When is thyroid surgery indicated, and what pre‑operative workup, surgical technique, postoperative care, and non‑surgical alternatives are recommended?

Thyroid Surgery: Indications and Management

Thyroid surgery is indicated for confirmed or suspected malignancy on fine-needle aspiration, symptomatic compression from large goiters, toxic nodular goiter when radioiodine is contraindicated or refused, and bilateral nodular disease requiring definitive treatment.

Indications for Surgery

Malignancy-Related Indications

• Confirmed malignancy on FNA cytology warrants surgical intervention 1
• Indeterminate cytology (follicular neoplasm) in high-risk clinical context including history of head and neck radiation 2, 1
• Thyroid nodules in patients with prior head and neck radiation exposure, given the subsequent risk of malignant transformation 2

Benign Disease Indications

• Symptomatic multinodular goiter causing compressive symptoms in the neck 3, 4
• Bilateral thyroid nodules where definitive treatment avoids future reoperation risk 2
• Toxic nodular goiter when radioiodine is refused or contraindicated, though radioiodine remains first-line for this condition 4
• Large goiters causing mass effect symptoms 1

Pre-operative Workup

Essential Diagnostic Steps

• Serum TSH measurement to assess thyroid function status 1
• High-resolution thyroid ultrasonography performed by specialists with thyroid sonography expertise 1
• Fine-needle aspiration cytology (FNAC) for nodules ≥1.0 cm with clinical or sonographic risk factors, interpreted using Bethesda Classification System 5, 1
• 99Tc thyroid scan if TSH is suppressed, to distinguish hot nodules, toxic multinodular goiter, or Graves' disease 1
• Vocal cord assessment (laryngoscopy) to document baseline recurrent laryngeal nerve function, particularly important before reoperations 3

Key Clinical Context

• Document any prior neck radiation exposure 2
• Identify symptoms of compression (dysphagia, dyspnea, voice changes) 3
• Assess for thyrotoxicosis symptoms if toxic nodular disease 4

Surgical Technique Selection

Total Thyroidectomy

Total thyroidectomy is the preferred approach for bilateral benign disease, as it eliminates reoperation risk and can be performed safely with meticulous technique 2

• Indicated for bilateral thyroid nodules, toxic goiter, and patients with radiation history 2
• Complication rates with experienced surgeons: permanent RLN injury 0.9-1.9%, permanent hypoparathyroidism <1% 2
• Avoids the 13-44% reoperation rate associated with subtotal procedures 2

Completion Thyroidectomy

• Required when initial pathology changes from benign to malignant 3
• Reoperations carry significantly higher complication risk (permanent RLN injury up to 3% in reoperative cases) 3
• Every effort should be made to perform definitive initial treatment to avoid reoperation 3

Postoperative Care and Monitoring

Immediate Complications to Monitor

• Postoperative hemorrhage (occurs in approximately 2% of cases) requiring urgent airway assessment 2
• Early hypocalcemia (calcium ≤8.0 mg/dL) occurs in 8.5% of total thyroidectomies but typically resolves within 1-6 months 2, 3
• Recurrent laryngeal nerve injury: transient in 2.8% (resolving in 3-4 months), permanent in <1% with primary surgery 2

Long-term Management

• Thyroid hormone replacement required after total thyroidectomy 2
• Serial calcium monitoring for hypoparathyroidism, though permanent cases are rare with careful parathyroid preservation 2, 3

Non-Surgical Alternatives

For Hyperthyroidism

• Radioiodine is first-line therapy for toxic nodular goiter and increasingly used for Graves' disease 4
• Antithyroid drugs (12-18 months) may induce remission in Graves' disease but do not cure toxic nodular goiter 4
• Radioiodine contraindicated in pregnancy, lactation, and children; pregnancy should be avoided for 4 months post-treatment 4

For Benign Nodules

• Conservative management with observation is appropriate for benign nodules without compressive symptoms 5
• Serial ultrasonography for monitoring 1
• Accurate preoperative diagnosis using FNAC and ultrasound reduces unnecessary thyroidectomies by 50% or more 5

Critical Pitfalls to Avoid

• Avoid incomplete initial surgery that necessitates reoperation, as reoperative thyroid surgery has 2-3 times higher complication rates 3
• Do not perform routine thyroid cancer screening in average-risk populations, as early detection has not improved survival 1
• Ensure experienced cytopathology interpretation of FNA specimens to minimize diagnostic errors 1
• Meticulous surgical technique with careful parathyroid gland identification and preservation is essential to minimize permanent hypoparathyroidism 2