How to manage globus sensation after thyroidectomy?

Management of Globus Sensation After Thyroidectomy

Globus sensation after thyroidectomy should be managed with a systematic approach that includes ruling out post-operative hematoma, providing symptomatic relief, and addressing both physical and psychological factors that contribute to persistent symptoms. 1, 2

Immediate Assessment for Complications

First, it's critical to rule out post-operative hematoma, which can be life-threatening:

Signs requiring urgent evaluation (DESATS):

• Difficulty swallowing/discomfort
• Elevated early warning score
• Swelling in the neck
• Anxiety
• Tachypnea/difficulty breathing
• Stridor

If hematoma is suspected:

1. Administer supplemental oxygen immediately
2. Position patient in head-up position
3. Call for urgent senior surgical or anesthetic review
4. If airway compromise is present, proceed with SCOOP approach:
   • Skin exposure
   • Cut sutures
   • Open skin
   • Open muscles (both superficial and deep)
   • Pack wound

Monitoring requirements:

• Hourly observations for first 6 hours post-operatively
• After 6 hours, tailored frequency based on individual risk
• Emergency airway equipment must be readily available 1, 2

Management of Uncomplicated Globus Sensation

Once life-threatening complications are ruled out, address the globus sensation:

Understanding the prognosis:

• Research shows that 80% of patients with pre-operative globus symptoms experience resolution after thyroidectomy 3
• However, approximately 51% of patients without pre-operative symptoms develop new globus sensation one month after thyroidectomy 4

Risk factors for persistent globus symptoms:

• Female sex (HR 2.605)
• Central lymph node metastasis (HR 3.533)
• Central neck dissection (HR 3.652)
• Pre-operative psychological factors 5, 4

Management algorithm:

1. Reassurance and education:

   • Explain that symptoms often improve over time
   • Most symptoms gradually decrease by 12 months post-surgery 5

2. Speech and swallowing therapy:

   • Targeted exercises to address changes in speaking fundamental frequency
   • Swallowing techniques to reduce sensation

3. Pharmacological management:

   • Consider intravenous dexamethasone for acute post-operative symptoms to reduce edema 2
   • Proton pump inhibitors if concurrent laryngopharyngeal reflux is suspected

4. Psychological support:

   • Psychological screening and intervention when needed
   • Higher preoperative self-rating depression scale (SDS) scores predict persistent globus symptoms at 12 months 5

Follow-up Recommendations

• Scheduled follow-up at 1,3,6, and 12 months post-operatively
• Monitor for improvement in globus symptoms over time
• Consider additional interventions if symptoms persist beyond 6 months

Special Considerations

• Patients who underwent total thyroidectomy with lateral neck dissection experience more severe and persistent globus symptoms compared to those who had lobectomy only 5
• Patients with histological features of inflammation in the thyroid specimen show greatest improvement in pre-existing globus symptoms 3

Pitfalls to Avoid

• Don't dismiss persistent globus symptoms as purely psychological without thorough evaluation
• Avoid overlooking the relationship between extent of surgery and symptom severity
• Don't underestimate the impact of psychological factors on symptom persistence
• Never delay evaluation of potential post-operative hematoma, as it can rapidly progress to airway obstruction 1, 2