Anesthesia for patients with thyroid disease and for patients who undergo thyroid or parathyroid surgery

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©2024 UpToDate®

Anesthesia for patients with thyroid disease and for

patients who undergo thyroid or parathyroid surgery
Author: Amy C Robertson, MD
Section Editor: Stephanie B Jones, MD
Deputy Editor: Marianna Crowley, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Apr 2024. | This topic last updated: May 08, 2024.

INTRODUCTION

Thyroid disease and thyroid surgery present specific challenges for anesthesiologists.

This topic reviews the perioperative anesthetic management of patients with thyroid
disease and anesthetic management of patients who undergo thyroid or parathyroid
surgery. Preoperative medical management of patients with thyroid disease, perioperative
surgical management of patients undergoing thyroid surgery, and urgent management of
severe and life-threatening overt thyroid storm are reviewed separately. (See "Nonthyroid
surgery in the patient with thyroid disease" and "Surgical management of
hyperthyroidism" and "Thyroidectomy" and "Thyroid storm".)

Perioperative risk as it relates to the degree of thyroid dysfunction is also discussed

separately. (See "Nonthyroid surgery in the patient with thyroid disease", section on
'Surgical outcomes' and "Nonthyroid surgery in the patient with thyroid disease", section
on 'Clinical manifestations that may impact perioperative outcome'.)

Parathyroidectomy may be performed for patients with primary or secondary

hyperparathyroidism. Clinical manifestations of hyperparathyroidism and indications for
surgery are discussed separately.
● (See "Primary hyperparathyroidism: Clinical manifestations".)
● (See "Primary hyperparathyroidism: Management".)

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● (See "Refractory hyperparathyroidism and indications for parathyroidectomy in adult
patients on dialysis".)

MULTIORGAN SYSTEM EFFECTS OF THYROID DISEASE

Patients with existing hyper- or hypothyroidism have associated physiologic changes that
may affect anesthetic care and perioperative outcomes. Most such changes resolve with
treatment as the patient becomes euthyroid.

Hyperthyroidism — Hyperthyroidism can be classified as subclinical (ie, low thyroid-

stimulating hormone [TSH] with normal free T4 and T3), or overt (ie, suppressed TSH with
elevated free T4 and/or T3). As the degree of hyperthyroidism increases, clinical
manifestations are more prominent and have a greater potential impact on anesthetic
care. In patients with overt hyperthyroidism surgery can, rarely, precipitate thyroid storm,
a potentially life-threatening condition. (See "Overview of the clinical manifestations of
hyperthyroidism in adults" and "Nonthyroid surgery in the patient with thyroid disease",
section on 'Overt hyperthyroidism'.)
● Cardiovascular changes may lead to perioperative hemodynamic instability.
Hyperthyroid patients have increased heart rate, circulating blood volume, cardiac
contractility, and myocardial oxygen consumption, as well as enhanced diastolic
relaxation and reduced systemic vascular resistance ( table 1). Patients with
hyperthyroidism are also prone to sinus tachycardia and atrial fibrillation, coronary
spasm, and ischemia, and may develop cardiomyopathy over time [1-9]. (See
"Cardiovascular effects of hyperthyroidism".)
● Hyperthyroidism does not increase minimum alveolar concentration (MAC)
requirement [10,11]. However, induction of anesthesia may be slower and may
require increased concentrations of inhaled anesthetics because of elevated cardiac
output in patients with hyperthyroidism, and resultant effects on uptake and
distribution of anesthetics. Patients with hyperthyroidism may have increased
anesthetic requirements, primarily to control blood pressure and heart rate. There
are no existing data supporting an increased MAC with contemporary inhaled
anesthetics. Older animal studies demonstrated no clinically significant increase in
halothane requirements [11]. (See "Inhalation anesthetic agents: Properties and
delivery", section on 'Cardiovascular factors'.)

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● Vasoactive medications should be chosen based on clinical and patient factors,
independent of thyroid function ( table 2 and table 3).

