What is the management for post-thyroidectomy (after thyroid removal) dizziness?

Management of Post-Thyroidectomy Dizziness

Post-thyroidectomy dizziness requires immediate evaluation for potentially life-threatening causes such as neck hematoma with airway compromise, followed by assessment for hypocalcemia, which are the two most common serious complications requiring urgent intervention. 1

Initial Assessment and Management

Immediate Evaluation for Neck Hematoma

• Assess for signs of neck hematoma using the DESATS approach: Difficulty swallowing/discomfort; increase in Early warning score; Swelling; Anxiety; Tachypnea/difficulty breathing; and Stridor 1
• Immediately administer supplemental oxygen if there are concerns about hemorrhage or hematoma 1
• Position patient in head-up position to optimize airway patency 1
• If signs of airway compromise are present (oxygen desaturation, difficulty breathing, stridor, tachypnea, or rapidly expanding neck swelling), immediately call for help and proceed to hematoma evacuation 1

Urgent Management of Suspected Hematoma

• For patients with signs of airway compromise, immediately notify a senior anaesthetist 1
• If hematoma with airway compromise is suspected, use the SCOOP approach at bedside: Skin exposure; Cut sutures; Open skin; Open muscles; Pack wound 1
• Increase frequency of observations if there are concerns about potential hemorrhage 1
• Consider transfer to operating theatre, PACU, or ICU for close observation if stable but concerns persist 1

Management of Hypocalcemia-Related Dizziness

• Hypocalcemia is a common cause of post-thyroidectomy dizziness that requires prompt identification and treatment 2, 3
• Check serum calcium levels immediately if dizziness occurs post-thyroidectomy 4
• Measure parathyroid hormone (PTH) levels, as a PTH level <13 pg/mL at postoperative day 1 indicates high risk for symptomatic hypocalcemia 5
• A decrease in PTH ≥30% at 10 minutes after skin closure has 92.3% sensitivity and 92.6% specificity in predicting hypocalcemia 6

Treatment of Hypocalcemia

• For patients with confirmed hypocalcemia or PTH <10 pg/mL, administer 0.25-μg calcitriol twice daily and 2-6 g of calcium carbonate daily 2
• For symptomatic hypocalcemia with severe dizziness, consider intravenous calcium administration 2, 4
• Patients with normal PTH levels (≥10 pg/mL) may be treated with calcium supplementation only 2

Monitoring and Follow-up

• Perform routine observations at least hourly for the first 6 hours postoperatively, as hemorrhage and subsequent hematoma most frequently occur within the first 24 hours (with approximately half occurring within 6 hours) 1
• After the initial 6-hour period, tailor the frequency of observations according to individual patient risk 1
• Ensure patients are nursed in a bed where they can easily attract attention of nursing staff 1
• Monitor for subtle signs of complications including agitation, anxiety, difficulty in breathing, and discomfort 1

Common Pitfalls and Caveats

• Stridor may be a late sign of airway compromise and warrants immediate management 1
• Drains do not prevent hematoma formation in routine thyroid surgery, and clot formation may prevent free drainage, providing false reassurance 1
• Low-dose calcium supplementation alone may not be sufficient to prevent symptomatic hypocalcemia; calcitriol should be added for patients with low PTH levels 2, 5
• Dizziness may also be related to anesthesia effects, pain medication, or positional changes - these should be considered after excluding more serious causes 1