What are the pre and post operative management strategies for patients undergoing total thyroidectomy?

Pre and Postoperative Management of Total Thyroidectomy

All patients undergoing total thyroidectomy should receive preoperative laryngeal examination to assess vocal fold mobility, and postoperative examination should be performed between 2 weeks and 2 months to detect recurrent laryngeal nerve injury, which occurs in approximately 9.8% of cases. 1

Preoperative Management

Laryngeal Assessment

• Perform preoperative laryngoscopy on all patients to establish baseline vocal fold mobility, particularly those with voice changes, thyroid malignancy, or invasive disease 1
• Flexible laryngoscopy is preferred over mirror examination as it allows video recording, evaluation during speech tasks, and detection of subtle motion abnormalities 1
• Preoperative vocal fold paralysis occurs in 6.5% of patients and strongly suggests invasive malignancy (>70% in invasive disease vs 0.3% in noninvasive disease), which fundamentally changes surgical planning 1

Thyroid Function Optimization

• For hyperthyroid patients, achieving euthyroidism before surgery is traditionally recommended, though recent evidence suggests surgery can be safely performed in biochemically hyperthyroid patients without significantly increased complication rates 2
• Document baseline thyroid function tests (TSH, FT3, FT4) as these guide postoperative hormone replacement dosing 1

Preoperative Staging (for Malignancy)

• For suspected medullary thyroid carcinoma (MTC): obtain baseline serum calcitonin, CEA, calcium, and plasma/urine metanephrines to screen for pheochromocytoma 1, 3
• For differentiated thyroid cancer: perform neck ultrasound to assess lymph node involvement and determine extent of surgery 1
• Preoperative risk stratification determines whether prophylactic central neck dissection is warranted 1

Immediate Postoperative Management

Airway Monitoring and Hematoma Prevention

• Place a post-thyroid surgery emergency box at bedside containing wound opening supplies during the entire postoperative period, including transfers 1
• Emergency front-of-neck airway equipment (scalpel, bougie, tracheal tube) must be readily available on the ward 1
• Minimum monitoring includes wound inspection, early warning scores, pain scoring, and vigilance for subtle signs: agitation, anxiety, breathing difficulty, or discomfort 1
• Postoperative hematoma occurs in 0.45%-4.2% of cases and can cause rapid airway obstruction even with small volumes 1

Emergency Hematoma Management

• If airway compromise from hematoma is suspected, use the SCOOP approach at bedside: Skin exposure, Cut sutures, Open skin, Open muscles (superficial and deep layers), Pack wound 1
• Arrange immediate senior surgical review (registrar or consultant) for any concern about hematoma; if unavailable or airway compromise present, call senior anesthesiologist immediately 1

Calcium and Parathyroid Monitoring

• Monitor for hypocalcemia, which occurs temporarily in approximately 8.1% of patients after total thyroidectomy 1
• Check serum calcium levels postoperatively as hypoparathyroidism is a common complication requiring calcium and vitamin D supplementation 1

Voice Assessment

• Systematically assess voice between 2 weeks and 2 months postoperatively using patient-reported outcomes or formal voice evaluation 1
• Examine vocal fold mobility or refer for laryngoscopy in any patient with voice change after surgery 1
• Temporary vocal fold paralysis occurs in 9.8% of patients; permanent paralysis occurs in 2.5%-4.3% 1
• Voice changes are common (29% at 2 weeks) and typically improve by 6 months, but persistent changes warrant laryngeal examination 1

Long-Term Postoperative Management

Thyroid Hormone Replacement

For Differentiated Thyroid Cancer:

• Initiate levothyroxine (L-T4) immediately after surgery for both replacement and TSH suppression 1
• TSH suppression targets based on risk stratification: 1, 4
  • Low-risk patients (papillary microcarcinoma ≤1 cm, no invasion/metastases): TSH 0.5-2.0 mIU/L (low-normal range) 4
  • Intermediate-risk patients: TSH 0.1-0.5 mIU/L 4
  • High-risk patients: TSH <0.1 mIU/L 1, 4
• Patients require approximately 30% higher L-T4 doses post-thyroidectomy compared to preoperative requirements (median 1.95 μg/kg/day vs 1.50 μg/kg/day) to achieve equivalent TSH levels 5
• TSH-suppressive doses are needed to achieve preoperative T3 levels; moderately suppressed TSH levels restore native T3 concentrations 6
• Check thyroid function tests (FT3, FT4, TSH) at 2-3 months post-surgery to verify adequate L-T4 dosing 1

For Medullary Thyroid Cancer:

• Do NOT use TSH suppression therapy—MTC cells lack TSH receptors and do not respond to TSH stimulation 1, 3
• Maintain TSH in normal range with replacement-dose levothyroxine only 1, 3

Radioactive Iodine (RAI) Therapy Decision

• High-risk differentiated thyroid cancer patients: RAI ablation is indicated 1
• Low-risk patients (papillary microcarcinoma): RAI is NOT indicated 1, 4
• Intermediate-risk patients: individualize decision based on specific risk factors 1
• Medullary thyroid cancer: RAI is contraindicated as MTC does not concentrate iodine 3

Surveillance and Follow-Up

For Differentiated Thyroid Cancer:

• At 6-12 months: physical examination, neck ultrasound, basal and rhTSH-stimulated serum thyroglobulin measurement with or without diagnostic whole body scan 1
• For patients free of disease: annual physical examination, basal serum thyroglobulin on L-T4 therapy, and neck ultrasound 1
• Dynamic risk stratification should be performed during follow-up, reclassifying patients as excellent response, biochemical incomplete, structural incomplete, or indeterminate based on imaging and thyroglobulin levels 1

For Medullary Thyroid Cancer:

• Measure serum calcitonin every 6 months for first 2-3 years, then annually 1, 3
• Calculate calcitonin and CEA doubling times from sequential measurements to assess disease progression 3
• If post-surgery calcitonin is undetectable after provocative testing, repeat calcitonin every 6 months for 2-3 years, then annually 1
• If basal calcitonin >150 pg/ml: screen for distant metastases with comprehensive imaging 1, 3
• If calcitonin <150 pg/ml: limit evaluation to careful neck ultrasound 1

Critical Pitfalls to Avoid

• Never delay opening the wound at bedside if hematoma with airway compromise is suspected—waiting for operating room access can be fatal 1
• Do not assume normal voice means normal vocal fold function—up to 6.5% of patients have preoperative vocal fold abnormalities without voice complaints 1
• Avoid over-suppressing TSH in low-risk thyroid cancer—this increases risks of atrial fibrillation and osteoporosis without mortality benefit 4
• Do not use radioiodine or TSH suppression for medullary thyroid cancer—these are ineffective and expose patients to unnecessary treatment 1, 3
• Recognize that postoperative hypothyroidism after lobectomy occurs in 64.2% of patients, with 32.6% developing late hypothyroidism after the first year, requiring long-term TSH monitoring 7