This document discusses the surgical management of benign thyroid disease. It covers: 1) Evaluation of thyroid enlargement including clinical examination, FNAC, ultrasound, and TSH levels. 2) Surgical principles including pre-operative, per-operative, and post-operative care. 3) Surgical options for thyroid enlargement including lobectomy, isthmusectomy, and total thyroidectomy. 4) Potential complications of thyroid surgery including recurrent laryngeal nerve injury, hypocalcemia, and bleeding.

1. Surgical Management of
Benign Thyroid Disease
Dr. MTD Lakshan
MBBS (Col) MS (OTO) DOHNS FEB ORL-HNS FRCSEd ORL-HNS

2. Facts
1.
Palpable nodules – 5% women, 1% Men (High
Resolution US 19 – 67%)
2.
Risk of Cancer 5 -15%
3.
Non-neoplastic diseases of the thyroid affect
nearly 3/4 of a billion worldwide
4.
Iodine deficiency common worldwide Iodine
excess common in US (and in SL?) – contribution
to thyroiditis – Jod-Basedow phenomena

3. Management of Thyroid
Enlargement
1. Clinical Evaluation
– Malignant hints
– Activity hints
– Compression hints
2. FNAC
3. USS
4. TSH

4. Surgical Principles
1. Pre-operative
2. Per-operative
3. Post-operative

5. Clinical Evaluation
●
History childhood head and neck
irradiation
●
Family history of thyroid
carcinoma or thyroid cancer
syndrome
●
Rapid growth
●
Hoarseness
●
VC Palsy
●
LN enlargement
●
Fixation of nodule to the skin

6. FNAC
●
Sensitivity for malignancy 65 – 98%
●
Specificity 76 – 100%
●
Overall accuracy 69 – 97%
●
Guided FNAC improves diagnostic yield

7. Thy
Thy 1
Non-Diagnostic for cytological diagnosis
Thy1c
Non-Diagnostic for cytological diagnosis Cystic Lesion
Thy 2
Non - Neoplastic
Thy 2c
Non – Neoplastic Cystic Lesion
Thy 3a
Neoplasm Possible
Atypia/Non-diagnostic
Thy 3f
Neoplasm Possible
Suggesting follicular neoplasm
Thy 4
Suspicious of malignancy
Thy 5
Malignant

9. Action Based on Thy
Thy 1
Thy 2
Thy 3
Thy 4
Thy 5
1+c
a +c
a+f
Repeat FNS
Consider USS
guidance
Describe as
cystic if no
epithelial cells
present
Repeat FNA if
no surgery
planned
Discuss at MDT
Discuss at MDT
Discuss at MDT
Diagnostic
Lobectomy
usually
recommended
Diagnostic
lobectomy +/on table frozen
section to
proceed to total
thyroidectomy
+/- central node
clearance in
high risk
patients
Radiotherapy/ch
emotherapy or
surgery where
indicated
Consider total
thyroidectomy in
larger lesions
>4cm where
incidence of
malignancy is
high
Appropriate
further
investigations
for staging when
indicated
Total
thyroidectomy
+-central node
clearance in
appropriate high
risk patients

10. USS
●
Suspicious
–
–
Hypervascularity
–
Irregular borders
–
Taller rather than wider nodule on transverse imaging
–
●
Micro calcifications, hypo-echoeic solid nodules
Extra glandular invasion
Other info
–
contralateral lobe
–
lymph nodes

11. CT

12. Radio Isotope Scanning

13. Surgical Decision Making
●
Nature of the goiter
–
Degenerative
–
Neoplastic
–
Physiological
●
Function of the goiter
●
Compression and Extension
●
Cosmetic
●
Patient comorbidities

14. Indications
●
Compressive symptoms esp. with sub-sternal
goitre
●
Concerned about the risk of malignancy –
diagnostic lobectomy and isthmusectomy
●
Controlling hyperthyroidism
●
Cosmetic – 5cm
Laryngoscope, 121:60–67, 2011
The Surgical Management of Goiter: Part I. Preoperative Evaluation
Jennifer J. Shin, MD; Hermes C. Grillo, MD*; Doug Mathisen, MD; Mark R. Katlic, MD; David
Zurakowski, PhD; Dipti Kamani, MD; Gregory W. Randolph, MD
Laryngoscope, 121:60–67, 2011

15. Preoperative planning
●
Review of data
–
●
Clinical, imaging, pathology, TSH
Informed consent
–
Bleeding, hypocalcaemia, recurrent laryngeal nerve
damage, infection, cosmetic
●
IDL – 2% pre-op IDL VC palsy +
●
Lugol's iodine (KI)

16. Surgical Options
●
Lobectomy and isthmusectomy
●
Total Thyroidectomy

17. Steps
●
Skin incision
●
Flaps
●
Lateral border and middle thyroid
●
Upper pole
●
Isthmus
●
Lower pole
●
Identification of RLN

18. Basic Sciences - Anatomy

22. Incision

23. Flaps

24. Straps

25. Upper Pole

26. Ex. Br. SLN

27. RLN

28. RLN
●
Carotid Triangle
–
Carotid artery, Trachea and Thyroid gland
–
Lateral to medial – may devitalise parathyroids
–
Medial to Lateral
●
Cricothyroid joint level consistent
●
Branching 40% before reaching CTJ

29. Branching of RLN

30. Wound Closure

31. Scar Management

32. Complications
●
RLN – 7%, permanent 3.6%
●
Hypocalcaemia – 10-20%, permanent 1-5%
●
Bleeding – Haematoma formation – 5%
●
Scar
Assessment of the Morbidity and Complications of Total Thyroidectomy
Neil Bhattacharyya, MD;Marvin P. Fried, MD
•
Conclusions Postoperative hypocalcemia is the most common immediate surgical
complication of total thyroidectomy. Other complications, including recurrent laryngeal nerve
paralysis, can be expected at rates approximating 1%.
JAMA Network | JAMA Otolaryngology–Head & Neck Surgery | Assessment of the Morbidity
and Complications of Total Thyroidectomy

33. Controversies
●
Drain or not to drain
●
Wound Closure
●
Routine Calcium Supplementation
●
DL examination of VC function at recovery
●
Post op T3 or T4
●
Contrast in CT in imaging

34. New Frontiers

35. Endoscopic Thyroidectomy
What is the Evidence for Endoscopic Thyroidectomy in the
Management of Benign Thyroid Disease?
E. Th. Slotema, F. Sebag, J. F. Henry
World J Surg. 2008 July; 32(7): 1325–1332

36. Intra-operative Nerve Monitoring

37. New Frontiers
•
MicroPLIC
•
RhTSH
•
vMDT

38. Personal Perspective

40. DGH Thyroidectomy Audit
–
Period : 36 months from September 2009 to
October 2013
–
Number of Cases : 107
World Figures
Our Audit
RLN – 7%, permanent 3.6%
2%
Hypocalcaemia – 10-20%, permanent 1-5%
4%
Bleeding – Haematoma formation – 5%
2%

41. MDT South Virtual Head and
Neck Cancer Meeting

42. William Halstead
• Sterile Operating Room
Concept
• Invented Surgical Gloves
• Introduced Radical
Mastectomy
• Performed first emergency
blood transfusion
• Intestinal Suturing

43. William Halstead
“The extirpation of the
thyroid gland for goitre ……
provide(s) perhaps more
than other operations the
supreme triumph of the
surgeons art”
William Halstead

44. Thank You