OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

THYROIDECTOMY Eugenio Panieri & Johan Fagan

Thyroidectomy is a very common opera-

Superior Laryngeal n (Internal)
tion. The most frequent indications for
surgery are uncertainty about the nature of Superior thyroid artery
a thyroid mass, or treatment of a large
goitre causing compressive symptoms, Superior Laryngeal n (External)
thyroid cancer, or thyrotoxicosis refractory
Common carotid artery
to medical management.
Internal jugular vein

Surgical Anatomy Thyroid Isthmus

(R) thyroid lobe

A detailed knowledge of thyroid anatomy
is a prerequisite for thyroid surgery. Parti- Inferior thyroid vein
cular attention needs to be paid to identi-
fying and preserving the recurrent laryn- Trachea
geal nerve (RLN), the external branch of
the superior laryngeal nerve (SLN) and the Figure 2: Anatomy of thyroid gland
parathyroid glands. RLN
The pyramidal lobe is a superior extension
Thyroid gland near the midline and is Common
presentcarotid
in up to
70% of cases (Figure 1).
The gland consists of two lateral lobes
joined anteriorly by the isthmus which The thyroid is encased by a fine capsule of
typically overlies the 2nd and 3rd tracheal pretracheal fascia which is part of the
rings (Figures 1, 2). middle layer of deep cervical fascia. The
fascial layers fuse to form Berry’s
ligament which posteromedially firmly
attaches the thyroid to the trachea.

The gland encircles the anterior and lateral

aspects of the cervical trachea and is
applied to the surface of the larynx. Lateral
to the gland are the carotid sheath (com-
mon carotid artery, internal jugular vein
and vagus/Xn) and the sternocleidomastoid
(SCM) muscle (Figures 1, 2). Anterior to
the thyroid are the infrahyoid strap muscles
(sternohyoid and sternothyroid) (Figure 3).
The deep/medial anatomical relations are
the thyroid (caudad to attachment of
sternothyroid muscle to oblique line) and
Figure 1: Anatomy of thyroid gland, cricoid cartilages, trachea, inferior con-
pyramidal lobe and relations to carotid strictor and cricothyroid muscles, oesopha-
sheath and vasculature gus, superior and inferior thyroid arteries,
and RLNs (Figures 3, 4, 5).
 Ext Carotid artery

Sup thyroid art

Inf constrictor
Cricothyroid

Parathyroids

Figure 3: The superficial relations of the Inf thyroid art

thyroid are the infrahyoid strap muscles RLNs
(sternohyoid and sternothyroid) and SCM
Oesophagus

Thyrocervical
trunk

Figure 5: Posterior view of the thyroid

gland demonstrating the deep / medial
anatomical relations, the RLNs and the
superior and inferior thyroid arteries

parathyroid gland. The tubercle usually

projects lateral to the RLN. Elevating the
tubercle allows the RLN to be readily
located. Less commonly the RLN courses
Figure 4: Structures deep to thyroid gland: lateral to an enlarged tubercle; this places
Note the oblique line to which the sterno- the nerve at risk of injury. The superior
thyroid muscle inserts and which defines parathyroid gland, also derived from the 4th
the anterosuperior limit of the thyroid branchial cleft, is commonly located close
(Wikipedia) to and cephalad to the tubercle.

The thyroid gland weighs 15-25g. The

thyroid lobes are normally cone-shaped
and measure approximately 5cm in length TZ

and 2-3cms in width in both transverse and

Superior parathyroid
anteroposterior dimensions.
RLN
The Tubercle of Zukerkandl is a pyramidal
enlargement of the lateral edge of the
thyroid lobe that stems from the fusion of
the lateral and medial thyroid anlages
(Figure 6). It is recognisable in up to 75% Figure 6: Tubercle of Zuckerkandl (TZ)
of thyroids. It is anatomically closely and its relationship to the superior para-
related to the RLN, the inferior thyroid thyroid gland and RLN
artery, Berry's ligament and the superior