Patients with hyperthyroidism have been thought to exhibit increased sensitivity to

catecholamines. Thus, the typical recommendation is that hypotension should be
treated with direct acting vasoconstrictors (eg, phenylephrine) rather than with
catecholamines or medications that release catecholamines (eg, ephedrine).
However, evidence in support of this recommendation is indirect and conflicting.
Some in vitro human studies have reported an increase in beta adrenergic receptor
density in the heart in patients with hyperthyroidism [12-14]. However, there is also
evidence that the increased receptor density may be counteracted to a degree by
cellular changes that reduce adrenergic receptor responsiveness to catecholamines
[15]. The net effect may be that cardiac adrenergic responsiveness is unaltered in
patients with hyperthyroidism. (See "Cardiovascular effects of hyperthyroidism",
section on 'Adrenergic effects'.)
● Respiratory muscle weakness occurs with hyperthyroidism, and in patients with
severe hyperthyroidism, this may mandate postoperative mechanical ventilatory
support after general anesthesia [16,17]. (See "Respiratory function in thyroid
disease".)

Intraoperative thyroid storm — Thyroid storm is a rare, life-threatening condition

characterized by severe clinical manifestations of thyrotoxicosis [18]. It has been reported
during surgery and in the first 18 hours after thyroid and non-thyroid surgery in
hyperthyroid patients, though the incidence is very low in patients who receive
preoperative antithyroid treatment. (See "Nonthyroid surgery in the patient with thyroid
disease", section on 'Thyroid storm'.)

The diagnosis of thyroid storm is based upon the presence of severe and life-threatening
signs and symptoms (eg, hyperthermia, cardiac dysfunction, altered mentation) in a
patient with biochemical evidence of hyperthyroidism. (See "Thyroid storm", section on
'Diagnosis'.)

During anesthesia, thyroid storm can be difficult to differentiate from malignant

hyperthermia, which may share clinical characteristics.
● If clinical signs of thyroid storm develop during or shortly after surgery in a patient
with known hyperthyroidism, therapeutic measures should be initiated immediately,
including administration of a beta blocker unless contraindicated. An endocrinologist
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should be consulted urgently, and further treatment will likely include administration
of a thionamide (eg, methimazole or propylthiouracil), though these drugs cannot
readily be administered intravenously (see "Thyroid storm", section on
'Thionamides'). Other supportive measures include aggressive treatment of
hyperpyrexia with cooling blankets and acetaminophen, administration of a
glucocorticoid (eg, hydrocortisone), and treatment of metabolic abnormalities.
● In patients without known hyperthyroidism, and prior to laboratory confirmation of
hyperthyroidism, it is reasonable to also manage the patient for malignant
hyperthermia crisis (ie, administer dantrolene and discontinue potent inhaled
anesthetics). (See "Malignant hyperthermia: Diagnosis and management of acute
crisis", section on 'Acute management of suspected MH' and "Malignant
hyperthermia: Diagnosis and management of acute crisis", section on 'Others'.)

Ongoing support and monitoring in the critical care setting is strongly recommended
after surgery since the mortality rate is substantial in patients with thyroid storm [19].
(See "Thyroid storm", section on 'Initial management' and "Nonthyroid surgery in the
patient with thyroid disease", section on 'Thyroid storm'.)

Hypothyroidism — Hypothyroidism may be classified as mild, moderate, or severe, as

follows:
● Mild hypothyroidism – Subclinical, elevated TSH with normal serum free T4
● Moderate hypothyroidism – Elevated TSH, low free T4, without clinical features of
severe hypothyroidism
● Severe hypothyroidism – Severe clinical symptoms such as altered mentation,
pericardial effusion, or heart failure; myxedema coma; or very low levels of total T4
(eg, <1.0 mcg/dL) or free T4 (eg, <0.5 ng/dL). (See "Nonthyroid surgery in the patient
with thyroid disease", section on 'Defining the severity of hypothyroidism'.)

Severe hypothyroidism has a greater impact on anesthetic care than mild or well-
treated disease. Patients with moderate or severe hypothyroidism may exhibit
exaggerated responses to anesthetic agents, sedatives and opioids, and appear to be
at increased risk of perioperative complications. Case reports have described
significant respiratory depression from opioids, vasopressor-resistant hypotension,
and prolonged recovery from anesthetic agents in patients with severe
hypothyroidism [20,21]. Studies of the pharmacokinetics and pharmacodynamics of

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sedatives and anesthetic medications in these patients are lacking, and it is unclear
whether prolonged effects relate to reduced cardiac output and/or other physiologic
effects, or are a direct result of thyroid dysfunction [22]. There is no evidence that
these patients have a reduced MAC for contemporary inhaled anesthetics [23,24].
(See "Nonthyroid surgery in the patient with thyroid disease", section on 'Defining the
severity of hypothyroidism' and "Nonthyroid surgery in the patient with thyroid
disease", section on 'Surgical outcomes'.)

