Thyroidectomy

Surgical approach

Transverse low anterior neck incision (Kocher collar incision) with subplatysmal flaps; strap muscles separated/retracted
Mobilisation of thyroid lobe(s); ligation/division of superior and inferior thyroid vessels close to gland to reduce nerve injury/bleeding
- Superior pole dissection risks injury to external branch of superior laryngeal nerve (EBSLN)
Identification/preservation of recurrent laryngeal nerves (RLN) and parathyroid glands (may autotransplant if devascularised)
Extent: hemithyroidectomy / total thyroidectomy ± central/lateral neck dissection (malignancy)
Haemostasis; possible drain; layered closure; neck dressing

Anaesthetic management

Type of anaesthesia: General anaesthesia with controlled ventilation
Airway: Cuffed ETT is standard; consider reinforced ETT if significant neck manipulation; avoid SGA for most thyroidectomy
- If intra-op nerve monitoring planned: use EMG endotracheal tube and avoid/limit long-acting neuromuscular blockade after intubation
Duration: typically 1–3 hours (longer if large goitre, malignancy with neck dissection, re-do surgery)
Pain: usually mild–moderate (anterior neck); multimodal analgesia usually sufficient
- Local infiltration by surgeon common; superficial cervical plexus block can reduce opioid requirement
Key aims: safe airway strategy, meticulous haemodynamic control, prevent/treat post-op neck haematoma and airway obstruction, detect hypocalcaemia and laryngeal nerve injury

Indications and patient factors

Indications: malignancy/suspicious nodule, compressive goitre (tracheal/oesophageal compression), toxic multinodular goitre/Graves’ disease, recurrent cysts, retrosternal goitre
Common comorbidities: hyperthyroidism (Graves/toxic nodules), hypothyroidism, airway distortion, OSA, cardiopulmonary disease, anticoagulation
Re-do thyroid surgery and malignancy with nodal dissection increase risk of bleeding and RLN injury

Pre-operative assessment

Airway assessment: symptoms of compression (dyspnoea, orthopnoea, stridor, positional symptoms), voice change (pre-existing RLN palsy), dysphagia; examine for tracheal deviation, limited neck extension, large/retrosternal goitre
- Consider pre-op nasendoscopy if voice change or previous neck surgery (document cord function)
Investigations: TFTs (ensure euthyroid where possible), FBC/U&E, calcium ± vitamin D, ECG; imaging (CT neck/chest) if retrosternal/airway compromise; CXR may show tracheal deviation
Hyperthyroidism optimisation: antithyroid drugs (carbimazole/PTU), beta-blockade; consider iodine (Lugol’s) pre-op in selected cases; treat arrhythmias/heart failure
- If urgent surgery in thyrotoxicosis: aggressive beta-blockade, antithyroid drug, steroids, supportive care; plan for thyroid storm risk
Hypothyroidism: mild/moderate usually proceed with caution; severe hypothyroidism/myxoedema—defer if possible and treat (risk of hypotension, hypothermia, delayed drug metabolism, respiratory depression)
Medication planning: anticoagulants/antiplatelets per local policy; continue beta-blockers; consider aspiration prophylaxis if large goitre/GERD

Airway strategy (key FRCA area)

Most patients: standard IV induction and tracheal intubation
Anticipated difficulty: large goitre, retrosternal extension, stridor, previous radiotherapy/surgery, fixed trachea, limited neck movement
Plan options (choose based on symptoms/imaging): awake fibreoptic intubation (AFOI), awake videolaryngoscopy, inhalational induction maintaining spontaneous ventilation, rigid bronchoscopy on standby
- If significant fixed obstruction/stridor: favour awake technique with ENT help available; avoid paralysing until airway secured
Tracheomalacia: rare but important (long-standing large goitre). Consider risk of post-extubation collapse; plan for cuff-leak assessment, staged extubation, ICU/HDU
Difficult front-of-neck access: large goitre may distort landmarks; ensure clear plan and equipment; consider ENT standby