2
Blood supply blood supply to the thyroid, upper oeso-
phagus and trachea, and is the sole arterial
The arterial supply is based on the supe- supply to all the parathyroid glands, both
rior thyroid (STA) and inferior thyroid superior and inferior. The relationship of
(ITA) arteries. Occasionally the thyroidea the ITA and RLN is reviewed later.
ima artery is encountered inferiorly but is
seldom of surgical relevance. It arises from Venous drainage is quite variable and
the innominate artery or aortic arch and occurs via a capsular network of thin-
ascends along the front of the trachea. walled, freely intercommunicating veins
which drain through the superior thyroid
The superior thyroid artery (STA) is the veins (adjacent to the STA), the inferior
first branch of the external carotid artery thyroid veins (exit the inferior pole), and
(Figures 2, 5, 7). It courses over the exter- the middle thyroid vein(s), which course
nal surface of the inferior constrictor mus- laterally to drain directly into the internal
cle of the pharynx, entering the gland pos- jugular vein (Figure 1). The middle thy-
teromedially just below the highest point roid vein is surgically most relevant; it is
of the upper pole where it usually is encountered early during thyroid mobilisa-
located superficial to the external branch of tion, and failure to secure it causes bother-
the SLN (Figure 2). Its branches commu- some bleeding.
nicate with the ITA and cross to the contra-
lateral thyroid lobe via the thyroid isthmus. Lymphatic drainage parallels the venous
drainage and occurs to the lateral deep cer-
vical and pre- and paratracheal lymph
nodes (Figure 8). Understanding the pat-
tern of nodal drainage is particularly
important in managing patients with
thyroid cancer since the cervicocentral
STA
compartment is most commonly involved
in metastatic thyroid cancer.
ITA

Thyrocervical

Subclavian a

Figure 7: Superior thyroid artery (STA),

subclavian artery, thyrocervical trunk and
inferior thyroid artery (ITA)

The inferior thyroid artery (ITA) is a

branch of the thyrocervical trunk which
originates from the subclavian artery
(Figures 5, 7). It courses superiorly along
the surface of the anterior scalene muscle Figure 8: Posterior view of the course of
before it turns medially behind the carotid the lymphatics and RLNs
sheath from where it reaches the inferior
pole of the thyroid (Figure 5). It provides

3
Recurrent Laryngeal Nerve (RLN) The RLN may be non-recurrent in approxi-
mately 0.6% of patients i.e. does not pass
During thyroid surgery, identification and around the subclavian artery, but branches
preservation of the RLN and all of its from the Xn higher in the neck, passing
divisions is essential to minimise morbi- directly to the larynx close to the superior
dity. The RLN innervates all the intrinsic thyroid vessels (Figure 9). This aberration
muscles of the larynx except the crico- almost always occurs on the right side and
thyroid muscle (SLN) and provides sen- is associated with a retro-oesophageal
sory innervation to the larynx. Even minor subclavian artery.
neuropraxia may cause dysphonia; irrever-
sible injury confers permanent hoarseness. Knowledge of the anatomical relationships
The reported incidence of RLN injury of the RLN to the tracheoesophageal
during thyroidectomy is 0 - 28% and is the groove, ligament of Berry, and ITA is
most common reason for medico-legal essential. The course of the RLN with
claims following thyroidectomy. respect to the ITA is quite variable. Most
commonly it crosses behind the branches
The RLNs originate from the Xn. After of the artery, more predictably so on the
circling around the subclavian artery left. However, the nerve may pass deep to,
(right) and aortic arch (left) the RLNs superficial to, or between the terminal
ascend superiorly and medially toward the branches of the ITA. Up to twenty
tracheoesophageal groove (Figures 8, 9). anatomical variations have been described.
The right RLN enters the root of the neck In Figure 10 the RLN is seen to pass
from a more lateral direction. Its course is anterior to the artery.
less predictable than that of the left RLN.
The RLNs enter the larynx deep to the
inferior constrictor muscles and posterior
to the cricothyroid joint.

Xns
Figure 10: RLN passing over the inferior
thyroid artery (right neck, thyroid reflected
RLNs medially)
Subclavian arteries
The majority of RLNs are located within
Aortic arch
3mm of Berry’s ligament; rarely the nerve
is embedded in it, and more commonly lies
laterally to it.

