Post-thyroidectomy haemorrhage and vocal cord assessment
THE CONTEXT
Early postoperative surveillance focuses on potentially fatal neck bleeding and assessment of vocal cord function.
Haemorrhage and airway obstruction
•
Haemorrhage is the most frequent life-threatening complication of thyroidectomy. Haematoma occurs in around 1 in 50 patients, almost always within the first 24 hours.
•
An arterial bleed can raise central compartment pressure above venous pressure, causing laryngeal venous oedema, airway obstruction and death.
•
Despite improved anatomical understanding and haemostatic technology, bleeding has not been eliminated. It is the stated reason thyroidectomy remains an inpatient procedure in the UK.
Prevention and urgent management
•
Meticulous intraoperative haemostasis is critical. Avoiding watertight strap muscle closure may allow a haematoma to escape into subcutaneous tissues.
•
Wound drains have not demonstrated a protective effect, and close postoperative wound monitoring is advised.
•
If a haematoma develops, remove skin sutures to release pressure and seek senior advice immediately.
•
Secure the airway with endotracheal intubation while the haematoma is evacuated and the bleeding point controlled.
Recurrent laryngeal nerve injury
•
Recurrent laryngeal nerve injury can be unilateral or bilateral, transient or permanent.
•
Early routine laryngoscopy detects more transient cord paralysis than simple assessment of voice and cough. The source describes this temporary dysfunction as not clinically important.
•
Assess voice and cord function at the first follow-up, 4 weeks after surgery.
•
An audit of first-time operations reported palsy rates of 1.8% at 1 month and 0.5% at 3 months. Permanent paralysis is rare when the nerve has been identified during surgery.