Physiologic effects of hypothyroidism that may affect anesthetic management include the
following:
● Cardiovascular abnormalities may lead to perioperative hemodynamic instability or
myocardial ischemia. Clinically hypothyroid patients may have bradycardia,
diminished response to adrenergic agents, diastolic dysfunction, increased systemic
vascular resistance, and impaired venous return ( table 4) [1,2,25-27]. Patients with
hypothyroidism, even subclinical disease, are at increased risk for ischemic heart
disease [28,29]. (See "Clinical manifestations of hypothyroidism", section on
'Cardiovascular system'.)
● Hypothyroid patients may have a diminished response to alpha and beta adrenergic
agents, and larger than usual doses of vasopressors may be required [30-32]. (See
"Cardiovascular effects of hypothyroidism", section on 'Cardiac contractility'.)
● Obstructive sleep apnea is more common and should be suspected in patients with
hypothyroidism (see "Respiratory function in thyroid disease", section on 'Obstructive
sleep apnea').

Perioperative management of patients with obstructive sleep apnea is discussed

separately.

• (See "Surgical risk and the preoperative evaluation and management of adults
with obstructive sleep apnea".)

• (See "Intraoperative management of adults with obstructive sleep apnea".)

• (See "Postoperative management of adults with obstructive sleep apnea".)
● Respiratory effects of the hypothyroid state include impaired ventilatory drive and
respiratory muscle weakness, which can lead to alveolar hypoventilation [33-35]. Also,
hypothyroid patients are extremely sensitive to the effects of drugs that depress
respiratory drive, such as opioids and sedatives [20,21,36].
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● Patients with severe clinical hypothyroidism are at risk for delayed emergence and
may require prolonged ventilatory support. (See "Respiratory function in thyroid
disease".)
● Metabolic abnormalities may include hyponatremia due to a reduction in free water
clearance, reversible increases in serum creatinine, and reduced clearance of
hypnotic and opioid medications [37]. Other concerns include hypoglycemia, anemia,
and hypothermia.

PREANESTHESIA EVALUATION

Preanesthesia evaluation always includes a medical history and anesthesia-focused

physical examination, including airway examination. Testing should be determined by the
patient's medical status and the surgical procedure. Preanesthesia evaluation is discussed
in detail separately. (See "Preoperative evaluation for anesthesia for noncardiac surgery".)

Perioperative thyroid medication management is discussed separately. (See "Perioperative

medication management", section on 'Drugs used for thyroid disease'.)

Euthyroid patients — For patients with known, treated thyroid disease, clinical euthyroid
status should be confirmed during preanesthesia evaluation. Patients taking a stable dose
of thyroid medication with documented euthyroid status within the past three to six
months do not need additional testing prior to surgery. (See "Nonthyroid surgery in the
patient with thyroid disease", section on 'Is preoperative measurement of TSH necessary?'.)

Patients with abnormal thyroid function — If history and physical examination suggest
thyroid disease, it is reasonable to try to make a diagnosis, starting with laboratory thyroid
function tests, since it can affect perioperative management. (See "Diagnosis of and
screening for hypothyroidism in nonpregnant adults", section on 'Diagnosis' and
"Diagnosis of hyperthyroidism", section on 'Diagnosis'.)

Elective surgery should be delayed in patients with recently diagnosed thyroid disease and
in those who remain hyperthyroid or severely hypothyroid, until treatment results in a
documented euthyroid state. If urgent or emergency surgery is required, patients with
severe hypothyroidism or hyperthyroidism should receive treatment of their disease prior
to surgery, as time allows, in order to minimize complications. (See "Nonthyroid surgery in
the patient with thyroid disease", section on 'Hypothyroidism' and "Nonthyroid surgery in
the patient with thyroid disease", section on 'Hyperthyroidism'.)
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For emergency surgery in patients with moderately severe or severe hypothyroidism,

advanced intraoperative monitoring (eg, continuous intraarterial blood pressure
monitoring) may be indicated, and such patients may require intensive care
postoperatively. Preoperative thyroid hormone replacement and postoperative concerns in
such patients are discussed separately. (See "Nonthyroid surgery in the patient with
thyroid disease", section on 'Management'.)