Classically, the RLN is identified intra-

operatively in Simon’s triangle, which is
Figure 9: Typical anatomical course of formed by the common carotid artery
RLNs (Non-recurrent RLN in red)

4
laterally, the oesophagus medially, and the XIIn
ITA superiorly (Figure 11).
SLN (internal)

SLN (external)

Oesophagus STA

RLN
Sup pole thyroid

ITA

Carotid
Figure 12: Anatomical relations of inter-
nal and external branches of right SLN to
Figure 11: RLN crossing Simon’s triangle
superior thyroid artery and to superior
formed by oesophagus, inferior thyroid
pole of thyroid
artery (ITA) and common carotid artery
(right neck, thyroid reflected medially)
The usual configuration is that the nerve is
located behind the STA, proximal to its
The Tubercle of Zukerkandl may also be
entry into the superior pole of the thyroid.
used as an anatomical landmark to identify
The relationships of the nerve to the
the nerve (Figure 6). The RLN generally
superior pole and STA are however extre-
courses between this structure and the
mely variable. Variations include the nerve
trachea. However, this relationship can
passing between the branches of the STA
vary with enlargement of the tuberculum
as it enters the superior pole of the thyroid
thereby placing the nerve at risk during
gland; in such cases it is particularly
exploration.
vulnerable to injury.
Superior Laryngeal Nerve (SLN)
SLN Ext branch

The SLN is a branch of the Xn and has STA

both an external and internal branch
(Figures 2, 12). The internal branch is Thyroid
situated above and outside the normal field
STVs
of dissection; it is sensory and enters the
larynx through the thyrohyoid membrane.
The external branch innervates the crico-
thyroid muscle, a tensor of the vocal cord.
Injury to the SLN causes hoarseness,
decreased pitch and/or volume, and voice Figure 13: Note close proximity of external
fatigue. These voice changes are more branch of SLN to STA and thyroid vein and
subtle than those relating to a RLN injury, to superior pole of thyroid gland
and are frequently underestimated and not
reported. The external branch of the SLN Parathyroid glands
is at risk because of its close proximity to
the STA (Figures 12, 13). Understanding There are typically four parathyroid
its relationship to the upper pole of the glands; however, supernumerary glands
thyroid and the STA is crucial to preser- have been reported. The parathyroid glands
ving its integrity.
5
are generally symmetrically located in the or the posterolateral surfaces of the lower
neck. Their characteristic golden colour pole of the thyroid (42%, Wang et al); or in
varies from yellow to reddish brown, and the lower neck in proximity to the thymus
permits them to be distinguished from the (39%). Other locations are: lateral to the
pale-yellow colour of adjacent lymph thyroid or within the carotid sheath (15%),
nodes, thymus, mediastinal fat, and the within the mediastinal thymic tissue and
dark-red thyroid parenchyma. They are the pericardium (2%).
usually oval and measure 3–8 mm. The
ITA is the predominant vascular supply to If the RLN’s course is viewed in a coronal
both the upper and lower parathyroids. plane, then the superior parathyroid gland
Consequently dividing the trunk of the ITA is located deep (dorsal) and the inferior
is discouraged as it places all the parathyroid superficial (ventral) to the
parathyroids on that side at risk of plane of the nerve (Figures 14a, b).
ischaemic injury.

The superior parathyroid glands originate

from the 4th pharyngeal pouch and attach
to the posterior surface of the caudally
migrating thyroid. They have a much
shorter migration distance compared to the
inferior parathyroid glands; this accounts
for their more predictable location. They
are embryologically and anatomically
closely related to the Tubercle of Zucker-
kandl, and are usually located at the level
of the upper two-thirds of the thyroid, in a Figure 14a: The superior parathyroid
posterior position, about 1cm above the gland lies deep (dorsal) and the inferior
crossing point of the RLN and inferior parathyroid superficial (ventral) to a
thyroid artery (Figure 6). Ectopic positions coronal plane along course of RLN
of the superior parathyroid glands such as
in the posterior neck, retropharyngeal and
retroesophageal spaces and intrathyroidally
are very uncommon (1%).

