What is the recommended approach to diagnosing and managing a thyroid abscess that requires drainage?

Thyroid Drain Management

Routine drainage after thyroid surgery is not necessary and does not prevent postoperative hematoma or seroma formation. 1

Evidence Against Routine Drainage

The 2022 multidisciplinary consensus guidelines from the Difficult Airway Society, British Association of Endocrine and Thyroid Surgeons, and British Association of Otorhinolaryngology explicitly state there is no evidence to support the use of drains for prevention of haematoma in routine thyroid surgery. 1 This represents the highest quality, most recent guideline evidence available.

Key Supporting Evidence:

• Prospective randomized trials demonstrate no difference in complication rates between drained and non-drained thyroid surgery patients, including rates of hematoma, seroma, reoperation for bleeding, or wound infections. 2, 3

• Drains provide false reassurance because clot formation may prevent free drainage, and hematoma can still form even with drains in place. 1

• All four patients requiring re-exploration in one surgical series had drains in place, suggesting drains do not prevent the most serious complication. 4

• Hospital stay is significantly reduced in non-drained patients (p = 0.007) without increased complications. 2

When Selective Drainage May Be Considered

Drains should only be used in specific high-risk situations: 4

• Large dead space remaining after surgery
• Large substernal goiter removal
• Subtotal thyroidectomy for large multinodular goiter or Graves' disease

Critical Pitfall to Avoid

Never rely on drain output as reassurance against hematoma formation. Clotted blood will not drain through catheters, and life-threatening hematomas can develop despite functioning drains. 1

Post-Thyroid Surgery Monitoring (With or Without Drains)

All post-thyroidectomy patients require close observation using the DESATS criteria for early detection of complications: 1

• D - Difficulty swallowing/discomfort
• E - Early Warning Score (EWS/NEWS) elevation
• S - Swelling
• A - Anxiety
• T - Tachypnea/difficulty breathing
• S - Stridor

Emergency Management Protocol

If any DESATS signs present: 1

1. Oxygenate immediately - Give 15 L/min O₂
2. Position head-up before further assessment
3. Arrange immediate senior surgical review (registrar or consultant level)
4. If airway compromise signs present (desaturation, stridor, tachypnea, difficulty breathing):
   • Evacuate hematoma immediately at bedside
   • Request immediate senior anesthetic review
   • Do not wait for operating room

Essential Equipment

Post-thyroid surgery emergency box must be at bedside containing equipment for opening the neck wound emergently, and must accompany patients during any transfers. 1

Management of Thyroid Abscess (Rare Complication)

Thyroid abscess is extremely rare in developed countries but requires aggressive management when it occurs: 5

Diagnostic Approach:

• CT scanning is first-line imaging for identifying and characterizing the abscess 6
• Ultrasound is superior for identifying septations and loculations (81-88% sensitivity) 6
• Blood and tissue cultures should be obtained to guide antibiotic therapy 5

Treatment Algorithm:

1. Intravenous antibiotics covering gram-negative bacteria and anaerobes 5, 7
2. Drainage - required for most thyroid abscesses:
   • Percutaneous drainage for accessible collections 5
   • Surgical drainage for complex/multiloculated abscesses 5, 7
   • Multiple drainage catheters may be necessary for loculated collections 6
3. Thyroidectomy may be required in severe cases or treatment failures 5, 7

Special Considerations:

• Thyroid storm can complicate thyroid abscess, requiring antithyroid drugs, steroids, and aggressive supportive care in addition to abscess drainage and antibiotics. 7
• Median antibiotic duration is 13.5 days (range 10-41 days) for thyroid abscess. 5
• Prognosis is favorable with prompt treatment, though median hospital stay is 7.5 days. 5