Airway evaluation — Preanesthesia evaluation always includes an airway assessment

with the goal of predicting any potential difficulty with airway management (see "Airway
management for induction of general anesthesia", section on 'Airway assessment'). While
an enlarged thyroid (goiter) may cause airway compromise due to invasion of airway
structures, extension into the mediastinum, and compression of the trachea, we do not
routinely order imaging studies specifically to assess the airway in patients with thyroid
disease or a goiter [38-40]. In two prospective studies of intubation in thyroidectomy
patients, difficult endotracheal intubation was predicted most often by the usual anatomic
predictive factors ( table 5), rather than the size of the goiter or the presence of tracheal
compression or deviation [38,41]. In a meta-analysis of 8 studies (5800 patients) of airway
management in patients who had thyroid surgery, tracheal deviation was the only thyroid-
specific factor associated with difficult intubation [42]. Other identified risk factors were a
high Mallampati score, a short thyromental distance, a low interincisor gap, obesity, and
male gender. In practice, the presence of a large benign goiter without symptoms of
obstruction seldom changes airway management plans.

Surgical evaluation prior to thyroidectomy usually includes laryngoscopy to evaluate vocal

cord function, as well as thyroid ultrasound (see "Thyroidectomy", section on 'Preoperative
evaluation and preparation'). If respiratory symptoms are present or substernal goiter is
suspected, computed tomography or magnetic resonance imaging is often obtained to
assess the size of a goiter, its caudal extent, the extent of tracheal compression, and the
location of the mass (eg, anterior or posterior mediastinum) [40,43]. Other studies may
have been ordered to evaluate the full extent of the mass and its effects upon surrounding
structures. (See "Clinical presentation and evaluation of goiter in adults", section on 'Goiter
with obstructive symptoms or suspected substernal goiter'.)

All available studies should be reviewed by the anesthesiologist, with particular attention
to the following clinical entities:
● Cancerous goiter – The presence of a cancerous goiter may be a risk factor for

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difficult intubation, possibly due to tissue infiltration with associated fibrosis, which
may reduce the mobility of laryngeal structures and impede the view of the glottic
opening during laryngoscopy [38]. The limited literature on this issue is conflicting. In
one prospective review of 320 patients who underwent thyroidectomy, presence of a
cancerous goiter was an independent risk factor for difficult intubation [38]. In
contrast, in another prospective study of 324 thyroidectomy patients, thyroid
malignancy was not associated with difficult intubation [41]. Neither study provided
details on the severity of thyroid malignancy or related imaging.
● Obstructive or substernal goiter – Extension of the thyroid below the sternal notch
(ie, substernal goiter) results in respiratory symptoms in 90 percent of patients and
dysphagia in one-third [40]. Respiratory symptoms, including hoarseness, dyspnea,
wheezing, obstructive sleep apnea, or cough, may be caused by tracheal compression
or nerve involvement. (See "Clinical presentation and evaluation of goiter in adults",
section on 'Obstructive symptoms'.)

Substernal mediastinal goiters can cause obstruction of airway and major

cardiovascular structures with induction of anesthesia. (See 'Induction of anesthesia'
below and "Anesthesia for patients with an anterior mediastinal mass", section on
'Anesthetic preparation and management'.)

ANESTHETIC MANAGEMENT FOR THYROID AND/OR PARATHYROID

SURGERY

Anesthetic management is generally similar for thyroid and parathyroid surgery, except as
noted in the following discussion.

Choice of anesthetic technique — Thyroid and parathyroid surgery (open or minimally

invasive) can be performed with general anesthesia or with local/regional anesthesia,
which usually includes a cervical plexus block. Excision of a single parathyroid gland can
often be performed with local infiltration alone, without a nerve block. The choice of
anesthetic technique should be based on patient factors and patient, surgeon, and
anesthesiologist preference.

We prefer general anesthesia for thyroid or parathyroid surgery, unless local or regional
anesthesia is requested by the patient and/or the surgeon. However, practice varies, and in
some high volume endocrine surgery centers, local or regional anesthesia is used more
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commonly than general anesthesia [44,45]. General anesthesia provides a secure airway
from the start of anesthesia and an immobile surgical field. Regional anesthesia allows
intraoperative voice monitoring, avoidance of endotracheal intubation, and may have
other benefits for patients with some comorbidities, such as avoidance of hemodynamic
changes in patients with cardiac disease. (See 'Recurrent laryngeal nerve monitoring'
below.)

Several studies that compared general with regional anesthesia for thyroid surgery have
reported reduced length of stay and costs with regional anesthesia, and similar clinical
outcomes [44,46,47].