The dorsal wing of the 3rd pharyngeal Inferior PT

pouch gives rise to the inferior para-
thyroid glands. They join the thymus as it Superior PT
travels caudally and medially to its final
RLN
position in the mediastinum. This accounts
for the fact that they are usually found in a
plane ventral to that of the superior Figure 14b: The superior parathyroid
parathyroid glands, and that ectopic gland lies deep (dorsal) and the inferior
inferior parathyroid glands can be found parathyroid superficial (ventral) to a
anywhere along this large area of descent coronal plane along the course of the RLN
up to the superior border of the
pericardium. Their commonest location is
between the lower pole of the thyroid and
isthmus, equally commonly on the anterior

6
Types of thyroidectomy glands and reduces the risk of hypo-
calcaemia. Total thyroidectomy is however
Thyroid lobectomy: Either lobe is re- associated with both increased short- and
moved, usually with a small segment of the long-term morbidity relating to RLN
thyroid isthmus; the contralateral lobe is paralysis and hypocalcaemia, particularly
left undisturbed. It is most commonly in an occasional thyroid surgeon’s hands.
performed as a diagnostic procedure for a Short-term complication rates for total
thyroid nodule of uncertain nature. It may thyroidectomy occur in 10-40% of
be a sufficient for cure in some cases of patients; long-term complications (mainly
thyroid carcinoma with favourable prog- hypoparathyroidism) occur in 5-20%. Most
nostic criteria. thyroidectomies are done in general
hospitals by surgeons not specialising in
Subtotal thyroidectomy: 90-95% of thy- endocrine surgery; complication rates have
roid tissue is removed bilaterally, leaving a been reported to correlate with the number
small (1x2cm) thyroid remnant in situ of thyroidectomies done. In the absence of
overlying the RLN. This operation has convincing evidence that total thyroidec-
slowly lost favour as it is by its very nature tomy confers survival benefit in favourable
inexact, is prone to recurrence of the differentiated thyroid cancers (especially
thyroid pathology, and in expert hands when I131 therapy is not available), coupled
does not result in lower rates of RLN with the morbidity and mortality of total
injury when compared to total thyroid- thyroidectomy, the occasional thyroid
ectomy. surgeon or the surgeon practising in a
setting where calcium monitoring and re-
Total thyroidectomy: Both right and left placement are suboptimal may therefore
lobes, isthmus and pyramidal lobe (when elect rather to perform thyroid lobectomy
present) are removed; no macroscopic thy- or subtotal thyroidectomy for differentiated
roid tissue is left in situ. This is the proce- thyroid cancer.
dure of choice for the treatment of thyroid
carcinoma and is commonly performed for
a MNG with compressive symptoms, or Pre-operative evaluation
for thyrotoxicosis.
Ultrasonography (US) permits accurate
Subtotal vs. total thyroidectomy for distinction between the common thyroid
differentiated thyroid carcinoma pathologies and is the imaging technique
of choice for a thyroid mass. Neoplasms
Bilateral RLN injury causing airway com- typically cause focal enlargement within a
promise and hypoparathyroidism causing normal gland (“solitary nodule”). Features
hypocalcaemia in situations where moni- strongly suggestive of thyroid carcinoma
toring serum calcium and treating hypo- are hypoechogenicity, increased and
calcaemia with calcium and Vitamin D are haphazard vascularity patterns within the
not possible may have fatal consequences. lesion, microcalcifications, irregular mar-
Regardless of surgical expertise, the com- gins, elevated height-to-width ratio, and
plication rates rise with the extent of regional lymphadenopathy. A multinodular
resection. Unilateral thyroid lobectomy goitre (MNG) typically shows multiple
rarely causes RLN injury and almost never hyper- or isoechoic nodules, some cystic
causes significant hypoparathyroidism. changes and coarse macrocalcifications
Subtotal thyroidectomy preserves the involving both thyroid lobes.
blood supply to the ipsilateral parathyroid

7
Focal thyroid masses or suspicious lymph- Thyroid uptake scans may be requested in
adenopathy should be investigated by fine cases of thyroid enlargement with thyro-
needle aspiration cytology. toxicosis, but are not routinely done as
they seldom add more information to that
All patients with thyroid complaints must available from the US.
undergo thyroid function tests as clinical
manifestations of thyrotoxicosis or hypo- Laryngoscopy: It is medico-legally prudent
thyroidism are notoriously unreliable. Thy- to document vocal cord function prior to
rotoxicosis must first be controlled medi- thyroid surgery; it is essential in patients
cally before surgical intervention. Failure with symptoms of dysphonia.
to do so may precipitate a thyroid storm.

