Definitive Surgical Management of Thyroid Disease in Adults

Patient Guideline Summary

Publication Date: February 1, 2020

Last Updated: December 22, 2023

Objective

This patient summary means to discuss key recommendations from the American Association of Endocrine Surgeons for Definitive Surgical Management of Thyroid Disease in Adults.

Overview

Thyroid diseases include over- and under-activity of the thyroid, cancers, cysts, and benign masses.

This patient summary focuses on surgical management of thyroid diseases.

Thyroid surgery is particularly complicated because it involves complex, delicate anatomy with multiple high-risk factors, the proximity of the parathyroid glands and the airway, and hormonal complications including both thyroid and calcium metabolism. Your doctor will discuss with you the risks, benefits, and alternatives to the surgery.

Diagnosis

Evaluation of thyroid disease includes questions about personal history, family history, clinical characteristics, and symptoms.
The preoperative physical examination includes a voice assessment.
- Your healthcare team may ask you to speak in different pitches or volumes.
Thyroid-stimulating hormone (TSH) should be measured (via blood testing) in patients with nodular thyroid disease.
Additional laboratory studies may help in specific circumstances.
Diagnostic ultrasound (US) should be performed in all patients with a suspected thyroid nodule and for other reasons specific to the individual circumstances.
CT or MRI with intravenous contrast may be indicated for cancer evaluation.
Fine needle aspiration biopsy (FNAB) using US guidance is a standard component of thyroid nodule evaluation
Molecular testing (MT), which is a type of genetic testing, may be done to identify certain cancers more specifically or to detect and trace familial thyroid conditions.

Surgical Treatment

Surgery is often the first-choice treatment for certain thyroid conditions:
- Compressive symptoms that compromise breathing
- High-risk cancers are often graded by the Bethesda system.
- Bilateral goiter.
Total thyroidectomy:
- should be performed for patients undergoing prophylactic thyroidectomy for medullary thyroid cancer.
- should be considered as a first-line definitive treatment for Graves ophthalmopathy (protrusion of the eyes).
A high-volume thyroid surgeon is preferred for more complex procedures.

Before surgery

Patients should be evaluated for hypercalcemia, including blood tests for calcium and 25-hydroxy vitamin D levels.
Gastric bypass patients should be counseled about a higher risk of severe postoperative hypocalcemia after total or completion thyroidectomy.
Chemical prophylaxis for blood clots should be reserved for selected patients at higher risk.
Antimicrobial prophylaxis is not necessary in most cases.
Prior to thyroidectomy, in the absence of contraindications, a single preoperative dose of dexamethasone should be considered to reduce nausea, vomiting, and pain.
Patients with Graves’ disease preoperatively should:
- be clinically euthyroid (have normal thyroid function)
- receive potassium iodide
Patients with unilateral goiter should undergo imaging to look for a substernal component.

During surgery

All or part of the thyroid gland may be removed.
Lymph nodes may be removed
Parathyroid glands may need to be removed.
Great care must be taken to preserve the parathyroid glands, the external branch of the superior laryngeal nerve (EBSLN), and the recurrent laryngeal nerve (RLN).
- The integrity of the nerves may be monitored during surgery.
- If parathyroid glands are injured or require removal, they may need autotransplantation (moved to another location in the body away from the surgical site).
- The parathyroid function may need to be monitored after surgery.
Specimens for laboratory analysis may be needed to identify:
- cancer in lymph nodes
- parathyroid tissue
- tumor margins
The entire surgical specimen should undergo complete laboratory analysis.

After surgery

Nonopioid and nonpharmacologic therapies and patient education are preferred for pain management.
The lowest effective dose of immediate-release opioids is recommended if the pain is uncontrolled.
The risk of a blood clot, low blood calcium levels, or other post-surgical complications may require an overnight stay in the hospital.
Voice assessment and laryngeal examination should be performed in patients with known or suspected RLN dysfunction or aspiration.
If problems are suspected, early referral of the patient to a laryngologist is recommended.
A test for parathyroid hormone levels may be done.
If familial thyroid cancer is found, genetic testing and family screening may be recommended and should include pre- and post-test counseling.
Certain cancers may require postoperative radioactive iodine (RAI) therapy.
Reoperation may be required for residual or recurrent disease or bleeding.
Remote-access thyroidectomy, primarily to avoid ugly neck scars, is not frequent in the United States.

Abbreviations

CT: Computed Tomography
EBSLN: External Branch Of The Superior Laryngeal Nerve
FNAB: Fine Needle Aspiration Biopsy
MRI: Magnetic Resonance Imaging
MT: Molecular Testing
RAI: Radioactive Iodine
RLN: Recurrent Laryngeal Nerve
TSH: Thyroid Stimulating Hormone
US: Ultrasound

Source Citation

Patel KN, Yip L, Lubitz CC, Grubbs EG, Miller BS, Shen W, Angelos P, Chen H, Doherty GM, Fahey TJ 3rd, Kebebew E, Livolsi VA, Perrier ND, Sipos JA, Sosa JA, Steward D, Tufano RP, McHenry CR, Carty SE. The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg. 2020 Mar;271(3):e21-e93. doi: 10.1097/SLA.0000000000003580. PMID: 32079830.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.