Table of Contents
Thyroidectomy may be performed for various pathologies, consisting of either thyroid lobectomy or total gland removal. Both benign and malignant disease processes necessitate surgical intervention. Thyroid nodules, compressive thyroid goiter, or persistent thyrotoxicosis represent some of the benign indications. Malignant conditions affecting the thyroid include papillary, follicular, medullary, and anaplastic carcinomas. In the present case, a thyroidectomy via standard cervical incision is performed on a cadaver with overlying animations to emphasize the key anatomy. The discussion is in relation to a patient with obstructive goiter presenting with worsening wheezing, cough, and dysphagia, with the ultimate goal of relieving the compressive symptoms through the removal of the gland.
Patients with thyroid pathology may present with variable symptoms, including difficulty breathing, voice changes, or endocrine issues. Others may have no symptoms, as the incidental diagnosis of thyroid nodules occurs with some frequency. Obstructive symptoms such as exertional dyspnea, wheezing, or cough often warrant urgent intervention. Rapidly growing thyroid glands should alert the clinician to an underlying malignant process.1
Patients with endocrine pathology may demonstrate hyperthyroid symptoms (palpitations, myopathies, weight loss, heat intolerance, diarrhea, amenorrhea) or hypothyroid symptoms (constipation, brittle nails, cold intolerance). Medical management targeted at downstream relief or thyroid suppression/supplementation may be sufficient.2
Thyroid malignancies may or may not have a palpable mass in the thyroid. Specific criteria for biopsy of a thyroid nodule include a size greater than 1.5 cm or concerning signs on ultrasound (irregular borders, microcalcifications, central vascularity). The Bethesda classification system helps guide the specific recommendations for surgery or observation.3 The Bethesda classification system classifies thyroid nodules into six categories based on findings from fine needle aspiration(FNA): nondiagnostic, benign, atypia or follicular lesion of undetermined significance, follicular neoplasm or suspicion for follicular neoplasm, suspicious for malignancy, and malignant. Each category corresponds to a different cytopathology and malignancy risk, and therefore different treatment options exist for each category.
In patients with obstructive goiter, a slow-growing mass is typical, to the point where symptoms of tracheal and esophageal compression are brought on slowly: exertional dyspnea, wheezing, cough, and dysphagia. These symptoms often present when the trachea is compressed and its diameter becomes less than 8 mm. Less commonly, acute compressive symptoms of a thyroid goiter have been reported.4,5 Compressive symptoms caused by an enlarged thyroid, whether cancerous or noncancerous, should be treated via thyroidectomy. Longstanding compression can result in structural changes to the underlying cartilaginous framework of the airway, and postoperative tracheomalacia may warrant additional intervention.
Our case scenario is of a patient with a slow-growing thyroid gland over many years presenting with several weeks of worsening wheezing, cough, and dysphagia. The patient was previously evaluated by the primary care provider for concern of an enlarged thyroid, but screening TSH and T4 levels were normal, no compressive symptoms were present at that time, and ultrasound indicated no further workup. When the patient presented a second time a decade later, the patient had no complaints of palpitations, anxiety, diarrhea, constipation, cold or heat intolerance, or other concerns. The patient was most distraught by difficulty swallowing and breathing. Further history elicited that the patient had particular trouble breathing when laying supine.
In a patient with an obstructive goiter, enlargement may be visible or palpable. Unilateral or bilateral enlargement should influence the differential diagnosis. Signs of underlying endocrine issues (exophthalmos, thin/brittle hair or nails, and skin quality) should be assessed. For any patient being worked up for surgical intervention, the mobility of the vocal cords should be documented with flexible fiberoptic laryngoscopy.
Patients presenting for surgery should be euthyroid, with any abnormalities identified and managed prior to surgery. TSH and free T4 should be done and within normal limits. Thyroid ultrasound would be homogenous without indications for FNA. Computed tomography (CT) may show compression into the trachea, esophagus, or surrounding structures. Ancillary tests may include thyroid-stimulating autoantibodies, anti-thyroid peroxidase, calcitonin, and a barium swallow.
The natural history of obstructive thyroid is a slowly-enlarging mass. Removal is indicated when a patient has signs of compression. Research has not shown that removal of non-obstructive goiter provides decreased mortality to a patient, and the risks may be greater than any benefit.6
- Hormonal suppression for small goiters
- Iodine replacement (for multinodular goiter with iodine deficiency)
- Radioactive iodine therapy
- Surgical excision
The ultimate goal is to remove the compressive thyroid to relieve symptoms.
Contraindications to thyroidectomy are uncontrolled Grave’s disease, due to concern of intraoperative or postoperative thyroid storm, and Riedel’s thyroiditis, due to fibrotic tissue and complications associated with removal including hypoparathyroidism.