CT scans are helpful in selected cases, Preoperative consent

particularly with a MNG with a suspected
retrosternal component (Figure 15), or Scar: The incision is generally well con-
when uncertainty exists about the extent of cealed if made within a natural skin crease,
tracheal compression (Figure 16). but tends to descend with ageing.

Airway obstruction/wound haematoma:

1% of thyroidectomy patients develop stri-
dor postoperatively, either due to airway
oedema or a haematoma.

Voice changes: It is essential for the

patient to have a clear understanding of the
risk of postoperative voice change. While
most are subtle and recover fully, approxi-
mately 1% of patients will have permanent
hoarseness. The risk is highest for patients
having surgery for carcinoma, large retro-
sternal goitres, and with repeat surgery.
Figure 15: Coronal CT scan demonstra-
ting retrosternal extension Hypoparathyroidism: Transient postopera-
http://chestatlas.com/gallery/Thyroid/HUGE goitre CT tive hypocalcaemia occurs in about 20% of
total thyroidectomy patients. Permanent
hypocalcaemia occurs following 1-5% of
total thyroidectomies.

Hypothyroidism: Hypothyroidism occurs

uncommonly (5%) with thyroid lobec-
tomy. It is common practice to routinely
check TSH levels approximately 6-8
weeks after surgery to identify such cases
before it manifests clinically. It is self-
evident that a patient will be hypothyroid
following total thyroidectomy. The clinical
effects only become apparent once the pre-
Figure 16: Tracheal compression on CT existing thyroid hormone levels drop; this
scan

8
generally becomes evident 3-4 weeks Placing the incision too low causes an
following surgery. Thyroxine replacement unsightly low scar over the heads of the
therapy is routinely instituted immediately clavicles when the extended neck is
postoperatively to prevent hypothyroidism. returned to its normal position. The width
The exception is if total thyroidectomy has of the incision may need to be extended for
been performed for a well-differentiated large goitres or for a lateral lymph node
carcinoma and I131 therapy is envisaged; a dissection.
hypothyroid state is deliberately induced in
such patients until the I131 therapy has been Subplatysmal flaps: Subcutaneous fat and
administered. platysma are divided, and a subplatysmal
dissection plane is developed superiorly
(platysma is often absent in the midline)
Anaesthesia, positioning and draping remaining superficial to the anterior
jugular veins, up to the level of the thyroid
 General anaesthesia with endotracheal cartilage above, and the sternal notch
intubation below (Figure 18).
 Prophylactic antibiotics are not
indicated
 Neck slightly hyperextended by
placing a bolster between the scapulae
 Head stabilised on a head ring
 Table tilted to 30º anti-Trendelenberg
position to reduce venous engorgement
 Head is free-draped to allow turning of
the head

Surgical technique

Skin incision (Figure 17): A curvilinear Figure 18: Subplatysmal flaps elevated
incision is placed in a skin crease two
fingerbreadths above the sternal notch
between the medial borders of the sterno-
cleidomastoid muscles.

AJV
s

Figure 17: Curvilinear skin incision two

fingerbreadths above the sternal notch Figure 19: Subplatysmal skin flaps held
with Jowell’s retractor. Note anterior
jugular veins (AJVs)
9
The skin flaps are secured to a fixed by medial rotation of the gland. It is
retractor (e.g. Jowell’s retractor) to expose divided between haemostats and ligated
the thyroid region for the remainder of with a 3/0 tie. This permits further mobili-
operation (Figure 19). sation of the gland and delivery of the bulk
of the lobe into the wound.
Separating strap muscles and exposing
the anterior surface of thyroid: The fascia
between the sternohyoid and sternothyroid
muscles is divided along the midline with
diathermy or scissors (Figure 20). This is
an avascular plane, though care must be
taken not to injure small veins occasionally
crossing between the anterior jugular
veins, particularly inferiorly. The infra-
hyoid (sternohyoid, sternothyroid and
omohyoid) strap muscles are retracted
laterally with a right-angled retractor. With
massive goitres the strap muscles may be Figure 21: Medial rotation of (R) thyroid
divided to improve access. lobe exposes the middle thyroid vein

