-8 while others advocated TT because of similar com-
3.1 days for ST for the Assaf Harofeh Hospital and 17.4,
plication rates to those of the ST procedure and the sug-
19.2, and 19 days, respectively, for the Ivanovo Medical
gested lower pathologic recurrence rate.9,10 NT evolved as a
Academy Hospital. The differences in lengths of hospital-
compromise between TT and ST operations,11 but it had no
ization between the two medical centers reflect hospital
significant effect on the rate of complications. When feasi-
policy.
ble, however, TT was nevertheless replaced by partial op-
Conservative postoperative treatment was sufficient in
erations with the intention of avoiding injuries of laryngeal
2984 cases, while reoperation was required for the remain-
nerves and accidental excision of parathyroid glands as well
ing 486 patients who suffered recurrence of benign disease
as postoperative hypothyroidism (TT by definition causes
hypothyroidism).
While hypothyroidism after ST is not at all rare and almost
Table 2
inevitable after NT, an HT approach might be considered
Distribution of the three types of partial
thyroidectomies
“safer” in terms of postoperative hypothyroidism in cases of
unilateral disease. A recent study, however, set the overall
Near- incidence of post-HT hypothyroidism at 27% and noted that
Medical center Hemi- Subtotal total the majority of cases developed within the first 6 to 12 months
after surgery.12 Risk factors for the development of hypothy-
Assaf Harofeh
roidism included pathologic diagnosis (Hashimoto thyroiditis
(Israel) 457 516 364
Ivanovo Academy and MNG) as well as a high-normal serum thyrotropin level. In
(Russia) 594 1022 517 our study, the incidence of 28% hypothyroidism after HT
Total 1051 1538 881 versus 87% after ST and 100% after NT is clearly significant
and a decisive advantage; the surgical decision, however, is
100 Otolaryngology–Head and Neck Surgery, Vol 138, No 1, January 2008

Table 3
Type and percentage of hypothyroidism after hemi-, subtotal, and near-total thyroidectomies carried out in the
two medical centers*

Hemi-total Subtotal Near-total

Type Israeli Russian (mean) Israeli Russian (mean) Israeli Russian (mean)

Temporary 45 47 (46) 92 94 (93) 100 100 (100)

Permanent 25 31 (28) 83 90 (87) 100 100 (100)
Temporary, a serum thyrotropin level ⬎ 6.0 mIU/L that persisted for at least 8 weeks after surgery; Permanent, a serum
thyrotropin level ⬎ 6.0 mIU/L that persisted at 6 months and more after surgery.
*P ⬍ 0.01 (␹2 test)

usually made on grounds of nodule location, ie, unilateral or FINANCIAL DISCLOSURE

bilateral location of the nodules.
Technically speaking, hypothyroidism is not a postsur-
gical complication but an expected outcome of the removal
of a significant portion (or all) of the thyroid gland. The
subsequent functional role of the remaining thyroid tissue
has been addressed by only a few reports. Koyuncu et al13
reported that L-thyroxin was not required in 36.6% of cases
after the Dunhill procedure (unilateral ST) and in 47.8%
after bilateral ST. Ozbas et al reported the requirement of
supplemental L-thyroxin in all cases of partial and total
thyroidectomies in their study, with higher prescribed doses
as the extent of surgery rises.14
In summary, our study results demonstrate that both ST
and NT procedures produce high rates of hypothyroidism,
close to that of TT. The incidence of postsurgical hypothy-
roidism after HT was 28%. Since ST has a high rate of
surgical revision similar to HT and high rate of supplemen-
tation similar to NT, ST has demonstrated no advantage in
either category.
ACKNOWLEDGEMENT
Esther Eshkol, MA is thanked for editorial assistance.
AUTHOR INFORMATION
From the Departments of Otorhinolaryngology–Head and Neck Surgery
(Drs Vaiman, Kessler, and Gavriel) and Endocrinology (Dr Hagag), Assaf
Harofeh Medical Center, affiliated to the Sackler Faculty of Medicine, Tel
Aviv University, Israel; and the Department of Head and Neck Surgery (Dr
Nagibin), Ivanovo State Medical Academy.
Corresponding author: Michael Vaiman, MD, 33 Shapira Street, Bat Yam,
59561 Israel.
E-mail address: vaimed@yahoo.com.
AUTHOR CONTRIBUTIONS
Michael Vaiman, main idea, editing; Andrey Nagibin, main idea, editing;
Philippe Hagag, evaluation and counseling; Alex Kessler, writing, data
collection; Haim Gavriel, writing, data collection.
None.
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