Surgical contraindications to a local/regional anesthetic technique include a plan for

sternotomy or lateral neck dissection. Patient factors that are contraindications for
local/regional anesthesia include cervical lymphadenopathy, locally invasive cancer, local
anesthetic allergy, and patient refusal. [45,48]. General anesthesia is usually preferred for
prolonged surgical procedures, for patients who cannot communicate, cooperate, or lie
still or with their neck extended for the length of the surgery, for patients with severe
anxiety, and for patients who are claustrophobic. General anesthesia with secure airway
control may also be preferred for patients with predicted difficulty with airway
management, or expected airway difficulty during sedation (eg, patients with obstructive
sleep apnea or morbid obesity). In large case series, 2 to 12 percent of patients
undergoing thyroidectomy with local or regional anesthesia require conversion to general
anesthesia because of anxiety, inadequate anesthesia, surgical difficulty, or airway
problems [45,47-49].

Local/regional anesthesia can be used for minimally invasive thyroid surgery, unless
alternative incision sites are used (eg, axillary or retroauricular). (See "Thyroidectomy",
section on 'Minimally invasive thyroid surgery'.)

Local or regional anesthesia — Regional anesthesia for thyroid or parathyroid surgery

usually involves the use of a cervical plexus block along with local infiltration by the
surgeon, as well as monitored anesthesia care and sedation. Superficial cervical plexus
block is the regional anesthetic technique of choice for thyroid and parathyroid surgery.
Deep cervical plexus block is more difficult to perform, less effective, and associated with
more anesthesia-related complications than superficial block. (See "Scalp block and cervical
plexus block techniques", section on 'Cervical plexus blocks'.)

We do not typically perform superficial cervical plexus blocks solely for postoperative
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analgesia after routine thyroid surgery. Pain is usually modest after uncomplicated
thyroidectomy and is typically well controlled with local anesthetic wound infiltration and
multimodal nonopioid analgesics, with addition of opioids if necessary.

Some institutions have implemented enhanced recovery after surgery (ERAS) protocols
that include superficial cervical plexus blocks. However, the available literature has not
shown clear benefits of superficial cervical plexus block in this setting, and studies have
not typically compared these blocks with multimodal analgesic regimens. A 2018 meta-
analysis of 14 randomized trials (1150 patients) that compared superficial cervical plexus
blocks with saline or no block for thyroid surgery found small improvements in pain scores
with blocks, with a mean difference 0.5 to 0.7 on a 0 to 10 visual analog scale (VAS) over the
course of 24 hours [50]. There was longer time until first request for analgesia with the use
of superficial cervical plexus block (mean 143 versus 38 minutes), and reduced hospital
length of stay (two trials, mean 2.1 versus 2.4 days). Several subsequently published
studies have reported statistically significant but likely clinically irrelevant reductions in
postoperative pain scores and analgesic consumption in patients who had superficial
cervical plexus blocks [51-53].

Intraoperative anesthetic management

Monitoring — Standard physiologic monitoring (ie, electrocardiography, noninvasive

blood pressure monitoring, pulse oximetry, and capnography) is sufficient for most
patients who undergo thyroid or parathyroid surgery ( table 6). Advanced monitoring
(eg, intra-arterial continuous blood pressure monitoring) may be indicated based on
patient comorbidities. Special monitoring that may be used during these procedures
include the following:

Recurrent laryngeal nerve monitoring — If recurrent laryngeal nerve monitoring is

to be used during the procedure, either a specialized endotracheal tube (ETT) may be used,
or a conventional ETT with electrodes applied above the ETT cuff. The electrodes must be
placed at the level of the vocal cords during intubation. Neuromuscular blockade should
then be avoided during maintenance of anesthesia. Intraoperative nerve monitoring is
discussed separately. (See "Thyroidectomy", section on 'Intraoperative nerve monitoring'.)

Parathyroid hormone monitoring — Intraoperative parathyroid hormone

monitoring may be performed during parathyroidectomy for hyperparathyroidism, to
indicate when hyperfunctioning parathyroid tissue has been excised. One or more blood
samples can be drawn from a peripheral vein, an arterial catheter, or by the surgeon from
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the internal jugular vein. The decision to place an arterial catheter or a second intravenous
(IV) catheter should be individualized; we usually draw the necessary sample from a vein in
the foot or lower leg for these samples, since the patient's arms are tucked at the side and
inaccessible. Another common approach is to place an IV catheter in an antecubital vein
just below a blood pressure cuff (and use the cuff as a tourniquet prior to withdrawing a
blood sample). Some surgeons simply prefer to draw a sample from the internal jugular
vein in the operative field. (See "Parathyroid exploration for primary hyperparathyroidism",
section on 'Intraoperative parathyroid hormone monitoring'.)