Figure 20: Fascia between sternohyoid

and sternothyroid muscles divided to Figure 22: Dividing the middle thyroid
expose thyroid gland vein

It is usual at this stage for the surgeon to Dividing the STA (Figure 23): The retrac-
move to the side of the table opposite to the tors are repositioned to allow full visua-
thyroid lobe to be resected. lisation of the superior pole of the thyroid.
This brings the STA into view. The author
Medially rotating the thyroid: Using does not routinely identify the external
gentle digital retraction the surgeon rotates branch of the SLN, but simply takes great
the thyroid gland medially (Figure 21). care to divide the artery as close to the
thyroid parenchyma as possible so as to
Dividing the middle thyroid vein(s) avoid injury to nerve. The superior arterial
(Figure 21): The first important vascular pedicle is double ligated with 2/0 or 3/0
structure to come into view is the middle tie.
thyroid vein(s), which is tightly stretched

10
 meticulous haemostasis. The gland must
remain in situ with blood supply intact.
This is best achieved by carefully dissec-
ting it off the posterior aspect of the
thyroid gland, and using short bursts of
bipolar cautery to control bleeding.

Figure 23: Dividing STA pedicle below

external branches of SLN
Inferior PT

Identifying superior parathyroid gland Superior PT

(Figure 24, 25): Full mobilization and
anterior delivery of the superior pole of the RLN
thyroid brings the region of the superior
parathyroid gland into direct view. The Figure 25: Superior and inferior para-
superior parathyroid gland is normally thyroids (PT)
located at the level of the upper two-thirds
of the thyroid, in a posterior position and Dividing inferior thyroid veins (Figure
closely related to the Tubercle of Zucker- 26): The retractors are again repositioned
kandl, and about 1 cm above the crossing to expose the lower neck and the inferior
point of the recurrent laryngeal nerve and thyroid vein(s). The veins are divided, and
inferior thyroid artery. ligated. This exposes the trachea and per-
mits full delivery of the thyroid gland
outside the wound.

TZ

Sup parathyroid

Crossing point
of RLN & STA

Figure 24: Position of superior para-

thyroid relative to Tubercle of Zuckerkandl Figure 26: Inferior thyroid vein being
(TZ), RLN and STA divided

If the RLN’s course is viewed in a coronal Identifying inferior parathyroid gland:

plane, then the superior parathyroid gland The inferior parathyroid glands are
lies deep (dorsal) to the plane of the nerve normally located between the lower pole of
(Figures 14a, b). It has a characteristic rich the thyroid and the isthmus, most com-
orange/yellow colour (Figure 25). The (oc- monly on the anterior or the posterolateral
casional) parathyroid surgeon may find the surface of the lower pole of the thyroid
parathyroids difficult to identify especially (42%, Wang et al), or located in the lower
if there has been bleeding in the surgical neck in proximity to the thymus (39%).
field, so care must be taken to ensure

11
If the RLN’s course is viewed in a coronal
plane then the inferior parathyroid is super-
ficial (ventral) to the plane of the nerve
(Figures 14a, b). The inferior gland may
now become visible on the inferior aspect
of the lower pole of the thyroid or within
the thyrothymic ligament (Figure 25). Care
must be taken to preserve it in situ and to
avoid damaging its ITA blood supply.

Identifying the RLN: The thyroid is Figure 27: Ligament of Berry still needs to
rotated medially; lateral retraction is be divided
applied to the carotid artery and jugular
vein. The RLN is located by carefully dis- Dividing the thyroid isthmus: When doing
secting/teasing apart the tissues in Simon’s a thyroid lobectomy the isthmus is cross-
triangle which is formed by the common clamped with a haemostat and divided.
carotid artery laterally, the oesophagus The residual remnant is oversewn using a
medially, and the inferior thyroid artery continuous, interlocking technique (Figure
superiorly (Figure 11). Others favour 28).
finding the nerve at its point of entry into
the larynx approx. 0.5cm caudad to the
inferior cornu of the thyroid cartilage. The
nerve must remain undisturbed and in situ
i.e. is not skeletonised or handled.

