Parathyroid insufficiency, thyroid storm and wound complications
THE CONTEXT
Additional complications of thyroid surgery include impaired parathyroid function, acute exacerbation of hyperthyroidism, infection and abnormal scarring.
Parathyroid insufficiency
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Parathyroid insufficiency results from gland removal or infarction following damage to parathyroid end arteries; both may occur together. Vascular injury is probably more important than inadvertent removal.
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Permanent hypoparathyroidism should occur in less than 1%. Most cases present dramatically 2–5 days after surgery; rarely, onset is delayed for 2–3 weeks or marked hypocalcaemia is asymptomatic.
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The source limits this complication to total thyroidectomy because contralateral parathyroid glands maintain calcium after lobectomy.
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Total thyroidectomy with central neck dissection particularly threatens the glands and their blood supply. It should be reserved for evidence of metastatic disease or a high risk of occult regional nodal disease.
Thyrotoxic crisis
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Thyrotoxic crisis is an acute exacerbation of hyperthyroidism and is now extremely rare. It can follow inadequate preparation of a thyrotoxic patient for thyroidectomy.
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Rarely, a thyrotoxic patient presents in crisis, including after an unrelated operation.
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Supportive treatment addresses dehydration, hyperpyrexia and restlessness using intravenous fluids, ice packs, oxygen, sedation and intravenous hydrocortisone. Diuretics are used for cardiac failure and digoxin for uncontrolled atrial fibrillation.
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Specific treatments listed include carbimazole, oral Lugol’s iodine or intravenous sodium iodide. Propranolol blocks beta-adrenergic effects.
Wound infection
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Cellulitis requiring antibiotics is more common than many surgeons appreciate.
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A significant subcutaneous or deep cervical abscess is exceptionally rare and should be drained.
Hypertrophic and keloid scars
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Abnormal scarring is more likely when the incision overlies the sternum and in dark-skinned individuals.
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Give intradermal corticosteroid injections promptly and repeat monthly if necessary. Scar revision rarely produces significant long-term improvement.