The patient should be consented to surgery after understanding the risks that are specific to total thyroidectomy. The risks include bleeding, infection, scarring, pain, hypothyroidism (and the need for lifelong hormone replacement), possible hypoparathyroidism, and problems related to calcium metabolism that may be transient or permanent, possible recurrent laryngeal nerve (RLN) injury resulting in dysphonia, dyspnea. In the possible event of bilateral RLN injury, a tracheostomy may be necessary. Dysphagia may be present after surgery as well.
With the patient sitting upright, an incision just below the level of the cricoid cartilage in a natural skin crease can be marked.
The preferred anesthesia method for this surgery is general anesthesia with endotracheal intubation. Specifically, an endotracheal tube with electrodes in contact with the bilateral vocal cords to monitor for RLN activity should be implemented. No paralytic agents should be used.
Patients should be faced supine with straps securing them to the bed. A shoulder roll or bolster is placed between shoulders to hyperextend the neck slightly for access to the surgical region. Head can be placed in a head-ring for stabilization. The table can be positioned either flat or tilted to 30° anti-Trendelenburg to minimize venous engorgement.
Prepping the Patient:
Facility preferred preparation methodology can be used (e.g., betadine, chlorhexidine) for skin disinfection before the incision is made.
A curvilinear incision is made two finger-widths above the sternal notch, within a natural crease of the patient’s neck determined prior to incision. The underlying subcutaneous fat and platysma are divided to expose the underlying strap muscles. Then, the fascia between the sternohyoid and sternothyroid muscles is divided at the midline to identify the anterior surface of the thyroid. Once this is complete, the trachea and isthmus are identified. The exposed thyroid is rotated medially to expose and divide then ligate the middle thyroid veins. Next, the superior pole of the thyroid is exposed to bring the superior thyroid artery into view, dividing it out as closely as possible to the thyroid parenchyma to avoid injury to the superior laryngeal nerve. The superior parathyroids are brought into view with the delivery of the superior pole; they should be preserved. Retractors should then be shifted to view the inferior thyroid veins which allow ligation of the veins and then identification of the inferior parathyroid glands. It is vital to identify and preserve the RLN, found within Simon’s triangle (made up of the common carotid laterally, esophagus medially, and inferior thyroid artery superiorly). All branches of the inferior thyroid artery should be carefully divided and ligated. Next, re-identifying the RLN posterior to the ligament of Berry is vital before sharply dissecting the ligament from the trachea. For a total thyroidectomy, all the above steps should be repeated for the opposite side.
The surgical site is irrigated, and the Valsalva maneuver is done to ensure appropriate hemostasis. A wound drain may be applied and secured to the skin with a 3-0 nylon suture. The strap muscles are approximated for 70% length, and the platysma is closed with absorbable 3-0 Vicryl stitches. Subcuticular skin closure is achieved with absorbable 4-0 Monocryl running suture. A light dressing is applied with antibiotic ointment and Steri-Strips, or Dermabond.
Patients must be monitored for bleeding and airway obstruction, in addition to endocrine symptoms. A normal diet is preferred, as tolerated. Following a total thyroidectomy as in this case, serum PTH is obtained in the recovery area, as well as a baseline calcium value (whole blood versus ionized). If the PTH is low (<15), both supplemental calcium and vitamin D should be initiated. Calcium may be given in oral form at 900 mg TID, and vitamin D at 0.25 mcg BID. If a drain was placed, removal of the drain occurs when output is less than 30–50 ml over 24 hours. The morning after surgery, thyroid hormone supplementation should be initiated. The dose for this is based off of ideal body weight and may be increased for malignant pathologies to aid in TSH suppression. Subsequent management to ensure appropriate dosing should be carried out with an endocrinologist.7,8
Hypocalcemia, vocal cord paralysis, postoperative hematoma or infection, transverse neck scar.
We present here a case of a patient with obstructive goiter undergoing thyroidectomy simulated on a cadaver with overlying illustrations to better appreciate the procedural steps and anatomy of the region. In summary, our patient presented with several weeks of worsening wheezing, cough, and dysphagia, and a visibly enlarged thyroid on the exam. TSH and T4 screening labs were within normal limits, and ultrasound did not show evidence of need of a biopsy. CT showed evidence of compression on the trachea and the esophagus. The ultimate goal of therapy is the removal of the compressive thyroid gland while preserving the parathyroid glands and RLN. Post-surgery, patients require thyroid hormone supplementation, and immediate labs must be monitored to ensure appropriate calcium homeostasis.