Intra-operative conduct

Monitoring: standard + temperature; consider arterial line for major goitre, significant thyrotoxicosis/cardiac disease, anticipated blood loss, or need for tight BP control
Position: supine, head-up tilt, shoulder roll, neck extension; protect eyes; ensure ETT secure (surgical field close to tube)
Anaesthetic technique: volatile or TIVA; consider TIVA if nerve monitoring and to reduce PONV; avoid excessive sympathetic stimulation (especially thyrotoxic)
Neuromuscular blockade: facilitate intubation; if RLN monitoring planned, use short-acting agent and avoid further doses; use quantitative monitoring
Analgesia: paracetamol + NSAID (if not contraindicated) + small opioid; local infiltration; consider superficial cervical plexus block (bilateral) with attention to LA dose/toxicity
PONV prophylaxis: high priority (neck haematoma risk with retching); use dual/tri-therapy (e.g., dexamethasone + ondansetron ± droperidol) and minimise opioids
Haemodynamics: avoid hypertension/tachycardia (bleeding); treat promptly; smooth emergence to reduce coughing/straining

Extubation and immediate post-op care

Extubation should be planned and controlled: fully awake, normothermic, good ventilation, minimal coughing; consider lidocaine, remifentanil washout strategy, or deep extubation only in selected low-risk patients
Before extubation: check for airway concerns (difficult intubation, tracheomalacia, significant bleeding, prolonged surgery, large retrosternal goitre). Consider cuff-leak test if concern about laryngeal oedema/tracheomalacia
Post-op destination: PACU for most; HDU/ICU if major airway risk, severe thyrotoxicosis, significant comorbidity, re-do surgery, or complications
Early assessment: voice quality, work of breathing, neck swelling/tightness, pain, nausea; check calcium per local protocol (often 6–12 h and next day after total thyroidectomy)

Key complications (and anaesthetic relevance)

Neck haematoma: can cause rapid airway obstruction; may occur in PACU/ward. Signs: neck swelling, tightness, dysphagia, stridor, respiratory distress, venous congestion
- Immediate management: call for help (ENT/anaesthesia), high-flow O2, sit up, prepare for urgent wound opening at bedside if airway compromised; then definitive haemostasis in theatre
- Airway: may require RSI with videolaryngoscopy; consider awake technique if time; be prepared for difficult FONA due to swelling/distorted anatomy
Hypocalcaemia (hypoparathyroidism): peri-oral tingling, tetany, cramps, carpopedal spasm, seizures; ECG QT prolongation; can cause laryngospasm/stridor
- Treat symptomatic: IV calcium gluconate with ECG monitoring; correct Mg; start oral calcium/vit D as advised
RLN injury: hoarseness, weak voice, aspiration; bilateral palsy can cause airway obstruction/stridor
- Post-op stridor differential includes bilateral RLN palsy, laryngeal oedema, hypocalcaemia-related laryngospasm, haematoma, tracheomalacia
EBSLN injury: loss of high pitch/voice fatigue (important in professional voice users)
Thyroid storm (rare if optimised): hyperthermia, tachycardia/AF, hypertension then hypotension, agitation/delirium, diarrhoea, heart failure
- Management: supportive (cooling, fluids, O2), beta-blocker (e.g., propranolol/esmolol), antithyroid drug (PTU/carbimazole), iodine after antithyroid, steroids, treat precipitant; ICU
Bleeding, airway oedema, pneumothorax (rare), infection; post-op nausea/vomiting; pain

Special situations

Retrosternal goitre: may cause fixed intrathoracic obstruction; CT helpful; consider awake intubation, maintain spontaneous ventilation until airway secured; sternotomy possible (more blood loss/pain, longer case)
Graves’ disease: higher risk of thyroid storm, ophthalmopathy (eye protection), difficult control of sympathetic response; ensure euthyroid and beta-blocked
Tracheal compression: symptoms and flow-volume loop/CT may guide; remember that symptoms can worsen supine; have difficult airway equipment ready
Day-case thyroidectomy: increasingly common in selected patients; requires low risk of bleeding/airway compromise, robust PONV control, clear safety-netting and access to urgent review

You are anaesthetising a patient for total thyroidectomy. What are your main anaesthetic concerns?