Pericapsular dissection of branches of

ITA: It is best to individually divide and
ligate (3/0 ties) all the branches of the ITA
at the capsule of the thyroid so as to reduce
the risk of handling the RLN. Avoid all
forms of cautery to avoid thermal injury to
the nerve. Figure 28: Oversewing the thyroid isthmus

Dividing Ligament of Berry (Figure 27): With total thyroidectomy the above surgi-
The posteromedial aspect of the thyroid cal steps are simply repeated on the oppo-
gland is attached to the side of the cricoid site side.
cartilage and to the 1st and 2nd tracheal
rings by the posterior suspensory ligament/
Ligament of Berry. The RLN is in close Wound closure
proximity (<3mm) to the ligament and
usually passes posterior to the ligament  The wound is irrigated
and must be identified before the ligament  A Valsalva manoeuvre is done to elicit
is divided with sharp dissection to free the venous bleeding, and haemostasis is
thyroid from trachea. Carefully dissect achieved
thyroid tissue from the trachea in the  Wound drainage is not routinely re-
region of Berry’s ligament. quired; where deemed necessary a
suction drain is positioned in the

12
 thyroid bed and brought out through a uncommon. A CT scan is indicated as US
laterally placed skin puncture is not ideal for the evaluation of media-
 The strap muscles are approximated for stinal pathology. It is essential to exclude
70% of their length, and the platysma other causes of a mediastinal mass such as
is closed with interrupted absorbable lymphoma, thymoma or teratoma. Addi-
3/0 sutures tional steps required for removal of a large
 A subcuticular skin closure is achieved retrosternal goiter include:
with an absorbable monofilament su-  Full neck extension
ture  Skin incisions are unchanged
 A light dressing is applied  Transection of the strap muscles (ster-
nohyoid & sternothyroid) greatly
facilitates exposure of the middle
Postoperative care thyroid vein and STA
 Digitally dissecting the gland in the
 The patient is monitored overnight for mediastinum with concomitant traction
bleeding and airway obstruction of the already-mobilized superior pole
 The intravenous line is removed and a will always result in delivery of the
normal diet is taken as tolerated gland into the neck wound
 If a drain has been placed it is removed  A delivery instrument such as a sterile
when drainage is <50ml/24hrs spoon or Kielland’s obstetric forceps
 Following total thyroidectomy, serum has been reported to facilitate this step,
PTH must be recorded at 24hrs post- although this has never proven neces-
operatively. If the PTH reading is low, sary in the authors’ experience
then calcium and Vitamin D1α are  It is MOST UNCOMMON for a
commenced even in the absence of thoracotomy to be required
symptoms of hypocalcaemia. If PTH  See chapter: Surgery for retrosternal
assays are unavailable the calcium goitres
levels are monitored postoperatively.
Postoperative stridor: Early stridor may be
encountered due to a haematoma and/or
Additional points airway oedema; more uncommonly it
occurs due to bilateral RLN injury or
Devascularised parathyroid: Should a tracheomalacia. Delayed onset may be due
parathyroid gland accidentally have been to hypocalcaemia (tetany).
devascularized or come free during dis-
section it should be reimplanted. This is Haematoma: Avoid large, bulky dressings
particularly important when performing so as not to conceal a haematoma. A large
total thyroidectomy. It is stored in saline haematoma is a surgical emergency as it
until the conclusion of the thyroidectomy, may cause airway obstruction.
then cut into 1 mm cubes and placed in
small pockets within the sternocleido- Seroma: Small seromas are very common
mastoid muscle. and are simply followed clinically and
allowed to resorb. Larger, symptomatic
Retrosternal goiter: Presentation, workup seromas may be (repeatedly) aspirated
and technique: Retrosternal goiters may under sterile conditions.
present with airway compression, stridor,
and effort intolerance; venous congestion RLN injury: Unilateral RLN paralysis
of the head and neck region is not presents as a breathy voice and hoarseness,