This case depicts a standard cervical incision thyroidectomy. Additional procedures include transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transaxillary robotic thyroidectomy.9,10 Indications for TOETVA include thyroid is less than 10 cm, benign tumor, follicular neoplasm, papillary microcarcinoma, Graves’ disease, and substernal goiter grade 1. The transaxillary approach is primarily used for papillary thyroid microcarcinoma, in addition to expansion to papillary thyroid cancer. These alternative types of thyroidectomy can be extremely efficient however, the standard cervical incision approach offers a broader inclusion criterion. Additionally, while the thyroid is an extremely vascular organ with many vital nerves and structures surrounding it, the procedure has extremely low morbidity with the meticulous care taken for hemostasis and antisepsis.
Basic head and neck tray
C. Scott Brown also works as editor of the Otolaryngology section of the Journal of Medical Insight.
This case is a thyroidectomy demonstrated on a cadaver; no consent was required. All other persons seen in the video consented to publication of the media.
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- Raise Superior and Inferior Flaps
- Divide Strap Muscles
- Separate Sternothyroid from Sternohyoid
- Identify Airway and Midline
- Find Isthmus
- Dissect Strap Muscles Off Thyroid Gland
- Identify External Branch of Superior Laryngeal Nerve
- Retract Lobe and Divide Superior Thyroid Vessels
- Retract Thyroid
- Dissect Down to Nerve
- Identify Nerve
- Clear off Inferior Pole
- Identify Trachea
- Resect Thyroid
- Trace Nerve into Larynx
- Identify and Control Vessels
- Identify Berry’s Ligament
- Include Peroneal Lobe in Dissection
So - so it's not going to be that easy to visualize the incision here relative to the - the sternum, but basically you want to find the skin crease that is sort of accessible to where you need to go, but you want to make sure that you’re keeping a sense of where midline is but… Make your incision just like every other. So you’re coming down through - you'll see platysma on the lateral aspects of the incision. Often, it’s dehiscent to the midline, so you won’t see it there, but come down and you'll start to see the anterior jugular vessels.
So then you're raising up the superior inferior flaps, and it's a bit different than your typical - you want it to be a little bit deeper right on top of the vessels. So you raise it in the super venus plane. Basically that limits the amount of tissue between the straps and your - there we go - now we come down here I guess. So that raises it just above the vessels. Doctor Sumad will talk about undercutting the platysma, which is a useful trick to get you some more exposure that’s wider than your skin incision. Let's see - pulling at your skin incision a little bit.
So the next step is to divide the straps in the midline here. So divide the straps all the way down to the sternal notch, and you want to go up as well. There we go. So, what I like to do…
Next, I separate the sternothyroid from the sternohyoid, which in this case it might be a bit difficult, and then I - I divide the sternohyoid in each and every thyroid. It just gives you a lot better exposure, and I don't think that the - the voice - there any voice decrements from it. But anyway I think it's probably got divided in there. The plane isn't very good but…
The next thing that I do is to - is to find the airway in the midline. So you find your isthmus, which I can't tell where that is it all, but I’m just dividing the tissue overlying the trachea here and - and maybe that’s isthmus there - that's probably Isthmus there. So this just provides you with a useful landmark for the next part.
So, once you identify the airway in the midline. What I do is bluntly dissected the straps off the thyroid gland inferiorly, pull the thyroid gland medially, and bluntly dissect inferior to the thyroid and find the nerve down there. And I think we'll have to dissect this. It’s not going to be very pretty otherwise. Got a nice size thyroid gland here. So typically you can bluntly dissect and find the nerve inferior to the thyroid gland, but if you can't find it, as is the case in this case, you come up to the superior pole here, and you dissect the sternothyroid from the superior pole, exposing the superior pole of the thyroid gland, which is right up in here, and then you get your tractor in there and…
So then what I do is identify the external branch of the superior laryngeal nerve, and this is the cricothyroid space that y'all heard so much about. And usually you can find - you can actually identify the nerve running in the fascia on the cricothyroid muscle, and that way you can you can definitively say that you haven't transected it. What a lot of people do also is just to dissect it very close to the capsule or within the capsule so that you're not going to injure it that way.
Then, once you've identified it you can take the lobe and retract it inferiorly and divide the superior thyroid vessels. And this is where you're going to find your parathyroid, your superior parathyroid is your - see, need to retract that a bit more here. You can walk it - walk the retractor along the - the superior pole. So, the parathyroid gland - I don't know if - I don't know how well it's going to be preserved in this kind of setting, but as you're dividing your superior pole vessels, it's going to be up near the joint and near the nerve. It's probably in this sort of fatty tissue right in here, and so this is where you want to be meticulous in your dissection in getting this off without disrupting the blood supply. I like to do this with a bipolar and a Kitner.
