endocrine module: steps of Surgery on Thyroid_lect 2.pdf

The second lecture in the series for the endocrine module for final year mbbs students describing steps of thyroid surgery . readers can approach the author for links for the videos included in the presentation at [email protected]

1. SURGERY ON
THYROID
by Ahmad Uzair Qureshi

2. COMMON
OPERATIONS
Lobectomy
Subtotal Thyroidectomy
Near Total
Thyroidectomy
Total Thyroidectomy

3. COMMON
APPROACHES
Classical Kocker’s
incision
Transoral route
Tran-Axillary
route

4. TOTAL THYROIDECTOMY

11. SUPERIOR SUB-PLATYSMALPLANE CREATED TILL
ADAM’SAPPLE/ THYROID NOTCH

12. Inferior Sub-platysmal plane created till sternal notch

37. TRANS_AXILLARYVIDEO
ASSISTED THYROID

42. COMPLICATIO
NS AND THEIR
MANAGEMENT

43. COMMON
COMPLICATIONS
AFTER THYROID
SURGERY
Hematoma
Recurrent Laryngeal Nerve
injuries/ Hoarseness
Hypoparathyroidism
Chyle Fistula

44. NERVE INJURIES
▪Irritation from the endotracheal tube, vocal cord edema/hematoma and arytenoid dislocation
from intubation RLN injury.
▪Transient RLN injury is seen in 5% of patients, and permanent RLN injury is seen in 1%.
▪Complication rates, on average, are higher when thyroidectomy is performed by less
experienced, low-volume thyroid surgeons. An RLN injury should be suspected in patients
with hoarseness, dyspnea, coughing, or symptoms concerning for aspiration that persist for
more than 48 hours after surgery.
▪Patients with significant dyspnea or symptoms concerning for aspiration should be
immediately referred for laryngoscopy to evaluate for vocal cord paresis. These patients may
require early intervention to prevent aspiration.

45. NERVE INJURIES
▪Most RLN injuries are transient and due to stretch or compression of
▪the nerve, so they should resolve. Evaluation and treatment by a speech
▪therapist can improve voice quality and reduce voice strain and patient
▪anxiety until nerve function recovers. If vocal cord paralysis does not
▪resolve by 6 months, it is usually permanent. Patients who have significant
▪symptoms may undergo collagen injection into the paralyzed vocal cord,
▪thereby medializing the cord. Medialization allows the contralateral cord
▪to close the larynx during swallowing and phonation. If vocal cord
▪function does not recover after 6 months and the patient remains
▪symptomatic, a permanent medialization of the vocal cord may be
▪performed.

46. NERVE INJURIES
▪Bilateral vocal cord paralysis is an uncommon but dreaded complication after total thyroidectomy.
Patients typically present with difficulty breathing and stridor after extubation. Immediate intubation
should be attempted, but may not be possible if the vocal cords are in a closed/adducted position. The
surgeon must be prepared to perform a tracheostomy if the patient cannot be intubated or is unable to
maintain an adequate airway.

47. NERVE INJURIES
▪Injury to the external branch of the laryngeal nerve may lead to inability
▪to reach high pitches, voice fatigue, and decreased voice projection. These 1569 injuries can be difficult
to diagnose, except with electromyography. Most of these injuries are transient and should recover with
time. Voice therapy is the mainstay of the treatment of permanent injury

48. ▪Hoarseness
▪Dyspnea
▪Coughing
▪Aspiration
▪More than 48 hours
after surgery