Structure as pre-op optimisation, airway, intra-op conduct, and post-op complications.

Airway: potential difficulty (large/retrosternal goitre, tracheal deviation/compression), difficult FONA, plan A–D including awake technique if symptomatic
Thyroid function: ensure euthyroid; manage thyrotoxicosis (beta-blockade) and recognise thyroid storm
Bleeding/haematoma risk: smooth induction/emergence, avoid hypertension, aggressive PONV prophylaxis; readiness to manage post-op haematoma
Nerve injury: RLN/EBSLN; consider nerve monitoring implications for neuromuscular blockade
Hypocalcaemia: monitor and treat; consider laryngospasm/stridor and QT prolongation

How would you assess and plan the airway for a large goitre with stridor?

Stridor implies significant obstruction: prioritise awake, controlled airway management with help.

History: positional dyspnoea/orthopnoea, stridor, voice change, dysphagia; previous surgery/radiotherapy
Exam: mouth opening, neck movement, tracheal deviation, inability to lie flat; baseline SpO2 and work of breathing
Investigations: CT neck/chest for degree/level of compression and retrosternal extension; consider flow-volume loop if available (limited utility acutely)
Plan: awake fibreoptic intubation or awake videolaryngoscopy; topicalisation + minimal sedation; maintain spontaneous ventilation
Back-up: ENT present, rigid bronchoscopy available; discuss feasibility of emergency tracheostomy (may be difficult) and have FONA kit ready

A patient develops acute respiratory distress 1 hour after thyroidectomy. What is your differential diagnosis and immediate management?

Treat as airway emergency; neck haematoma is time-critical.

Immediate actions: call for help, ABC approach, high-flow O2, sit up, monitor, prepare airway equipment and emergency drugs
Differential: neck haematoma, bilateral RLN palsy, laryngeal oedema, hypocalcaemia-related laryngospasm, tracheomalacia, bronchospasm/aspiration
Look at neck: swelling/tension, wound ooze, venous congestion; if suspected haematoma with compromise—open wound immediately at bedside while preparing for definitive theatre
If stridor without swelling: consider cord palsy/oedema/hypocalcaemia; give nebulised adrenaline, IV dexamethasone; check calcium and treat if symptomatic
Airway plan: oxygenation first; consider awake intubation if time; otherwise RSI with videolaryngoscope; be prepared for difficult FONA

Describe the management of post-thyroidectomy neck haematoma causing airway compromise.

This is a classic FRCA emergency scenario: decompress first, then secure airway and return to theatre.

Recognise: neck swelling/tightness, dysphagia, stridor, hypoxia, agitation; may progress rapidly
Immediate: call for help (ENT, anaesthetic senior), high-flow O2, sit patient up, prepare suction and airway kit
Decompress: remove clips/sutures and open wound at bedside if airway threatened; evacuate clot to relieve pressure
Airway: once decompressed, proceed to controlled intubation if needed; if cannot intubate/oxygenate, perform FONA (may be challenging—consider scalpel-bougie technique)
Definitive: urgent return to theatre for haemostasis; correct coagulopathy, manage BP, antiemetics to prevent retching

What are the features of hypocalcaemia after thyroidectomy and how do you treat it?

Usually after total thyroidectomy due to hypoparathyroidism (transient or permanent).

Symptoms/signs: peri-oral tingling, paraesthesia, cramps, carpopedal spasm, tetany, seizures; laryngospasm/stridor; Chvostek/Trousseau signs
ECG: QT prolongation ± arrhythmias
Investigate: serum adjusted calcium and magnesium; consider PTH depending on local pathway
Treat symptomatic: IV calcium gluconate with ECG monitoring; correct Mg; involve surgical/endocrine team; commence oral calcium/vitamin D for ongoing management

How does recurrent laryngeal nerve injury present and what are the airway implications?

Unilateral palsy affects voice; bilateral palsy can obstruct the airway.

