Are steroids recommended before thyroidectomy?

Preoperative Steroids for Thyroidectomy

While preoperative dexamethasone 8 mg IV significantly reduces postoperative nausea, vomiting, and pain after thyroidectomy, the American Academy of Otolaryngology-Head and Neck Surgery states that no recommendation can be made regarding its impact on voice outcomes—the most critical quality-of-life measure—due to methodological limitations in existing studies. 1

Primary Indication: Symptom Control, Not Voice Protection

What Steroids Definitively Improve

• Postoperative nausea and vomiting (PONV): Dexamethasone 8 mg IV given preoperatively before anesthesia induction significantly reduces PONV incidence and severity (P = 0.001) 1, 2, 3

• Postoperative pain: The same dose significantly reduces pain scores (P = 0.008-0.009) 1, 3

• Duration of benefit: Effects are most pronounced within the first 16-24 hours postoperatively, with no significant differences apparent by 24-48 hours 1, 3

What Remains Uncertain: Voice Outcomes

• Official guideline position: The American Academy of Otolaryngology-Head and Neck Surgery explicitly states "no recommendation can be made regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes" 1

• Conflicting evidence on voice: One RCT showed modest improvement in vocal fold lengthening ability on postoperative day 1 (P = 0.015-0.018), but these differences disappeared by 24 hours and were measured with non-validated instruments 1, 3

• Another RCT showed no benefit: A separate double-blind study found no differences in subjective voice analyses (P = 0.693) 1

Practical Dosing Recommendations

Standard Prophylactic Dose

• Dexamethasone 8 mg IV administered preoperatively before anesthesia induction is the evidence-based dose 1, 2, 3

• Lower doses may be equally effective: A 4-5 mg dose may provide similar PONV prevention as 8-10 mg, though this is based on lower-quality evidence 4, 2

Timing Considerations

• Administer before induction of anesthesia, not intraoperatively, as the preoperative timing showed superior outcomes in RCTs 1

Critical Safety Considerations

When Steroids Are NOT Routinely Recommended

Patients already on chronic steroids should NOT receive additional "stress dose" steroids for routine thyroidectomy. 1

• Recent evidence shows no benefit from perioperative "push-dose" steroids in patients on chronic steroid therapy as long as they continue their usual regimen 1

• Exception: Only administer stress-dose hydrocortisone 100 mg IV if unexplained, fluid-unresponsive hypotension occurs, suggesting adrenal crisis 1

Documented Risks in Chronic Steroid Users

• Patients on chronic steroids undergoing thyroidectomy have significantly increased risk of postoperative bleeding requiring transfusion (OR = 0.375, P = 0.046), wound infection (OR = 0.226, P < 0.001), pulmonary embolism (OR = 0.312, P = 0.034), and prolonged ventilator dependence (OR = 0.401, P = 0.008) 5

• These patients require medical optimization before surgery, not additional steroids 5

Monitoring Requirements

• Watch for hyperglycemia, infection, delayed wound healing, and cardiovascular abnormalities, though no steroid-related complications were observed in the RCTs using single-dose dexamethasone 1, 3

• A recent study found patients receiving preoperative corticosteroids had mildly lower calcium levels on postoperative day 1 (though mean remained >8.5 mg/dL) with more frequent hypocalcemia episodes, but no difference in rates of hypoparathyroidism 6

Special Context: Hyperthyroid Patients

Preoperative Preparation for Graves' Disease

• Corticosteroids are part of combination therapy to prevent thyroid storm in hyperthyroid patients undergoing thyroidectomy, blocking peripheral conversion of T4 to T3 7, 8

• This indication is separate from and additional to the PONV prophylaxis indication 7, 8

• Combination therapy includes thionamides, beta-blockers, iodine, and corticosteroids to target synthesis, secretion, and peripheral effects of thyroid hormones 7, 8

Algorithmic Approach

For Routine Thyroidectomy (Euthyroid Patients)

1. Administer dexamethasone 8 mg IV preoperatively for PONV and pain reduction 1, 2, 3
2. Do not expect voice outcome improvement as evidence is insufficient 1
3. Monitor calcium levels on postoperative day 1, as mild hypocalcemia may be more common 6

For Patients on Chronic Steroids

1. Continue usual steroid regimen perioperatively 1
2. Do NOT add stress-dose steroids routinely 1
3. Only give hydrocortisone 100 mg IV if unexplained hypotension occurs 1
4. Optimize medically before surgery due to increased complication risk 5

For Hyperthyroid Patients (Graves' Disease)

1. Use corticosteroids as part of multimodal preoperative preparation to prevent thyroid storm 7, 8
2. Combine with thionamides, beta-blockers, and iodine 7, 8
3. This is a separate indication from PONV prophylaxis 7, 8

Common Pitfalls to Avoid

• Do not give steroids expecting voice improvement: The guideline explicitly states insufficient evidence for this outcome 1

• Do not add stress-dose steroids to patients already on chronic steroids: This practice lacks evidence and may increase complications 1, 5

• Do not confuse PONV prophylaxis with thyroid storm prevention: These are distinct indications requiring different approaches 7, 8

• Do not assume single-dose dexamethasone carries significant risk: RCTs showed no steroid-related complications, though vigilance for hyperglycemia and infection remains prudent 1, 3