Induction of anesthesia — The choice of induction technique and medications depends

on patient factors, and is discussed separately. (See "Induction of general anesthesia:
Overview".)

If nerve monitoring is to be used during the procedure, neuromuscular blockade must be

avoided during testing. Thus a short-acting neuromuscular blocking agent (NMBA), or no
NMBA, should be used for endotracheal intubation. Options include succinylcholine,
rocuronium or vecuronium reversed with sugammadex prior to testing, or a remifentanil
intubation (eg, remifentanil 2.5 to 4 mcg/kg IV with propofol 2 mg/kg IV and ephedrine 10
to 15 mg IV, modified for patient factors). (See "Rapid sequence induction and intubation
(RSII) for anesthesia", section on 'Alternatives to succinylcholine'.)

Substernal goiters are present in 2 to 19 percent of patients having thyroidectomy [54],

and are located in the anterior mediastinum in 75 to 90 percent of cases [55]. Induction of
anesthesia in patients with a very large or obstructing mediastinal mass may result in
obstruction of major airways or major cardiovascular structures. Management of
anesthesia for patients with mediastinal masses is discussed separately. (See "Anesthesia
for patients with an anterior mediastinal mass".)

Airway management — We routinely perform endotracheal intubation for thyroid or

parathyroid surgery, though supraglottic airways (SGAs) can be used for these procedures
as well [56-58].

ETTs provide a secure airway throughout the procedure, and are mandatory if recurrent
laryngeal nerve monitoring is used. SGAs are more likely to require adjustment after neck
extension for surgical positioning or during tracheal manipulation during surgery, but may
result in less coughing during emergence from anesthesia.

The airway may be managed with standard intubation techniques in most patients with
thyroid disease. However, for patients with a goiter that is symptomatic, invasive, or
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substernal, the approach to induction and intubation may need to be altered. (See 'Airway
evaluation' above and "Management of the difficult airway for general anesthesia in
adults".)

Patients with stridor due to severe tracheal compression should be intubated awake to
limit the risk of complete airway obstruction when spontaneous ventilation ceases. The
surgical team should be prepared and ready to perform an emergent tracheotomy (which
may be difficult in a patient with a goiter) or rigid bronchoscopy for patients with airway
compromise [40] (see "Management of the difficult airway for general anesthesia in
adults", section on 'Awake intubation').

Individual case reports have described the use of venovenous extracorporeal membrane
oxygenation (ECMO) prior to induction of anesthesia [59] or for airway rescue [60] in
patients with large thyroid masses.

Positioning for surgery — The patient is typically positioned on the operating table in a
supine position with the head elevated, with the arms tucked at the sides. The neck is
typically extended, with either a roll or an inflatable bag (ie, a "thyroid bag") under the
patient's shoulders. The patient's ability to extend the neck should be assessed
preoperatively, and patients with known cervical spine disease should be assessed by an
orthopedic surgeon or neurosurgeon for the safety of neck extension. (See
"Thyroidectomy", section on 'Patient position and skin preparation'.)
● After positioning, the patient's occiput should be resting on a head support (eg, foam
donut or blanket), rather than floating or suspended.
● The airway device may require adjustment after positioning with neck extension.
Neck extension may move the electrodes for nerve monitoring of the ETT out of
correct position relative to the vocal cords and can unseat an SGA.

Maintenance of anesthesia — The choice of anesthetic agents for maintenance of

anesthesia depends on patient factors, and is discussed separately. (See "Maintenance of
general anesthesia: Overview".)

The effects of abnormal thyroid function on the choice of anesthetic agents and
intraoperative management are discussed above. (See 'Multiorgan system effects of
thyroid disease' above.)

Concerns specific to thyroid or parathyroid surgery include the following:

● When recurrent laryngeal nerve monitoring is used, NMBAs should be avoided
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during maintenance of anesthesia.

