1.37 Thyroidectomy

Question 1

Preop assessment of a patient with Goitre from Graves

Answer 1

1. History
Airway + respiratory symptoms
PND - lying flat
Hoarse voice
stridor

2. Symptoms of hyper or hypo
   aim euthyroid clinically and biochemically

3. Examination
Airway / Goitre
trachea deviation or retrosternal extension
?SVC obstruction
Stridor
Thyroid signs
Neck ROM - require extension for surgery

Question 2

Preop assessment

Answer 2

Invx:

FBC U+E
Corrected Ca
TFTs

Imagine
tradionally CXR w/ thoracic inlet view
CT used determine site spread and encroachment on airway

Vocal cord check
Nasendoscopy
Preop by ENT or Pre induction

Question 3

Intraoperative considerations

Airway

Answer 3

1. Standard IV induction and intubation
   reinforced ETT
   sitting/semi recumbent
2. Significant stridor / obstruction
   consider inhaled induction
3. AFOI
   Cork in bottle obstruction in stridulous patient
   Distorted anatomy or neck pathology
4. Tracheostomy only if access to trachea is inferior to obstruction
5. Vent through rigid bronch if unable to pass ETT
6. Vocal cord check
   La to nasal cavity and oropharynx
   fibreoptic bronch
   assess vocal cord function

Question 4

Perioperative

Answer 4

1 Eyes
Taped and padded
especially if exophthalmos present

2 neck extended
reverse trendelenburg
aid surgical access
allow adequate venous drainage

3 ?adequate relaxation
periph monitor
remifentanil

4. Dex 8mg reduced oedema and antiemesis

Question 5

Periop analgesia

Answer 5

Bilateral superficial cervical plexus block

?remifentanil infusion

Paracetamol and NSAID
strong opiates if RA poor

Question 6

Postop complications

Answer 6

1. Post extubation resp stridor
   ABC 100% O2

Extreme
re intubate and ventilate (may need trach)

2. RLN palsy or tracheomalacia assess in recovery
   awake patient seated
3. Expanding Haematoma
   Can cause obstruction or resp distress
   remove skin clips and underlying sutures
   evacuate clot at bedisde

Question 7

Post op complications

Answer 7

4. Hypocalcaemia
   d/t parathyroid excision / injury

Serum Ca >2mmol/L
give Oral Ca supps

<2 10ml 10% gluc over 10 min

alfacalcidiol
or
dihydroxycholecalcfierol 1-5g

Question 8

Post op complications

Answer 8

5. PTX
   retrosternal thyroid dissection and thoracotomy
   CXR in recovery
6. Thyroid crisis Rarely -
   beta block
   steroids
   thyroid suppression in HDU