13
and less commonly as dysphagia and aspi- tic devices (Ultrasonic scissors/ Harmonic
ration. It may not be immediately apparent Scalpel and Ligasure Device), which
depending on the resting position of the achieve safe haemostasis and avoid the
vocal fold. Bilateral RLN paralysis usually need for multiple ligatures (Figure 29).
manifests immediately following extuba-
tion with stridor or airway obstruction.
Should the patient be unable to maintain an
adequate airway then emergency tracheos-
tomy or cricothyroidotomy is indicated.
Subsequent management depends on the
surgeon’s knowledge of whether the RLNs
were seen to be intact and hence the
likelihood of vocal fold function to reco-
ver. Options might include a watchful
waiting approach for up to a year or CO2
laser cordotomy/arytenoidectomy.
Figure 29: Harmonic Scalpel
Continuous electrophysiologic monitoring
of the RLN during thyroid surgery:
Recent studies have shown that intra- A number of randomised trials have shown
operative monitoring can assist with equivalence between the commercially
finding the RLN, but some pitfalls limit its available products, and a significant reduc-
usefulness: there is no consensus about tion in operating time without an increase
which types of electrodes should be used in complications when compared to stan-
for EMG registration which is the best dard thyroidectomy technique. The 1st
method for recording nerve action, or author uses the Harmonic Scalpel as a
which EMG parameters should be selected means of sealing and transecting vessels
as predictive of postoperative vocal cord and to re-duce surgical operating time.
dysfunction. The technology is not widely
available, and most endocrine surgeons
achieve equivalent RLN morbidity rates Minimally Invasive Thyroid Surgery: A
without it. number of techniques have evolved in an
attempt to reduce the extent of skin
Tracheomalacia: This is characterized by incisions and bring the putative benefits of
flaccidity of the tracheal cartilages which minimally invasive techniques to thyroid
in turn causes tracheal wall collapse. It is surgery. Minimally invasive thyroidectomy
thought that a longstanding goiter can act can be performed via a limited 2-3cm neck
as an external support structure for the incision with the visual assistance of an
trachea and predispose to secondary tra- endoscope, specially designed retractors
cheomalacia. Thyroidectomy unmasks and a harmonic scalpel. An alternative
tracheomalacia causing respiratory ob- approach is to place incisions for 3-4 ports
struction. In clinical practice this is an in the axilla and periareolar regions to
uncommon cause of airway obstruction avoid a neck scar altogether. The clinical
after thyroidectomy. benefits are marginal at best, but they will
continue to be driven by patient demand
Thyroid specific haemostatic devices and the industry. Only patients with small
(Figure 29): The last decade has seen the thyroid nodules are suitable for such a
introduction of thyroid specific haemosta- surgical approach.

14
Useful References
THE OPEN ACCESS ATLAS OF
1. Mohebati A, Shaha AR. Anatomy of OTOLARYNGOLOGY, HEAD &
thyroid and parathyroid glands and
neurovascular relations. Clin Anat.
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
2012;25(1):19-31
2. Bliss RD, Gauger PG, Delbridge LW.
Surgeon's Approach to the Thyroid
Gland: Surgical Anatomy and the
Importance of Technique. World J The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
Surg. 2000;24(8):891-7 johannes.fagan@uct.ac.za is licensed under a Creative
3. Wang C. The anatomic basis of Commons Attribution - Non-Commercial 3.0 Unported
License
parathyroid surgery. Ann Surg. 1976;
183:271–5

Relevant Open Access Atlas chapters

Surgery for Intrathoracic (retrosternal)

goitres
https://vula.uct.ac.za/access/content/group/
ba5fb1bd-be95-48e5-81be-
586fbaeba29d/Surgery%20for%20intrathor
acic%20_retrosternal_%20goitres.pdf

Parathyroidectomy
https://vula.uct.ac.za/access/content/group/
ba5fb1bd-be95-48e5-81be-
586fbaeba29d/Parathyroidectomy.pdf

Author

Eugenio Panieri MBChB, FCS

Head: Oncology / Endocrine Surgery Unit
Associate Professor
Division of General Surgery
University of Cape Town
Cape Town, South Africa
eugenio.panieri@uct.ac.za

Author and Editor

Johan Fagan MBChB, FCORL, MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
johannes.fagan@uct.ac.za

15