● Manipulation of the trachea during surgery is stimulating, and can cause cough or
patient movement. Remifentanil infusion (eg, 0.03 to 0.3 mcg/kg per minute,
modified for patient factors and other anesthetic agents) can be used to suppress
these responses without unnecessary postoperative opioid effect. Low dose
remifentanil infusion can also be administered during emergence and extubation to
minimize cough. (See 'Emergence and extubation' below.)
● We use standard oxygen supplementation for patients who undergo thyroid or
parathyroid surgery, with fraction of inspired oxygen typically approximately 30
percent, modified for patient factors (see "Mechanical ventilation during anesthesia
in adults", section on 'Fraction of inspired oxygen'). Whereas one study suggested a
beneficial effect of a high fraction of inspired oxygen (80 percent during and after
surgery) on certain complication rates, these data are preliminary and require
confirmation [61].

Prophylaxis for postoperative nausea and vomiting — We employ preventive

measures for postoperative nausea and vomiting for all patients who undergo thyroid
surgery to minimize the risk of wound hematoma due to retching or vomiting. We
administer at least one prophylactic antiemetic during surgery (eg, ondansetron 4 mg IV),
and use an opioid-sparing strategy for postoperative pain relief (eg, local anesthetic wound
infiltration, postoperative acetaminophen and nonsteroidal antiinflammatory drugs). In
high-risk patients, we also use total IV anesthesia. (See "Postoperative nausea and
vomiting".)

Emergence and extubation — Severe hypertension or coughing during emergence and

extubation may induce bleeding from the surgical site, with possible hematoma formation.
Strategies to minimize coughing include, but are not limited to, extubation under deep
anesthesia (which carries the risks of an unprotected airway in an anesthetized patient) or
administration of remifentanil, dexmedetomidine, or lidocaine during emergence [62-65].
The choice of technique and drugs is determined by patient risk factors for coughing (eg,
smoking status), as well as the preferences and the experience of the anesthesiologist.
(See "Extubation following anesthesia", section on 'Minimizing physiologic response to
extubation'.)

Postextubation airway complications — Immediately after extubation, airway

compromise may develop due to recurrent laryngeal nerve injury, causing vocal cord
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dysfunction; tracheomalacia, causing tracheal collapse in patients with long-standing

tracheal compression (extremely rare); or expansion of a cervical wound hematoma,
causing new tracheal compression. Immediate reintubation may be necessary. (See
"Thyroidectomy", section on 'Hematoma' and "Thyroidectomy", section on 'Nerve
injury/vocal cord paresis or paralysis'.)

Recurrent laryngeal nerve injury — All patients who undergo thyroid or

parathyroid surgery should be watched closely immediately after extubation for signs of
recurrent laryngeal nerve (RLN) dysfunction, including stridor, weak vocalization, or airway
obstruction, particularly after bilateral surgery. RLN injury may be suspected by the
surgeon or suggested by nerve monitoring, but may be apparent only after extubation
without intraoperative evidence of injury.

The RLN innervates most of the intrinsic laryngeal muscles. Injury to the nerve can be
partial and result in weak vocal cord motion, or complete and result in paralysis of the
affected vocal cord. The involved vocal cord assumes a median or paramedian position.
Unilateral RLN injury causes hoarseness but no airway obstruction, whereas bilateral RLN
paralysis can result in stridor, and possibly complete airway obstruction. Immediate
reintubation, and occasionally tracheostomy, may be necessary. (See "Thyroidectomy",
section on 'Nerve injury/vocal cord paresis or paralysis'.)

Injury to the superior laryngeal nerve (in contrast with the RLN) has no effect on
postoperative airway status. Rather, it manifests as voice fatigue and changes in voice
quality [66].

Neck hematoma — Postoperative neck hematoma requiring emergency surgical

evacuation is a rare but potentially serious complication of thyroidectomy. Bleeding and
hematoma formation may cause venous congestion of airway structures, and airway
compromise may develop rapidly due to compression of the trachea or laryngeal edema as
soft tissue swelling develops and as the hematoma expands ( figure 1). When surgical
bleeding causes airway compromise, emergency re-operation may be required to evacuate
the hematoma. Head-up position to lower venous pressures, nebulized epinephrine, and
systemic steroids may be useful temporizing strategies; however, definitive treatment
should not be delayed [67,68]. (See "Thyroidectomy", section on 'Hematoma' and
"Postoperative airway and pulmonary complications in adults: Etiologies and initial
assessment and stabilization", section on 'Acute upper airway obstruction'.)