Unilateral RLN palsy: hoarseness, weak/breathy voice, aspiration risk; may be delayed recognition
Bilateral RLN palsy: stridor, respiratory distress, inability to abduct cords; may require urgent airway support
Management: oxygen, senior help, consider nebulised adrenaline/steroids if oedema also suspected; early ENT assessment (laryngoscopy); intubation/tracheostomy may be required

What is thyroid storm? How would you manage it peri-operatively?

Life-threatening exacerbation of thyrotoxicosis, usually triggered by surgery, infection, or stopping antithyroid medication.

Features: hyperthermia, tachycardia/AF, hypertension then hypotension, agitation/delirium, heart failure, GI symptoms
Immediate management: ABC, ICU, cooling, fluids, oxygen, treat precipitant (e.g., sepsis)
Specific therapy: beta-blocker (propranolol/esmolol), antithyroid drug (PTU preferred acutely as reduces T4→T3; or carbimazole), iodine solution after antithyroid, steroids (e.g., hydrocortisone)
Anaesthetic considerations: avoid sympathetic surges; invasive monitoring; manage arrhythmias and heart failure

How would you modify anaesthesia if the surgeon requests recurrent laryngeal nerve monitoring?

Monitoring typically uses an EMG tube and requires minimal neuromuscular blockade after intubation.

Use an EMG endotracheal tube positioned correctly (electrodes at vocal cords); confirm with videolaryngoscopy and secure well
Neuromuscular blockade: use short-acting agent for intubation (e.g., suxamethonium or low-dose rocuronium with planned reversal) and avoid top-ups; use quantitative monitoring
Anaesthetic technique: TIVA often preferred to reduce interference and allow stable conditions; ensure adequate depth to prevent movement
Communicate: agree timing of stimulation and periods where absolute immobility is required

What are the key causes of stridor after thyroidectomy and how would you distinguish them clinically?

Think haematoma first; then cords, oedema, calcium, tracheomalacia.

Neck haematoma: visible swelling/tightness, rapid progression, venous congestion; treat by immediate decompression
Bilateral RLN palsy: stridor with minimal external swelling; voice may be weak/aphonic; confirm with laryngoscopy
Laryngeal oedema: history of traumatic intubation/long surgery; may respond to nebulised adrenaline and steroids; cuff-leak may be reduced
Hypocalcaemia: tingling/tetany; may precipitate laryngospasm; check calcium and ECG QT
Tracheomalacia: collapse after extubation, especially with long-standing large goitre; may need reintubation and staged extubation/ICU

Discuss the anaesthetic management of thyroidectomy.

Common long-form viva/SAQ theme: cover optimisation, airway, conduct, and complications.

Pre-op: assess thyroid status (aim euthyroid), cardio-respiratory optimisation, airway assessment (compression/stridor/voice), plan for difficult airway/FONA
Intra-op: GA with ETT, secure tube, positioning, haemodynamic control, PONV prophylaxis, analgesia, consider nerve monitoring implications for NMB
Post-op: extubation strategy, monitor for haematoma/stridor, assess voice, monitor calcium, treat complications promptly, consider HDU/ICU if high risk

You are called to recovery for a patient post-thyroidectomy with neck swelling and stridor. What do you do?

This maps closely to AAGBI/RCoA emergency management principles: decompress, oxygenate, secure airway, return to theatre.

Immediate: call for help, high-flow O2, sit up, assess rapidly; prepare for airway intervention
If airway threatened: open wound immediately and evacuate clot; do not wait for theatre transfer
Secure airway as required (intubation; be prepared for FONA); then urgent theatre for haemostasis and optimisation (BP, coagulation, antiemetics)

How does thyrotoxicosis affect anaesthesia and what are your goals?

FRCA often examines physiology/pharmacology implications and peri-operative goals.

Effects: increased sympathetic tone, tachycardia/AF, hypertension, high-output heart failure; increased oxygen consumption and CO2 production; heat intolerance
Goals: achieve euthyroid if possible; beta-blockade; avoid sympathetic surges (laryngoscopy, pain, hypovolaemia); treat arrhythmias; maintain normothermia
Recognise/manage thyroid storm promptly; consider invasive monitoring in severe disease