So once you've asserted freed up the superior pole, what you can do is you can start to retract the thyroid medially. Again if you keep your dissection along the capsule the gland, you're going to preserve your parathyroid, you’re going to protect your nerve. For thyroids like this where you can't find it easily inferiorly, I like to - to bluntly dissect along the thyroid gland after I divided the - the superior pole vessels, and as you pull it medially, it's going to open up that space, and you can find the nerve down in the trachea esophageal groove. Although on the right side, it’s often coming from a more lateral direction.
So at this point you can - if you're going to find it up in here - you want to go layer by layer right on the thyroid gland, and the nerve will make itself apparent. If you want to find it like I do, down inferiorly, than you can bluntly dissect. So when you're coming along the lateral aspect, you're going to encounter the middle thyroid vein, and that may be it there. You just want to stay within the capsule of the gland. Divide all that stuff - that - is that nerve there? That may be parathyroid here.
So it’s a bit hard to teach the method I usually use since it sort of relies on it being on stretch and finding it inferiorly, but the nerve is a bit more constant up in its position up at the - at the joint, which is why some people advocate finding it superiorly. Looks like a tubercle there maybe. So it’s helpful if you can find - identify some landmarks like the carotid, which is difficult in this case. So as I was saying, I usually find it with some blunt dissection. It makes it a lot harder when it's been cut, but that may be it there actually.
So once you identify the nerve inferiorly like this, when I - in a thyroid that’s not this large - I find it inferiorly and then takedown everything off of the inferior pole and connect it to what I had exposed before with the trachea and the midline - so take down all this tissue - and that typically will preserve your inferior parathyroid gland. So you keep - just keep your nerve in view, and you connect those two. You have to control the - there's some bigger vessels down here that can be a bit pesky, so you want to make sure that you're controlling those as you go. Where’s the airway there - there it is.
Alright, so once you identified the trachea and cleared everything off the inferior aspect, you trace the nerve up, so there - there's a nerve right there.
Trace the nerve up superiorly into its insertion into the larynx. So up at the - up at the joint, it becomes pretty adherent at the Berry’s ligament, so you have to be cognizant of that. And also you want to - especially on the right hand side - you want to be cognizant of how much you're retracting medially on the thyroid. There it is - there’s nerve there. So when you're coming superiorly, if you found the nerve inferiorly, you want to make sure that you're staying on the gland cuz there can be - the superior para can be right around that tubercle of Zuckerkandl, and the nerve can go often go right under it.
And again, the thyroid gets pretty adherent to the trachea up here, and there's some big vessels that are - that will always run in that general vicinity too. Cut that. I don’t like to clip because if you're going to get any subsequent imaging in central neck, then it's going to be - you're going to have a lot of artifact from that. So I use the harmonica a lot or the bipolar, and if it's too big for that, I like to tie.
So here is the nerve here, going up into the larynx. It’s obviously not on any tension, so we’re - it's usually not - there's not this much laxity on the nerve, but what I do is I come up along trachea and get the thyroid basically pedicled on Berry's Ligament.
And you’re starting to see - you can kind of see some of these vessels in here, and these are really bothersome if you don't control them, or if kind of - if you dissect really forcefully through here. But you want to stay along the gland as well and try to preserve that vessel as much as you can cuz it is the blood supply to the - the inferior and superior parathyroid glands generally. And once the nerve is sufficiently away, which I kind of think it is, you can be a bit more aggressive and coming through this tissue. But oftentimes down in this - gets to be a little crotch area where the nerve comes up and Berry’s Ligament is - you can distinguish yourself maybe from your - from other colleagues who do thyroidectomy by being very meticulous in this area and getting all of the thyroid tissue out. It's easier to come across and leave a little bit of thyroid tissue at that area, but I think if you get it off of the trachea and get it pedicled on that - that may be thyroid tissue there - get it pedicled on the Ligament of Berry, then typically, you can take all of that tissue out pretty easily. I like to use the bipolar again in that area.
This is the Berry’s ligament here that we’re coming through. See the knife. It's easy to leave thyroid tissue in here. You want to make sure you're getting all the way down into that crotch. The other place that's it’s easy leave thyroid tissue is at the superior pole, so that's why - you have to be - you have to be good at identifying the tissue planes up there and - and retracting inferiorly to make sure you get all of that. Another place where it's easy to leave it is at the pyramidal lobe here, so when you're coming up, bringing it medially, you know, be cognizant of that and watching superiorly since you can include the pyramidal lobe in your dissection. So here we’re on tracheal rings. There there we go.