If time permits, the patient should be returned to the operating room for re-exploration;
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Anesthesia for patients with thyroid disease and for patients who undergo thyroid or parathyroid surgery

however, rapidly developing airway compromise may require bedside evacuation of the
hematoma as an immediate airway protection maneuver. Soft tissue swelling may be so
severe that reopening the incision fails to fully normalize the airway anatomy. Since
substantial distortion of the airway may persist after the hematoma has been evacuated,
the safest method for intubation may be an awake intubation. No matter what approach is
taken, intubation should not be delayed; it should be performed expeditiously by the most
experienced member of the team ( table 7).

Tracheomalacia — Longstanding tracheal compression by a goiter may lead to

tracheomalacia [55]. Although extremely rare, prolonged compression may cause atrophy
and erosion of cartilaginous tracheal rings. After thyroid resection, the tracheal wall may
collapse in an anteroposterior direction, leading to airway obstruction. Incidence and
management of tracheomalacia due to goiter are discussed separately. (See "Treatment of
benign obstructive or substernal goiter", section on 'Tracheomalacia'.)

In patients with longstanding large goiters, we perform a cuff leak test to assess the
adequacy of air flow around the endotracheal tube prior to extubation (see "Extubation
following anesthesia", section on 'Cuff-leak test'). If there is no leak, we extubate over a
tube exchanger to facilitate rapid reintubation if necessary.

Postoperative care — Most patients are transferred to the post-anesthesia care unit for
recovery from anesthesia, with monitoring and discharge criteria similar to patients who
have other types of surgery. These issues are discussed separately. (See "Overview of post-
anesthetic care for adult patients".)

After thyroid surgery, patients may be admitted to the hospital for overnight observation
and management, or in select cases, may be discharged home within a few hours of
surgery. Inpatient versus outpatient surgery is discussed separately. (See "Thyroidectomy",
section on 'Inpatient versus outpatient surgery'.)

SUMMARY AND RECOMMENDATIONS

● Preanesthesia evaluation

• Thyroid dysfunction causes physiologic changes that may affect anesthetic care
and perioperative outcomes. Most of these changes resolve with treatment as the
patient becomes euthyroid. (See 'Multiorgan system effects of thyroid disease'
above.)
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Anesthesia for patients with thyroid disease and for patients who undergo thyroid or parathyroid surgery

• For patients with known, treated thyroid disease, euthyroid status should be
confirmed during preanesthesia evaluation. Patients taking a stable dose of
thyroid medication, with documented euthyroid status within the past three to six
months, do not need additional testing prior to surgery. (See 'Euthyroid patients'
above.)

• For patients with recently diagnosed thyroid disease, elective surgery should be
delayed until treatment results in a documented euthyroid state. Patients with
severe hypothyroidism or hyperthyroidism who need urgent or emergency
surgery should receive immediate treatment prior to surgery. (See 'Patients with
abnormal thyroid function' above.)
● Choice of anesthetic technique – We prefer general anesthesia for thyroid or
parathyroid surgery. Advantages of general anesthesia include secured control of the
airway and an immobile surgical field, as well as avoidance of the need for urgent
conversion from local/regional to general anesthesia. However, clinical outcomes do
not differ in patients who receive local or regional versus general anesthesia. (See
'Choice of anesthetic technique' above.)
● Airway concerns

• An enlarged thyroid gland (goiter) can cause difficulty with airway management
for anesthesia, particularly cancerous, substernal, or obstructing goiters. (See
'Airway evaluation' above.)

• A smaller than usual endotracheal tube (ETT) size may be required in patients with
potential airway problems related to a goiter. Patients with stridor due to tracheal
compression are intubated awake, with the surgical team standing by ready to
perform emergent tracheotomy or rigid bronchoscopy. (See 'Induction of
anesthesia' above.)

• After thyroid surgery, post-extubation airway compromise may develop, caused by

vocal cord dysfunction due to recurrent laryngeal nerve injury, tracheal
compression due to an expanding wound hematoma, or tracheomalacia due to
long-standing tracheal compression. Immediate reintubation may be necessary,
as well as emergency surgical decompression of any wound hematoma. (See
'Postextubation airway complications' above.)
● Recurrent laryngeal nerve monitoring – If recurrent laryngeal nerve monitoring is

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Anesthesia for patients with thyroid disease and for patients who undergo thyroid or parathyroid surgery

used during thyroid or parathyroid surgery, neuromuscular blockade should be

avoided during testing. (See 'Recurrent laryngeal nerve monitoring' above.)

ACKNOWLEDGMENT

The editorial staff at UpToDate acknowledge William R Furman, MD, who contributed to an
earlier version of this topic review.

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